Wednesday, 17 May 1978
Dáil Eireann Debate
That Dáil Éireann, noting the serious and growing anomaly in the income eligibility limits of non-manual workers for health services and maternity care under the  Health Acts relative to manual workers, and in particular noting that with rising income levels many thousands of non-manual workers are now excluded from free hospital care, calls on the Government to abolish all income limits forthwith.
“notes that it is the Government's intention to review the income limits and criteria of eligibility for the purposes of limited eligibility for health services in conjunction with the introduction of a pay-related health and social insurance contribution scheme in April 1979”.
Mr. B. Desmond: : The Labour Party wish to emphasise that any income limit for cover under the Health Acts for any category of worker is fundamentally wrong. We believe that there is a growing acceptance in our community that such an essential service as hospitalisation should be available to all persons, irrespective of income and category.
In April 1974 the income limit for insurability under the Social Welfare Acts was abolished. It was announced at that time that the income limit for limited eligibility under the Health Acts would also be abolished. This decision was only deferred pending the completion of negotiations with the medical consultants. In April 1974 an income limit of £2,250 was introduced pending the completion of negotiations. This income limit was raised to £3,000 in July 1976. At present, approximately 38 per cent of the population are covered by the general medical services scheme and therefore have full eligibility for health services.
While we know the extent of medical card issues, great doubt surrounds the extent of the availability of limited eligibility benefits. The Department of Health's present estimate is that  50 per cent of the population are covered for limited eligibility. There is, however, a margin of error, among other reasons because of the time lags between increases in incomes and the income limit being raised. It must be pointed out that in 1958 some 90 per cent were covered by free and limited eligibility as opposed to the current estimate of 85 per cent.
The remaining 15 per cent of the population are responsible for the full cost of any medical services they require. This 15 per cent can only insure themselves against such costs with the VHI, a private organisation. I consider it intolerable and highly undesirable to have a situation where health insurance becomes a matter of indvidual concern for the worker without employer or State involvement, as is the case in VHI cover. It must be noted that no provision is made by the VHI for cover against the costs involved in the birth of a child, cover that is available under the Health Acts.
The present income limit of £3,000 for limited eligibility for non-manual workers was set in July 1976. The scope of limited eligibility is declining rapidly due to changes in earnings since that date. We believe that unless the income limit is abolished by the end of this year a high percentage of workers at present with limited eligibility will have no cover. They will be forced to pay for the full cost of any medical services they require. I am convinced from correspondence I have had and from complaints received from trade unions that acute difficulties have been created for large numbers of workers and there is the threat posed to many thousands more as income levels increased this year as a result of the national pay agreement and so on.
Due to the present income limit of under £58 per week scores of thousands of non-manual workers in the public and private sectors are ineligible for free hospital treatment even though they are on comparatively low salaries, as we pointed out to the Minister. I was astonished when the Minister on 1 March stated that non-manual workers who were eligible under the  £3,000 a year limit when it was introduced in July 1976 would continue to be eligible for limited eligibility services at least until the beginning of 1979. There seems to be a complete gap in communication between the Minister and myself in that regard. The Minister slid away from the implications of what we were referring to on 1 March and we let him get away with it. Persons who exceeded £3,000 for the first time after 1 July 1976 will retain eligibility until at least the first Monday in 1979. However, what was not mentioned by the Minister and was not mentioned in this debate were those people who were entitled to limited eligibility and whose income exceeded £3,000 prior to 1 July 1976 and who were cut off on 31 December 1977. I put that point to the Minister but he slid away from the implications. I want to know how many thousands of people are involved.
Mr. B. Desmond: : I have my strong views about what Deputy Corish did in relation to this matter. The consultants hammered him and he knows it, but there is no reason to believe that the Minister with his aplomb and with his capacity for tough negotiations should not be able to take them on. I shall come to that point shortly.
I wish to point out that the first Monday of each successive year will be a cut-off point for further groups of people unless a new scheme is introduced immediately. The Minister gave a correct answer to the question on 1 March but it was only half an answer. I was astonished at his reply. The Minister knows much more about the implications of the cut-off point than he is prepared to concede. He said that non-manual workers who were eligible under the £3,000 a year limit when it was introduced would continue to have eligibility. I hope I have now convinced him that coverage until 1979 does not apply to employees whose earnings exceeded £58 per week due to increases other than increases under clause 3 of the national wage  agreement. Let him ask the staff of the Eastern Health Board who have been administering this scheme. Perhaps the Minister will reissue some regulation. Perhaps his Department will get in touch with the administrative staffs of the health boards but I have been assured that apart from the increases covered by clause 3 of the national wage agreement——
Mr. Haughey: : On a point of order, this is a very important point. Deputy O'Connell was very anxious yesterday that we should clear up the situation for the benefit of all concerned. I wish to state quite categorically that the source of income has nothing whatever to do with it. It does not matter where the money comes from. It is the amount of income received that matters.
Mr. B. Desmond: : I am delighted to hear that, but I suggest that the Minister informs the administrative staffs of the health boards. Workers come to me, they come to Deputy Barry in Cork and they come to organisations such as the Post Office Workers' Union, the Distributive Workers' Union and to the appropriate sector of the ICTU and they say that overtime payments, incremental increases, productivity increases and so on are sufficient to rule out a person for eligibility. There is a major anomaly here.
I want to contrast the situation with the farming community, which the Minister dealt with competently in his speech yesterday and which Deputy O'Connell also stressed. Farmers with a rateable valuation of £60 a year are eligible for limited eligibility services under the Health Acts. The Government acknowledged in the recent budget that that rateable valuation is equivalent to an annual income of at least £5,400 per year. This means that farmers with an income of up to £100 a week are eligible for hospital services and maternity care under the Health Acts, whereas non-manual workers with an income over £58 a week must pay for the full cost of these medical services. That is an outrageous anomaly. One should not have  to wait until April 1979—and I have the gravest doubts about that date— for the Minister to eliminate that anomaly.
I accept that the present system for determining eligibility is extremely complex and I accept that it contains many anomalies. The Minister gave an excellent example last night where a foreman in a pub is ruled to be a non-manual worker and the man behind the bar is a manual worker. I could give many more anomalies. A man driving an engine is deemed to be a manual worker but the person checking the tickets is a non-manual worker. These beautiful distinctions were introduced by Fianna Fáil—servants and nonservants. Such distinctions destroy social structures and are completely discriminatory. The whole system is enormously expensive to administer.
This problem can be resolved only by the abolition of the income limit for non-manual workers. I would urge the Government not to fall into the trap. There is a tremendous temptation open to the Minister here. All hell will break loose if the temptation is yielded to to introduce a new eligibility limit, a new cut-off point for manual and non-manual workers, that is to make it £5,000 or £6,000 a year and if a manual worker goes over £5,000 he will be hammered. I suspect the Minister would love to yield to that temptation but he knows the political consequences of it. That would mean that manual workers for the first time would have an outstanding service, which they have had down through the years, taken away overnight. That would be enough to get Fianna Fáil out of power in the next election without any great difficulty.
Thousands of workers are now affected because they cannot afford to wait until April 1979. There is no assurance that the system will be in operation by April 1979. I know the staff involved. I know the Revenue Commissioners' problems and I know the problems of introducing a pay-related social insurance contributory system. I know those problems are connected with the health services as well. God help the Minister if he dares to bring in a 1 per cent or 2 per cent clawback  on salaries in terms of the health services. It is bad enough getting an 8 per cent increase under a national pay agreement to be told the following year: “now we will take 2 per cent back because we will give you an extension of the health services”. This would cause great problems for the Minister. There are major administrative and political problems to be resolved which are currently being tossed around the Cabinet and I do not see those problems resolved by next April.
The Minister met the congress representatives on 19 December 1977. It was emphasised to him that the decision was urgently necessary and that further delay in rectifying the injustices and anomalies inherent in the present situation could not be tolerated. The Minister was then informed that thousands of workers on comparatively low salaries were losing eligibility. One of the factors we must bear in mind here is that the Government have implemented reduced social insurance contributions for insured people earning less than £50 per week. The Government have explicitly acknowledged in that that £50 a week is a relatively low pay threshold. It was some considerable time ago that that £50 was announced by the Minister but the operation of the income limit for non-manual workers for eligibility for hospital treatment and maternity care is not significantly above this figure of low pay. It is £58 per week. If one adjusted, even on a pay increase basis or a cost of living basis, the £50 from the time the Minister previously announced it, it would be around £58 now. It means that people on comparatively low incomes are losing eligibility. I do not accept the argument that if people are knocked out they can well afford the cost.
I do not believe it is necessary for me to repeat any other examples of the anomalies which have arisen in making a distinction between manual and non-manual workers. I believe that any discrimination in a socially just society, based on category of worker, must be unacceptable. Apparently the working party on the definition of limited eligibility, set up by the Department of Health in January 1977 by the then  Minister for Health, Deputy Brendan Corish, have not been able to resolve these problems. The Minister must know that the only way they can be satisfactorily resolved is by the abolition of the income limit for non-manual workers in order to bring them into line with manual workers.
I refer the Minister to the NESC Report, No. 29, published last July which conclusively refuted the arguments put forward against the abolition of the income limit on eligibility and, in particular, expose the absurdity of the distinctions made between manual and non-manual workers. The Minister is well aware that we have pressed for an immediate decision on the matter. Trade Unions, in particular, are astonished, that no decision has been reached. I could quote what was said about this matter in the Garda Editorial, The Garda Review and many other magazines where industrial and private sector workers are astonished that the Minister has not given a decision. It is no use saying that people are all right until the end of the year and that there is nothing to be worried about. Everybody is worried stiff as national pay agreements occur and their health costs increase.
As the Minister well knows a universal limited eligibility has been rejected by the consultants. I consider that Deputy Haughey is a most competent politician, that he is superb in many ways. I would not agree with him on many things but as a politician and a Minister he has a lot of experience and I believe he is the man to take on this job. The Minister said he would go down in the history of the country as the best Minister for Health the country ever had. Now is his chance to prove that.
Mr. B. Desmond: : That may be a Freudian slip, but we will continue. The consultants and the doctors maintain that if we had a universal limited eligibility there would be a massive increase in demand for the health services. The NESC Report, which dealt  with some major issues in health policy, suggested that the demand for hospital care is quite low. The last place on earth I want to go is into hospital. The people in Ireland are not rushing into hospitals demanding hospitalisation. They also suggested that the extension of limited eligibility to the remaining 15 per cent not covered would not result in them demanding immediate hospitalisation as the Irish Medical Association and the Medical Union suggest. They are trade unionists but when it comes to professional care and so on the delivery of income is far more important than the delivery of health care. I say that with the greatest respect to my collague, Deputy O'Connell.
I suggest that patients by and large demand care when they are not well. Some of the 15 per cent would inevitably opt to continue using private facilities. The public expenditure implications lashed around the place by the medical profession of universal limited eligibility are quite small. The medical associations unambiguously predict massive demands but their predictions are quite contrary to the evidence of health care systems in other countries. The doctors are the very people who determine by and large the demand for hospital beds. People do not go to doctors telling them to send them into hospital. People want to be cured.
I suggest that the case is quite clear. The Minister should tell certain people to go away. Limited eligibility will cost a certain amount of money but I believe that a careful costing within the Department will show that it will not cost a great deal of money. I also  believe that the cost of administering the current complex programme of full and limited eligibility must be substantial. Perhaps in the research section of the Minister's Department a very careful assessment has been made of the saving which would be possible if means testing was abolished. I am quite convinced that if one asked each of the health board programme managers tomorrow morning “How many of your staff are actually engaged in processing those claims? Let us release them to do more protective work for the community”, one would discover that the savings would be quite substantial. The present system is an administrative clumsiness and costliness.
I shall conclude on this note. The late Deputy Donogh O'Malley went out to the NUJ Conference in Bray and shocked everybody out of their trousers, including the then Taoiseach, and announced free post-primary education. He had to explain himself to the next Cabinet meeting as to what in God's name he was up to. He said that it was their problem. He told many a story about it. He said, to the then Taoiseach, “Your problem is to find the money. I made the decision. I made the historic announcement.” The present Minister for Health and Social Welfare should do a similar thing and say to his colleague, the Minister for Finance “Now, George, your problem is to find the money. I have got a lot of votes for my party at the next general election. I have made an historic decision.” Then, of course, he could disappear to Kerry onto his island away from the consultants before they got him to change his mind. The Minister should take an historic decision this year and I have no doubt——
Mr. B. Desmond: : The Minister knows precisely what it would cost. In  all seriousness it would have a traumatic effect on the situation at present obtaining in which many constituents I represent are quite uncertain as to their rights, quite apprehensive and even confused as to their precise eligibility. Above all, I believe a genuine injustice is being done, that of, say, somebody coming out of a hospital, getting a bill, checking it out and being told: “You are out.” That kind of traumatic experience for individuals and families is unfortunate.
I have approached the subject as far as I possibly could on a non-ideological basis, on as factual a basis as possible on the grounds that I want to see discrimination, class distinction, the professional cosiness, the particular allocations of resources to individuals within the profession, ended in the health services. Successive Ministers did not do it. They took on the last Minister for Health and they beat him. I believe the present Minister can do it. I also believe, in total deference to my colleague, Deputy O'Connell and other members of the medical profession, we would have a better health service, we would have consultants who would know where they were; the Medical Union and the Irish Medical Association would know exactly where they were in terms of the future development of the health services of this country and that we would have a national health service of which we would all be proud.
Mr. B. Desmond: : That would be another day's work but certainly, a national hospital service of which we would all be thoroughly proud and in respect of which the Minister could write into his memoirs in the 1990s, after he had retired as Taoiseach and so on, about how he made an historic decision when the Fianna Fáil Party came back to power. Therefore, the Minister may well be the best Minister for Health in the history of the State.
Mr. G. Brady: : I welcome the opportunity of contributing to this debate. I agree fully with the Minister when he says there is urgent need to review the  income limit of £3,000 for eligibility for hospital and maternity services.
It is quite unnerving to sit here listening to irresponsible talk about giving carte blanche to the Department of Health to extend the service without making any provision for the cost of such extension. I am not sure if the last speaker was being serious or glib about a very important area of health care here. The present Minister for Health is absolutely concerned about the Departments of Health and Social Welfare, is constantly in touch with the situation on a day-to-day basis. To listen to speakers making such remarks without making positive provision for a bland extension of the health services is quite appalling.
I have always been critical of the manner in which limits are structured, particularly in relation to the health services. This limit of £3,000 is no exception to that criticism. Before discussing the pros and cons of the limit itself it is important to bear in mind that a new set of circumstances will prevail next April when the new scheme of pay-related contributions by workers will be implemented. This will represent a new departure in health care to cover a sector of the community and replacing the present fixed contribution of 50p. We all realise that the present limit of £3,000 is inadequate. We are all in agreement on that but it is a matter of trying to devise, formulate and cost-out a more efficient system. It is more important to be able to operate a higher level of efficiency within the health services and not merely throw out figures and limits merely for the sake of political gain.
It was very interesting to hear the Minister in his speech last evening trace the history of the limit of eligibility from £600 in 1953 to £3,000 in 1976. I was prompted to make some calculations of the purchasing power of the £ in that period. For instance, the purchasing power of the £ in 1953 compared with 1978 represents £5, or five times the amount. Yet in medical terms that is not a realistic assesment at all because medicines, patient requirements, the complexity of the health services, cost of hospitalisation and so on have become far more  sophisticated and complex. Indeed the demands on doctors and so on are more immense. Let us say that £1 in 1953 would have purchased an enormous amount of medical aid compared with, say, £5 in 1978. The Minister's approach of trying to relate the amount of contribution to what a person earns is a sensible and constructive one. In passing it is my belief that private medicine and health care should work in harmony with the health services; both must be dove-tailed and operate complementary to each other. There is a place for both services. If you like, there must be the competitive element interacting between the health services and private medicine. It is strictly in the interests of the patient to maintain the highest possible standard of health care.
At this juncture it is important to take a look at the entire percentage of persons covered under the various health services. We have, say, 38 per cent covered by medical cards; 45 per cent would be covered under the limit of £3,000 we are now debating and the remaining 15 to 20 per cent would have no cover themselves at all but could attain cover through the voluntary health insurance scheme or any other private insurance cover available. It is my belief that a free-for-all hospital service would not necessarily lead to efficiency in the running of hospitals. Anyone familiar with the waiting lists in hospitals and the pressures that are occurring would quickly realise that just by extending overnight, as was suggested earlier, the entire service would in no way lead to a more comprehensive or efficient service from the patients' point of view. And this is all that matters. The service in the UK leaves a great deal to be desired from the point of view of the level of efficiency operating in the national health service there.
We have an excellent, harmonious relationship between doctors working in private practice and specialists as well and, indeed, in our public health care also. What is needed here is the highest level of efficiency, constantly monitored by the Department of Health. This particular area of the  £3,000 limit is one area being closely scrutinised by the Minister at the moment. The complexity of eligibility also arises. It is not clearly understood by many what they are eligible for. Many people feel when they attain a certain standard of earnings—£3,000 in this case—they cease to have any cover. It may not be widely understood, but it is a fact, that people have this cushioning or buffer period of two years extra cover. It is a carry-over period which protects them. Many people do not realise that. I would suggest that it might be a constructive exercise if the Minister were to mount some publicity campaign informing workers they are entitled to this carry-over period. It is something that is not clearly understood. I know literature has been put out and the book produced by the Department of Social Welfare is excellent. However, a quick reminder to people moving out of the £3,000 upper limit that they are entitled to an extra two years carry-over period would be a good idea. I have run into many cases where people were pleasantly surprised to learn their benefits continued on.
We are talking here about 1.3 million people or roughly 45 per cent of the population covered by this scheme. As I and previous speakers have said, we are unhappy about the level. It is not in present money terms in line with what we would all like it to be. However, let us take the years between 1973 and 1976 during which we had an accumulated inflation of nearly 86 per cent. In the early part of last year inflation was running at close to 18 or 19 per cent. This meant that 100 per cent inflation had occurred in four years. The limit was set in 1974 at £2,250. In 1976 it was increased to £3,000. That rate of increase is slightly less than 30 per cent. Yet, in that space of time, the accumulated inflation rate was running at nearly 60 per cent. There is really no gain, therefore, in finger pointing and saying that the level is now totally out of place. We all realise that. We all realise a more efficient system is needed instead of just striking upper limits of eligibility. It would be more prudent to wait until next  year when a new set of levels will prevail, a new pay related structure for health contributions. It would be imprudent to tamper with the present highly complex system. The gain would be minimal and perhaps cause more confusion in an already confused situation.
Where health is concerned rigid income levels of eligibility are not always the answer. Hardship cases are accommodated under the health services. This is a good thing. I would prefer to see a sliding scale of benefit and contribution. Health is not just a black and white issue in which you can fix a certain level. This is what was done in the past. There are many shades of grey and there is a big area for examination here. I have every confidence that the Minister and his Department are actively engaged in endeavouring to structure out the best formula whereby persons who fall into this category will benefit to the maximum degree.
Here, perhaps, we should take a look at the highly efficient working of the Voluntary Health Insurance Board. Maybe there is some area here that could be copied by the Department of Health. Perhaps it would be possible to allow workers to invest in whatever scale of eligibility they want with, of course, a minimum level. Maybe it would be possible to give them the option of buying extra benefit, if they wish to do so, provided they invest through their employment structure in a minimum level and their employers are given the option of investing more to give their employees that extra benefit if they desire it.
The Voluntary Health Insurance Board is an excellent body. It has served the community in a very desirable manner since its inception. Perhaps there is a case to examine the giving of a flexible system of coverage to workers. Everyone realises that people are at their most vulnerable when they are ill in hospital. They certainly do not want to be burdened by large hospital bills, by worry and the anxiety of trying to cost out of their budget how they will meet these bills. The Minister is aware of this. He has made many statements to the effect  that he is engaged in a very critical overhaul and examination of the level of cover that people can be given within the health services. But money cannot just be printed and lashed out just for the sake of doing something. It does not follow that by providing money you will solve a problem. You have to get to the root cause of the problem and correct it at the root and then by all means spend the extra money.
The Minister has made it clear that he is not satisfied with the criteria of eligibility. Over the years anomalies have developed in the system, the principal one being the distinction between manual and non-manual workers. It is all very well to say in 1978 that there should be no distinction between manual and non-manual workers, but this is discrimination and so on. But 20 years ago, or less, manual workers had to be protected within the health service. This is a carry-over from that time. The Minister is aware of this. Perhaps it is an unfortunate distinction that has been made through the years; nobody likes it but there was a time when it had to be made. We might be excused for saying now that it is a reflection of the advantages gained by manual workers in rates of pay and conditions generally. This is a good thing but we must approach it constructively and not try to be divisive or create an attitude which does not necessarily exist among workers. There were days when manual workers were badly paid and had poor security and were not getting a fair share of the cake. This is why the distinction was made.
It is unfortunate that it has given rise to an anomaly in eligibility for health services but seeing it in the broader context it could be regarded as the price of progress and a very good thing in a sense. Perhaps the Minister could consider the advisability of a survey to try to quantify the percentage of manual and non-manual workers, possibly through the Revenue. If that information could be gathered it would be invaluable to his Department.
The rate of inflation over the past few years has resulted in money losing  value. The rules of limited eligibility are such that they provide protection against large-scale loss of eligibility in times of declining money value. The Minister has made a clear statement and because of its importance and the misunderstanding that seems to have persisted in this debate it is necessary to underline it. All insured workers who were eligible because their earnings came within the £3,000 limit when it was introduced in July 1976 are still eligible and will retain eligibility at least until the beginning of 1979. It does not matter what was the source of the increase in their income. That is a factual statement of the position. This might be criticised in the system of limited eligibility. For example, if through some good fortune a worker whose pay is within the limit receives a massive increase in pay which puts him into the wealthy class, he retains his eligibility. This carry-over period is most important.
One benefit of this carry-over entitlement period is that it gives time to study how the system operates, its defects and the changes that can be made. The Minister has assured us that this is being done. He has highlighted some of the defects and indicated his intention of remedying them so far as is reasonably possible. He has accepted that the £3,000 limit is now out of date and urgently needs review. For reasons I have given I do not feel it is absolutely necessary that this should be done immediately. Hasty action now could cause more problems in the long term. Therefore the Minister's amendment to the motion is sensible and worthy of support.
Deputy Collins last night and Deputy Desmond this evening said that the carry-over provision applies only if the increase in income is due to the national wage agreement. The Minister clarified this position briefly but it is important to refer to it again. Any worker whose pay was within the £3,000 limit in July 1976 was eligible then and retains eligibility until the beginning of 1979 irrespective of the source of the increase. Wage agreement considerations do not apply here.  Even a change of employment would not matter, or if the extra money was earned from two jobs, he would still retain eligibility. The misunderstanding might have arisen due to a provision made in 1976 which related to payments under the national wage agreement. Under that specific provision a person whose remuneration went from less than £2,250 to more than £3,000 between April 1974 and July 1976 by virtue of pay awards under the national wage agreement was allowed to retain eligibility for one year in addition to the normal carry-over entitlement period. That provision was designed to meet a special situation which obtained then and affected only a limited number of people and was of limited duration. It did not affect the normal carry-over period. This may have caused the confusion. The carry-over period protects workers for its duration and this is the important point.
Deputy O'Connell produced estimates of what it would cost to extend free hospital service to the entire community. He estimated it would cost £12.5 million. I do not think that takes into account the cost of hospital maintenance for persons who are now ineligible. It is costed only for those who are eligible.
Mr. G. Brady: : There would be a substantial loss of income from ineligible persons who now make a payment towards their hospital service but who under a free-for-all scheme would be entitled to receive the services without charge. In addition, there would be an extra cost through the payment of subventions on behalf of patients in private accommodation, patients who are now ineligible for such subventions.
Another point was made by Deputy Collins concerning the position of persons who on starting work have an income above the limit of £3,000. He pointed out that such persons would  not have an opportunity of availing of the benefits of the scheme. A number of points arise here. A person coming into that standard of wage earning straight from school is on his way to very high levels of wage earning. It could also be argued that at that age there is not the same danger of needing hospital treatment as there would be at a later age.
To sum up, the House should treat this matter very cautiously and be prepared to give the Minister the opportunity of formulating a very much more workable system than that which pertained in the past. I have every confidence this is being done. It would be the height of folly to tamper with the present system. It has to be coaxed along now, bearing in mind that the carry over period will protect people who might feel they are ineligible at the moment. I urge the Minister to point this out quite clearly by way of press advertisements if necessary, to indicate to people that they have this extra period of time and this extra eligibility of which they might not be aware.
Mr. F. O'Brien: : I am glad to have an opportunity to speak on this motion because it is very serious. The income level is causing tremendous hardship to a large number of people. I am at a loss to understand why the income limit cannot be adjusted as a matter of course. No great mechanism is required to lift it to £4,500 or £5,000. It would not affect the smooth running of the health services in any way. There is no will to do this. It is quite clear the reason is simply that there is no money and no money will be made available.
An Leas-Cheann Comhairle: : Deputy O'Brien, please. This is the first time in three hours when we had to stop the debate. The Deputy cannot introduce something which has nothing to do with the debate.
Mr. F. O'Brien: : I am not discussing banks. I am discussing the fact that money is not available for hardship but it can be made available in other areas to people not suffering the same degree of hardship. I am at a loss to know why that happened. Large numbers of people genuinely thought they were covered under the health services but when they were hospitalised they got sizeable bills. When they disputed them, they were told they were non-manual workers. In many cases they were engaged in manual work. Who decided whether this job is manual and that job is non-manual? That is a very  moot point. In the case of many people I know, a great deal of the content of their work was manual but when they sought the cover and protection of the Health Act they found they had not got it.
A man with five or six children earning £3,000 a year has not got much scope to provide cover for himself and his family. Great stress is now laid on health and preventive medicine and care but a man who has not got the wherewithal may have to deprive himself and his family of much needed health care because the Minister will not accept this motion.
Deputy Brady sat on the fence. He did not know whether to agree or disagree with the motion. His view was that he saw hardship and he saw the need for the motion, but obviously on the instructions of his Minister he could not support it. I am more than surprised that no action is being taken. This is a breach of faith on the part of the Minister, or perhaps he is not responsible. Perhaps the Minister for Finance and the Minister for Economic Planning and Development sent out the instruction that they are not giving any more money for health. That appears to be the trend. Will we improve our health services? No; we will run them down. There is no question about that. If there were any genuine concern, this motion would be accepted. What would it cost to raise the thresholds to a reasonable figure? I doubt that it would put any great strain on the Exchequer.
Last June we had plenty of money for this gimmick and that gimmick, but now when we get down to the very bedrock of society, the health of the people, we have not got the money. It is an indictment of the Government that they will not provide this type of money. It is not a great deal, but I suppose if you are broke you cannot pay. They could go with the begging bowl and borrow more. This is something worth borrowing for. As we have to wait until April 1979, non-manual workers in particular will have to remain healthy until then as they cannot afford  to be hospitalised in the meantime. There is no point in saying that they can join the VHI, that they can join this and that. They will not have eligibility for a number of months but in the meantime they are contributing to social welfare and are not receiving any benefits.
It is a shame that this motion has not been accepted. The anomalies between manual and non-manual workers in these days of automation are not easily seen. Nowadays one wonders who is manual and who is non-manual. If you were a manual worker two years ago you could now be sitting behind a fancy control board operating switches. Is a bus driver or a bus conductor a manual worker? Is a barman a manual worker? The situation is farcical and I am surprised that action cannot be taken. I know several people in my constituency who received help when they needed it. Afterwards they were presented with the bill which they could not pay. These bills should be paid as an interim arrangement until we come to a satisfactory settlement in April 1979.
I wonder if the Minister realises the stress and hardship that is being created at present? It is not good enough to sympathise with these people because sympathy cannot pay the Eastern Health Board or any other health board. I am not blaming the Minister for this severe breach of faith. If the Minister controlled the pursestrings I am sure he would be only too willing to agree with the motion. He is obviously under orders not to accept the motion. I would ask him to consider the financial structures of his Department to see if any cutback can be made to meet the situation until April 1979. If the £3,000 limit had been linked with the cost-of-living index we would not be appealing to the Minister to do what is just and right. However, that has not happened and, consequently, we are faced with a serious situation.
I cannot understand why the Minister will not meet this motion. He admits that there are anomalies but says that they will be eradicated when the new scheme is introduced in April,  1979. That is all very fine but we cannot wait that long. We must not allow people to be exposed to the dangers in which they will have to put themselves because of their noncover. The denial of this motion means that we are putting people at risk and this is a serious matter. What can I tell them when they come to see me? I cannot tell them to wait until April 1979. I will have to tell them that the Minister will not increase the thresholds because there is no money in the kitty.
The Government have deprived this area by overspending in other areas. In their first few months in office there were fanfares of trumpets coming from the Department of Health about all the great things they were going to do. This is the first measure that we have pressed for, and rightly so. I do not know the amount of money that would be involved in improving the service. Whether it was a great amount or a small amount of money it would alleviate stress and hardship. There is no point in telling someone that he is not entitled to cover because he is a non-manual worker. People who earn £58 per week are not covered. It is the worst type of hypocrisy to blow our trumpets about the great health service that we are going to have. It does not do this House any good when we use it as a platform for PR exercises and for self-glorification. The test is here. If we are so concerned we should deliver the goods instead of shillyshallying. A case cannot be made against immediately raising the thresholds. There is no point in the Minister talking about the great scheme which he intends to introduce. We want the money on the table now. We cannot put so many people with such low incomes at risk. We have heard of America as the country where you have to have the readies in before you go in through the hospital door. They have a reasonable degree of wealth. The people I am talking about with large families and that kind of income are relatively poor, but they will have to have the money before they will be signed into hospital now. Is that our new approach? Is that our social conscience towards health? I hope it  is not. If it is, God help the health of this nation; it will deteriorate.
It gives me no pleasure to stand up and be critical of the Minister not accepting this motion, but I know the hardship that Deputies, particularly in urban areas, see among people who are non-manual workers on low incomes—and a large number of them are because their social status has changed slightly. Many years ago manual workers were the badly paid section, but because of changes in technology and emphasis on industry the manual worker now is well paid, and rightly so. But the non-manual worker now is the one left behind in earning, and we should recognise this. To give this recognition surely we must raise the income allowance. What should be done is abolish the non-manual and manual situation. That can be done at the stroke of a pen and surely there will be no opposition to that, and it will give the people the protection they deserve and should have but are not getting. I appeal to the Minister——
An Leas-Cheann Comhairle: : I am sorry, Deputy, I take it that the House wants to finish this motion tonight. We do not want to carry over the five minutes. Therefore I must call Deputy O'Connell at 8.15 p.m.
Mr. F. O'Brien: : I will conclude by appealing again to the Minister to show his goodwill and to cast aside the Department of Finance and say, “It is my Department, I want to do it and I will do it”. Unfortunately, like other Ministers he is under the thumb of the Minister for Finance and cannot get out from under it.
Dr. O'Connell: : This motion in the name of the Labour Party has given all of us an opportunity to debate the issue and to highlight the gross injustice in the present system. We must be clear about what we are asking the House to do. We are not asking the House to extend the income limit for eligibility. We are asking for total abolition of the limit for eligibility. This motion which asks us to increase the £60 valuation is not our motion and I am totally opposed to it. We are  not asking the House to bring the millionaire farmers into the scheme. We are not asking it exclusively for them.
Dr. O'Connell: : Yes, but we are not asking that we merely extend the income limit for eligibility and at the same time bring in the millionaire farmers. That is contrary to our thinking. The £60 valuation for farmers is the equivalent of £5,400 a year which represents £108 per week. We are talking about the gross injustice in the situation of the farmers vis-à-vis the urban worker with £57.70 per week at present but we do not think that extending the limit of eligibility will correct it.
Since I moved this motion in the House I have been inundated with telephone calls about people who were barely above the £3,000 on 1 July 1976, some of them by as little as £20, and they are ineligible for free hospitalisation.
Dr. O'Connell: : The amount at the moment would be about £4,000 and they are ineligible. This is a gross injustice and a considerable hardship to them. If we take the £3,000 on 1 July 1976 and bring it into line with the cost of living allowing for a 14 per cent increase last year and an 8 per cent increase this year, we would be talking in terms of £71 per week at the moment. They would have been eligible immediately and they would have been covered. There are 85,000 people involved in that. That is not my figure, it is the Department's figure, and represents a lot of hardship for many people.
The Minister has on his hands a big problem which he has inherited. It is a problem which has arisen over the years. As the Minister has emphasised, it is the case of the manual workers— who were lowly paid at one time but who, through the strength of unions, have achieved their rights—and of the non-manual workers, who have no industrial muscle to bring their levels of payment or their salaries into line with what they should be at present and therefore they find themselves in a predicament. It is grossly unfair to leave such people out. The Minister cannot resolve it by deciding next April to declare a ceiling of £6,000. I do not exaggerate when I say that there are manual workers getting £10,000 a year at the moment or £200 a week, and they are entitled to free hospitalisation. If next April the Minister should bring in this new arrangement making the cut-off point £120 per week he would render ineligible at least 200,000 manual workers. There would be an outcry and they could take the Minister to court for depriving them of their established rights. The Minister is doing his best and I know he wants to resolve this. The working party did not really come up with an answer. They threw more anomalies in the Minister's way. They did not solve the problem for him. Therefore, he has a problem on his hands and I do not envy him. It is not his fault; it has arisen over the years, but it causes tremendous injustice.
It would be in the interest both of the Minister and of the Department to solve this problem once and for all. Incidentally, Fine Gael have not declared their views or their policy on this matter. They talk, though, of extending the limit but it is time for them to declare their position and to say whether they are in favour of free hospitalisation. That is what is involved—free hospitalisation for the extra 15 per cent.
It has been argued that as soon as such a scheme is introduced people opt for hospitalisation. The evidence is that this is not the case. So far as we are concerned the 15 per cent who are excluded are in the professional class. They are not the lower income group and, consequently, they are not the people who make the demands on hospitals. Given the Minister's positive moves in the field of preventive medicine and having regard to the realisation  on the part of doctors and consultants that hospitalisation is not the answer or that hospitalising one for the purpose of investigations is not necessarily the answer, there is not likely to be a tremendous demand for hospital beds. If we were talking only about the lower income group, the situation might be different but that is not the case. Many tests and investigations can be done outside the hospital. If we streamlined many of the diagnostic and out-patient services we would not need to send so many people to hospital.
Perhaps a further 7 per cent or so would avail of free hospitalisation. It could be argued in relation to maternity services that when we discouraged the practice of babies being delivered at home we threw a tremendous strain on the maternity hospitals. That was not the case but the result of that change was that the lives of many babies were saved who would otherwise have died as a result of not being delivered in proper conditions.
We must not continue to impose hardship on people who cannot afford hospitalisation. One man I spoke to recently told me that because he is only slightly over the limit for free hospitalisation he must pay and that his bills are colossal. People in that situation are reluctant to go to hospital. This can happen where there is danger of cancer or of something requiring urgent attention. The person says he will not bother having attention, that he will wait and perhaps the problem will go away. For such people the fear is not necessarily of hospitalisation but of the financial problems that would follow. We must realise that those people who from 1 July have incomes of even slightly more than £3,000 will be caused hardship in the event of having to go to hospital. If they have children at school and all the other costs that go with living today they will have enough on their plate already without the added burden of hospital bills. I am pleading the hardship clause for such people but that is a degrading procedure. It is humiliating to have to supply such information and very often what happens is that a man will borrow from the credit union rather than plead hardship.
 I know that there is rapport between the Minister and the profession. Once the profession are assured that they will not be steamrolled into any situation, they will co-operate with the Minister. Perhaps the Minister would consider indexing the £3,000 category by way of ministerial order. That would not cost a lot of money. I am sure it would not cost any more than invoking the hardship clause for the people concerned. The Minister might consider that as a temporary measure and not for those who were in the £3,000 bracket on 1 July 1976. The Minister was absolutely right in what he had to say about the situation. The health board corroborated everything he had to say in that regard. But if the Minister could see fit to introducing a temporary measure in order to deal with the situation of the other people involved he would be doing a good day's work. I am convinced that in any such move he would have the co-operation of the doctors. Anybody wishing to introduce a system must have the co-operation of the people who are expected to work that system but first there must be consultation. That is one of the principles of trade unionism. On the last occasion consultation did not take place. The doctors' objection was that they were simply told that the system was being introduced. Secondly, there was a lack of understanding in the whole area of payment to doctors. Again, that was a bad mistake. There is no point in anyone saying that the doctors forced the then Minister to capitulate. We were all deluded on this score and the question was put into cold storage in the name of the Finlay Review Body. In other words, it was put into a limbo.
I have no wish to introduce acrimony to the situation. However, I am putting it on the record that there was no question at that time of the profession refusing to co-operate but they did not wish to be left in a state of suspended animation. They wanted a solution. Many of them said they would work a salary system for oncall service but there was no question of the Department negotiating with them so that they were never made a firm offer by the Department. The doctors like any other organised group  are looking for a living. They, too, have a trade union. No one would wish them to have to work the old iniquitous pool system whereby a surgeon received £6 for a major heart operation. It is important that we realise what is involved in the motion, that is, the abolition of income limits  in respect of eligibility for hospitalisation.
In this examination of the situation I am confident that the Minister will realise that this is the only answer to the problem, that it is the only way of eliminating the problem of manual versus non manual workers.
Burke, Raphael P.
de Valera, Síle.
de Valera, Vivion.
Fitzpatrick, Tom (Dublin South-Central).
Fitzsimons, James N.
Fox, Christopher J.
Haughey, Charles J.
Wilson, John P.
Woods, Michael J.
Conlan, John F.
Cosgrave, Michael J.
D'Arcy, Michael J.
Deasy, Martin A.
Donnellan, John F.
Enright, Thomas W.
Fitzpatrick, Tom (Cavan-Monaghan). Pattison, Séamus.
Ryan, John J.
Harte, Patrick D.
Mannion, John M.
O'Toole, Paddy. Timmins, Godfrey.
Amendment declared carried.
Motion, as amended, agreed to.
The Dáil adjourned at 8.45 p.m. until 10.30 a.m. on Thursday, 18 May 1978.
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