Wednesday, 21 July 1971
Dáil Eireann Debate
These draft regulations have two purposes. The first, and main purpose, is to provide for an increase in the income ceiling for limited eligibility for health services from £1,200 to £1,600 in the case of the self-employed, other than farmers, and persons with private means. This is in line with the recent increase in the income limit for social welfare insurance of non-manual workers. It has been settled practice to follow the social welfare limit for the purposes of limited eligibility for health services.
Secondly, the regulations would substitute a definition of income in accordance with income tax practice for the present definition, which is based on rules set out in the Social Welfare Acts. Those rules were geared towards assessing the need for financial assistance, such as pensions, and took account of the realisable value of a person's property as well as his cash income. It is considered more appropriate to look at visible income, such as is done for income tax purposes, in reckoning eligibility for health services. This change, incidentally, would facilitate the arrangements under the Health Contributions Bill for the collection of certain health contributions through the agency of the Revenue Commissioners. It will not have any sensible influence on the number of persons eligible for services.
I had hoped also to include in these regulations a provision fixing income standards for full eligibility, that is for  that category who are entitled to medical cards. After very detailed and careful studies of the matter, I have come to the conclusion that, as circumstances other than the purely financial vary so much as between country and town and between one family and another, I should not at this stage make regulations on such standards but rather leave it to the chief executive officer of the eight health boards to try to achieve the greatest practicable uniformity in their decision on eligibility. I am arranging for my Department to bring the chief executive officers together with a view to working out a formula for achieving maximum unity of approach. The reduction from 27 to eight in the number of bodies responsible for the operation of the health services should facilitate a reasonable degree of consensus in the matter.
The chief executive officers will have available to them in their discussions the considerable volume of statistical material which was assembled in connection with the Departmental examination of this subject. I would hope that the outcome would be the removal of the inconsistencies which have in the past existed in relation to the issue of medical cards, without substantially altering the total number covered. This should mean more equitable treatment for both the persons seeking the service and for the taxpayers and ratepayers who must meet the cost of it.
Mr. R. Barry: I had hoped that we would be discussing that today in conjunction with the draft regulations now before us. The suggestion in the Minister's statement that he is to leave this decision to the chief executive officers of the different regional health authorities does not lead me to believe that this standardisation will be carried out with any great expedition. It certainly does not lead me to believe that it will be carried out with uniformity and in the way the elected representatives of the people would like to have it done.
I want to protest in the strongest possible manner at the by-passing of this House and public representatives by the Minister and his Department with regard to this regulation and, indeed, many others as well. The fixing of a national standard for medical card holders is one of the most urgent and pressing problems that besets the Minister and his Department just now. As he admits himself, regulations differ and the eligibility income differs not only from county to county but in Cork County, at least, between the three different parts— north, south and west and, indeed, Cork city also. I had hoped that we could discuss today that very serious problem and, indeed, help the Minister with regard to fixing a national standard for medical card holders. That is not to be.
With regard to the raising of the eligibility limit from £1,200 to £1,600, £1,600 at present day money values is a figure that should not be discussed here. We on this side of the House asked that that should be increased to £2,000, comparing present day incomes with those when the £1,200 limit was fixed some considerable time ago. I cannot understand why the Minister made no provision, when he was fixing this limit, for people with young families. There is no provision for children. Would the Minister tell us, when he is replying, whether he gave any thought to allowing for children? He knows quite well that in other cases incomes are related to the number of  children under a certain age in all families.
The regulations we have made here for some time now have been rushed and very ill-conceived. We have a further example today of what is happening. I believe that any person with an income of £1,600 in July, 1971, cannot provide the health safeguards that are required for his family. One of the greatest problems people have, especially young married people, is the dread of illness in their families when they have so many other commitments like house loans and hire purchase commitments. Now they are to be excluded from the benefit of the middle income group under the Health Act.
With regard to the £60 valuation which is not increased, I believe the Minister's idea of assessing the £1 valuation as being equivalent to £26 income does not stand up. I think the Minister said that that was decided by a group called An Foras Talúntais. I believe that farm incomes vary very much from one farm to another and from one county to another. The limit of £60 in the valuation is wrong also. On 12th July this year the Government themselves issued figures showing that the farmers' income last year was up less than 6 per cent on 1969 compared with an estimated rise of 11 per cent in non-agricultural income and a jump of almost 10 per cent in prices. The Minister must accept that farmers' incomes are not rising in line with those of non-agricultural workers. This House should call on the Minister to raise the income limit of £60 for farmers to £70 anyway. If we accept the figures issued by the Government— most of us know this already—farmers' incomes in those days of spiralling prices and rates are certainly lagging behind.
For these reasons, I want to say that unless and until some Government adopt the Fine Gael policy of graduated  contributions and an insurance system, where the balance would be met by a contribution from the Exchequer, and abolish the poor law system which has been retained in the regulations before us today, the people of the country will not be satisfied. This is an archaic way of doing things. It is an unjust way of doing things. Within the limits of the debate I want to say that we in Fine Gael will pressurise the Minister for Health until such time as these archaic regulations are changed.
Mr. Coughlan: As a member of a health authority for well over 20 years, I think I can speak from experience on this matter. We all welcomed the abolition of the old mental hospital boards; I was a member of such a board. We courted the local health authorities and adapted ourselves and applied ourselves as best we could to the needs of the people locally. As far as Limerick is concerned, in my over 20 years experience of this organisation, we did a perfectly good job. Out of the blue, we get these health boards which have regionalised us and integrated us with people who had not applied themselves as we in Limerick had done. The figures are there to prove what we had done in Limerick city and county. There are 34.7 per cent in the city and 41.5 in the county in receipt of medical cards. There is always a reason for this. Health cannot be defined. Nobody can imagine what it means to have a health problem until he has experience of it. Having been a member of the Mental Hospital Board and of the Limerick Health Authority and being a member now of the Mid-Western Health Board, I find myself now like a motherless foal trying to integrate myself with persons who have been associated with other authorities. Since 1st April we have made no constructive approach to the exercise for which we were formed, which is, the care of the patient. We have been engaged in exercises that are purely administrative, visiting committees, standing orders, all kinds of nonsense.
Mr. Coughlan: I hope the Minister will now realise what a health board means. He has not been a member of one. I have, unfortunately, and I will have to reconsider my position in the very near future.
Having said that, I now want to come to the regulations the Minister has introduced here today. The Minister's approach, as I see it, is a back stab. It is a way of getting at people who are adventurous enough and industrious enough to work overtime. He has included in these regulations the total income as cash income, which is how he describes it here. This has led to other problems in another Department, the Department of Local Government, in the matter of differential rents. A man who is prepared to work overtime, including Sunday, will now be victimised by the Department and by the Minister. This is the greatest backstabbing that I know of. It is another way of hounding the man who is industrious. The man who works his 40 hours and draws his basic wage and goes home and enjoys himself is in a much better position than the man who will work on Sunday. The Minister should know well that when we apply to the CEO—I will have a word about him in a moment—on behalf of some applicant for a medical card, a means form is sent out to be signed by his employer, asking what he earned over the past three months, over the past six months and over the past 12 months. Because of our—and my—agitation in Limerick, many employers have refused to give this information, for which I praise them. What a man earns is his private affair. The Minister is now treating employers as income tax collectors. Where are we going? Is our first obligation not to the patient? A person may receive a general medical card or a general medicines card or a medicines card on receipt of a contribution, for which you pay £1 a week or 10s a week or whatever it may be. When you hand your medical card into the dispensary you must pay whatever the CEO says. You get a medicines card for, perhaps, a month or  12 months or you may get a general medical card.
This is a subterfuge as far as I can see. The Minister is back tracking on what his predecessors had promised. We were to have free choice of doctor, free choice of chemist. We were to dispose of dispensaries. The recipient of the medical card was to be able to go into the chemist of his choice and have his prescription dispensed by the pharmacist there. We were promised all that in the past. What have we done? We have done absolutely nothing with the health services. If the Minister were honest he would admit that we have not the money to do it. If he did that we could examine our rates estimate and we might be able to do something for him.
Mr. Coughlan: If that is so, why are we in Limerick providing for further dispensaries? At the moment we are providing for three independent dispensaries to cater for the people of Limerick. If what the Minister says is true our CEO should have told us so. But he has not done that. He has applied for permission—at least I hope he has.
The Minister says that he will raise the ceiling from £1,200 to £1,600 in the case of self-employed people. What is a self-employed person? Is a cobbler, a bicycle mechanic, self-employed? Is an ordinary tramp self-employed? This is another way of saying that we will deal with self-employed people but the Minister forgets that a self-employed person could or, perhaps, would with luck, get the £1,600 in a week, a fortnight, or a month and might be self-unemployed for the next ten months. There is no consistency in this.
Mr. Childers: The Social Welfare Department will apply the same rules to stamps for the health element as they will for the social welfare element. Exactly the same rules will be adopted when the Minister for Social Welfare raises the limit to £1,600.
Mr. Coughlan: The social welfare recipients do not get the same advantages from social welfare as we give from health boards and those people are being brought back into the social  welfare group and the income tax group in order to bring them into the net. Is not the overtime included in all this? What we have been doing in the health field—and as a member from Limerick I can say we have done something for the people—the Minister has now jeopardised by the introduction of this. I appeal to him to look at the different health boards. He will find that, human nature being what it is, a CEO in one area will be good when another will be no good.
Mr. Coughlan: I agree but I want to show the Minister that CEOs, as they are at present, being human, adopt different approaches. Some are strict, forgetting the human element that must always be considered in these matters. The particular individual must be considered in relation to his capacity to pay. That is not the case. I know of one particular case where a farmer had a valuation well over £60. He had no family but he was up to his tonsils in debt with hospitals and doctors in Dublin. He was swamped with bills and went to his co-operative society and got advances and so on. Eventually, I took up his case with our health authority at the time and we got some recognition but in the end the man was forced to sell his farm and is now in England. CEOs can lay down a straight line; they can throw the book at one and quote this regulation and that, this subsection and that at health board meetings. This is not the Labour Party approach. We treat cases as they come, each one on his ability to pay according to the circumstances and the ailment involved.
Mr. Childers: The hardship arrangement  for the medical card group and the hardship arrangement for the upper end of the middle income group will continue. The farmer with over £60 valuation who has enormous hospital bills will continue to get a contribution from the health board if the CEO so decides. The Deputy need not worry about that : both hardship factors still operate after this is passed by the Dáil. It is written into the Health Act.
Mr. Coughlan: Is this not giving the CEO too much authority? Surely that man who is there by the choice of the people should have the right to question publicly any decision made. I should like to have this power over the CEOs, like section 4 in the Local Government Act. A member of the board should have the right to question the right of the CEO to make a decision.
Mr. Childers: The members of the board can appeal to the chief executive officer. His power to decide eligibility remains the same as the power of the county manager when there were 27 health authorities. There has been no change.
Mr. Coughlan: When we were under the control of the county manager it was a different situation completely. We had the right then but we have no right now. Authority is now given completely to the CEO. We are the representatives of the people but the CEOs are unseen people. They make their decisions and whether we agree or disagree with the decisions we must accept them. This is wrong. It is the negation of democracy.
The Minister has been told about the necessity to omit the overtime clause with regard to the issue of medical cards. This should not be tolerated in any democracy. If a man is industrious and is willing to work on Sundays or to work until 12 o'clock at night to supplement his income he should be encouraged. Many people find it is necessary to work overtime in a factory, to work at night time in a public house, or to play in a band or entertain in order to make ends meet, but they are being discouraged.
Mr. Childers: The Minister for Social Welfare makes regulations for the social insurance group of people. These regulations would apply to people socially insured in respect of the upper end of the middle income group. I am not interfering with the Minister. Whatever the regulations are in social welfare, they will be applied in the case of health, including the overtime. The Deputy could have discussed that on the occasion of the Social Welfare Bill.
Mr. Coughlan: The Minister's apology is accepted. A £60 valuation limit was introduced 20 years ago but the same valuation applies today even though valuations have increased due to reconstruction grants and other grants. I would remind the Minister that there is no such thing as a grant because what the Department give with one hand they take back with the other. Foolishly, people have availed themselves of these reconstruction grants but the valuation officers have been down like wolves on them and have increased the valuations. There should be some increase in the valuation limit. There has been a 33? per cent increase with regard to self-employed people, but there has been nothing done for the ordinary worker. So far as Fianna Fáil are concerned, he does not count until election times. The Minister should treat all the people of the country equally. Although the Government have told us frequently that all citizens are treated equally this is not true. People may have believed this in the past but they do not believe it any longer.
I have grave doubts that the regional boards will operate successfully. I speak with experience on this matter as I have been a member of a board since its formation. We are making no progress at the moment. We have applied for extensions to hospitals——
Mr. Coughlan: We are there by choice of the people and the health board should have the deciding voice regarding the issue of medical cards. We know the circumstances of the people better than the CEO or the home assistance officer. The home assistance officer is the person who supplies the information to the CEO.
Mr. Childers: The Deputy made a misstatement. Section 4 of the City and County Management (Amendment)  Act, 1955, does not apply to eligibility for medical cards, and never did. The health authorities were not able to direct the county managers to give a certain person a medical card on the basis of that Act, and everybody knows that. There is no change in giving the power to the CEOs to decide eligibility. There has been no fundamental change in the law. I hope the Deputy appreciates that. I am trying to help him.
Mr. Coughlan: Yes, but at the time the county and city managers had not got the authority that the CEO of any health board has at present. A CEO is all-powerful now. We come to board meetings now and he can refer us to this section and that section, and throw the book at us if he wants to. The Minister is supplying him with the armour and the ammunition to do that, despite what we have to say publicly. This is a democracy; we were elected by the people and the CEO, whoever he is, was not. I have not got anybody in mind. I am against giving all the power to any CEO to override a board representing three or four counties and comprising all the people concerned with health. The CEO can tell us: “This is it and no more about it. I am protected.” Is this democracy? It is not my idea of democracy. I want to advise the Minister. I am in grave doubt with regard to the success of the boards.
Mr. Childers: This regulation does not include any change in relation to the Health Act, or in relation to the powers given to CEOs, which were clearly spelled out after a very lengthy and helpful and constructive debate. There is nothing in these regulations which alters the powers of CEOs. They have already been determined in this House. Surely we cannot have a debate going back on the sections of the Health Act which gave CEOs certain powers, the great majority of which were already held by county managers before, with regard to eligibility for services, remuneration, conditions of staff, dismissal of staff, and so forth. We cannot discuss that again. I ask for the advice of the Leas-Cheann Comhairle on this day, 21st July, when we would hope that the business of the Dáil  could be carried out as expeditiously as possible under the circumstances.
An Leas-Cheann Comhairle: If the Deputy will allow the Chair to reply to the Minister's intervention, the Chair has already pointed out that what is under discussion is the document which has been distributed to Deputies dealing with the regulations. That is what is under discussion and only that.
Mr. Coughlan: ——we always had them under fire in one way or another —locally at our council meetings and at health authority meetings. The CEOs are now in a protected position. They are the CEOs of health boards and they deal with nothing else but health. We have to listen to them telling us: “This is the regulation. This is it.” We have no way, good, bad or indifferent, of compelling them to say they will give sympathetic consideration to a particular case.
Mr. Coughlan: With all due respect, I am dealing with cash income, No. 1, self-employed people, No. 2, and fixing income standards for full eligibility, No. 3. Therefore I am dealing with the regulations. This is what the Minister has done. Let us tell the people now that no longer is there any such thing as democracy under Fianna Fáil. The CEO, the county manager, the city manager, or whoever he is, is all powerful now. “We will suppress everything now, including the Press.” If the Minister wants to make a success of the Health Act—and, from my experience since 1st April, I doubt that it will be a success—I would ask him to reconsider the whole situation in view of my experience of over 22 years on a health authority, or a mental hospital board, or whatever it was. I ask him now even at this late stage to reconsider this and let our first consideration at all times be the unfortunate person on the stretcher, or in the ambulance, or in St. Luke's. If we do that, we will never go wrong. This is what we have been doing in Limerick. Now the Minister is stymieing us in our efforts.
Mr. T.J. Fitzpatrick: (Cavan): In my opinion these regulations provide further clear evidence of the effects that the rebellion within the Fianna Fáil Party about 18 months ago had on the Government, and on every member of the Government. We have further clear evidence here of the indecision under which the Government are operating directly, and under which each member of the Cabinet is operating. We have the evidence of Ministers and the Government changing their minds from day to day. Beyond making a passing reference to them I do not want to go back on those events except for the purpose of relating them to the point I want to make about these regulations.
We had the wobbling about the Prices and Incomes Bill at the end of last year, clear evidence of indecision in that Department. More recently still we had the example of the Employment Periods Order, 1971, terminating unemployment assistance in certain cases, hastily introduced, then revoked and another order brought in, and then that order amended again, clear evidence that Minister of this Government have not got their minds on their job and that they are suffering from the distraction that descended upon them last year when the entire party and Cabinet blew sky high.
A number of Deputies asked me about the standards for the medical card group. I shall bring them  before the Dáil and I think Members will be reasonably satisfied with them. I am sorry to disappoint Deputy Fitzpatrick, but we must continue with the method of calculating medical card standards for the farming community by assessment of their agricultural incomes.
Mr. T.J. Fitzpatrick: (Cavan): Column 334, volume 255 of the Official Report of Wednesday, 30th June, 1971. There we had from the Tánaiste and Minister for Health a clear and unambiguous undertaking that he would do something for the people for which we had all been crying out over a number of years, in other words, that we would have a uniform standard for allocating health cards and that it would be operated on a national basis.
Nothing has caused more dissatisfaction over the years than the uncertainty about the entitlement of people to health cards. Standards change from county to county and from case to case. Some people get them because strong representations are made on their behalf. We all look forward to an end to that. We all look forward to the implementation of the Minister's assurance on 30th June last, precisely three weeks ago, that we had seen the end of the uncertainty and that we would have a standard set for the whole could refer in order to know where he or she stood. No longer would people have to run with their hats in their hands to county councillors, or Deputies, to CEOs, or staff officers, or county managers, or anybody else, looking for something. I am extremely disappointed with the Minister's statement today that this will be thrown back to the chief executive officers and will be operated by them as heretofore.
I know that a statement on the health boards would be out of place except in so far as it is directly related to the statement the Minister has just made. We all know that the chief executive officers are in charge of a number of counties. We all know that in each  county the chief executive officer delegates his authority to a staff officer. Now these staff officers are overworked. Most of them are men who have given good service for many years in the health services and they are people for whom I have the height of respect. They are people who had not to shoulder the responsibilities of an accounting officer up to the present. They are men who operated under a county secretary and a county manager. They simply made recommendations. They had not to accept financial responsibility and the risk of being surcharged. They will have to do that in future. I understand that each staff officer operating under the CEO will now be an accounting officer. He is not paid the generous salary the CEO is paid and he will be careful not to make a mistake which might result in his being surcharged at the end of the year. If he has to operate under the vague system in operation at the moment he will operate carefully. He will operate in a way which will not expose him to a surcharge at the end of the year. That is something which may not have occurred to the Minister. It is something he should consider and consider carefully.
These regulations provide for the raising of the ceiling from £1,200 to £1,600 for what is known as the middle income group. This is a move in the right direction. Deputy Barry says that inflation is galloping so quickly and money is losing its value so rapidly that we, in Fine Gael, believe this is not a sufficiently high ceiling. However, it is a move in the right direction. I am disappointed that the Minister has not seen fit to increase the poor law valuation ceiling of £60 in the case of farmers. That ceiling has been set for a considerable number of years now. The farmer with a valuation of £60, or more, finds himself now in the higher income group. It is true he can still qualify as a hardshp case if he can convince the staff officer, who is liable to be surcharged for making a wrong decision, that he is a genuine hardship case. I am, I think, correct in saying that the farmer has the option of operating on a £60 valuation or proving that, although his valuation is £65, his income  is under £1,600. I think that is the position. I think the farmer can do that. I also know that under a decision from the Minister's Department not alone is the land of which the farmer is the owner and rated occupier taken into consideration but, if the farmer takes conacre, the poor law valuation of that is also rated against him in the same way as if he owned the conacre himself.
Mr. T.J. Fitzpatrick: (Cavan): Exactly. I tried to make a case about this to the Minister and his Department and to the health authority last year. Land that is being let year after year on the conacre system cannot be nearly as valuable or as productive as owner-occupied land which is nursed, looked after and cared for. The conacre land is like the horse with the hard hooves: you work it as hard as you can and you take all you can out of it and put nothing into it. It is disgraceful to have conacre reckoned as part of a farmer's poor law valuation and I take this opportunity of protesting in the strongest possible terms against this. As Deputy Tully says, it is reckoned in the hands of the owner and it is reckoned in the hands of the occupier for the purpose of depriving him of benefit under the Health Act.
Mr. T.J. Fitzpatrick: (Cavan): In the case I have in mind it did not happen because it was small enough; it was only when it was added on to the man who took it that it took him over the top. I think there is something sinister about these regulations because paragraph (b) of the Schedule, taken in conjunction with paragraph (2) (b) on page 2 will be the first introduction of many self-employed people to the inspector of taxes. That is what this is there for. Before a person will be placed in the middle  income group, if he is self-employed, he will have to submit his accounts to the inspector of taxes in order to get his income assessed and ensure that it is under £1,600. I cannot see any other explanation for the definition of income for the purposes of subsection (1) (b): income shall mean the income of the preceding year ended on 5th April and shall include all income which the person may have received in that year from all sources. I cannot see any other explanation for that definition when taken in conjunction with the Minister's own speech where he says:
It is considered more appropriate to look at visible income, such as is done for income tax purposes, in reckoning eligibility for health services. This change incidentally would facilitate the arrangements under the Health Contributions Bill for the collection of certain health contributions through the agency of the Revenue Commissioners.
Mr. T.J. Fitzpatrick: (Cavan): This is the first introduction of the small man with an income of perhaps £1,000, £1,100 or £1,200 to the inspector of taxes. This is his first introduction to an accountant. This is the first occasion on which he will have to keep a set of books, have them audited by an accountant and get a certificate from an inspector of taxes before he is in the middle income group.
This is nothing new. This has been borrowed from across the water because in my capacity as a Deputy I was asked on a couple of occasions to fill up a form for the parents of a girl who was being trained as a teacher in England, aided by one of the educational bodies there which are, I think, run by the local authorities. The parents were in receipt of a non-contributory old age pension. I wish you saw the form they received. It had to be filled in and certified by an inspector of taxes here stating that they were not liable for income tax. Really it would take an accountant, not a solicitor, to complete the form. Is that the position we are going to create here? If it is it is a move in the wrong  direction. On the 30th June I complained about the hens and chickens being counted in order to decide whether a person is eligible for a general medical card. The Minister clearly told me that practice is being continued. I had hoped he would introduce some sort of standard form, but he is not going to introduce a standard form and the hens and chickens are still to be counted. It is not going to stop at that. The weekly takings of the small shopkeeper are going to be looked into and counted as well. He has to have a stock at the beginning and at the end of the year for the inspector of taxes. If he is not paying the last penny in turnover tax he will have another section of the Revenue Commissioners down on him. This is a scandalous bit of opportunism on the part of the Minister who is obviously collaborating with the Revenue Commissioners and is introducing these unfortunate people for the first time to the inspector of taxes.
The answer to that may be that if they are liable to income tax, why do they not pay it? Many of these people may have an income of £1,000 a year, be married and have young children and they are not consequently liable for income tax at all. The vast majority of the middle income group which range from between £500 to £1,600 a year are married people with eligible children who will not be liable for income tax but yet they will have to go through torture—I do not think that is too strong a word—because they detest this. They will have to go through the inconvenience of submitting their accounts, having them audited and then going maybe 40 miles from Cavan to Dundalk to meet the inspector of taxes, satisfy him and get the forms cleared up, at a time when they are stricken with sickness. People will not bother doing that unless a wife or a child is sick or they have some reason to call on the hospitals. I do not suppose everybody will automatically get an income card as they get a lower income card at present. These people will have to go through all this inconvenience and torture at a time when they are already suffering the distress of sickness or, perhaps, a  long illness which ends with a death in the family.
I would ask the Minister to come down to earth and increase the poor law valuation in the case of a farmer to at least £70 and exclude from the farmer's rateable valuation conacre, or land taken on the 11 month system. The Minister has wobbled between the 30th June and today. It would be no harm if he were to change his mind again and have a standard form for health cards throughout the country and cut out this business of introducing the inspector of taxes into the health services.
Dr. Browne: These regulations make very depressing reading. It is possible to judge the success or failure of a community by the way it deals with its dependent groups, the people who have claims on society from time to time. Most of us in the Labour Party believe that the community should operate as a co-operative society in which direct taxation, according to a person's income, is paid into a central fund as a form of insurance contribution against some of the predictable needs of a family in society such as the education of children on the one hand and old age on the other. The other, of course, is the contribution made to the central fund belonging to this co-operative so that funds will be available for the assistance of those who need it because some of us do, some of us do not and some of us need it more frequently than others in relation to ill-health, for hospital bills, doctors' bills, chemists' bills and so on. For that reason we feel the general purpose of taxation should be to create a central fund into which money will be paid equitably and distributed equitably.
The serious limitations, referred to by all the speakers so far, of the eligible groups point, as no other factors can, to the enormity of the failure of the social and economic policies of the Fianna Fáil Government over the past 30 or 40 years. I do not think anybody is under any illusion at all but that these proposals are a perpetuation of the old poor law style medicine restricted to a minority within  the community and upgraded to meet the changing values of money due to inflation. With a couple of exceptions in relation to health, it would be fair to say that we have not even marked time with Lloyd George before the State was formed at all. The kind of proposal which the Minister has before us here is for the retention of benefit to a very limited sector of society which shows, as nothing else can, the measure of our failure as a community to order our affairs here as we had hoped that they would be ordered by a native Government. In the quality of care in our health services, care of old people, care of the unemployed, the homeless, it is these differences between ourselves and other countries, particularly in our particular situation when we are so anxious to establish the unity of our country, that give such powerful arguments to those who feel that we are not competent to run our own affairs and who always said that. This is the proof. This proof is provided by us. It is we who have established that in virtually every sector of the social life of the country—education, care of the aged, the unemployed, the homeless and the health services. They have an unanswerable case when they say: “We do not want to belong to a community which cannot care properly for these dependent sectors and you have failed to do that.” We have no answer except to produce this kind of proposal and concede our own failure.
Health has been debated here for so long and I believe it is fair to say that we are hardly even standing still at this Lloyd George era of health services. In fact, by the introduction of this contributory factor, we are imposing a further factor of taxation, a selective income tax on this minority within the society. We are no longer prepared to carry them simply from central taxation. Even the whole fiscal policy has, in itself, been redirected away from the just system that we have in mind in the labour movement to the one where the greatest burden of taxation is carried by the majority of the people in order to protect and preserve the wealth of the wealthy minority in our society through the operation of various taxes—purchase  tax, wholesale tax, indirect taxes of one kind or another. The new value added tax has the same function.
The Minister has no reason to be proud of this fact. I think he must be thoroughly ashamed of himself because he must concede this very radical change in his general attitude to the funding of health services and the approach to the groups who must benefit under our health services. I shall not repeat myself again on this matter beyond saying that the record of the Fianna Fáil Party in health for a very short period is second to none. The general principal adopted in regard to infectious diseases, fever hospitals and so on, was the free, no means test, universal application of the particular service, an excellent principle that cannot be improved on. What has happened in the 20 or 30 years since the 1947 Health Act which incorporated this principle? What is the reason? Is it a deliberate decision on the part of the Fianna Fáil Government to desert its early radicalism? Have they decided to become more and more conservative? Have they done it consciously and deliberately and, if they have done so, how can they rationalise that kind of decision? The extraordinary thing is that coming up to an election time the public are given to understand that if Fianna Fáil do not win that particular election then they will lose a wonderful health scheme. Time after time we have debated general elections on the issue of health and the general assumption and assurance that we are going to get a greatly expanded and improved health service. That has not happened.
Dr. Browne: As long as the Minister will tell the public that he does not believe that these provisions will improve the health services in any way and that he has brought these provisions into the House in spite of the fact that numerous inquiries, numerous commissions, most of the Deputies, in the House, all of the Deputies, I think, said that the health services generally badly need improvement——
Mr. Childers: We will be here all summer. I am trying to help the House by not extending the debate. We will be here all summer otherwise. These contributions are for the existing health services this year. I am being quite frank with the House.
Dr. Browne: As long as the Minister makes it quite clear that this will have no effect whatever towards improving health services, then I think we are at one because that has been the basis of the general criticism here, that this is a complete betrayal of various undertakings given by Fianna Fáil speakers from time to time on television and in general election and political literature of one kind or another. We have got the admission from him, at any rate, that this is not going to make any significant change or improve in any way our health services. What an extraordinary admission for a Minister for Health to make. He must know, as we all know, that the health services so urgently need improvement.
Mr. Childers: I have said that I am not going to discuss in this House anything to do with whether these contributions are helping to improve the health services or not. We will be here all summer if we do.
Mr. Childers: Acting Chairman, do you want the House to sit indefinitely? We discussed the improvement in the health services on the Health Estimate. This is a regulation that changes the limits for limited eligibility groups.
Acting Chairman (Mr. Tully): The  Minister will have to appreciate the fact that I have only taken the Chair but I would ask him not to interrupt the Deputy until at least I find out whether or not he is in order. Personally, I believe that the Minister's reference to the fact that he does not propose to publish regulations for medical cards does make the debate rather wider than it was. However, he can be assured that I will keep the House within the rules of order——
Dr. Browne: The position is that a proposal is brought into the House concerning the future pattern of benefit under the health services and if our function is simply to say “Good on you, Minister” and sit down, if that is what they want, then they will have to change the rules of the House because I have always understood that the purpose of the Minister's bringing in a proposal to the House is to get the benefit, if I may use that word, of the Deputies' opinions about the merits of his proposal or, alternatively, the demerits of the proposal before the House. I, like my predecessors in this debate, am afraid I can only talk about the demerits of the proposal. That is what I am trying to do and have been trying to do until the, I suspect, disorderly interruptions by the Minister because he dislikes being faced with the realities of the situation. This is on all fours with the pattern to which we were referring last night—I am not going to develop it—but it is the same sort of idea that if you do not like something you simply suppress it, it is not there, and you bring in a law to stop them talking about it, and so on.
None of us likes the proposals here.  We think they have many serious and grave defects and possibly the biggest defect is the one which the Minister very kindly informed us about in the provisions, that is, that they do not in any way improve the quality or standard of the existing services.
I found the proposals, I have to confess, very difficult, indeed, to understand, since they are so intricate, complicated and involved as well as containing a number of simple inaccuracies which I think the Minister should have corrected before he brought them to the House. I have here his own document which either he has not read or he cannot spell or does not understand the meaning of simple words. I see here “facility the arrangements”. I assume he means “facilitate”. “It will not have any sensible influence on the number of persons eligible for services.” Is that meant to be “sensible” or what word is it meant to be? Could the Minister tell us that?
Mr. Childers: It is “sensible”, yes, but I have told the Deputy now that it means it will not have any influence on the number of persons eligible for services in the middle income group which comprise about 50 per cent of the population.
Dr. Browne: Again, it is on all fours with his general statement that the health services are, at best, as they were. What an appalling admission in 1970 and we pirouetting around Europe as an equal partner with West Germany, France, Denmark, Great Britain and all these other countries, as a country with active, viable, industrial  and agricultural incomes which allow us to take them all on both in regard to agriculture and industry and in relation to our social services.
It is possible—and the Minister in reply may explain this to us—that these regulations may have some influence on the number of persons eligible for services, for reasons that I will talk about in a moment. Before that I should like to talk about the point raised by the other speakers, that is, this completely inexplicable decision by the Minister to fix income standards for full eligibility himself, that is, the category who are entitled to medical cards. Every single one of us, I am certain, in all parties has been completely exasperated, as have the general public, by the vagueness, uncertainty, complete unpredictability of decisions made by managers in regard to this question of eligibility. No one ever knew why somebody got a card and somebody else did not get a card. Nobody ever seemed to be able to explain why this happened. If one goes through the number of persons eligible, county by county, it will be seen that the percentages vary from one county to the other and, allowing for the understandable variations from one poor county to a wealthy county, and so on, in an underpopulated county with demographic differences, changes and so on, there are too many wide discrepancies in the application of the eligibility clause as things are at the present time.
There is one general principle on which the Minister might like to comment, that is, that because of this variation between, say, 26 per cent in one county and 40 per cent in another county and the variations then in six, seven, eight counties which will be part of the new regional authority, the figures are likely to be averaged out by managers over the eight counties, based on their old experience and with the new minor adaptations that the Minister refers to here. Broadly, we can assume that, just as at present there is a variation from one part of a county to another, there will be a variation from one part of a county to another, until there is a general uniformity in the averaged out figure, when the eight counties are put together  and the managers and chief executive officers get together and we will have, I think inevitably—the Minister may like to contradict this —the position in which the 40 per cent county and the 26 per cent county have to be averaged out and we will get to a stage where we will see a 35 per cent average over the eight which will bring down the 40 per cent county and for that area you will have a reduction in the number of eligible persons in a county which up to now would have had all the people eligible. All this simply points to the complete absurdity of attempting to introduce an equitable means test system into our health services. I said this before in discussing this matter with the British Labour Party representatives in 1948 or 1949. We were opposed to a means test on ideological grounds but were nearly more opposed to it on administrative grounds because of the near impossibility of ensuring there would not be people with grievances because somebody had got something who had more than somebody else or that somebody was denied what another person got in similar circumstances or because of the various attempts they made to decide why they did not get a medical card.
In addition, there is the necessity to establish this inquiry system to which most Deputies have referred occasionally. There is the extreme complexity of trying to establish an investigation system in relation to a farm, especially a small mixed farm in our type of rural economy. If one gives any serious thought to it one gets to a picture of such absurdity that one can only see the completely ridiculous side of it, the laughable side of it, the haycocks and productivity, the hens, eggs and milk and all the other factors on the farming side.
There is also the self employed person's income and the fact, mentioned by other speakers, of the penalties implicit for the individual who works particularly hard, does overtime or gets a bonus or works at week-ends. The Minister seems to be between two minds about this because I understand that recently in the  Seanad he said overtime would not be taken into consideration in assessing eligibility. Is this so? In the years I have been listening to the Minister nobody has recorded more frequently and with greater pomposity the general capitalist doctrine of the need for tax remission incentives, freedom to make as much profit as is humanly possible, the necessity to increase dividends and shareholdings of every kind in the capital owning class. In his opinion, apparently, there has always been this right on the part of the minority to make the maximum amount of money. This is the carrot that will drive them forward to expand their business or industry and as a sort of by-product the community will get some money in some way that has never been clearly explained to me. Where taxes are reduced for these people, where we introduce purchase taxes, wholesale taxes, rates and indirect taxes we are easing the burden on these people. Where do we get the benefit when they make more money when they are allowed to take that money and, if they are foreigners, export it?
Dr. Browne: Sorry. The relevance of this is that the general principle of the disincentives that we see is contained in the fact that, because there is a limit of £1,600, the man who works overtime or week-ends or gets a bonus, if he goes to the £1,601 class, renders himself ineligible. Does the Minister not see the significance of that in relation to the employed man at this income level? We do not believe that the number covered by the £1,600 limit is adequate. It is much too small a group. The income limit should be raised considerably to at least £2,000 or £2,500 so that a larger percentage of white-collar workers will be saved the great fear and anxiety inevitably associated with ill health in a society such as ours.
I know a lady with a small shop in a local town whose husband is dying from a stroke and, not only is she  losing the breadwinner with all the terrible agony and distress that entails, but recently she got a bill for £500 from a hospital for the care of this man. In addition to the distress and sorrow of his illness, she is now wondering how she can pay this bill. That instance can be repeated many times over in the case of white collar workers. We have frequently made the case that voluntary health insurance is not the answer. If it were, the application of a similar type of scheme with its limitations to the lower income group would be just as useful. The Minister knows that if the limitations of the voluntary health insurance scheme were applied to the Department's scheme it would be even more unsatisfactory than it is at present.
Why cannot the Minister include a greater number, a greater sector than the limited one he is now including? In relation to the £60 valuation which was established long ago in an earlier Health Act, there is no proposal to include a greater number of farmers than there are at present. A farmer, while the limit stays at £60 valuation may have his buildings valued at £20 of that £60. Similarly, in relation to those in the £1,600 and over group—they still live in fear of the consequences of ill-health. How can the Minister justify his failure? Deputy Fitzpatrick rightly pointed out that on a number of occasions the Minister has given us to understand that he could fix a definite upper limit for eligibility in each area rather than leave it to the CEO of the health board.
The Minister has said he is arranging for his Department to bring these people together and that they will have available to them the considerable volume of statistical material assembled in connection with the Departmental examination of this subject. I am sure there is an enormous volume of statistical material available. For many months I sat through the extraordinary and completely farcical inquiry carried out by the then Minister for Health, Deputy MacEntee, into the health services. There was an enormous amount of material—evidence of one kind or another by the trade unions, by the  local health authorities and by various bodies, private and voluntary. I doubt if any subject has been more inquired into, more debated on, more considered, more researched into, more analysed and assessed than this question of our health needs.
When the former Deputy MacEntee brought in the 1947 Health Act there was no means test; it was free for everybody. The Deputy introduced the scheme because he knew it was the correct one to fulfil the needs of the whole population. As that was true then it is as true today and we are all aware of this fact.
What has happened to the Fianna Fáil social policy since that time? How is it that the State then could provide a service of that kind—not only the infectious diseases services—as part of the 1947 Act? The universal application of the health services involved considerable expenditure particularly in regard to the services to be provided for young people up to 16 years and for mothers. What has happened to the financial position of the State since that time? I recall Deputy MacEntee quite correctly saying that we put the health of our children above everything else. He said the money was there and all we had to do was to spend it. That was a fair comment.
I am not going back into the history of that episode but it is significant that it was the then Government's belief that the community could carry that kind of the universal application of a free, no means test service, with no direct contributions of any kind. What has come over the Fianna Fáil Party since that time when the present Minister for Health is so unsure of himself, is so timorous and incapable of using what he calls “a considerable volume of statistical information”? The Minister has that information, his executive officers have their information. In heaven's name, what has stopped the Minister during the two years since the Government have been in office—not to mention the fact that Fianna Fáil have been in power since 1957? What has prevented the Department of Health from reaching a decision arising out of an assessment  of the material? The Minister tells us that all that will happen is that eight men will gather round a table and because of their examination of the material from the Department of Health and the Department of Local Government they will come up with a magic formula which we must accept. It is an astonishing situation. We believe there should not be any means test. If a general insurance contribution in the transition stage is needed, we would accept that but it should have universal application.
Each of us has some idea except the Minister for Health and he is delegating this function, as Deputy Coughlan has pointed out, to non-elected representatives. As I pointed out, it is nearly inevitable that they will take the existing figures, average them out and that will be the figure. The Minister should have taken his courage in his hands. He has that responsibility and that is why he is Minister for Health. He should use that privilege to say: “This is the type of person I think should have a health service”.
In a society such as ours another factor should be taken into consideration in the assessment of eligibility, namely, there should be some way of relating eligibility to the size of family. I do not believe there should be any means test, but if a means test is introduced it is particularly important to remember that in a society which continues to advocate that people shall have large families and that there shall be no question of family limitation, in relation to ill-health each child is an additional source of anxiety and is an additional responsibility to the average family. It is the least we owe to parents who have large families. Therefore, in relation to health care the income level is not the important point—it is the number of persons for whom the parents are responsible. In some way we should try to bring this into our assessment of means.
I confess to being confused about the implications of these proposals. Perhaps, the Minister could clarify one point in relation to a suggestion I recall in a vague way of a complicated kind of means test, namely, that at a certain stage the contributions will be varied  with the income of the individual by the introduction of a rather more complicated means test. Will this be included under this scheme and is provision made for it, or to be made under the regulations we are dealing with here?
Mr. Childers: These regulations deal only with the limits. The graduated contributions are in the Health Contributions Bill which has been passed by the Dáil and the Seanad and they do not arise in connection with these regulations.
Dr. Browne: I should like to ask the Minister at what stage does he propose to introduce that element into the existing health services. Having examined the provisions before us, and faced with the Minister's admission that, in spite of the fact that he has all the information that he must have at his disposal, and which he confesses he has, and faced with the further fact that the Minister has told us on a number of occasions that he would do what he could to try to establish some fixed standards for eligibility, we find he has been unable to do so. If he cannot provide us with a clearcut figure in relation to this relatively simple proposal—and  I use the word “relatively” advisedly—it would be interesting to know whether he is inclined to have second thoughts about the other provisions he referred to in the recent Health Act.
This is a completely pitiful, grossly inadequate, mean and petty health scheme. It is completely unworthy of a society which has spent the past 50 years in control of its own affairs. It is particularly inadequate, in my view, because of its failure to provide services for the white collar worker who has exactly the same sense of fear of sickness or illness and whose family suffers the same dreadful results of the loss of the breadwinner either through a short illness, a prolonged illness or death as any of the other two groups: the group covered here on the one hand—and I am glad they are covered; I welcome the fact that this group are covered—and on the other hand the group who are so wealthy that they do not have to look to the Government for a scheme at all.
There is an enormous group in between those two levels still left uncared for. There is no good in the Minister telling me that they are cared for in the Voluntary Health Insurance Scheme. They are not cared for as adequately as they should be. If the community had so ordered its affairs over the period of half a century, the Minister should now be coming in here and telling us that he was bringing in a health scheme like the one which was introduced as far back as 1947 in Great Britain and Northern Ireland. I hope he does not come back at me with the suggestion that we cannot afford that kind of scheme. If we cannot afford it, it is because of the failure of the economic policies of the Government and, for that reason, they should be prepared to change them. We now know that, in fact, this is not a poor country and that it has enormous wealth. It is because of the misuse of that wealth, or the failure to use it equitably, that the Minister is faced with the humilating job of carrying on the work of Lloyd George, 40 or 50 years later. He should be ashamed of himself.
Mr. P.J. Burke: We have come a  long way with our social legislation, and this is another step forward. We heard a number of statements from the other side of the House that we were not going far enough. Of course, we are not going far enough. Everyone on this side of the House would like to see everything possible done for our people. We do not want to deprive any of our people of any treatment. We should like to see them living in a Utopia, if that were possible. We are also very practical people and we know that you cannot take the trousers off a Highlander. We have to work within the resources of this country. There is no use in going back 50 years. We have come quite a long way and our social legislation is very good by our standards.
When the Health Act was first introduced and when we started to look after the people with TB, there was a special allowance for the breadwinner. This was an advance in those days and we have made great advances since. At that time I was very pleased with the discretionary clause in the Act. I knew the case of a traveller on commission who was drawing £3,000 a year. He had a family. He became very ill and he had no income. If regulations are too strict there will be some people who cannot get any help from any authority or from the Minister. I always remember that case. He was in receipt of about £3,000 a year. He then had to spend six months in a hospital and he had no money coming in. We had to look after his wife and family in the welfare department of the health authority.
No human could possibly please everybody. It must be remembered, too, that any time we try to give more to the poorer sections of our people we are faced with opposition. Whatever we propose is voted against. That may appear to the Opposition side of the House to be political wisdom and the proper political way of life, but money cannot be found except through the medium of increased taxation. I welcome all social advances and I hope that the resources of our country in the years ahead will enable the Minister to go on improving our health services.
I am glad the discretionary clause  is being kept. I believe independent examination is the only method on which to base a proper decision. In time, I hope we will be able to give free health services to the millionaires among us as well as to the poorer sections of our community.
The Minister has a most onerous job. Practically every section of the community is his responsibility in one way or another. Costs are going up all the time. Then the ratepayers complain because the cost of the health services increases. We have to accept that and, as public representatives, we have to answer to the people. It is for the people then to pass judgment when we go to election. But we have to be reasonable in this and we have to do what we can within our resources.
Dr. Byrne: One of the first discrepancies here is the fact that there is no provision for raising the eligibility limit in regard to hospital in-patient and out-patient, maternity and child care services. The ceiling is being raised from £1,200 to £1,600 to keep in step with the Department of Social Welfare. This is a kind of forced improvement necessitated by the diminishing purchasing power of the £. There are two things wrong with this ceiling. First, it is too low. Secondly, 90 per cent of the population will be covered; that is, the 30 per cent who have medical cards and the 60 per cent whose incomes will be under £1,600 but, next year, there will be less than 90 per cent covered and the year after less again. It will be a progressive decline until such time as new regulations are brought in to raise the ceiling above £1,600. This is one of the biggest defects I see in this. It is a “Stop-Go” kind of measure and it is not satisfactory. There should be some built-in mechanism whereby the income limit would keep pace automatically with the increase in the cost of living.
There is no provision for added allowances in the case of dependants. A man with two or three children with a salary above the £1,600 limit should get an allowance for each dependant and that should bring him within the scope of the health services. A married man with £1,601 will have to make  application to the CEO before he will be considered. At the moment local authority allowances are given for dependants. If this practice were continued costs of administration could be kept down. If a married man with dependants, with a salary above the £1,600 ceiling, wants to avail of the health services for himself and his family he will have to go through a type of means test. He may be a bank clerk or a lorry driver, earning a relatively good wage or salary, but, because he is above the ceiling, he will cease to be eligible and he will have to make special application. If we retained the allowances system that would solve this problem. Some speakers have advocated raising the ceiling to £2,000. With allowances, a man with a wife and three children, would easily reach that figure. The scheme would be simple to administer. The Minister's argument is that this method brings the scheme into line with the income tax code. So would the granting of allowances bring the scheme into line with the local authority system of assessing a person's eligibility for a local authority grant and, if you can take an example from one Department, the Department of Finance, you can also take an example from the Department of Local Government in the other case.
For too long people have been deprived of anything near the kind of services they should be getting in this day and age. I think it was Deputy Dr. Browne who pointed out that we have proved now that over the years we have not been giving the people the kind of health services they should have been getting. The services which these people may avail of are maternity and child care services and in-patient and out-patient services.
Dr. Byrne: As a person's income increases so his expenses also increase. He pays more tax and he moves outside the limit of eligibility for grants for health service assistance and such like. This Bill should contain an allowance per dependant and some form of provision whereby the £1,600 would increase every year. The Minister will probably say that 90 per cent of the people will be covered by some form of free hospitalisation under this regulation but there will be less and less as each year goes by.
Although people earning under £1,600 a year have to pay a certain amount towards their maintenance in hospital, when they are at home they have to pay very expensive medical bills. Successive Fianna Fáil Budgets have increased turnover and wholesale tax and thereby put up the cost of medicines. The Government have made no effort whatsoever to improve the service and help these people. Because of the high cost of domiciliary treatment people go to the casualty departments in hospitals and consequently are admitted to the hospital at a cost of £16 a day to the State, whereas they could be treated much more cheaply at home if some form of provision or allowance was made for them to stay at home.
The only concession to be made was made three years ago by the then Minister for Finance who brought in a provision in the Budget that if one member of the family had medicines prescribed for him which were over the value of £50 in one year that sum would be allowable against income tax. That is the only concession made to non-medical card holders. More and more people are going to opt for routine type treatment in hospital and the £76 million which the health service costs each year will snowball out of all proportions as it did in Great Britain, where they had reckoned that after ten years they would be able to close down some of their hospital beds but instead they found they needed twice as many. If the Minister were to introduce 20 essential type medicines  to a list and make these available either free of charge or at a minor prescription charge to those earning under £1,600 a year he would cut his hospital bills which as he knows are increasing.
I am disappointed the Minister has not been able to arrive at a figure on an income level at which an applicant for a medical card could be adjudged to be automatically eligible for a medical card. The Minister should at least have brought in a minimum figure which would have dispensed with the means test and covered a great many people including the unemployed, the unemployable, widows and such like. He should have brought in a minimum basic figure so that anyone under it would be automatically eligible for a medical card and anyone over it would have to undergo the present humiliating test until such time as the Minister had a chance to discuss the situation with his seven chief executive officers on the health board.
I do not think the income of the spouse or the income of others in the family should have anything to do with a person's eligibility for hospitalisation free of charge. Very often a man with six or seven children, two of whom are working and living at home, may be adjudged as not being entitled to a medical card. If at any stage expensive medicines are prescribed for him he can reapply for assistance towards them. A widow with 15 children, two of whom were working, and one of whom was handicapped, who worked herself was adjudged as not being eligible for a medical card although if expensive medicines were prescribed she could then make reapplication forwarding on the prescription. The woman was driven to writing to the Irish Press to “Ask the Experts” for advice.
The Minister has said that this does not represent an improvement in the health service but at the same time we are embarrassed into increasing the rate from £1,200 to £1,600 because the Department of Social Welfare have done it. There would be a big improvement if the Department of Social Welfare were to increase their rate of allowance to widows in the same way as the  Department of Justice adjudge that a deserted wife should get——
Dr. Byrne: But the Minister is following his example and it is a good thing he is because otherwise we would still be at the figure of £1,200. The Minister for Social Welfare brought in the figure of £1,600 in the first place. All I am saying is that if the Minister watched the Minister for Justice he might get somewhere in the very near future.
In the last paragraph of his speech the Minister said “without substantially altering the total number covered”. He is referring there to medical card holders. Everybody knows that less than 30 per cent of the population are covered by medical cards and that the health boards, the successors to the health authorities, are cutting down substantially the total number covered by medical cards. If they were to increase the number of medical cards issued, and possibly decrease some of the compounds that are made available to the dispensaries, they would do a lot better with the money at their disposal. The fact that the Minister has not brought in a flat figure for eligibility for medical cards is a type of planned delay. If you set up a subcommittee of seven chief executive officers and they have to meet and report back to their health boards there will be a delay of at least a year. It is unfortunate that there is no allowance made for a flat rate. We see a lot of this in Ballymun. The harder people work the more income tax they must pay, the more differential rent they must pay; they lose their medical cards, they lose their opportunity of getting a local authority grant to get a purchase house in Donaghmede. I have seen the will to improve, the will to work being sapped out of these people. This is another thing. They will go over the £1,600. You do not have to be that bright nowadays to earn £30 a week. You could do it selling ice cream. Health is wealth and it is unfortunate that people whose livelihood depends on their health are being limited to this £1,600. The  £1,600 should be basic and you could then increase the percentage of the population from 90 per cent to a little more and build in a safety measure which would increase it per year—say, the cost of living or the consumer price index. You would not then have a decreasing section of the population. It would be a terrible thing to find next year that the percentage of people eligible has decreased. I should like the Minister to consider those points.
Dr. O'Connell: As a Deputy I am entitled to stand up and speak and the Minister will not dictate to me on this matter. I will tell him that from the beginning. That is how we start. It is disgraceful of the Minister to try to object to our speaking on this. What does he want? Does he want us all to go home and let him do what he likes? It is a terrible state of affairs that a Minister is becoming very annoyed because we are making contributions to this. We have reason to criticise this because there is in the Health Act, 1970 section 45 which says:
(2) In deciding whether or not a person comes within the category mentioned in subsection (1) (a), regard shall be had to the means of the spouse (if any) of that person in addition to the person's own means.
It is spelled out in the Health Act,  1970 that where application was made for a medical card consideration would only be given to the income of the person and the person's spouse. Here we have back tracking by this Government as they have back tracked on so many things. They are determined to push the Forcible Entry Bill through but they would not give time to proper consideration of this.
I know, as a public representative, that people come to find out if you will get them the medical card. There is no question of entitlement. What is being asked is whether the TD will get them the medical card. It is interesting to see who gets the medical cards. I received a reply to a question two weeks ago and it is interesting to see the variations through the country. We see that in the Eastern Health Board area 14.7 per cent of the population are in receipt of medical cards. This represents in Wicklow 34.2 per cent, Dublin 12.3 per cent, Kildare 26.2 per cent. Laois is 34 per cent, Longford 35 per cent, Offaly 40 per cent and Westmeath 29.9 per cent. Clare is 31.8 per cent, Limerick 25.9 per cent, Tipperary north 22.9 per cent. Cavan is 29.6 per cent. The Minister's county, Monaghan, is 41.9 per cent. I wonder where he gets the medical cards from for all these people. Louth is 28.4 per cent and Meath is 35.3 per cent. Meath is 35.3 and Dublin is 12.3 per cent. That seems to be a tremendous disparity between these two. Donegal is 41.2 per cent, Leitrim 40.5, Sligo 39.6, Carlow 44.7, Kilkenny 43.7, Tipperary south 35.7, Waterford 32.1 and Wexford is 48.2 per cent. Cork is 26.5, Kerry 44.1, Galway 50.7, Mayo 47.1 and Roscommon is 51 per cent.
It should be obvious to the Minister that there is a tremendous disparity throughout the country in the number of people and the type of people who are eligible for medical cards. It depends on the TD. What is better than representation is better representation. It is how good a case a TD can make for a person which decides whether a person will receive a medical card or not. Entitlement is not a factor. I always feel ashamed when people say: “You got me the medical card”. I think it is a terrible thing that people  have to come grovelling to TDs to get them a medical card. I am finding more and more people who have not realised that they are entitled to medical cards and have been crippled with medical expenses and it is only when representations have been made that it has been conceded that they were entitled to medical cards. I expected the Minister to come up with a formula for deciding who is entitled to medical cards. Instead he comes along and says:
I had hoped also to include in these regulations a provision fixing income standards for full eligibility, that is for that category who are entitled to medical cards. After very detailed and careful studies of the matter, I have come to the conclusion that, as circumstances other than the purely financial vary so much as between country and town and between one family and another, I should not at this stage make regulations on such standards but rather leave it to the chief executive officer of the eight health boards to try to achieve the greatest practicable uniformity in their decisions on eligibility.
I am wondering who in a health board office decides who will get the medical card, I remember writing over and over again for a patient of mine who was a severe asthmatic and crippled with the financial burden of the cost of drugs and other treatment. I tried in vain as a doctor to get her a medical card. On the day that I was elected to this House I could make representations on her behalf and she had the card that afternoon. That is a terrible indictment on us as public representatives. A doctor would be more aware of the problems, much more concerned and more able to put forward her case than a TD or other public representative. Because of this I am very concerned and annoyed that the Minister has decided on the status quo and is not making any proper regulations to determine who are entitled to the medical card.
It is humiliating to have to disclose all one's means and all the treatment one is undergoing, the exact nature of one's medical condition and to have  to send in the prescriptions. It takes months. A certificate of income must be obtained from the employer. The person humilitates himself in saying to the employer: “I am destitute. I need a certificate of income because I am applying for a medical card as I cannot afford a doctor and to pay for drugs.” That is exactly what is implied in a certificate of income. When the certificate is presented to the employer for completion it is obvious to him that the person is not able to cope with medical and other expenses. It poses the problem as to whether the employee should be retained because where medical expenses occur so often the employer may be inclined to the view that the person is not a good employee or that he may have trouble with him later. This is a very serious matter. It should not have been decided to leave things as they were, especially after the promises made by the Minister.
It is shameful to take into account the income of a son or daughter in a household. The son may already be paying income tax and contributing to other things. He may be planning to get married. He may be paying his mother merely enough for his keep. Many a father or mother has been faced with the problem of literally asking the children to leave the house because of the fact that as long as they remained in the house the father or mother could not get a medical card. I have been told this by many parents. I have told them that their sons or daughters were depriving them of the medical card and were of no advantage to them in the household and, perhaps, the only way to get the card was to ask them to leave. This is a serious state of affairs and not something to be fobbed off by the Minister with a statement to the effect that there will be consultations and some form of uniformity throughout the country in the number of persons receiving the medical card. That does not alter the present humiliating situation where people have to disclose intimate details of their personal life and their medical history. How often have medical reports to be sent in with  full details of prescriptions? This is a very small country. It can be known exactly what is happening in a household through details being submitted to health authorities. I have often received letters saying that a person is not eligible, with the addition: “If they need assistance towards the cost of drugs ...” Does the Minister know exactly what is implied in that? Take Dublin, with which I am very familiar —I do not have the situation existing in the Minister's county where 41.9 per cent of the people have medical cards. If you walked around that county I do not think you would see anyone without one. In my constituency, and in Dublin generally, for this assistance towards the cost of drugs, a person must travel to the headquarters of the Eastern Health Board and must pay in a sum each week, usually 10s to £1. Then he has to come back again with the receipt and present it at the local dispensary to receive the drugs. I have seen cases where drugs have been supplied, the basic cost of which to the Eastern Health Board has been £1 and the persons were charged £1 by the Eastern Health Board. To me that does not represent assistance towards the cost of drugs because the Eastern Health Board and other health boards all receive drugs at 50 per cent of the retail price. There is subterfuge. The retail cost of the drugs may be £2 and the medical card holders will pay £1, whereas the cost to the board is only £1. It is a disgraceful situation that people should be put to such inconvenience and trouble in having to travel so far to get the receipt and bring it to the dispensary. This is supposed to be done to relieve hardship cases. I say it is a pathetic effort and one that must be condemned.
With 12 per cent of the population of Dublin receiving the medical card, there is something radically wrong. I am not content to listen to the Minister saying he is doing the best he can and will ensure uniformity. I say we have to change the whole system. In the first place we have to decide on a figure of income of the husband and wife to be taken into account, a figure of £20 or £22 a week,  then we should have flexibility where there is prolonged therapy or chronic illness. You must decide on a basic figure so that people will know exactly where they stand.
In one case a person who was in receipt of a medical card in one county moved to Dublin, where she was informed that she was not eligible for the medical card. This seems wrong. If there is a switch around of population, things will become chaotic, with people not knowing when they are entitled and to what they are entitled.
Where the parent in a household is in need of treatment, the income of the children should not be taken into consideration. There is no law in this land that can compel a son or daughter to pay a certain amount to the household. Therefore, the income of the son or daughter should not be taken into account. It is ludicrous to take it into account and it is terribly unfair in the context of improving the health services. This rule should be discarded. The incomes of sons and daughters should be ignored.
I do not think we can accept this as being a proper way of determining who are and who are not entitled to medical cards. At present the advice of a medical officer is not taken into consideration. The medical officer will know the nature of the illness, the treatment required. It is left in the hands of officials, who have no knowledge of medicine, to decide under the jurisdiction of the chief executive officer. This is very wrong. At least there should be some appeal to a medical officer or someone in charge in a health board. If we are not going to specify the income limit for medical card holders, we must be more specific than to leave things as they are. We are leaving it open to political influence, to representation by a Deputy. This should stop and the sooner the better. We should not depend for our seats on the number of medical cards we get for people. This is the situation prevailing at the moment; the more medical cards you get, the more votes. This is very wrong. We shall not improve Parliament by this arrangement. This system should be abolished, and the sooner it is the sooner the image of Parliament and of public representatives will  be enhanced in the eyes of the public. I object very much to this system and shall continue to do so. People should get cards on their entitlement and not on efforts or representations of public representatives. I have seen cases where my intervention on behalf of applicants was successful when it was rejected for others or rejected where it was successful in the case of representations by other Deputies. This is very wrong. I want to know what the Minister will do about it. Is he going to leave things as they are?
I am very suspicious about this. Reading between the lines, I can see that an effort will be made to reduce the number of people becoming eligible for medical cards. The Minister has realised that his deal with the doctors will cost a good deal of money. It should be possible to determine the number of people with £22 a week and from that decide the number who would qualify for medical cards. It should not be beyond the ability of the Department to work out these figures. If this were done, the Minister would find, perhaps, that more than 30 per cent of the population would become eligible for medical cards. This is why it is not being done. Instead, an attempt will be made to reduce the number becoming eligible. More and more applications for medical cards are being rejected. I think there has been a directive from the Department to the health boards to reduce the numbers eligible for medical cards. This is happening at a time of rising prices, increased costs of medicines and drugs. Reducing the number eligible for medical cards is the only way that the Minister would be able to arrange things. Because of the deal he has made with the doctors he is saying: “We can only afford to pay for it by reducing the number entitled to medical cards.” I have no doubt this is what he has in mind. I think it is wrong and that the system is wrong.
By discussing it with the CEOs of the health borads I do not think he will arrive at a uniform system of applying standards of eligibility. This should have been decided on income with certain factors also to be taken into account. This could have been easily  done. Unless the Minister decides to ignore cases of families with sons and daughters in the household I think he will cause a great deal of trouble because more and more people realise the costs are so great that they will have to ask their families to leave. The Minister must do something about this. This matter is creating great concern. It is causing discord in households when it is realised that a father who is a chronic asthmatic or bronchitic cannot have treatment because his son or daughter is contributing fairly to his or her maintenance.
Dr. O'Connell: I have told many people who are not eligible that the Minister would very shortly be bringing in section 45 under which the income of the spouses only is taken into account and I should feel a fraud and a liar having said that if I found the status quo would continue to operate.
Mr. Childers: The incomes of members of a family who are earning will naturally be taken into account so far as their medical cards are concerned but their incomes will not be grossed with that of the husband and wife in order to decide whether the husband and wife will have medical cards.
Mr. Childers: There is no change at the moment but when the CEOs begin to examine the medical card limits in order to get a consistent pattern throughout the country they will be told that, among other things, they must have regard to that change in  accordance with the section of the Health Act the Deputy has quoted.
Dr. O'Connell: I should like to bring another point to the Minister's notice. We find every day people who in an effort to pay different debts work overtime and they are asked to produce a certificate of income for the six months in which they have worked overtime. Because of the overtime they are disqualified despite the fact that from then on their income is basic and they may be doing no overtime. Is there any means whereby this certificate of income could be eliminated because many people, husbands, sons and daughters are refusing to ask employers for certificates of income? It is humiliating to acknowledge they are unable to pay their medical expenses. Time and again we find applications cannot be considered because applicants have not submitted certificates of income. Is it not possible to accept wage slips, or something like that, which will not divulge to their employers that employees are seeking health cards? Health and ability to pay are personal matters. To declare yourself a pauper, as you do by producing a certificate and asking an employer to fill it in, is very humiliating and this should be avoided or made less humiliating so that people can produce the necessary proof without disclosing such personal facts to employers. Wage slips are provided by every employer nowadays. Would they not serve the purpose?
I think also that deciding the question on the previous six months or the previous year is very unfair because in the following six months people are deprived of the medical card even though they are eligible on their basic weekly wage. This is another grievance and another problem that we should make every effort to solve. There is a further problem as a result of asking people to submit prescriptions. People must retain a prescription or else go to a doctor and pay £1 to get it but they find they must submit it to the health board and they do not get it back for a couple of months. They must then return to the doctor for a prescription at £1 a time.
 I know of cases where they have had to submit the actual prescriptions. We should be able to solve these problems and not make it more humiliating, more expensive and more inconvenient for the people. With regard to those people who seek assistance towards the cost of drugs, I should like the Minister to bear in mind what I have said about the inconvenience and expense caused to people. In many cases it is not worth their while seeking this assistance when account is taken of the expense of travelling to the headquarters of the health board. I should appreciate it if the Minister would look into this matter and see how the problem could be solved.
Mr. O.J. Flanagan: The Minister should not be too hasty in endeavouring to conclude a discussion on the regulations now before the House. There have been views expressed by Deputies regarding what I would term the “medical card racket”. All Members of this House know that the greatest political gimmick is the medical card. We have had a discusion on this matter because a number of Deputies realise it is too important to become a political racket.
A medical card is a licence for free medical care. At the moment we are dealing with regulations for the granting of a licence to have free medical services provided for the ordinary man, his wife and children. I would ask the Minister if there could be anything more important to the citizen than the provision of free medical, hospitalisation and other services to which he is automatically entitled as the holder of a medical card.
No one knows better than Fianna Fáil Deputies that a most effective trump-card at election times is the medical card. They whisper at the doors that unless Fianna Fáil are returned to office the medical card will be taken from the person; if he is not in possession of a card he is told that if Fianna Fáil are elected he will be granted a card. The medical card issue has been responsible for getting hundreds of votes for Fianna Fáil, particularly in the rural areas, because Fianna Fáil candidates have made  promises and given pledges that they can grant this licence.
I condemn this practice utterly. I consider the Minister for Health has a grave responsibility in this regard. I must express my keen disappointment regarding these regulations. Perhaps I have misinterpreted the Minister. Perhaps I am not as clear in the intellect as I was 25 years ago and that the longer I am in this House the duller I am becoming. I understood from the Minister that he was going to introduce provisions fixing the income standards for full entitlement to a medical card. When I heard this from the Minister I believed this was going to take place. At meetings of the health board of which I am a member, at political meetings and in conversations with numerous constituents I told them there would be universal standards whereby a person would know exactly whether he was entitled to a medical card.
For any person in the lower income group who may be on the borderline and who considers he is entitled to a medical card—although an official of the local authority may consider he is not so entitled—it must be a great source of worry and can contribute to a breakdown of the health of that person when he knows he cannot avail of the medical services.
The medical card is a valuable licence, particularly as doctors' fees for consultations have increased considerably. The father of every family knows that it may be necessary to call a doctor twice a week or several times a month. The visits cost two or three pounds and for any person who has been deemed ineligible for a medical card because of family income, if he has to obtain the services of a doctor he can reckon on at least three pounds per week in payment of fees and in the cost of prescriptions.
Everyone knows that with the high cost of drugs and medicines any medicine a doctor may order will cost at least £1 or £1.50. That may have to be repeated in a month or, in the case of a person with three or four children, it may have to be repeated frequently and there is nothing that will put people out of house and home quicker than  visiting doctors and paying chemists' bills.
The Minister said he had hoped to include in these regulations a provision fixing income standards for full eligibility. Can he tell the House why he has not laid down some regulations which would at least be a guide to the health boards in relation to the granting of medical cards? Reference has been made to the power of chief executive officers of health boards. It is too soon for us to condemn these health boards, or to pass judgement on them. I can speak for no one but myself in this regard. I know the chief executive officers. They have a very high standard of integrity. They realise that their first duty is to the poor, the under-privileged, the needy, the sick and the hospitalised. One of their duties in the administration of the health services is the granting of medical cards. They are men of a very humane calibre. They will consider cases of hardship and they will go as far as possible to meet the wishes of members of a health board and the wishes of any citizen who feels he is being unfairly treated.
I agree with Deputy O'Connell that there is nothing more degrading or despicable than that a poor person should have to seek the aid and assistance of a TD to obtain a health card. This power should not be vested as it is vested at the moment. Recently a strong recommendation was made that a medical card should be granted to an individual. A reply was received that the person was not eligible. Within the same week another TD was tried, representations were made, and the medical card was granted. This puts Deputies in a most embarrassing position. The circumstances had not changed. This meant that it was the political flavouring of the Deputy which was responsible for the granting of the medical card.
When the health boards were set up on 1st April last, we all thought that when the Minister would be presenting regulations to the House there would be a departure from that kind of carryon, but it seems we are not going to have a departure from it. There will be  practically no change whatever. The chief executive officers will have the same right, the same power, and the same authority as the county manager. They will be advised by the same people. They will be using the same organisation as the old health authorities. Each applicant for a medical card will have his means and his circumstances investigated by the local home assistance officer. Is it not time to get away from that? Would it not be more in keeping that social workers should visit the homes and speak to the families? This would be less embarrassing than to have the home assistance officer arriving at the house to make a full investigation into the family means and circumstances. On the report of the home assistance officer a decision is taken. If the medical card were to be granted on his report that would be all right but, in addition, a certificate from the employer must be submitted.
I have known many cases in which the employer refused to certify. He had his own good reasons for that. Either he was underpaying his worker or he did not want to disclose to the local authority what he was paying because he had not made satisfactory returns for income tax purposes. He did not want to become involved with the income tax authorities on information he gave to the local authority and so he refused to certify wages to the local authority for medical card purposes. I have known cases where employers failed to respond to a request from the local authority and the medical card was not granted to the applicant. They wrote to the applicant and said: “Until such time as your employer certifies, your application cannot be proceeded with.”
Mr. O.J. Flanagan: I have had dozens of similar cases. That is quite wrong, but what can one do about it? A Deputy is helpless in a case of that type He cannot make an employer certify what he is paying to a man if he does not want to.
Mr. O.J. Flanagan: Is it really fair  to ask him to do it for this purpose? I have long experience as a member of a local authority, far longer experience than I have as a Member of this House. Looking around me I see that I am the longest serving Member here, with the exception of the Minister, at this moment. There is no problem in relation to medical cards that I have not dealt with, many times, may I say, with success and often, to my disappointment, unsuccessfully. There are some people who buy a cheap old motor car to get to work. In the advertisements in the provincial papers motor cars are for sale for £50, £60 or £70.
Mr. O.J. Flanagan: As I speak I have a case in mind. The health authority officials told me that the reason the medical card was taken from a man with a delicate wife and a large family was that he had a motor car and that if he could tax a motor car he should be able to pay a doctor, buy tablets and pay for prescriptions. If that man had not got that car he could not have gone to work so conveniently. We have now reached the stage at which a motor car is no longer a luxury. It is a necessity even in the most remote parts of the country.
Mr. O.J. Flanagan: Of course. We have now a practice whereby the medical card section of the health boards in consultation with the motor taxation office make out a list of people, which is supplied by the home assistance officer, showing that they have either motor bicycles or motor cars and, because they have the “luxury” of a £30 car or a secondhand motor bicycle to bring them to work, their medical cards are taken away. The argument is that, since they are able to pay for the petrol, they should be able to pay for the doctor. This is causing severe hardship to people. I believe it is utterly wrong. In the case to which I referred the medical card was taken from the father and he was told that, since he  could pay for the petrol, he could equally pay for the doctor. He must now pay £2 per visit to a doctor. He must pay for prescriptions. Despite the fact that he has had two increases in pay he is now much worse off financially.
Mr. O.J. Flanagan: I have a fatal capacity for not making myself clear. I should have said, for the information of the Parliamentary Secretary and the Minister, that the services of the doctor were required for the family. None of the family is earning.
Mr. O.J. Flanagan: Despite the fact that he has had two increases in pay he is now poorer than ever because he must pay the doctor £2 per visit and pay for all prescriptions. His family are by no means robust and he always had a medical card until he purchased the £30 motor car. The Minister has raised the ceiling from £1,200 to £1,600 in the case of self-employed persons other than farmers. That is a step in the right direction, but it is a poor step, having regard to the value of money today in comparison with what it was when the £1,200 ceiling was fixed. That £ is useless today.
Mr. O.J. Flanagan: Since conversion to decimal currency the £ has practically vanished. The Minister should have taken into consideration the fall in the purchasing value of the £ and raised the ceiling to £1,800 at least. We did not expect the Minister  to lower the ceiling from £1,200 to £1,100. We expected him to raise it, but we expected a ceiling which would reflect some benefit to the self-employed.
With regard to the £60 valuation limit, that should be raised to £70 or £75. Buildings should be excluded. I have known cases of hardship because the valuation of buildings and out-offices had increased as a result of landowners taking advantage of reconstruction grants and following the advice of the Minister for Agriculture and Fisheries to modernise their out-offices. The moment they did so the valuations were increased and they were deprived of the benefit of the health services. The £60 valuation should exclude all buildings. Big buildings are a liability. They yield no return. There is no financial return from a house, a piggery, a cow parlour, a hay barn, or whatever it may be. I hope the Minister will give some serious thought to this aspect and exclude buildings. The Minister will have no difficulty in ascertaining from the various local authorities the many marginal cases of landowners deprived of the benefit of the health services because the valuation of buildings drove them over the prescribed valuation.
Deputy Fitzpatrick from Cavan raised one very important point. I want to assure the Minister now that the information I am about to give him is true, not alone to my knowledge but to the knowledge of numerous others. Local authority health boards take into consideration the profits from conacre when making their assessment. That means the land is doubly taken into consideration. If a landowner has part of his lands let in conacre the amount he receives through that conacre ought not be recorded against him as an income for the purpose of depriving him of the benefits of the Health Act. Many people are forced through domestic circumstances to let their lands. A circular should be sent to each of the eight health authorities expressing the opinion that in the case of landowners who have any part of their lands let in conacre the conacre proceeds should not be recorded  against the landowner as income for the purposes of the Health Act. I know of a number of such cases both as a Deputy and as an auctioneer who has set land. It is quite wrong that the proceeds of conacre should be calculated against the owner of the lands in connection with the health services. I had anticipated there would be a further regulation, but I presume the Chair will not allow me to discuss something which is not in print before us and he would be quite right. I do not want to take on the role of the Chair while speaking, but I feel there should be some regulation putting a time limit from the time an applicant applies for a medical card until it is granted.
Mr. O.J. Flanagan: I fail to understand why a medical card can be granted within ten to 14 days in one county and yet in another county it may take six weeks. Will the Minister not consider asking that a decision on each individual applicant for a medical card be given within 14 days? In many cases I would settle for 21 days. I have seen medical card applicants hanging on for three months while investigations were being carried out.
Mr. O.J. Flanagan: It is entirely wrong that an applicant for a medical card should be under the suspense of consideration for as long as two or three months. Any efficient health authority should be able to say whether or not a person is going to get a medical card within 14 days. It is a reasonable amount of time to give any health board in which to decide. One thing I have always felt very strongly  about is that a county manager—in future it will be a chief executive officer —can say, “yes” or “no” to whether or not a person is entitled to a medical card. I was told today there would be no change in that system; the chief executive officer is going to be exactly the same as the county manager.
Mr. O.J. Flanagan: There should be some form of appeal in relation to medical cards. Each of the eight health boards should have what is known as an appeals officer or an appeals committee. I have known cases where doctors have recommended that some of their patients should be on the general service medical register. I want to pay a tribute to many of our existing dispensary doctors because I have known them to give very courteous and efficient service to many people, who are not on the general service medical register, without receiving a reward of any kind. That in itself reflects very great credit on the devotion to duty and the high standard of integrity of the medical profession.
I know of doctors who have gone to the health authorities and said that in the circumstances of their patients they were obliged to attend them free and that these patients should be included on the general service medical register and granted medical cards. I have known the health authorities when investigating these cases to find them ineligible because they did not conform with whatever standards the county manager set for deciding these matters.
It is wrong where a medical card has been granted, that the moment the first member of that family leaves school and starts work, even at £2 a week, the medical card is cancelled. In such a case a separate and fresh application should be entertained for the person earning £2 or £3 a week and a card should be granted to such a person without it having a detrimental effect on the medical cards for the remainder of the household. Some CEOs may take a different view from others. I have known some county managers to take a  different view about medical cards from others. Doctors may differ and patients may die but that does not make the situation right. The granting of these medical licences to health, which is what they are, will not be disposed of in a satisfactory way by the new health boards because we now find the new health boards are the old health boards in different clothes. They are no different in so far as the granting of medical cards is concerned. The Minister has not had the courage to keep what I understood to be an undertaking to draft regulations under which a person would immediately know whether or not he was entitled to be on the general service medical register. Maybe this was debated at Government level. They may have come to the conclusion that they should not set the standards for medical cards particularly until after the next general election because they might want to whip out the old medical card gimmick for the next general election. It has worked successfully for Fianna Fáil in the past. As soon as standards are set everyone knows where he stands but while there is uncertainty and no one knows where he stands this can be used as a semi-threat. It can be used as a threat over the voter who has his card: the medical card can be used as a political bribe for the person who has not got one in the event of his recording his vote in a particular direction. When will we take health, in all its aspects, out of the dirty field of politics? The foundation on which that can be done must rest on a decision on who is or is not entitled to free medical services.
That is why I am expressing my keenest disappointment that the Minister has not come into this House with at least the skeleton of standards. If he brought in the skeleton of standards he could leave the health boards chief executive officers to put the flesh on it. They are as wise now as the county managers were. They are working in the same field and they are probing in the dark. There are the same clouds of uncertainty and the same grievances among the public. One neighbour will have a card and the other will not, even though the breadwinner in both instances has the same rate of pay  in the same concern. I could never make out why some landowners have medical cards and others with the same valuations and in the same circumstances have not. I could never make out why certain individuals, who were better off than others who were refused, enjoyed the honour and privilege of registration. Good luck to them. They were able to secure it but I am concerned with the unfortunate people who cannot secure these things.
I want to assure the Minister that there are numerous people in parts of the midlands who are too proud to make it known that they are not in a position to pay a doctor, too proud to make it known to the doctor that they are anxious to avail of his medical skill and advice but cannot pay him. Because they cannot pay him they are allowing their health to deteriorate. I know of at least a dozen such cases in my constituency, people who do not want the home assistance officer coming near the house because of that old pride which is nonsense, we all agree, but nevertheless it is there and there is nothing we can do about it. I know people who are denied drugs, treatment and medical advice because they have not got medical cards and are not in a position to pay. These people are running into a very poor state of health simply because they cannot pay and they have not got the pull to obtain medical cards.
I shall conclude by paying a tribute to the doctors who have looked after a vast number of people who did not qualify for medical cards or did not satisfy the whim of some public official. That did not prevent these doctors from cheerfully giving of their best in accordance with the best traditions of the medical profession. There is something very wrong in a society in which an activity of that kind must be experienced. It is degrading for the public. When we compare our medical services and the general situation in relation to health with the Six Counties position we do not compare favourably. The Minister represents a Border constituency. If he offered the medical services in his constituency to the people of Fermanagh and Armagh would there be a rush on the part of  the people of these two counties to avail of Fianna Fáil medical services?
These regulations are of very little advantage either to the self-employed worker or to the farmer. The Minister's statement contains an admission of his failure to set out an all-round general standard. It also conveys an admission of failure in relation to providing for all our people a first-class and highly efficient health service which the Minister for Health who went before him forecast. The present Minister for Health must be noted in this House for his courtesy. One thing that can be said about him is that he is always prepared to listen. All the health boards will agree that he is prepared to sit down and to talk and to listen. Those of us who have had the experience of serving on these boards and dealing with people who require these medical cards say to the Minister: Let these regulations be only of a very temporary character and let the Minister set about presenting this House, within the next six months, or certainly within the next 12 months, with regulations that will let every citizen know exactly where he stands in relation to all the health services. I have some degree of confidence in the Minister doing that. He is the only member of the Government in whom I would have the slightest confidence in taking any step in that direction. He can play a worthwhile part in the matter of health. He has time to do it, although very little. Time is running out.
The people have been aggravated by the method by which medical cards are issued and have expressed widespread dissatisfaction. I am sure every Deputy has had this experience. The Minister has it in his own hands now to clear up that unsatisfactory situation. These regulations will not do it. Let us have a set of regulations that will do it. I am convinced that if the Minister makes up his mind to do it and if he consults with the eight chief executive officers and comes back to the House with a new set of regulations, they will receive a greater degree of appreciation than his statement this evening has received. Practically every statement made here this evening was based on experience, whether it  was a city constituency or a rural constituency for which the Deputy was speaking. I can speak from 30 years experience of being associated with the work as a member of a local authority. I say that these regulations are not the remedy for the situation, they merely present the same old face with a different smile.
Mr. Kavanagh: I want to add my voice to the voices of Deputies who have already spoken, rather with disappointment, about the contents of the regulations which the Minister has presented to us today. I am disappointed mainly on two fronts. The first is the new limit set for self-employed persons, which I consider to be totally inadequate. The second disappointment for me is that the medical card applicant's position is no different now as a result of this document from what it has been.
If I might go back to the first disappointment, we find that the limit is raised from £1,200 to £1,600. This is totally inadequate as a result of what has happened in the past five or six years since this limit first came into force. A limit of £1,200 five or six years ago compares very favourably with £1,600 now. As a result of the erosion of money values, it would take at least another £500 to put us back in the position obtaining in the mid-1960s. An upper limit of at least £2,000 would have been necessary at this time in order to make allowance for the very fast erosion occurring in the value of money, and which has occurred particularly in the past three years. Money values have dropped by at least 25 per cent in that period.
I am disappointed also that the £60 valuation for farmers has not been changed. This disappointment has been expressed by practically every speaker on these benches and in Fine Gael. This limit has remained for very many years. At this time when farming is becoming more mechanised and there is need for much more intensive building on farms, this limit is completely out of line. Farm buildings, obviously, are valued at a much higher rate than land. As a matter of fact, the valuation of land from county to  county and even within the same county varies greatly. It is not unusual now for a rather moderate-sized house to have a valuation of £20 and if one adds a valuation for outhouses and buildings then at least half of the figure for valuation could be on buildings alone. I submit that the Minister could have included in these regulations that the £60 valuation should relate only to land. It would then have borne some relation to the size of holding where an income of at least £2,000 could be made. As it stands, with no change in the valuation ceiling, I am afraid the farming community, particularly the smaller farmers to whom this upper limit relates, will be very disappointed with the regulation.
The second objection I have is that medical card applicants find themselves in almost the same position as they were in formerly. Deputy Flanagan has dwelt at length on this but I should just like to say that up to recently, before the recent Health Act came into effect, the county manager was to all intents and purposes the arbiter as to who should and who should not have a medical card. Most of us who work in rural constituencies found that this was not a very satisfactory method. The position is further aggravated now by the fact that the CEO of the health board is being put in that position because at least in counties such as Wicklow, we had a county manager available at a reasonably centralised place. Now we find the office is in Dublin and from the point of view of the Eastern Regional Health Board this is completely unsatisfactory for us in Wicklow. As a member of a rural county we are now tagged on, like the tail on the dog, to the large Dublin population. We find that this certainly makes comparison between the situation in the city and the situation in a rural county impossible. A look at a report delivered to us only yesterday from the Committee of Public Accounts bears this out.
Mr. Kavanagh: I wonder why the Parliamentary Secretary did not stop Deputy Flanagan. This is dealt with in the Minister's speech and I intend to deal only with points raised by the Minister in his speech. I was trying to show the disadvantage for counties like Wicklow and Kildare that are part of the Eastern Regional Health Board. From that point of view we are at a great disadvantage. The decisions on medical cards will be made in this city. Comparison between conditions in the city and in the rural areas are impossible. From this point of view I was pointing out that in figures issued in the Report of the Public Accounts Committee for 1968-69, sent to us yesterday, I find that in County Dublin 8.2 per cent of the population are covered by medical cards while in Dublin city 15.7 per cent are covered.
Mr. Coughlan: There is a health problem in County Donegal among people who have been exploited for the past 40 years and they never bothered their bloody heads to look after them. They should look after the unfortunate people who are being exploited in Scotland.
I would hope that the outcome would be the removal of the inconsistencies which have in the past existed in relation to the issue of medical cards, without substantially altering the total number covered.
I should like to know how the Minister intends to fulfil this hope of removing inconsistencies because, compared with other rural areas, Wicklow's health position is much more serious as regards the amount of money spent and the number of people covered by medical cards. Under both headings we compare favourably. In Wexford 44.3 per cent of the population are covered by medical cards.
Mr. Kavanagh: I hope the comparison for a rural county like Wicklow will be with other neighbouring counties. Because of our position in the Eastern Regional Health Board I hope the comparison will not be with the wealthy people in Dún Laoghaire or south or north County Dublin, or in the city; I hope the comparison will be made outside the health board areas and with other counties. I hope when the CEO goes through his massive statistics he will consult neighbouring rural counties and not Dublin city and  county. We who meet people requiring medical cards know that particularly since the 12th round increases came into effect local authority employees have suffered severely through their medical cards being removed. The increases they received in phased agreements under that 12th round resulted in very many cases in medical cards being taken up. In one instance a person who received an increase of 8s lost his medical card as a result.
Another inconsistency which exists particularly in Wicklow compared with neighbouring counties is the expenditure on medicine. For each person in Wicklow, 62 new pence was expended on medicines in 1969 while in Kildare almost double that amount or £1.20 was expended. In Wexford the average expenditure was £1.50. This is an inconsistency that I hope will be levelled out as a result of these regulations. I cannot make comparisons for Dublin city because the figure is not readily available in the statistics of the Committee of Public Accounts.
These regulations have disappointed me on a number of counts. I should have thought section 45 of the Health Act could have been applied to people of limited eligibility just as to people of full eligibility where the income of the husband and wife would be the only income for the household. There seems to be a departure here whereby the income of the household, whether from children in the family or otherwise, will be taken into account in arriving at the £1,600 limit. This would be a dangerous precedent to introduce in these regulations. I hope the Minister will clear up that point when he concludes.
Mr. Cooney: Fairly briefly, I should like to comment on these regulations. There are three categories of persons: those entitled to full services, commonly known as medical card holders; the persons dealt with by these regulations, the middle income group and the third class who are not entitled to any services under the Health Act except, perhaps, in marginal cases which the Minister referred to in clearing up a point earlier today. The medical card holders are mentioned merely in the sense that the Minister has not  yet been able to have regulations drafted to define that category of persons. I think he is hoping that from the meetings of CEOs of the eight health boards a reasonable degree of concensus, as he expresses it, will appear and enable him to draft the regulations. I hope that degree of consensus will appear very soon because at the moment the position is difficult. No uniform standards are being applied in determining who is eligible for full Health Act services.
There must necessarily have been variations from county to county in the past and now there must be variations from area to area and, indeed, still from county to county because in effect the allocation of medical cards will be done by the staff officer dealing with the health services in a particular county. Nominally, the allocation will be made by the CEO but he is now so remote that he cannot make allocations personally. It would be quite impossible for him to deal with all the applications and make individual decisions on them. There must be delegation and as this in most cases will involve at least four counties there is bound to be variation. I should like to see uniform standards applied as quickly as possible. They would get us away from the situation that is encountered at present where, because of variations, there are cases which on the surface should perhaps be rejected but in regard to which there may be some intimate matter of family business not reavealed at the investigation stage but which might be made known to a local representative who could convey it privately to the person making the decision.
That was an ease which was available in the present circumstances; I do not know if it is good to have it removed or not. It will certainly remove the temptation for a public representative to abuse the privilege of being able to make representations. However, from personal experience I have no doubt that that privilege did in some cases relieve a hardship and obtain cards for people who, on the face of things, might not be eligible because of some embarrassing piece of domestic business they did not want to reveal, but which I could reveal in  confidence to a county manager. I was able to reveal those things in confidence to a county manager because he was an official who was readily accessible to me in connection with my activities as a county councillor. Now the official making the decision is gone one remove. He is a remote personage not readily accessible, and this facility will not be readily available to public representatives. This will result in positive hardship for applicants for medical cards who are in the lowest category but who, for one reason or another, cannot show themselves to be so qualified. I make those remarks in passing in the hope that they might encourage the Minister to draft regulations for the lowest category. Above all, I hope he will provide us with regulations that are humane in all their details.
With regard to the middle income group, there are a number of comments I should like to make on the changes proposed. The first comment relates to persons—other than farmers —whose yearly incomes are less than £1,600. I welcome the increase from the former level of £1,200 but I must take issue with the Minister on the means of assessing income for the purpose of deciding eligibility. The Minister said that the income will be the equivalent of the income as assessed for income tax purposes. I would suggest to the Minister that there will be considerable trouble in making these assessments. The confidential nature of the income tax code will prevent the income tax inspector from giving information to the chief executive officer and, as I read the regulations, the CEO will be the assessor. If the CEO is presented with a situation, and if he has some apprehension about whether the amount tallies with the returns made to the inspector of taxes, is it envisaged that the CEO can go to the appropriate inspector of taxes, show the figures that have been returned to him and ask for a comparison with those returned to the inspector of taxes? If so, can the inspector of taxes reveal to the CEO the figures that have been returned to him? If this is the case, the confidential nature of income tax,  which was so rightly defended here today by the Minister for Finance, will be seriously breached.
If the CEO cannot go to the inspector of taxes for assistance and if he is presented with a return which could have complications, about which he would not be qualified to investigate or make a decision, what will be the position? I could visualise a situation where a retired person might have set up a discretionary trust, the income under that trust being ordered to be paid to a third party. On the face of it, the person setting up the trust —for the sake of argument let us assume he is the applicant for limited services under the Health Acts—has no property because he has settled all his property under the trust. The real nature of the trust is that the money will be paid back to him. This will not avoid any income tax because that loophole has been closed, but what is to prevent it being used in relation to these regulations? I do not see anything to prevent it being so used unless the CEO will apply an intricate and detailed part of the income tax code in coming to an assessment under the Health Acts. When we reach that stage we will have got into a ridiculous situation.
Furthermore, I see another difficulty in that income for the purpose of subsection (1) (b) is to be the income for the preceeding year ended on 5th April. My income for the year ended 5th April last could have been such that I would qualify for limited eligibility but my need to avail of the health services might not arise until 5th September, at which stage, because of a depression in my business, my income had been consistently reduced. When I seek the services to which I consider I am entitled, if my income was in excess of £1,600 for the year ended 5th April last I am told I do not qualify. Perhaps I am misreading the regulations and perhaps this kind of situation is covered but I do not think it is. For that reason, I consider the old method of assessing income was much to be preferred, namely, the method as provided for in the Seventh Schedule, as amended, under the Social Welfare Acts. In that case the assessment was made artificially but it was made as at the time of assessment  when the need arose. Section (2) (b) of the draft regulations states:
That is ambiguous in that it could mean two years ago. It would be much clearer if it were to read: “Income of the year ending on the 5th April last before the date of application.” Otherwise, it will lead to a hardship situation for a self-employed person whose business diminishes between 5th April and the date of his application for services under the Act. I make that point and would ask the Minister to deal with it.
I do not want to labour the situation that will arise by applying income tax standards and income tax types of assessment to assesors in order to decide eligibility under the Health Acts. However, unless the CEO acquaints himself with the income tax code he will be fooled.
We are getting into the realm of tax accountability at this stage. If all these things must be decided before a decision is made regarding the eligibility of a person for limited assistance under the Health Acts we have placed ourselves in a fantastic situation.
With regard to farmers—persons whose yearly means are derived wholly or mainly from farming—they are excluded if the valuation, including the buildings on the farm, exceeds £60. It has been pointed out by several Deputies that this is an injustice if it is meant to equate farmers with people having incomes in excess of £1,600 but it does not do this. I am quite certain that the intention of the Minister is to do this but, as drafted, the regulations do not do it. The standard was that £1 valuation equals £20 income. This standard was decided for the purpose of loans under the SDA Acts and for certain supplementary housing grants provided by the county councils. The standard was  applied and accepted in various fields of Government, both central and local. I suggest to the Minister that he should maintain that standard. On that basis, the valuation would be £80——
Mr. Cooney: This increase in ratio suggests that farm income has increased but this is something that must be debatable. The old standard of £20 to £1 worked fairly well and took into account the differences between the two modes of making a livelihood. Even with the increased ratio announced by the Minister the income does not equate to the non-farmer. It is something less than £1,560, as he told me, whereas the non-farmer can have £1,600.
In addition to that the valuation includes buildings. I know that the justification for including buildings as well as land valuation is that farm buildings are a generator of income whereas a non-farmer merely uses his dwelling as a place of residence. I suggest that is an unrealistic approach because the contribution made in generating an income on a farm by farm buildings is minimal. It is so small that in fairness it should be entirely disregarded. In my experience the vast majority of farm buildings are merely places of shelter for stock. One exception would possibly be on a dairy farm where there is a milking parlour. Apart from that, farm buildings are essentially places of shelter. They are not essentially places that generate income. That factor belongs almost exclusively to the land itself. Consequently it is very unfair to bring in the valuation on farm buildings for the purpose of arriving at a farmer's means.
If the idea is to equate the farmer with the non-farmer, the farmer's buildings should be regarded as the same as the non-farmer's buildings, places of shelter, or places of residence. Consequently, the only valuation should be the income producing  valuation, that is, the income of the land. I would suggest to the Minister that he should change the word “including” in page 1, paragraph (1) (c) to “excluding”. He would then be doing justice to the farming community.
Again, if it is to include farm buildings—and this point was made by Deputy Kavanagh—there have been improvements in farm dwellings. I understand that improvements to farm buildings are exempt from increases in valuation. Farm dwellings are certainly not exempt from such increases. Farm dwellings have been improved generally over the past number of years, and these improvements are continuing to be made. Consequently the valuations on the buildings are increasing, whereas the valuation on the land has remained static.
You can have a situation where the proportion of building valuations in the total valuations is increasing so that the income earning part of the valuation is proportionately less and the injustice being done to the farmer, by including buildings in the assessment of valuation, is being compounded. I would suggest to the Minister that this is another and very strong reason for excluding building valuations from the test.
It has been suggested here, too, that in cases where serious and heavy medical expenses are incurred by persons marginally outside the upper limits, there is discretion on the part of the health authority to give marginal relief. It is good to see marginal relief but, in my experience, it is most difficult to get it. It will be even more difficult to get it in future because the people who will be granting this marginal relief will be the chief executive officers. The persons normally looking for it will be farmers. That has been my experience. I find that persons with an income in the £1,600 region are generally in the voluntary health insurance scheme and a number of people who find themselves caught by heavy medical and hospital bills are generally insured, because they are urban-oriented and  know all these things. The people who are caught are generally farmers.
As I say, the discretion as to whether marginal relief will be granted will be in the hands of the CEO. The biggest factor that will influence the CEOs throughout the country, as to whether they will give this marginal relief, will be the state of their budget. I have not the slightest doubt that they will be under severe orders from the Department to keep their budget as tight as possible because, when McKinsey begins to bite home, expenditure under the new administration will go wild. The chief executive officers will have to try to budget and try to economise in every way possible. If they get any applications which are not strictly within the rule of the law, where there is a discretion, the temptation will be to exercise the discretion in favour of making economies rather than in favour of relieving the hardship of the person seeking that discretion. Unfortunately that is what the reality of the situation will be.
The hardship will bear on farmers because, if the regulations as drafted —where the building element is part of the valuation for making the assessment—are retained you could have a situation where there could be a farm with £15 valuation on buildings and £45 on land. That £45 on land would indicate a farm of about 45 acres of average quality land. It could be arable land. It would not be extraordinarily good. It would be average land. But, 45 acres is a small farm. I suggest that, under this regulation if a person has 45 acres and a valuation of £45 on land and £15 on buildings, he just comes within this. A person with a £65 valuation is outside the scope of this. He is one of the marginal cases to which I have referred. Again, £15 on buildings and £50 on land would suggest a farm of about 50 acres, a size of farm which the Land Commission now consider barely viable. Yet that farmer is outside the scope of the limited eligibility services to be provided by the Health Act. That is altogether unfair, and it is certainly not what is intended.
If that person has to meet any out-of-the-ordinary medical expenses he is in the position of having to seek hardship  relief from a chief executive officer who is obliged to try to effect as many economies as he can. All the arguments in regard to farmers are in favour of excluding the building valuation. I would urge the Minister to look at that again. If he is not prepared to exclude buildings, I would ask him to increase the valuation applicable to farmers up to at least £80. A valuation of £80 on a farm nowadays does not denote a large farm. It denotes the type of person who is meant to be covered by these regulations. I appreciate the spirit behind the regulations increasing the non-farming incomes to £1,600 and I would ask the Minister to apply the same standard to the farmers, bearing in mind that they are more likely to be without voluntary health insurance.
There is one further point I want to make to the Minister in relation to income. Unfortunately, income is going on to the income tax basis rather than the humane if complicated-looking assessment under the Social Welfare Acts. I say it is humane because there could be excluded income of a windfall nature. I mean by that a bonus that might be payable in a particular year or overtime for some months. I just cannot think of any other examples at the moment but they are two that are common enough examples. If they are not excluded from these regulations, in the unfortunate way they are drafted as applying a year afterwards, so to speak, a person could be excluded on income that he had earned perhaps nine or ten months previously. I would ask the Minister, if possible, to amend these regulations in regard to the matters I have mentioned.
Mr. Treacy: To those of us who looked forward to a much-needed and long-awaited improvement in the health services these draft regulations come as a deep disappointment. They will be received with shock and dismay throughout the country, especially by the categories referred to, the middle income group and, in particular, the lower income group. The ceiling of £1,600 now stipulated is to my mind grossly inadequate. Having regard to the exceptionally high cost of living and the rapid growth of inflation, it is  fair to assume that this figure of £1,600 will be rapidly negatived and become wholly ineffectual and more and more people will be put outside the scope of the health services.
We know how difficult it is to get the Government to raise an income ceiling of this kind. The figure of £1,200 has remained on the Statute Book for some considerable time. I am fearful that this figure of £1,600 may likewise remain for an indefinite period to come thereby depriving very many hundreds, if not thousands, of people of essential health services. An income of approximately £30 a week for the average family could not be said to be a high figure nowadays. Many industrial workers, artisans and tradesmen are earning approximately this figure and, if they are not, they are finding it difficult to make ends meet. This is by no means a generous figure. As I said earlier, I regard this ceiling as very inadequate indeed.
I am concerned, too, that, for the purposes of verification of income, people will be expected to seek returns from the income tax authorities. It is bad enough that one should have to go to one's employer for verification but it worsens the situation considerably when the Revenue Commissioners are dragged into the health services. This will make for delay in securing what may well be urgent medical attention because there will be all the usual delay in securing the relevant information.
I am utterly astonished at the Minister's reference to income standards for eligibility for medical cards. When one remembers the positive promise made in respect of a choice of doctor, the abolition of the dispensary service and an improvement in the determination of eligibility for medical cards, the proposal here to leave the matter in the hands of the chief executive officers of the regional health boards is nothing but a gross betrayal of the promise made in the White Paper, made on many other occasions as well and, indeed, in the Health Act itself. We are not going to have the promised liberalisation of the means test for medical cards. The Minister is going back on his word. He said that account  would be taken only of the income of the breadwinner and the income of other members of the family would be ignored. This is a betrayal of that positive promise by the Minister.
Mr. Treacy: The Minister stands condemned for deviating from this fundamental principle and for failing to remove from the health services this odious means test. This is what we all sought to achieve. We sought to remove from the Health Act the odious means test for medical cards, this degrading and humiliating exercise which causes widespread indignation and upset. This is being retained. The home assistance officer will still operate, will still carry out this odious means test as to family income, as to the income of the children or of any relatives. The income of the whole household will most certainly be taken into account. It is no use pretending otherwise.
Mr. Treacy: If the Parliamentary Secretary wants to raise a point of order, he should do so. He has been sitting here for the last hour or two obstructing Deputies and seeking to usurp the authority of the Chair.
I had hoped also to include in these regulations a provision fixing income standards for full eligibility, that is for that category who are entitled  to medical cards. After very detailed and careful studies of the matter, I have come to the conclusion that, as circumstances other than the purely financial vary so much as between country and town and between one family and another, I should not at this stage make regulations on such standards but rather leave it to the chief executive officer of the eight health boards to try to achieve the greatest practicable uniformity in their decisions on eligibility.
Now, we had hoped that the regulations would provide that only the income of the breadwinner would, as promised, be taken into account and that there would be a genuine attempt made to secure uniformity in the kind of test applied for eligibility for medical cards. We had hoped that there would be a proper and recognised criteria applied and that we would achieve something in the nature of a national test for medical cards. But this is not being done. The means test will still apply. This is a going back in a very serious way on the positive promise made by the Minister, on a proposal initiated by the late Deputy Donogh O'Malley when he was Minister for Health, in his White Paper on the health services. He promised us that there would be this great liberalisation of the means test for medical cards. This was taken up by his successors and in recent elections in particular it was used as a cardinal point in telling the people they could look forward to this great advancement and improvement in the health services, that there would no longer be this means test, that cards would be given out on a much more honourable basis having regard to the dignity of the human person and family life.
This is a great betrayal and a shame on the Minister and the Government who perpetrated this kind of fraud on the people—it is political fraud of a serious kind. Many thousands of votes were secured for Fianna Fáil in the last general election on the basis of this improved Health Act on which they are now going back. No doubt the people will remember this. We had hoped the means test would be  abolished for a number of reasons, one being that a choice of doctor scheme would be brought in quickly. It is generally believed, let us be frank and admit it, by medical card holders that they are not treated with the same bedside manner as are those who are prepared to pay. A medical card holder is frowned upon and there is a feeling abroad in the minds of many of them that they are getting less medical treatment than the person who can pay.
Mr. Treacy: I am merely pointing out that there are three grades of medical treatment in this country: the kind of treatment which is available for the higher income group who can pay irrespective of the demands made upon them by reason of their wealth; the kind of treatment available for the middle income group and the kind of treatment available for the medical card holder. It is classified in the hospitals in the matter of private accommodation, semi-private accommodation and the public ward.
Mr. Treacy: That is why we were hoping to secure genuine equality in the application of medicine and the health services. The first way to tackle that is to provide equality at the lower base in respect of the lower income group.
Mr. Treacy: The Minister did make a remark to me in an aside earlier when I was expressing concern at his placing responsibility in regard to eligibility for medical cards on the CEOs of the health authorities. I have been a member of a health authority since I was elected to public life in 1955. I am a member of the South Eastern Regional Board and I know that there is no recognised test or criteria for the granting of a medical card. The test laid down in the Health Act is that people entitled to medical cards  are those who are unable of their own industry or other lawful means to provide medical services for themselves and their family. This is a very vague and ambiguous statement. I believe it was coined from the old British poor law system and Acts of Parliament. It means nothing. It means that the county managers up to the establishment of the health boards had the right to decide who was and who was not entitled to a medical card. They did this on the basis of a report from the assistance officer. That function is now being passed on to the CEOs of the health authorities who are established in a particular centre. This centre may be very far removed from our respective counties and towns. My health centre is some 30 miles away from my home and up to now in the case of a medical card problem or a health service as such I was able to contact our county manager but it will be far more difficult for us to contact our respective CEOs. They are removed from us and we may well find them to be inaccessible. This is a worsening of the service and as far as the people are concerned it will make it more difficult for them to secure services of this kind.
I have quoted the Bill in respect of eligibility. There is no recognised yardstick but there is a notional figure in the mind of either the manager or the chief executive officer of a health board. The Minister intimated to me earlier that he might very well prompt them about the kind of test they should apply. I would be glad if he would say if he will honour the promise made so many times that in assessing the means only those of the breadwinner will be taken into account and the income of other members of the household will not be taken into account, because this has bedevilled the system. Because of that stipulation many families have been denied essential services. We want to know clearly what will be done in those circumstances. I know well that this national figure of income is there. It was very largely agreed upon by the County Managers Association when they had responsibility for the operation of the health services and no doubt the CEOs and the new regional boards will get together and they too will have a  notional figure in their minds as to what the means test shall be for the issue of a medical card.
The national figure that I know to apply in certain areas—these figures vary from region to region and from county to county—are totally inadequate. They can be as low as £12.50 for a married man. Another notional figure is applied in respect of children. That figure will be found to be in the region of 75p per child. Regard may be had to rent but at present all the family income is taken into account. The figures of £12.50 and 75p per child are ridiculous figures and on the present basis will not permit the securing of a medical card for even the lower income group and I refer to farm labourers because they are probably the lowest paid workers. It is as difficult today despite all the promises made by the Fianna Fáil Government, to secure a medical card as it was five years ago. The means test is still as rigorous, the income limits still ridiculously low. There is in this statement by the Minister a continued stipulation in relation to the issue of medical cards. He talks about the issue of medical cards “without substantially altering the total number covered”. The policy is, I submit, not to enlarge the scope, not to liberalise means tests to take in larger numbers of people who are borderline cases at present, but to restrict. This is a conservative, restrictive measure. It is a betrayal of promises made. It is a perpetration of a political fraud on the people. It will come as a deep disappointment to the ordinary working classes who were gulled to vote for Fianna Fáil at the last general election on the basis primarily of an improvement in the health services.
We are conferring nothing on the middle income group when we apply a ceiling of £1,600 which is low and which will quickly become ineffective. Insured contributors are getting nothing from the Minister or the Fianna Fáil Government to which they are not entitled. We claim this improvement in the health services for them not as a charity but as a fundamental right. They are paying dearly for this service  every week in the contributions they make to the social welfare fund. Let no one on the Government benches suggest that we are conferring on them some kind of sop from Fianna Fáil. On the contrary, we are betraying them. We have gone back on the promises made by the late Donogh O'Malley when he sought to liberalise the health service and make for a great advancement. As yet, the choice of doctor scheme has not come in. The dispensaries have not been abolished.
Mr. Treacy: I am commenting on the statements of the Minister and the puny, inadequate regulations which he is asking us to support. I do not feel it in my heart to support these regulations. I could go on at very great length on this subject but I have said sufficient to demonstrate our disappointment, our feelings of disgust with this measure. The Minister may be able to allay some of the anxieties I have referred to when he tells us when he will do the things which they promised the people they would do in respect of an improvement in the health services.
I am particularly concerned about the means test for medical cards. This is what I have harped on most particularly because I know of the anomalies with which we have to contend in this system which varies from county to county, region to region, with no uniformity. We hoped and expected, we believed, and the people believed and were led to believe by Fianna Fáil, that in respect of medical cards they would know where they stood, that it would be stated clearly on a national basis. On the contrary, the whole system has been handed back to the nebulous and remote chief executive officers of our regions. This is a continuation of the very same system.
We know that people resent deeply  a system which involves examination by a home assistance officer. I am not reflecting on these gentlemen, as such. I am reflecting on the system, the poor law system which they are obliged to operate. We cannot blame these men if they look at the average working class family through the eyes of the poor law system, the jaundiced eye which is prejudiced if it sees within that household any sign of opulence or comfort of any kind. A television set is sufficient to ruin one's chances of a medical card.
There is also an aspect of Tammany Hall politics involved in the issue of medical cards. It has been known to be a great political gimmick in the past. It is the kind of sop which has been held out to our people. It is the kind of thing which Fianna Fáil have worked well and very effectively. This is probably the real reason why they are not prepared to give our people a better system, why they are holding on to the odious means test, the home assistance officer and the local politician who will pretend to secure benefits for people to which some are perhaps not entitled. We know of the anomalies which exist in respect of the award of medical cards and the disquiet in some parts of our country because some sections are granted them and others are denied them. We know that in respect of certain industries once one is known to be working in a certain job it is automatically presumed that one is not entitled to a medical card. These are anomalies that we had hoped would have been cleared up. They have not been cleared up and we are now asked to support regulations which go back on all the promises made in respect of the liberalisation for means test for medical cards and the advance in the medical services for which we all hoped. It is a retrograde step that this important function should be placed in the hands of the chief executive officers.
Mr. Treacy: It is audacious of him to interrupt. The CEOs are remote from all of us, difficult to contact. Clearly the problems of our people will be more difficult to resolve. I appeal to the Minister not to go back on his word, to honour the promises made to the people, to honour the trust reposed in them, on the basis of the votes they secured, that they would improve the health services and that they would, in particular, liberalise the means test for the middle income group and lower income group and remove the odious means test from the Health Act. If the Minister does not do that, then I say it is a shame and a disgrace on him and on his Government. They have once again fooled the people and perpetrated on them a great political fraud which I feel certain will not be forgotten.
Mrs. Hogan O'Higgins: I shall be very brief. It would appear to me from listening to the Minister's remarks and reading the various documents we get that the CEO in each region will be greatly over-worked and that they will require to be extraordinary people having a knowledge of subjects ranging from social welfare to the income tax code. One would almost need to be a tax accountant to become a successful CEO. However, that is beside the point.
Heretofore we have always had access to our county managers and I hope we will have access to our CEOs because I find in my constituency, which embraces three counties and where standards for eligibility for medical cards vary enormously, that a great deal depends on personal contact with the official dealing with the various cases. I find going through my constituency that a number of people, particularly farmers, are not able to  make a case for themselves. I do not know why. In some cases they are not prepared to admit that they are as badly off as they really are and you arrive at a situation where people are fully entitled to a medical card but, through lack of communication with their home assistance officer, are not considered eligible and then they will work back to their local representative who has to make the representations all over again. This should not happen. Accessibility to the county manager has always been the situation. I hope accessibility to the CEO will be the same.
What is bothering me most and why I rose to speak is the limited eligibility of farmers with a valuation of not more than £60. This figure is quite unrealistic because it includes the dwellinghouse and the yard. In many cases a large farmyard is a liability. You have to maintain the roof and the gutters. As Deputy Cooney ably pointed out, all it does in some cases is provide shelter and more often than not it is completely unused.
I have found that the Clare County Council do not take this into account when allowing limited reduction in medical bills. Just to illustrate the point, I made representations on behalf of a constituent who had a valuation of almost £100, most of which was on buildings; there were only 20 acres of land. At one time it had been a very large farm. The owner divided it between his four sons, leaving the house and yard and 20 acres to one son. This man subsequently died and his widow had extreme difficulty in getting a medical card, because of the valuation.
In this day and age the valuation of the house and farm buildings should not be counted for limited eligibility. Even £60 on land is too low. I do not know where the Minister gets his £26. It is very easy to go by surveys. I find the people who make these surveys are rarely ever farmers. In fact, I find that the only people who make accurate farming surveys are the NFA because they are comprised of farmers and they take into account actual profit and loss on a farm, a good year against a bad year. For that reason I would ask the Minister to take another hard  look at this £60 valuation. If he would consider £60 on land, it would not be too bad but when he includes the buildings it is not enough in this day and age. It does not represent a £1,600 income. That has been my experience in my constituency. It may in County Dublin where there would be intensive market gardening, or in Cavan or Monaghan where they go in for broiler chickens and intensive pig rearing, but not in counties west of the Shannon. This is bothering me a great deal.
I am glad that the Minister hopes to make provision fixing a standard for full eligibility. This was promised to us and the sooner it is done the better because the variations are shocking. There is too much flexibility as between counties. I did not realise it until I got the Roscommon and Clare end of the constituency. While it is reasonably easy to get medical cards in two parts of my constituency, in another county they are absolutely inflexible in their rules. This is not fair. A fixed standard should be brought in as soon as possible and adhered to. It should not, as it has in the past, vary because of one's political qualifications. This should be done away with forever. I would appeal to the Minister again to look at that £60 valuation for farmers. It is too low. It should be £80, and £80 on land.
Dr. O'Donovan: I have listened to many rural Deputies talking about this matter of eligibility under the Health Act. I have no doubt that conditions are difficult in the country but what are we to think of conditions here in the city of Dublin? I was two years in this House before I got a letter saying that somebody on whose behalf I had made representations had got a medical card and I had not been that inactive on the subject. The figures demonstrate it—8 per cent of the people in County Dublin and 15 per cent in the city, taking the city and county, 12½ per cent, one family in eight. Does anybody really believe that a county like Limerick is that badly off compared with the city and county of Dublin that 40 per cent of the families in the county and city of Limerick have health cards? Does anybody really believe there is any reality  in that comparison? The only place in this county which compares with the city and county of Dublin is the city and county of Cork.
The case that has been made here this evening is that the removal of this whole matter to the CEO of the regional health board will make for difficulty. Of course, that was already in effect the case in the city of Dublin and the city of Cork. They were remote. I am not reflecting in any way on the officials concerned. I take it that certain rules were laid down for them from the top.
One of the difficulties about this matter is that the cost of the medical cards is a negligible part of the cost of the health services. I have said in the House what the health services are costing altogether by comparison, in this city, with housing. The money spent on health is altogether excessive by comparison with the amount spent on housing—£1.9 in the £ valuation; £2 in the £ valuation as against £.6 on housing. Anybody who thinks on the subject knows quite well that in any normal life at all, even a person like myself who has not had by any means a perfect health record, the amount of money you spend on health relative to the amount you spend on housing is negligible. This has got completely out of hand. There seems to be no leadership in the Department of Health to try to have some reality brought to bear on the matter. I do not know what the reality is. I do not pretend to know. I do know when something is costing altogether more than it should cost. That is the position. Worst of all, in relation to the city of Dublin, the dispensary system might just not exist.
Dr. O'Donovan: I want to emphasise that making regulations like these, so far as the people of Dublin are concerned, does not alter the fact that whatever conditions in the country may be, they are three or four times worse in this city. They must be. The Minister works hard and, as he said, he can be trusted to give decisions to the best of his judgment but it is a  serious shock after all the time given by the Minister and Members of the House to the 1970 Health Act to find ourselves back where we started. We have added largely to the cost without getting anywhere in regard to results. No matter how bad the health service may be in rural areas it is very much worse in Dublin city. Whatever part of the system you look at the same applies. A medical card is a myth so far as Dublin city is concerned. To make make matters worse, people get limited medical cards to enable them to get a free supply of drugs and medicines from the local dispensary but these cards are given out for as little as three or six months. When Deputy Flanagan spoke of delays of three months in getting a medical card he must have been joking: delays in Dublin city run into years. Three years, if one thinks of the limit, would be a much more accurate figure for Dublin.
I do not want to be unfair to the Minister. He gave us these figures before. I have a distinct recollection of getting these figures for 1968-69 which were published in the Report of the Committee on Public Accounts which we got yesterday. They are appalling. For example, we find 46 per cent of the people in Kerry have medical cards and 44 per cent of the people in Wexford, coming down to 15.7 per cent of the people in Dublin city and 8.2 per cent of the people in Dublin county. Does anybody really believe that only one family in 12 of the people living in Dublin county should come into the health system? This is a completely false figure.
I take it the Minister will reply to this relatively long debate at some length. Would he be good enough to tell us whether it was what faced him in relation to the city and county of Dublin that prevented him from doing as he said he had hoped to do, to:
include in these regulations a provision fixing income standards for full eligibility, that is for that category who are entitled to medical cards. After very detailed and careful studies of the matter I came to the conclusion that, as circumstances other than the purely financial vary  so much as between country and town and between one family and another, I should not at this stage make regulations on such standards but rather leave it to the chief executive officers of the eight health boards to try to achieve the greatest practicable uniformity in their decisions on eligibility.
This will not happen. If it did, no doubt the poorer people would benefit. I have no objection to using the word “poorer”. Nobody nowadays uses that word. Deputy Burke talks about the less well-off sections of our community. I talk about the poor. This is a good, old, classical word to describe those concerned. In this city if you go to places like Hollyfield Buildings or Mount Pleasant Buildings you find that most families have no medical services. It is an appalling state of affairs.
We all had great hopes—I think the Minister himself was pleased and certainly the House was pleased with the Minister—while the Health Act, 1970, was going through. Now that April 1st, 1971, has come and gone we find ourselves no nearer to what most people had hoped for. Personally, I believe we shall get no nearer to it but we are about to spend a great deal more money on all these services under all these orders. Even in real terms a great deal more effort and sacrifice will be made by the community in connection with health and the whole thing will end up in a puff of smoke.
The allegations made on this side of the House this evening are true. There have been occasions in elections where health cards have been waved about like banners of freedom. We all know this. The difference between a blue card and a white card was once a great topic but as a friend once said to me: “When they get the white card they will be no better off than with the blue card. This is what they do not understand.” The percentage of ordinary workers in Dublin city who have medical cards is a disgrace and an outrage. From personal experience I can testify that you might as well try to dredge diamonds from the Liffey as try to get a medical card from Dublin Health Authority. Granted, different  men have different views, so, the CEOs of the regional health boards will have different views. It does not surprise me that Deputy Kavanagh, having regard to the competent and concerned county manager he has in Wicklow, should be concerned at the thought of his people being moved under this central, faceless group of people who will now decide matters on the basis of some figure, some paper qualification which has no bearing on the realities of the situation.
It was well put by Deputy Cooney when he said the moment a television set was seen in a house there was no question of a medical card for that family. Presumably this is why the Dublin figure is so low and why there is such an appallingly low volume of medical services here compared with other parts of the country.
Dr. O'Donovan: We have a forest of aerials over Dublin city. It was mentioned earlier that there were more television sets around Dublin, particularly among the working people, than in other areas. If you have a very small income and you cannot go out to the world the obvious thing is to try to bring the world in to you. If you cannot go to the cinema, the theatre, or an hotel or even to “the local” the obvious thing is to have television in order to keep you reasonably contented with life. That sort of thing does help people to be content. I do not disagree with Deputies who have spoken here tonight. I do not know but the figures suggest very definitely in relation to counties where the land is good, such as Counties Kildare and Meath, that a very different standard must apply in regard to health services in these counties from that which applies in the city of Dublin. It is the duty of representatives of the city of Dublin to speak about this matter. It is time that some attention was paid to it. As Dublin is rapidly encroaching on Counties Wicklow and Kildare— the Eastern Regional Health Board includes both counties—it does not surprise me that Deputy Kavanagh or any representative of the workers in these counties would be concerned. Judging  by what has happened in Dublin they have every reason to be concerned. I have put the case fair and square and I see no reason to repeat it.
Mr. Coogan: The delay in the supplying of medical cards is a problem in my constituency. Some people do not apply for a card until either they or their family fall ill. By the time the card is received it is not unlikely that the sick person might have died. The delay in supplying cards should be cut to the minimum. Frequently I have found that home assistance officers are loath to send in their reports. On the other hand, I must admit that there are decent health officers who do their work in an efficient way.
Television sets were mentioned during this debate. In many cases these sets are provided by the sons and daughters because the parents cannot afford them. The provision of a television set should not be the criterion for depriving a person of a medical card.
I have said before that it has cost us millions of pounds to ensure that our cattle are in good health. There is more respect for the blue card and for the bullock than there is for human beings. I recall a time when Fianna Fáil said: “The bullock for the road and the farmer for the land.” The bullock is regarded as the golden calf. Until we set our standards to the human level we shall have achieved very little.
Mr. Finn: There are a few points I should like to make which affect my own constituency and county. Approximately 45 per cent of the people in County Mayo are holders of medical cards, mainly due to the small holdings of land and the low income derived from them. Many of the farming community who made applications for cards have valutions of approximately £10. I could never understand how any Department could assess buildings as income. However, this has been done not only in deciding eligibility for medical cards; it has been done by other Departments also.
Mr. Finn: I am not happy about the situation whereby the CEO who lives approximately 120 miles from the furthest point of my constituency should decide who gets a medical card in that area. I never agreed with the reorganisation of the health boards.
In so far as the provision of medical cards was concerned, the system that operated in my county was that the county councillor or local representative made representations to the county manager. In making those representations, the local representative knew who was entitled to a card and every person got a fair deal. I can say that the county manager in my county was an admirable person to deal with in regard to these matters and his staff were extremely efficient. Now we must apply to the CEO in Galway who will decide who gets a medical card.
I welcome the decision to increase the income limit to £1,600. This is more than necessary in view of the depreciation in the value of money at this time. It is the home assistance officer who will have to investigate and report back to the CEO who will make the decision.
Some questions are asked on the application forms for medical cards. Deputy O'Connell mentioned television sets. In my county you are asked have you a private car. Surely to a man with five or six children a car is a must to get to work. He may be working for a low wage. There was a time in my county when, if you had a private car, you were deprived of a medical card. We adjusted that and we removed that question. About 45 per cent of the people in County Mayo who have medical cards have not got a choice of doctor.
Mr. Finn: I know of different decisions that were made by home assistance officers. We should have a standard qualification for medical cards. As was stated by several speakers tonight, you would be surprised at the people who were refused medical cards. I had occasion recently to make a recommendation to a chief executive officer for a medical card. This person was being attended by a doctor and needed a medical card badly, but she was refused. She had to take expensive tablets. A man with £20 a week, with a family of five or six children, may not get a medical card even though his wife is not well. On the other hand, another person with a larger income can get a medical card. There should not be this variation. Everybody on a certain standard should qualify automatically. The Minister should seriously consider the question of valuation on buildings. If a man is living in an old house on 20 acres of land, surely that should not be considered as income in assessment for a medical card. Valuation on buildings should be disregarded when applicants are seeking medical cards or health benefits.
Mr. Clinton: It is difficult to come in at this time, not having heard the discussion that has taken place during the evening. Reading the Minister's statement seeking approval for these regulations, I certainly get the impression that he has left far more unsaid than he has said in his short speech. I have a feeling that, having heard the opinions expressed here this evening, the Minister will have much more to say in his reply than he had to say in his introductory statement. The fact that his statement was so vague and open to so many interpretations is the main reason why this discussion, which one would have expected to finish in a very short time, has dragged on throughout the evening.
At first look this improvement in limited eligibility from an income limit of £1,200 to £1,600 must be welcomed by all of us in this House, but one wonders as a result of the other changes that are taking place in the basis of assessment whether, in fact, a considerable amount of this £400 is  not taken back in the income tax methods being used to make the assessments. It may be obvious to the Minister that this is not so, but it is certainly not obvious in the statement he made to the House. This needs very careful scrutiny before we could arrive at the conclusion that a considerable amount of the increased income is not taken back through the method of assessment.
We are not told what is taken into consideration. Is it family income? Is it the income of the head of the house? Is it the income of the head of the house, his wife and family? Does it include all income? Does it include overtime? No matter where income comes from, is it included in making the assessment? If it is, the last position might easily be considerably worse than the first. I should like the Minister to explain this much more fully to the House. Is this basis of assessment more favourable, or likely to be more favourable, to the applicant? To what extent is it likely to be more favourable? The Minister should give us examples of the circumstances in which it would be favourable to the applicant.
It is considered more appropriate to look at visible income, such as is done for income tax purposes, in reckoning eligibility for health services. This change incidentally would facilitate the arrangements under the Health Contributions Bill for the collection of certain health contributions.
The Minister did not explain why it would facilitate the collection of the contributions that have been introduced recently for the relief of the Exchequer, let me say, and not for the relief of the ratepayer.
There is a good deal to be said for reducing the number of means tests already being carried out for various services. If one assessment or one means test were sufficient for the various services provided, that would be a great relief to the people, instead of having a different assessment for each service as at present. I have  always objected to this, because people have been plagued by a variety of means tests. There is a good deal to be said for reducing them to one, if that is possible, without interfering seriously with the situation in which people already are.
Under the old regime, so to speak, we had this limited eligibility. We also had full eligibility and we had something that is not mentioned here at all; we had the question of drugs and expensive medicines covered under a sort of hardship clause. The Minister has not explained how this matter will be dealt with in the future or how these will be covered. This was something that was extremely important because it relieved serious hardship and serious expense in the case of many people whose incomes could not bear an excessive expenditure on either drugs or medicines or both.
Mr. Clinton: The Minister will agree there is no reference to it here. It is not proposed to interfere with that. I welcome that. With regard to the medical card, if one wanted to open up a discussion on limited eligibility, full eligibility and all the rest of it, the discussion could go on for a very long time. I must say I have always been fairly well satisfied with the present position as regards eligibility for health cards and I have always found those concerned in the Dublin Health Authority area quite reasonable when the case was properly made. There were times when the case on behalf of the applicant was not properly presented and, on re-examination, the person proved to be eligible even though turned down originally. No matter what system you have you will always have that kind of thing.
In the past every county had a health authority. Now the number will be reduced to eight. Because of that contact will be difficult and control will be remote. The Minister may say this can be overcome very easily and he will give instructions that it must be overcome by delegating responsibility down to a county level. Unless you have this, unless you have those responsible for issuing medical cards at a fairly local  level, where public representatives can move in if they feel quite honestly there is somebody who is not getting fair play and get in touch with the actual person responsible, the person with the authority, this may well fall down. I think there will be an immense dissatisfaction unless this sort of contact is there. There in no appeals machinery indicated here and the people concerned, the applicants for medical cards, will have no recourse except at eight points in the country. This will be very remote and I think it will be completely unacceptable by the people, and rightly so, unless the regulations contain an instruction to the CEOs to delegate authority down to county level. At least in large areas, like Cork city, for example, there will need to be even more local accessibility from the point of view of elected representatives getting in touch with those responsible.
Mr. Clinton: If that is so, then that is quite acceptable to me but I believe the Minister would want to send out an instruction to this effect. It will be done by some CEOs. It may not be done by others. As things stand, it need not be done. I do not think this is a good idea. I do not think it should be left as open as this. I think the Minister is quite correct in leaving it to the experienced people who have been providing the health services over a long number of years. They are far more capable of assessing the situation than anybody else provided they are accessible to the elected representatives because, whether we like it or not, we are the bulwark between the individual and bureaucracy and someone must be in a position to come in and say: “Here is a case that has not been properly presented and here is an applicant who has been refused.” If it is left entirely to the discretion of eight people throughout the country and there is one “wrong un” among them, or one unreasonable person, and the thing has to go back to him he can do immense damage over a very wide area. This is a serious situation. It is one that must  be taken care of by the Minister. I am sure he will take care of this before he finalises the regulations. When he comes to reply, I hope he will have a much fuller explanation of what is proposed and the means and methods that will be adopted in implementing the regulations for which the Minister is now seeking approval.
Mr. McLaughlin: I am wondering how this will work out. We are told the main purpose is to raise the income ceiling for limited eligibility from £1,200 to £1,600 in the case of self-employed persons other than farmers. I am wondering where the farmers will come in. I come from a constituency in which the majority of the valuations are very low. I cannot see how these small farmers can be excluded when other groups with an earning up to £1,600 will be included. A small farmer does not make £1,600 a year. He has his herd of cows. He has six or seven young stock. Milk prices are somewhat similar to what they were ten years ago. The Minister will have to consider very seriously the position of these people. He will also have to consider very seriously the position of people with private means. These will have to have their means checked on in the same way as those who apply for the old age pension. These are two groups who will feel very uneasy about this. With regard to the self-employed, that reduces the number considerably because, when you exclude the farmers and persons with private means, you cut down the number considerably. The Minister will have to re-examine this. I will await his reply on this with interest.
I should like to see the valuation left out altogether. Valuation is very often not a genuine guideline. Farmers who have improved their premises have had their valuations increased. That increase will be taken into consideration when a farmer applies for a medical card. This £20 is being used against a farmer, even though it may very often be only a number of empty sheds, with seven or eight children who may be very much in need of a medical card for medical services. I would ask the Minister to examine this very carefully.
 Is a person entitled to a medical card if he earns less than £1,600? My experience of the local authority in Sligo/Leitrim is that everyone is given a means test. A person with a very high valuation who has run into hard times may be very much in need of medical services. In all fairness to the county manager and his executive officers they did give due consideration to those cases. That is the reason why many of the Deputies here today are not in favour of the new regional health boards which have been appointed. This point has been recognised much more since the regional health boards were appointed. If the various bodies were called in today they would vote 100 per cent——
Mr. McLaughlin: The eight chief executive officers are going to be called together to discuss the question of medical cards. Heretofore the elected representatives attended a county meeting where they met the county secretary and then went to the county manager about his final decision on a case and the matter was settled. If it was a genuine case, the manager usually took the recommendations into consideration and a medical card was given. Now each chief executive officer will discuss with the Minister the question of medical cards against the opinion of county managers who have given 20 years service to this type of work.
Mr. McLaughlin: Those men came from various walks of life and some of them were far removed from administration of this sort. They are asked to discuss the question of medical cards for the poor people we represent. The day we took this power from the local authority and the local county council chairman was a bad day. The  time is coming when a change will have to be made.
Mr. McLaughlin: People may talk about free medical services but I know of people requiring orthodontic treatment who were told they would have to wait three years before they could be attended to in Dublin, but if they were able to pay they could be attended to within a week.
Mr. Begley: Ba mhaith liom cúpla focal a rá ar an dtairiscint seo. Luaitear £1,200 agus £1,600. Is mór an trua nár árdaigh an tAire é sin go dtí £2,000. Tá cuid mhaith daoine idir £1,600 agus £2,000 agus ní mór dúinn cuimhneamh orthu san. Tá cáin á h-íoc acu leis na blianta agus níl rud ar bith á fháil acu ón Rialtas. B'fhéidir nach bhfuil sé ró-dhéanach fós an £1,600 úd a chur suas go dtí £2,000.
Mr. Begley: Ní fheadar an bhfuil a fhios ag an Aire cad tá á rá againn. Ní fheadfar an bhfuil aon Ghaeilge aige. Níl a fhios agam. Níl? Is mór an trua é sin. Tá rud amháin ag cur isteach orm go mór. Caithfidh gach feirmeoir sa tír £7 a íoc agus b'fhéidir nach mbeadh sé breoite in aon chor.
Mr. Begley: Bí cinnte go ndéan-faidh mé amhlaidh. Tá 30 nóimeat agam agus beidh mé ag caint ar feadh an ama sin. Más áil leis an Teachta éisteacht liom mholfainn dó bheith ciúin. B'fhéidir go bhfoghlamhódh sé rud éigin uaim. Bhíos ag caint mar gheall ar na feirmeoirí. Ag cuid de na feormeoirí sin tá mac agus iníon sa teach acu atá os cionn 21 bliain. Seo an rud atá ag déanamh scime dhom. An gcaithfidh an triúr acusan £7 a íoc?
Mr. Begley: Tóg bog é. Tá an talamh in ainm fhear an tigh. Ina chónaí leis sa teach tá a mhac. Bhí an dole le fáil aige go dtí le déanaí ach níl a thuilleadh mar tá a fhios ag gach Teachta. Tá deirfiúr sa teach freisin. An gcaithfidh an triúr acusan £7 a íoc? Níl aon fhreagra le fáil ar an gceist sin in áit ar bith sa pháipéar seo. Tá sé ceart go leor i gcás feirme ar a bhfuil luacháil £60 ach cad mar gheall ar na feirmeoirí beaga, go h-áirithe i gContae Chiarrai agus sa chuid sin dem dháil-cheantar atá i gCorcaigh? Bhí an taobh  sin tíre ag Flor uair amháin. Dob é Caoimhghín Ó Beoláin a chuir an chuid sin de Chontae Chorcaigh isteach le Contae Chiarraí. B'fhéidir go raibh Flor ag caint leis an iar-Aire agus gur thug sé an giota beag sin de Chontae Chorcaigh do Chontae Chiarraí. Tá feirmeoirí an-bheaga i gCorcaigh Theas agus i gCiarraí Theas.
To get back to this debate, I am really surprised at the heckling I got from my friends on the other side. I do not know whether they understood my Irish or not. I admit that some of the boys are from Connacht and there is a big difference between Connacht Irish and Munster Irish.
Mr. Begley: Na Teachtaí Dála. Na Teachtaí úd. I thought they would have some bit of Irish but from their interruptions, rude interruptions at times,  I have come to the conclusion that they have not got much Irish with the exception of a few Deputies like Deputy Tunney and Deputy Power who, I know, have excellent Irish.
Mr. Begley: There are a few items in these regulations about which I am greatly disturbed. The first is the collection of the £7 levy from each farmer and the method of this collection. It is not defined in these regulations how it will be collected. I wonder will new jobs be created by the Southern Health Board for the collection of this £7 or will the assistance officers who are now operating the Health Act in these areas have the responsibility of collecting the £7? It should be spelt out clearly to Deputies whether new jobs are to be created. If it is to be collected by the assistance officers that is a very retrograde step indeed.
Mr. Begley: Yes. I am dealing with them and with persons with valuations up to £60 who will be liable for this new health contribution, which is £7. If these people are liable for it there  must be a method of collection and surely that is relevant?
Mr. Begley: I do not think the Minister dealt with it very well. He did not spell it out. I tabled a question to the Minister last week asking how many people in Kerry were getting disability allowance under the Kerry County Council and how many were getting it under the Southern Health Board. I was not present in the Dáil when the reply was given; I was on a deputation with Deputy Donal Creed. The reply was that it was a matter for the Southern Health Board. I want to point out that I am not a member of the Southern Health Board. This State contributes 55 per cent towards the cost of health in the country. This Dáil passes the money and surely we are entitled to question the expenditure of this 55 per cent? That is the point I am making.
Mr. Begley: Unfortunately I was with a deputation. We were meeting some officials of the Department of Agriculture and Fisheries. Deputy Creed was also on the deputation with representatives of the milk suppliers from Rathmore. That is the reason why I missed the reply. I do not understand why the Minister has adopted the attitude that he is not prepared to tell us here tonight how this £7 will be collected.
Mr. Begley: Will new jobs be created? That is the question I am putting to the Minister. Who will have the discretion to levy a farmer with £7? When speaking in Irish, when  the Minister left the House, there were a few things I mentioned which I shall repeat now in English. One of them was that in certain houses on the western seaboard, especially in County Kerry and that part of County Cork now in the south Kerry constituency, the valuation of many farms are in the region of £15 to £25. That would be a fair average to take. According to a recent survey carried out by the county development team in Kerry and in Cork there are four persons in every house—father, mother, son, 22 or 23 years of age, daughter, 21 or 20 years of age. The ages may vary between 18 and 30 years of age. In such a household with a wife and two other persons depending on the husband it is very unfair that they do not qualify for a medical card because the valuation is too high. These people never looked for a shilling from anybody as far as health was concerned. If they got sick they sent for the doctor and gave him the £1, 30s or £2 that he asked for. These people will now have to pay £7. Out of each household there might be something in the region of £21 going towards health.
Mr. Begley: Would the Minister show me in his regulations any mention of relatives? I do not see any mention of the word “colceathar”. Would the Minister tell me where it is? It is not here. If the Minister is prepared to say at this late stage that relatives are covered, I will have little more to say. These are the people I am worried about—the son and the daughter who stay at home, the son hoping he will get the farm and the daughter hoping she will get married to the neighbour's son. If the Minister gives me an assurance that they are covered, my contribution here will have been worthwhile. I do not seem to be getting that assurance from the Minister. There is no mention of relative.  There is mention of dependant. How does one classify “dependant”? “Dependant” for old age pension purposes means the man's wife or the woman's husband or children under 16 years of age. There is no mention of the person from 16 to 40, 45 or 50. Perhaps the Minister would clarify the position? If he does I am prepared to conclude my contribution. I do not think he has said it anywhere in his regulations, speeches or otherwise. For that reason I would ask at this late stage that the Minister would seriously consider the case of the persons I have mentioned because it is not right to levy £21 a year on a family who might not have to call the doctor from one end of the year to the other. The people in that part of the country are healthy.
Mr. Childers: I have told the Deputy that dependants are not mentioned in the Health Contributions Bill simply because they will not be paying. If they were paying they would have had to be mentioned in the Health Contributions Bill.
Mr. Begley: Non-earning relatives, people living in the house with a farmer —a brother, a sister—anybody who is non-earning, are included in the middle income group in the £7 ceiling payment made by the farmer? Under what regulation is that mentioned? Where is that mentioned?
The Minister for Health, in exercise of the powers conferred on him by section 46 of the Health Act, 1970 (No. 1 of 1970), with the consent of the Minister for Finance, hereby makes the following Regulations, as respects which, pursuant to the said section, a draft has been approved by a resolution passed by each House of the Oireachtas:—
I shall not bore the House by going through it all. I do not want to make a farce of the proceedings. There is no mention of relatives in these regulations. According to what I know of the Civil Service mind as it operates, they are only looking for a chance to cut off any benefit to which a person is entitled. That is fair comment. We have a duty to the people who put us here to see that their misgivings are aired. This misgiving has been very forcibly expressed to me at Fine Gael branch meetings in south Kerry and west Cork. The Minister should be fair to the House and say that a young lad of 21 and a daughter, whether 18 or 21 years of age, will be considered as dependants when this Act is in operation. If the Minister will give me that assurance I shall not labour the point further but the point must be made.
I am very concerned that the new CEOs in the Southern Health Board will have power to levy this £7 on these people. The Minister should have a set of rules governing the operation of the Act by these people. Between what the Minister has said and what is printed there is a vast difference. If this represents the official instructions that the CEOs will have as guidelines —I am sure they will be circulated to the staff officers in the different counties who will circulate them to the assistant officers who will read them— they will give them the interpretation that I have given them, that a son or daughter over 18 is not regarded as a dependant under the Health Act.
As regards medical cards—this is the guideline I am using—if a medical card is issued it is only good for the husband and wife and any children under 16. If a farmer has a valuation over £12 or £13 he does not qualify for a health card. I can see this regulation bringing in a vast amount of revenue to the State. I wonder if the assistance officers who will be collecting this money will do so on a commission basis. If so, God help every small farmer whether he is from Kerry, Cork, Galway, Mayo or Donegal. We should have an independent arbitrator who would decide about this £7 because if it is collected on a commission basis  the assistance officers would regard it as an incentive bonus: the more they collected the more they would pocket. The Minister has not spelt out how this money will be collected.
Mr. Childers: I shall not go into it any further. I shall not reply to the Deputy. Otherwise we would wreck the procedure of the House. If people can discuss matters relating to another measure that already came before the House it would wreck procedure.
Mr. Begley: There is no question of wrecking procedure. I want to make my position clear. I began to speak in Irish and the Minister walked out and if I have to repeat myself in English I am doing so because, obviously, the Minister walked out because he did not understand my Irish.
This change is being made because the latter method is regarded as more equitable and also because it will ease the introduction of the arrangements under the Health Contributions Bill for the collection through the Revenue Commissioners  of contributions from self-employed persons.
However you look at it, these regulations should specify how this £7 is to be collected. Every Deputy on all sides of the House—I mean this—will have people coming to him saying they are exempt from the £7. I want to know who is exempt. The Minister has pointed out that to qualify for a medical card, if you are over 18, you are not regarded as a dependant and to be exempt from the £7, once you live in the house, once the father or mother is paying the £7 you are regarded as a dependant. That is the inconsistency. We are entitled to be told how this £7 will be levied and collected. I can see widespread abuse of this——
Mr. Begley: The Minister says the local health board will not dispute what he lays down. I agree with that but when we looked for information here about the health boards the Minister said we should apply to the health boards. In other words, the Minister was washing his hands of it. This is where the inconsistency arises. Last Wednesday I asked a question about the Southern Health Board and  the Minister told me it was a matter for the Southern Health Board. Today the Minister said he was responsible for the health boards: yet he would not answer a question on the health boards. Where do we stand?
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