Tuesday, 27 July 1971
Dáil Eireann Debate
Mr. Tully: I know the Minister for Health is anxious to get in to conclude this debate. I do not blame him. The Minister is a person for whom most of us have a very high regard as an individual but his handling of this whole matter—we must blame him for it even though his Department prepared it— makes us believe that as a politician he is not as astute or as honest with the House as we would wish. This sort of thing which he introduced last week and which he has made numerous efforts to conclude has left those of us on this side of the House who pay any attention to matters of this kind with the idea that there must be something to hide. We saw enough in it to know what he is trying to hide but there must be something more.
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.
Since we started talking about the new Health Act the Minister, on every possible occasion, assured us that with effect from a certain date he proposed to introduce a list of incomes under which insured workers would be entitled to medical cards and I assume other people would have their incomes assessed in a certain way which would show whether or not they were entitled to medical cards. Even as recently as two weeks ago, in answer to a question in this House, he told me that he proposed to introduce this regulation before the 1st October. When I impressed on him that this could reasonably be introduced or at least the conditions could be reasonably introduced now he said that there was a certain amount of work to be done on it and it would not be possible to do it before 1st October. At the end of his speech in a brief throwaway he says he does not propose to do it at all. In fact, he proposes to allow the matter to be dealt with by the eight CEOs. Does the Minister understand exactly what he has said? He has said that now he is giving to a group of people, some of whom had absolutely no information about or experience in health matters until their appointment as CEOs, the right to determine who should or should not be entitled to free medical treatment.
During discussion on the Bill dealing with health which was concluded before this issue was discussed, I said that instead of charging 15p for people to pay for hospital treatment he should use that amount on every insured worker and entitle him to have free medical treatment at all levels without  having to go cap in hand to any person. If the Minister did this he would be doing a good job but he did not adopt my suggestion. Instead, he introduced a selective tax in an effort to raise further income from those who are, according to the Minister, outside the medical card category. The Minister then says that he is not going to say who is entitled to a medical card, after talking about it for at least two and a half years.
Deputies who live in country districts —and the situation must be as bad, if not worse, in the cities and towns— know that there are people unable to pay for medicines and for doctors. Doctors who pay house calls, particularly in country districts, charge fairly hefty fees. When people are unable to pay for medicines they do not bother to send for the doctor because they know that the cost of the medicines and the doctor's visit will mean that a member of the family must go without a meal. We had hoped that the Minister would take some measures to ensure that all those entitled to free medical attention would obtain it. The Minister has said that he cannot do it but that he is giving somebody else the job—somebody who must, of necessity, know less about the matter than the Minister or his officials.
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.
 The only people who could have all the information available are the Minister and his officials. According to the Minister, a “considerable volume of statistical material” has been assembled. In some peculiar way the Minister proposes to pass that information to eight other people and to ask them to set a number of standards that may vary from town to country and from area to area. As a result of this, the situation will be much worse than it was originally.
Mr. Childers: Perhaps I should have told the Deputy that the chief executive officers will consult with the superintendent assistance officers and the staff officers who were concerned with this before the establishment of the health boards. Obviously they would have to. This may help the Deputy in his argument.
Mr. Tully: It would, but for the fact that during Question Time today I asked the Minister if I heard him correctly when he mentioned that in the south eastern area three senior officials on the Cork board had been transferred to the new health board and the Minister said that was correct. The Minister may not be aware that throughout the country a special effort appears to have been made to ensure that the staff officers, to whom he has referred, do not get appointments on the new boards. In fact, they were not considered as eligible to apply until I asked the Minister in the House if he would do something about the matter. As a result of his representations, the staff officers were informed that if they wished to apply they would be considered but this was not done until after an interview was held. In a number of cases the staff officers did not apply and I do not blame them. It is obvious they were being told they could apply if they wished but they had very little chance of getting the appointments.
How can the Minister now say that these people will be in a position to advise the CEOs when, in fact, most of them have terminated—or are about to terminate—their employment under health and are going back to local authorities as staff officers on roads, on  housing or in some other section? I know a number of such officers who have spent most of their public life dealing with health matters but a deliberate effort has been made to ensure they do not continue with this work.
In view of this, does the Minister wonder that some of us are suspicious about what will happen? Those of us in public life from time to time have received representations from people who considered they were entitled to medical cards. As holders of the cards they were entitled, under the Health Act, to certain services and if they did not get those services we could discuss the case with the staff officers. In no case could we intimidate the staff officer concerned, even if we wished to do so, because the officer was doing his job efficiently. The Minister can understand the situation that exists now. Prior to this we could talk to the staff officers employed in the local authority, of which we might have been members or have been associated with the authority. Now we must talk with somebody who does not know, or care, who we are.
The Minister has stated that the new arrangement will be an improvement. I can see nothing but chaos arising as a result of this gesture. Instead of the regulations being laid down by the Department so that nobody could accuse any person of giving medical cards to those not in need, or debarring those who were entitled, we now have a situation whereby the CEO will be entitled to decide who should have a medical card. This is the source of all the trouble.
It is not merely a matter of a regulation being introduced every year or every two years. We are discussing a new Health Act. It is framed in such a way that it will come into operation in stages during the next 15 or 20 years. We are discussing a measure that will bind not only those people we know but will affect their children and grandchildren. This is because some people have not taken the trouble to find out the best method; instead, they took the easy way out. In this case I accuse the Minister of allowing someone to sell him a story, which he accepted apparently without question,  that the proper method to deal with the problem was to hand it over to someone else instead of doing the job himself. I am deeply disappointed the Minister has not carried out what he has said he would do. I understood when the Minister gave his word to do something he would keep his word. I cannot understand why he has changed his mind in this matter or who has twisted his arm for the purpose of ensuring that the matter would be dealt with in the way now suggested.
There is another matter to which I should like to refer, namely, how means are to be calculated. Maybe I do not understand it fully. Like every other piece of legislation this particular piece of legislation is worded in such a way that it is extremely difficult for some of us to understand what exactly is meant. The suggestion here is that, instead of calculating yearly means by the method used to calculate them up to now, a new system of determining income is to be introduced. Section (2) (b) provides:
“Income” for the purposes of subsection (1) (b) shall mean the income of the preceding year ended on the 5th April and shall include all income which the person may have received for that year from all sources.
During the Seanad debate a Labour Senator asked the Minister if, in fact, income tax was being included or excluded. I am sorry; I should have said overtime. He asked if overtime was being included or excluded and the Minister very explicitly stated that overtime was being excluded. Would the Minister care, when he is replying, to explain what he means by saying:
“Income” for the purposes of subsection (1) (b) shall mean the income of the preceding year ended on the 5th April and shall include all income which the person may have received for that year from all sources.
I caught the Minister's comment—self-employed persons. There are, of course, self-employed persons who do other work and, as the Minister knows,  the income tax authorities will collect whatever should be collected as a result of any work done, including overtime earnings. It is very difficult to define the term “self-employed” and the Minister and his officials must be aware of this because, instead of saying self-employed persons who qualify under a certain heading, they have put in this section out of the income tax code. Am I to take it that what the Minister is saying is that self-employed persons who may be claiming medical attention under this particular section will need to produce a certificate of tax free allowance before they can claim? Is that so or is it not? Is the Minister saying that the only certificate which will be accepted will be the one accepted by the income tax authorities, not the visit from the home assistance officer or the superintending assistance officer, or anyone else? It is provided here in subsection (c) of section 2:
(i) regard shall be had to the amount of any income which would be chargeable to income tax under Schedule D or Schedule E as it would be determined for the purposes of an appropriate income tax assessment based on the income of the year.
The Minister was being a bit naïve when he said that these are self-employed because the reference even in his own brief is to people who are, in fact, employed and who, as well as being self-employed, may do a different job from time to time. It will be “God help the poor” if the Health  Act, the operation of which we have been watching for the past 12 months, the Health Act which will, we expect, be in operation for the next 15 or 20 years, it will be “God help the poor” if that Act is continued in the way apparently visualised in this particular section. I think the Minister has deliberately or otherwise—I would hope it was otherwise—created a situation which, instead of improving the position from the point of view of those seeking medical services, will in fact make it a thousand times worse. We know that the medical profession is in the main constituted of very humane persons, very dedicated persons who go out of their way to ensure that health services are given to those who need them. We also know, however, that there are people in the medical profession who believe that the primary object is to make money. All of us from time to time—I am sure no one more than the Minister—have had complaints from persons who tell us that the first thing the doctor did on coming into the house was to ask who owned the car outside the door, the car the breadwinner was using to get to work, or commented on the fact that there was a television set in the house and, because there was, the people living in the house were not entitled to a medical card. By a strange coincidence, in cases like that a medical card is very often withdrawn until a row is kicked up and the card is returned. We were hoping that the Minister in his introduction of a list of incomes for a medical card would do away with that kind of thing. In fact it now appears as if the situation will be worse than it was before.
The Minister referred the other day to a free choice of doctor coming into operation on 1st April, as well as certain other things. I do not know whether or not it is simply a question of the Department trying to fit things in in a certain way so that there will not be too much trouble for them or whether they are really interested in having a decent health service. It is my opinion that the former is the case. Like other speakers here, I am a member of a new health board. So far that health board is no better or no worse  than any of the others. So far it appears as if it will not do very much for the health of those who really need help. I have had experience of individuals who felt they were entitled to certain types of treatment. I had one particular experience in which the husband was earning the princely sum of £21 per week, including overtime. There were three children, one of whom was an invalid. The mother had a nervous breakdown. There was a history of unemployment in the family before that. The mother found it absolutely impossible to get a medical card. So did her husband. They found it impossible to get surgical boots for the invalid child. They found it impossible to get drugs. Everything seemed to go wrong. I kept assuring them when this new list was introduced they were the people who would of necessity come under the new scheme and there would be no doubt as to their entitlement or, as the Minister likes to call it, their eligibility to this card. Now we find that the Minister has no intention whatever of trying to draw up a list. He just dumps it back again —Paddy-go-easy; what was good enough for those before me is good enough for me—and he will deal with it in the same way.
The right of Members of this House to seek information from health boards has been challenged by some of the people running the boards and the Minister has been very definite that information which is available should be given to Members of this House and that Members of this House are entitled to information. Would the Minister state what he considers to be the right of a Member of this House, or of a county councillor who is not a member of a health board or, indeed, a member of a health board to comment, advise or make representations on the issue of medical cards? This is an issue which will become very live after 1st October and most of us would like to know where exactly we stand on this. There is no point in burying our heads in the sand and saying it is bound to turn out all right on the day. Many a thing has gone wrong because that attitude was adopted. There is the suggestion that this is something which  is only a matter of form and the Minister was very anxious to ensure speakers would not go outside the terms of reference of his regulations. If this particular regulation were not issued now in the dying days of this session—perhaps of this Dáil, as I believe it is—it would be debated for several weeks. I believe a number of people who would have taken part in this discussion are not doing so because they feel there are other matters that must be debated before the Summer Recess.
I should like to know from the Minister what are the opinions in his own party, not the opinions of those who will vote with him if a vote is challenged but the opinions of the backbenchers of his own party who do not appear to have been allowed to say a word about this Bill. We can always gauge the support a particular Government measure has in the House by the number of backbenchers or front-benchers who come in on the Government side to support it. Not many of them are rushing to speak in favour of the motion now before the House. The Minister has not got a word of support or encouragement from any of the Fianna Fáil Members in the House. Does he not think this strange? Is it not true that they feel as we do, that this is not the way to do things, that the Minister is taking short cuts which he should not take and that they are not prepared to stand up and be counted.
There are many aspects of this matter to which I should like to refer. Unfortunately, the section has been put into a sort of straitjacket so that the debate cannot be widened too much. We must keep within the rules of order. It is very difficult when commenting on something like this to keep within these limits in respect of something that has so many side effects which, in my opinion, could and should be debated. Unfortunately, we cannot do that; we must stick to what is on the Order Paper. Therefore, I shall conclude by saying again to the Minister that a mistake has been made. He should reconsider this question of issuing the instructions as to who is or  is not eligible for a medical card in black and white so that everybody will know without having to ask anybody else whether he or she is entitled to a medical card. Being a highly intelligent man with a sense of responsibility, as his record shows, the Minister should not try to bring in something such as he brought in here last week and think it would go through without comment or think it would solve the problems of medical cards. I believe the problems will only begin when this news breaks to the country that the long-promised and often-promised list will not be published.
I appeal to the Minister to reconsider this matter and not leave it to eight appointed people who are not approachable and who cannot be held answerable even in their own health committees because I am sure we shall be told that this is a matter which is reserved for the CEOs. At least the Minister can be held to be answerable in this House. The decision should be made to publish the list as promised and satisfy those who at present feel that they are not being treated fairly in regard to the issue of medical cards.
Mr. Fox: There are some of the Minister's proposals about which I as a Deputy representing a rural constituency, the one which the Minister himself also represents, cannot feel happy. In regard to the farming community we are told that a valuation of £60 is the maximum allowed, or an income of £1,600 for a non-agricultural worker. I find it difficult as a small farmer, to understand how the Minister, who represents mainly small farmers, can decide that a farmer with £60 valuation has an income equivalent to £1,600. It is still harder to understand how a farmer with £60 valuation made up mainly of buildings can be held to have an income of £1,600 a year.
I know, and I am sure the Minister knows, a number of holdings where the farmers may have a very small amount of land and a sizeable dwellinghouse and out-offices all of which are nonproductive of income. How often have we seen the Land Commission advertise a residence on a 400 or 500 acre estate together with a farmyard of 20  or 30 acres of land for sale. Suppose a farmer buys a place like that, his valuation would be much more than £60. Will those large and in many cases obsolete and tumbledown houses with high valuations bring in to the occupier or owner an income of £1,600 a year?
I think anybody living in such circumstances will demand from the Minister an answer to such a question. Personally, I know many people in Monaghan constituency who will expect the Minister to say how, on a small farm with a large valuation on houses, they are expected to earn £1,600 a year. I expect the Minister in replying to explain, not only to me but to everybody in those circumstances, how they can earn £1,600 a year from derelict buildings. I agree with Deputy Tully on the matter of giving the CEOs full control of the handling of medical cards. I do not agree with this idea. I believe the CEOs should have been consulted before the Minister put his proposals to the House.
As a member of a local authority, and a Member of the House, but not a member of a regional health board I want to know where I stand in relation to the regional authority. I want to know if they are in any way answerable to me or if I have the authority or power to go into a regional health office and inquire about certain cases with which I am acquainted, as are other Deputies.
Mr. Fox: It may not arise but it is a very important point, which I should like the Minister to clarify. It was not specifically stated in the debate who is responsible for the £7 or whether if a farmer has two or three sons residing with him and working on the farm that they in turn pay £7 each; or, if a farmer has two or three sons each of whom has a portion of land with a valuation of £5 or £6—which is common in our constituency—they must pay a contribution of £7 each.
Mr. Fox: I admit that we are not now discussing the Health Contributions Bill. Nevertheless, I am answerable to my constituents, many of whom have demanded an answer from me. On their behalf I am demanding an answer from the Minister.
The Minister knows that farm income is not keeping in line with incomes  in industry. Therefore, I would ask him if the £60 valuation will be reviewed annually and altered annually. Figures published by the Government in the past two or three weeks show that the farmer's income is lagging behind incomes in other employments. For that reason it is only reasonable that the Minister should tell us whether this maximum of £60 will be reviewed annually. If it is not reviewed annually, the equation mentioned by the Minister, £1 valuation equals an income of £26, might be upset. The Minister should tell us if this ceiling will be reviewed and altered annually. I am afraid I disagree with his theory that £1 valuation is equivalent to £26 income.
A person in receipt of £1,700 annual income, who has a wife and three or more children, should get some allowance over a single person earning £1,600 and having no dependants. I would respectfully suggest to the Minister that in respect of a married man with three children the ceiling should be £2,000. This would include an allowance of £100 for each dependant. There is no comparison between the financial position of a single person with a salary of £1,600 and a married man with a family of three or more earning £1,500 to £1,700 and being responsible for the cost of medical treatment for that family. I suggest that the case of the married man with an income of £1,700 and with three children should be reviewed.
Mr. Desmond: An effective national health service should have a number of very clear-cut characteristics. One feature which our national health service should have and which it does not have at the moment is an open administration. Within the health services there should be full publication of the general rules on eligibility, limited or general, and of administrative practices. In particular, there should be precise delimitation of the area of individual discretion left to the local inquiry officers and the CEO. This should be  statutory. There should be some form of appeals system. An appeals system is absent from the existing national health services in respect of the limited eligibility that we are now discussing.
I am afraid the performance of the Minister in introducing these regulations was not one of his better performances. That opinion was confirmed on reading the Dáil debate of 21st July. I would regard myself as being a partial admirer of the Minister's expertise.
The Minister did say that the chief executive officers would have available to them in their discussions with the Department of the formulae for eligibility a considerable volume of statistical material assembled in connection with the departmental examination of the whole subject of eligibility, both limited and general. It would be very valuable to Members of the House to have a reasonable amount of the statistical data prepared by the Department.
I am sure it makes every elector entirely cynical when he reads, as we have been obliged to read over the past decade, of the tremendous, the quite amazing variation in regard to general eligibility for medical cards. We have the situation, as has been eloquently pointed out by many Deputies, that for example in Dublin 12.3 per cent of the population are covered, in Roscommon 51 per cent are covered, in Donegal 41 per cent, Leitrim 40 per cent, Carlow 44.7 per cent, Kerry 43.7 per cent and Wexford 48 per cent. These figures are well known to Deputies. There is a disparity in the manner in which eligibility is arrived at and anomalies exist in many areas, county by county. This gives rise to the most outstanding area of cynicism and of straightforward allegations of corruption in relation to the health services in terms of the supply of medical cards to those who need them.
As a trade unionist and as one acting on behalf of other trade unionists I have always resented attacks on officialdom because most of those attacks are entirely unwarranted. Those officials have to administer systems as they find them, bearing in mind the local variations, but nobody  can accept the current widespread disparity of eligibility in the issue of medical cards.
The Minister said, when introducing this motion last week, that there was a considerable volume of statistical material available. I am quite certain the Minister has in his Department a tremendous amount of documentation available to prove the scandal that has developed in relation to the issue of medical cards throughout the country. This information should be issued to Members of the House. It would save us the difficulty, now that we know that statistical information is available, of having to put down all those tedious Dáil questions, even if they are only for written reply. The Minister should have been more forthcoming in giving us some indication of the formula for achieving maximum uniformity of approach. He has said that the officers in his Department are bringing the CEOs together with a view to working out a formula for achieving maximum uniformity of approach.
It is not good enough to come before the House and say: “This is going to happen, therefore give us the regulations, let us have the regulations adopted and we will then in good faith and good trust proceed to try to work out a formula.” As a public representative I have to suffer public humiliation every time I meet constituents who have applied for medical cards and who have had their applications either accepted or rejected for reasons which are unknown to me, and which cannot be conveyed to me. I have often been blue in the face assisting and advising people in filling up this famous Dublin Health Authority application form.
In the corner there is printed a statement that special circumstances, including unemployment, frequency or length of illness of the applicant or any of his dependants, should also be included. It also has on the back “For official use. Inquiry officer's report”. Then there is the peculiar mathematical formula, the details of which are unknown to us, numbered one to seven and then there are a few subtractions so that eventually by some computation  there is a decision taken in the Dublin Health Authority. The only objection I have is that the formula is unknown. If we could have the formula of the CEOs published or get some indication from the Minister about the maximum uniformity which he would like to see brought in, it would set our minds at rest. When travelling around the country I meet relatives in south Cork and in Kerry and I can give them a completely different version regarding their eligibility for medical cards from that which I might give to some constituent in south county Dublin.
We had laid before each House of the Oireachtas in January, 1966, the White Paper, “The Health Services and their Further Development”. I presume this was prepared immediately following the general election of 1965 with a view to obtaining a general rationalising of the health services. On page 34 of that White Paper the Government made a specific proposal when they said:
These regulations, it is considered, should be subject to the approval of each House of the Oireachtas before coming into effect. Persons within these limits would automatically be entitled to participate in the new General Medical Service, but it would be necessary to leave a discretion to the authorities operating the service to admit other cases experiencing undue hardship at any time because of special circumstances, in meeting privately the cost of medical care. The income limits fixed by these regulations would be widely publicised, thereby overcoming one of the shortcomings of the present system.
A persistent basis of criticism of the present service lies in the different standards of eligibility which are a consequence of local variations in interpreting the formula for the lower income group mentioned in paragraph 10, and in the fact that  the standards for eligibility are not published. Local health authorities must operate the law as they find it and variations such as these are probably inevitable in the operation of this somewhat vague criterion. It is, therefore, no reflection on these authorities that the Government accept these criticisms as valid.
We were told in 1966 something which we knew from 1952 onwards. The tragedy is that we are now in 1971 and that as yet the Government have not got to grips with this problem by giving the Dáil detailed information as to the precise formulae which we had hoped they would impress on chief executive officers at local level.
Therefore, I approach these regulations with a great deal of trepidation and I feel that the Minister, rightly or wrongly, is not anxious to upset the political apple cart by assuring, as he should do, all those Fianna Fáil Deputies, particularly those from the western counties who are so meekly silent in relation to medical cards and limited eligibility, that it is quite a different matter having half the population covered by medical cards on the basis, as Deputy Oliver Flanagan said here on 21st July, that no one knows better than Fianna Fáil Deputies that a most effective trump card at election time is the medical card. Deputy Flanagan spoke of the whisper at the door that unless Fianna Fáil are returned to office the medical cards will be taken from them. He said that the medical card has been responsible for getting hundreds of votes for Fianna Fáil, particularly in rural areas.
There is the other point that there should be some statutory offence laid down under the regulations or in general legislation in respect of employers who refuse to certify income for applicants for medical cards. It is not good enough that a health authority should have to reply to an applicant that until such time as his employer certifies the application it could not be proceeded with. I realise the majority of employers certify gross earnings. The vast majority are quite helpful, but there  are some who, either for income tax purposes or because they do not want to disclose what they are paying to such persons, are extremely reluctant to facilitate health boards. Such refusal should provoke instant reaction from the Minister. There should also be a method of assessing general income of families in this respect.
If the Minister accepts the suggestions of the House, he will be making the system fairer and more efficient. We will be changing the nature of the system and we will get away from the present system of medical cards and will be taking the assessment of eligibility out of the hands of the politicians. It is absolutely necessary we should do this. The medical card and eligibility for it should be taken right out of the hands of Members of both Houses of the Oireachtas. This is so because it is a subjective area of representation. I am always shocked in this House when Fianna Fáil Deputies stand up and say: “We in the Fianna Fáil Party have a special responsibility for looking after the poor.” Then one's blood begins to go cold when one begins to see political patronage, a kind of Tammany Hallism being substituted for national politics. One finds a constituent saying: “Thank you very much for getting me a medical card; if it were not for you I would not have got it.” When that happens to me I say that political and social education in Ireland is at a very low level. These are the social rights of the electorate who should not have to go to any politician in order to be able to enjoy those rights and to obtain the benefits of them.
It is with that in mind that I ask the Minister to speak from the rooftops so that people will not have any illusions as to their rights. I know the difficulties involved in assessing incomes of self-employed, of farmers and of certain urban workers. A better effort should be made on this. The Minister has been rather agitated throughout the debate. I do not think he expected the vehement reaction of the Opposition. Such reaction was deserved as far as the system is concerned and because the Government have been spending far more time  tearing themselves apart than tearing apart the health system.
Mr. O'Donnell: I can assure the Minister I will not detain the House too long but I must add my voice of protest against his failure to honour the clear undertaking he gave to the House in relation to the fixing of criteria for the granting of medical cards. We had hoped the Minister would have introduced some equitable system whereby the assessment of eligibility for medical cards would be standardised. Instead, the Minister has now decided to allow decisions in regard to the determination of eligibility to lie with the CEOs in the various health regions.
It is my conviction that the fact that in 1971 Dáil Éireann is discussing a health system which has come to be known as the medical card system is a terrible indictment of the social thinking of the Fianna Fáil Government. It became apparent long ago to every representative in this country that the medical card system is a diabolical method, that it is a degrading system, a relic of the old poor law mentality which an enlightened Government could have and should have abolished long ago. We still have this horrible system as an integrated part of our medical services and I hope the day is not far away when an enlightened Government will take steps to abolish the system in favour of a more equitable rational system.
I realise this debate does not permit a discussion of the full health services but I should like to say that the Minister has made a serious mistake in not attempting to accept his obligations in this matter. In view of the regionalisation of the health services, the Minister should have laid down some well-defined criteria for judging eligibility for medical cards. With the creation of this much larger administrative system, I cannot see how the chief executive officer in the new health region could be expected to have the personal knowledge of not merely the financial circumstances but the domestic, human and maybe psychological circumstances which very often enter into the determination of the eligibility of an applicant for a medical card. In  the system which has operated hitherto there was the closest relations between the public representatives and the health authorities. I can say from my ten years experience of dealing with the Limerick Health Authority that the officials were people who had a thorough knowledge of local problems, who understood the domestic and other circumstances of applicants. The officials were prepared to discuss the matter with public representatives and invariably interpreted the health regulations according to the spirit rather than the strict letter of the Act.
The laying down of well-defined criteria is now absolutely essential. Seeing that the Minister is a man who, when he has given an undertaking in this House, has invariably honoured that undertaking, I do not know what has happened in this case. Perhaps it is a further indication of the topsy turvy Government we have had in this country particularly over the last year and a half, who make a decision today and reverse it tomorrow. Even at this late stage I would appeal to the Minister to reconsider this matter. While we still have this medical card system, which I condemn, it is vitally important that the Minister would enable the new regional health boards to ensure that the question of eligibility for medical cards would be looked at equitably and realistically.
Mr. M. O'Leary: Many Deputies have mentioned the lack of uniformity in the granting of medical cards. This has been brought before the Minister on several occasions in the past year or two, and it is regrettable that we are still as far as we were two or three years ago from getting a national scheme under which all of us here could understand the principles on which the eligibility of applicants for medical cards is decided.
I had with me last night in my own constituency clinic a lady who had a liver complaint, whose husband was a cancer patient and who has one daughter working. They were involved in very heavy expenditure and, while they did get some help towards the supply of tablets which were needed by herself and her husband, because the daughter was working the medical  card had been withdrawn. She explained that it would be necessary to send for the doctor at various times during the week and even though her husband was in a serious condition she was very reluctant to call the doctor because of the expense involved. I am sure other Deputies could cite cases from their own experience in which similar hardship is involved whereby people must make a choice between saving the expense involved and meeting the gravity of the illness of the relative and must very often decide that they cannot call in medical advice because of the cost involved. It is regrettable that such a situation should prevail in our State in the year 1971.
Deputy Dr. O'Connell referred to the disparity in the number of people entitled to medical cards in one area as compared with another. Quoting from columns 2209, volume 225, of the Official Report of 21st July, 1971, he referred to information he got in reply to a question in relation to variations in the numbers of medical cards given. The reply gave him the information that in the Eastern Health Board 14.7 per cent of the population are in receipt of medical cards; in Wicklow it is 34.2 per cent; in Dublin, 12.3 per cent; Kildare, 26.2 per cent; and he remarked that in the Minister's own county of Monaghan it is 41.9 per cent; in Meath, 35.3 per cent and so on. There seems to be no acceptable national standard to decide eligibility. The result is that many people consider it necessary to go to this Deputy or that Deputy in order to get what they are entitled to. I am sure I speak for most Deputies in saying I look forward to the day when people will get their rights under the health system as citizens without the necessity of invoking the aid of any political ideology. The Minister promised he would do something before now but we still await standardisation in respect of eligibility.
Other speakers have mentioned that the £1,600 ceiling does not, in modern industrial conditions, adequately cover people who would need medical assistance. I accept that we have to temper  to some extent the defective system we have by this compromise where if necessary we at least give some assistance towards the cost of drugs where the financial position of the person needing help, according to the interpretation of the local health authority, seems to be over the ceiling. The ceiling of £1,600 is inadequate. It does not guarantee that we would bring within the safety net of the health services all those people who need help. An industrial worker might depend on his employer to provide a stretch of overtime. This overtime might not recur each year, but such a worker might earn over £1,600 in overtime conditions.
The nature of an illness should be taken into account. The cost of such illness should be examined. I cannot understand why the lady I mentioned has given all this information to the health authority. If I write to the health authority I would presumably be repeating the information which she has given and has already furnished to them. I am pretty confident that she should be assisted by the health authority to a greater extent than she is now assisted. I cannot understand why assistance should not be given to her.
Other Deputies may have experience of the fact that a letter with a title at the end of it apparently changes a case from one which does not require assistance to one which makes the person involved eligible. We would go a long way towards the elimination of the mystery in regard to eligibility if we laid down definite standards which all involved may understand—representatives as well as those requiring assistance.
The Minister's present proposals are an alteration of the regulations. It seems a pity that we cannot do more at this stage with regard to our health system. The Minister appears reasonably happy that the bodies which he has set up to administer the regulations will be more satisfactory than the old local authority system. The Minister may be right, but I have heard people say that they feared the lack of connection between these larger authorities and the ordinary people, and that the  number of vocational interests from the medical profession which are involved may result in more tenuous contact than the old system had. The members of the old local authorities had close connections with the community they served. It is open to doubt whether the same can be said of the new larger authority. The old authority kept in close touch with the area served. When we depart from the elective system, as we apparently have departed, when we consider the majority make-up of these new authorities, one certainty is that we will run into a great deal of community opposition of one kind or another even where there is an improvement in the service of the area concerned. A hospital might have greater rationalisation and the patients might get better service in a central hospital complex but the ignoring of the elective principle in the make-up of the new authority may result in great opposition even though the Minister's motives may be the best. I am not suggesting that there was a better authority under the old system but I am expressing a word of caution in relation to this matter and saying that unless the elective principle in such bodies is acknowledged then whatever improvements may result from the larger-sized authority must be weighed against the resulting lack of contact in the areas served. It is a pity when the Minister has shown such energy in reorganising the areas to be administered that he has shown such lethargy in attacking the main faults of the service, which speakers closely connected with the problems have drawn attention to down through the years. Deputy Dr. Byrne and others have called attention repeatedly to the unfair features of the old system. So long as we have people who must make the harsh choice between the need they or their relations have for medical treatment and the cost involved the problems remain, and we cannot say that we have a health service that we can be proud of.
Many of us are acquainted with the conditions in Britain and the north. We know that whatever the faults of the socialism which is so often attacked from the benches opposite the services inaugurated by “Nye” Bevan have made fantastic changes in the lives of  our fellow-Irishmen in Northern Ireland and in Britain. It is a great pity that a country which boasts so much of its former Christianity seems incapable of bringing any of this theoretical belief in Christianity into practical effect. It is a great tragedy that Deputies must listen to cases, such as I have listened to recently, of people having to come to a Deputy to claim what should be their ordinary rights.
I cannot congratulate the Minister on this regulatory change here nor can he in conscience blame the House for discussing what he might regard as irrelevant tangents. So long as the main features in the health services continue as they do and so long as the Minister evades his central duty as Minister of Health all Deputies must take every opportunity of bringing home to him and his advisers their total dissatisfaction with the health service as it stands.
Minister for Health (Mr. Childers): First of all, I want to make some general observations on the impact of the medical service relating to full eligibility and limited eligibility in past times. The whole community of this country is from 50 per cent to 60 per cent better off in real terms than they were ten years ago. Nobody can dispute that. There are pockets of poverty which have to be eliminated. No one suggests that the social problems have been solved, but it is interesting to note that in spite of the great improvements the numbers in the limited eligibility and full eligibility groups have not markedly changed. In other words, within the community which has become more prosperous there are 30 per cent in the full eligibility group and 60 per cent in the limited eligibility group. In so far as objections have been made in this House to the concept of limited eligibility—they were made to some extent by Deputy Dr. Browne—all I can say is that we have a long way to go in improving the health services. We have also to keep up with the advancing techniques which can be seen here and in other countries. The World Health Organisation figures for the general health conditions in this country show that a great deal of what Deputy Dr.  Browne said is grossly exaggerated. The health statistics provided by WHO leave us among the top ten or 15 nations. That does not mean we should be complacent because in every country as in ours there are defects, deficiencies and inadequacies in the health service. They vary from one country to another. We have a great deal of work to do to improve the services. Nevertheless, I thought I had better make that observation at the outset.
Secondly, I ought to say I have no evidence in my Department that there are large numbers of persons suffering from illness because, being in the limited eligibility group, they cannot afford to go to the doctor. This is partly due to the fact that the hardship clause in regard to medical card provision operates in the marginal area between those on full eligibility and those on limited eligibility. Were it not for that I would not be able to make that statement. The application of the hardship rule does make a very considerable difference in this marginal area.
I want to make clear to the House that there is no suggestion that the creation of regional health boards should have the effect of centralising those health services which are naturally decentralised services. Deputies and other persons will be able to appeal to the officers who are delegated to look after medical cards in local areas. They will not have to go to the chief executive officer who will have to rely on the opinions of officers delegated by him, staff officers or superintendent assistants officers. The idea that in enlarging the health administration area I was going to appoint some kind of maharajah at the head of each health board who would be utterly out of touch with people in local areas is completely false. I have made absolutely clear in all my descriptions of the health board that on the one hand there is an inevitable concentration of hospital facilities and a reorganisation of hospital facilities and on the other there is the growth of decentralised services such as the  public health service, and the operation of the medical card group in which the structure of the administration of the health board will be such that nobody will be able to say in the future that people's individual rights and problems will be ignored because of the enlargement of the health board. That is one promise I can make without any fear partly because those members of the health board who read the McKinsey Report could find no evidence in it that this firm of consultants was trying to centralise everything. In fact, in the detailed reports it was made perfectly clear that there would be a properly graded structure of officers within the health board providing better opportunities for promotion and providing at the top people whose qualification would be better than they had been up to now and that there would at the same time be very adequate local administration.
There has been criticism about the income limit of £1,600. The hardship arrangement has been operating in the case of persons with large families whose income is just above £1,600 and it will continue to operate in relation to people in the marginal group between limited eligibility group and the upper income group. The figure of £1,600 was based on a decision made by the Government looking at the changes in the cost of living over various periods. In 1953 the limited eligibility maximum was £800; in 1966 it needed only to be raised to £1,000 but was, in fact, raised to £1,200.
Mr. Childers: To keep the standard of living the same. In 1952 the figure of £600 was the upper limit, whereas in 1971 the figure should have been £1,400 but has, in fact, been made £1,600. On can argue at what point one should take a decision to make an allowance for the cost of living increase but I do not think there is anything inequitable in striking a figure of £1,600 at the present time. In the case of farmers where the upper limit is a £60 valuation, I want to make it  clear to the House that if the very few farmers in the country who have very highly rated buildings feel they are being deprived of limited eligibility, because with the valuation of their buildings being included with the land valuation they are comparatively small farmers, and if they can prove that their income is less than £1,600, they can remain in the limited eligibility group and this is absolutely definite.
Indeed, I was thinking back on the questions I have been asked in the Dáil debates in which I have taken part and very little mention has been made up to now of farmers with highly rated buildings. As far as I am concerned this question has not arisen until the present debate. I want to make it clear that if farmers in that special position can prove their incomes are not in excess of £1,600 by indicating their general means the fact that their buildings are highly valued can be taken into account in relation to their applicability in relation to the limited eligibility group.
Deputy Tully asked if overtime is excluded in relation to the limited eligibility group. The regulations in relation to income based on the income tax code apply to self-employed persons, insured persons are assessed by Social Welfare and we will accept whatever have been their rules in that regard. I have not had any complaints and I do not think my predecessor received complaints in relation to the former upper limits that Social Welfare were not making allowance for perpetual and continual overtime or that their decisions as to where to limit the Social Welfare class were inequitable. In any event, we propose to accept their rules in future, whatever they are at present in regard to overtime.
Deputy Tully also mentioned that the applicant must produce a certificate of tax free allowances. The evidence of eligibility in the future for self-employed persons will be either (a) the possession of a medical card or (b) having paid the contributions required under the Health Contributions Bill. This will be a receipt from the  Revenue Commissioners of the amount of contributions required.
Deputy Tully also referred to self-employed persons who work casually for employers. In such a case the employer would presumably have to stamp a social welfare card for the week in which the man was employed. This stamp would entitle the person to limited eligibility irrespective of the amount of his income from self-employment. These people would be in rather an unusual and, perhaps, more privileged position than others but I imagine there would not be very many of them.
I would like to say a little more about this whole question of the limited eligibility group. Not many Deputies said that people in this group could be classified as poor people although a number of Deputies did seem to speak in this way. The fact is that in relation to taxing anyone else in the community in order to provide more services for the limited eligibility group, we cannot tax the 30 per cent who have full eligibility and neither could we ask the 10 per cent of those who pay for most of their health services, with certain exceptions, to pay increased taxation. I have indicated to the House already that the rates of taxation for the upper 10 per cent compared very much with those than can be found abroad. I have not had any proof that the 60 per cent group are persons who are mistreated because of limited eligibility, allowing for the special services made available to them at present and which will be made available in the future.
May I remind the House that, first, there is the actual hardship clause for persons in this category and, secondly, that the Vote from my Department towards drugs for the limited eligibility group is of the order this year of between £250,000 and £280,000. This is matched proportionately with a rate contribution. Outpatient fees were abolished as and from the 1st April and I shall be introducing regulations for free drugs for adults of all income groups and free drugs and hospital treatment for young persons of all income groups in respect of special  disabilities, a list of which will be published with the regulations.
Later, we hope, as time goes on, to devise a system which is provided for in the Health Act whereby we might, if we can find the financial resources, arrange to pay for drugs costing more than a certain figure for those in the middle income group. That is something about which I can make no absolute promise but it is on the list of improvements in the service that I should like to undertake. However, as the House is aware, there have been very considerable improvements in the health services during the past two years. For example, there has been the child health scheme which, I am glad to say, is proving successful.
A number of Deputies raised the question of varying percentages of people in different areas who receive medical cards. Of course, the reasons for this are numerous. For instance, some countries may have more low income group people as a percentage of the total number of people in the county than others. Unquestionably, standards differ to some extent as between one county and another. It is true, equally, that in certain counties a certain number of people may not get medical cards until such time as they require them and occasionally one will find persons paying a private doctor and who do not obtain a medical card unless they require hospital treatment. Pay increases, too, change the numbers on the roll of the medical card list and there may be some different applications in different counties in regard to the hardship clause. All these factors affect the percentage of persons receiving medical cards. During the debate I heard observations in relation to the position in Dublin where, compared with other areas, a rather small number of persons receive medical cards. This may be due to a difference in standard but I would refer those Deputies who spoke on this matter to a comment by Deputy Garret FitzGerald in today's issue of the Irish Times in which he says:
Mr. Childers: I shall deal now with the observations made about the alleged corruption and Tammany Hall activity by the Fianna Fáil Party in relation to assisting or helping people to procure medical cards. This is ridiculous talk. I have been in politics long enough to know that if TDs of any party can bring evidence to bear when speaking to officials of county councils that a person should receive a medical card, the officers of those county councils are sufficiently honest to pay attention to parties of all political complexions. Does anybody here deny that? Was Deputy Oliver Flanagan speaking the truth when he suggested that Fianna Fáil could win elections because of the issuing of medical cards? Certainly medical cards have not been mentioned to me in the context of a live issue in any constituency that I have represented since 1938. There may be some individual cases in some areas where this matter is being raised by someone and where this suggestion can be made but I have no knowledge of this.
Deputy Oliver Flanagan and others have been insulting the intelligence and decency of people in suggesting that Fianna Fáil have retained office by reason of the enormous influence they can assert on local authorities in relation to the procurement of medical cards. Is not everybody aware that the vast majority of medical cards are awarded by the officers of local authorities without any intervention whatever or, if there is intervention, it is totally unnecessary and that most of the cases in which TDs, in my view,  intervene rightly—these include TDs from all political parties—and in which county councillors and the clergy intervene are in respect of hardship cases that never could be put down in the form of written standards either by the CEOs or by me as Minister? Is not everybody aware that no matter what system of public standards we have there will always be a considerable number of hardship cases in which officers operating on a health board may not know all the circumstances of a particular family? Do I have to tell Members of the Dáil that one of the reasons why TDs, county councillors and others are able to obtain help for constituents is because the constituents themselves do not know how to put their case in the best way? Deputies, in particular, are skilled in how best to present a case. They extract all the information and present it in as forceful a manner as possible. I see no harm in that. I regard it as one of the privileges of democracy. I do not see how we could change that system.
Mr. Childers: Certainly it operates here and in other countries where there is an element of hardship and there is hardly a case where rules could be prescribed so rigidly that there would not be hardship cases. As Deputies know, there can even be hardship cases in relation to matters such as land project grants or farm building grants where an inspector may have wrongfully judged or undervalued the work performed. Are we not all aware that this goes on and is it not inevitable in a democracy? One could not prescribe a national system of standards in which there would not be a hardship element.
Mr. Childers: I do not believe this talk of corruption and if Deputies boast too loudly about the medical cards that they can obtain and if they do it too professionally in the sense that they claim credit for getting medical  cards that would have been got anyway, that is merely a weakness of human nature and I can do nothing about it. I would hope that in the year 1971 when the people are far more highly educated than they used be, few Deputies would imagine that in the long run they could gain votes by that method.
Maybe I have too much faith in the common sense of the Irish people but I believe that the majority of people are aware of the position, particularly in cases where people are fully entitled to a grant or a service, and I would hope that Deputies would not exploit the position. I do not believe that many of them do. In relation to hardship cases there will, quite inevitably, continue to be intervention.
In relation to the medical card service there is one fact which has not been fully appreciated by the House and which, I think, I ought to mention. That is that the number of those receiving medical cards has gone down by about 6 per cent in the last four years. I think this is due partly to the growth in prosperity, but it is not being accompanied by any tremendous questioning in this House. Nobody seems to have noticed this. I merely mention it in passing to show that there can be a 6 per cent reduction in the number of medical cards in the country. It still remains at roughly 30 per cent of the whole population. I mention this in passing to illustrate that these changes can take place.
Mr. Childers: I have asked the chief executive officers to come together and to establish a consistent standard for medical cards, excluding the inevitable hardship element. I will ask the CEOs to publish those standards, if that is any help to the House. That answers some of the criticism made that up to now nobody seemed to know what the standards were.
There is, it is true, a great deal of information collected in my Department, but I felt very strongly that it would be extremely difficult for me to comprehend the whole of the variations that take place in the different  areas. The CEOs will take advice from all the persons in the counties who were formerly members of the county health authorities, and who are steeped in local information, in order to arrive at a consistent standard for medical cards. Quite obviously the CEOs themselves, those of them who are inexperienced in this work, could not do it; but they will not only have the information from my Department, but they will be able to get information from the local offices and I hope that they will do a good job. I will be responsible for their job. If they do a bad job it will be I who will have to face the Dáil and the public. I can only hope that their job will be successfully concluded and I am quite certain that the standards should be published.
May I make it perfectly clear that there are bound to be some changes as between one county and another when the standards are published because there are variations in different areas. I have made it clear to the CEOs that I do not expect to have an increased number of persons receive medical cards because I do not think that is necessary. I have also made it clear to them that they should observe that clause in the Health Act which declares that when the head of a household and his wife are being examined for a medical card the incomes of those who are earning and who live with the head of the house and the spouse should not be taken into account in deciding whether the head of the house and the spouse should have a medical card. That will have the effect, in some areas, of increasing the number of medical cards.
Those will be two specific indications to chief executive officers, (1) that  the total number should not increase and (2) the one I have just given about the income of the husband and the spouse in relation to their application for a medical card.
Deputy Cooney suggested that there will be a reduction in the number of persons receiving medical cards because of the enormous cost of the choice of doctor arrangement. That is untrue. The £600,000 odd will have to be found in any event and I have given absolutely no direction to anyone that the numbers of medical cards should be dramatically reduced in order that somehow or other £600,000 would be found from the medical card. Departmental and local authority expenditure will provide for the choice of doctor principle. The £600,000 will have to be found by those who pay taxes and rates.
Deputy Coughlan suggested that under section 4 of the Local Government Act elected members could change a manager's decision on eligibility. This is absolutely untrue. Under section 4 of the City and County Management (Amendment) Act, 1955, a local authority can direct a manager in the performance of many of his functions but the act specifically excludes, in section 4, any right to give directions on applicability of health services in individual cases.
I should mention that 90 per cent of the farmers of this country are under £60 valuation. I think when that is appreciated by the House they will realise that a very large number of farmers are covered either by medical cards or by limited eligibility services.
Deputy Cooney asked whether the CEO will have authority to go to the inspector of taxes for confirmation of a claim that a person has limited eligibility. This, he suggested, would conflict with the confidentiality of the income tax code. The CEO will not do this. In practice, the Revenue Commissioners would have assessed income for the purpose of collecting contributions  under the Bill and the applicant would have evidence of paying the contribution. This would satisfy the health board as to eligibility and the board would not have to make further detailed inquiry. Deputy Cooney also suggested that the fact that the income in the preceding tax year was taken into account would cause hardship if the current year's income was less. The Revenue Commissioners do have to relate their calculations to the preceding tax year's income but in any case where income subsequently fell this could be dealt with by the hardship provisions, section 46 (8) of the Health Act.
Deputy Fox made a point about farmers who have low land valuation and high valuations of buildings. He referred specifically to County Monaghan, which I represent. Only 596 farmers in County Monaghan are over £50 valuation and we might say that 400 of these are over £60. There are something like 6,500 farmers in Monaghan. This is about 6 per cent of all Monaghan farmers. It is only in the case of a fraction of the 400 that there is a possibility of the unusual case referred to by Deputies, namely, a very high building valuation. I think I have already dealt with that and pointed out that it is up to farmers to prove that they earn less than £1,600 if they feel that the valuation is not to their advantage.
Deputy Desmond and others referred to an appeals system in relation to  decisions on medical cards. In fact, this is provided for in section 47 of the Health Act, 1970, and regulations will be made under that providing for appeal, probably to the CEO.
Deputy Desmond complained that employers might refuse to provide evidence of earnings for decisions on medical cards. There is no provision in the law compelling them to do so. This matter has been raised only in this debate and if there were evidence of widespread refusal by employers to provide this evidence, which could not be overcome otherwise—for example, by legitimate union action—it would be necessary to consider this point in future legislation.
Dr. Browne: The Minister has talked about standards. It is not an income or valuation standard, nor is it a standard in relation to the number of children in a family. Can the Minister give a broad indication of the kind of standard he has in mind to be fixed by the local authority?
Brady, Philip A.
Connolly, Gerard C.
Cunningham, Liam. Meaney, Thomas.
de Valera, Vivion.
Gogan, Richard P.
Healy, Augustine A.
Hillery, Patrick J.
Kitt, Michael F.
Lalor, Patrick J.
Lemass, Noel T.
Lynch, John. Power, Patrick.
Clinton, Mark A.
Conlan, John F.
Cooney, Patrick M.
Dockrell, Henry P.
Dockrell, Maurice E.
Enright, Thomas W.
Fitzpatrick, Tom (Cavan).
|Flanagan, Oliver J.
Hogan O'Higgins, Brigid.
Jones, Denis F.
Murphy, Michael P.
O'Connell, John F.
O'Sullivan, John L.
Question declared carried.
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