Wednesday, 30 September 1953
Seanad Éireann Debate
Professor Hayes: Under Section 2 it appears that the Bill, when it becomes an Act, will come into operation after an Order is made by the Minister. It provides also, quite properly I think, that different Orders may be made for different parts of the Act. Could the Minister say whether he has now any idea of the order in which the Bill, when it becomes an Act, will be put into operation, which part of it will come first? Has he any idea in his mind as to the order in which the different parts of the Bill will actually come into operation?
Minister for Health (Dr. Ryan): I am afraid I have not. It will be, I am sure, as Senators are aware, a  matter for consultation between myself and the local authorities as to what particular parts of the Bill will come into operation first. I would not be able to give any indication at this stage of what these parts might be. Personally, I think that the section relating to maternity treatment and the section relating to hospital treatment will be the first to come into operation.
Professor Hayes: That also raises the question, which I think is relevant to Section 2, as to when the Bill will begin to come into operation. If you read Section 14, which is very general, and reflect upon the situation with regard to the dispensaries in the country and the actual physical space available, when could one expect that these general practitioner medical and surgical services would come into operation under Section 14? The Minister, surely, is not in the position that it is a question of this year, next year, sometime, never. There must be some idea as to when this would come into operation. Can Section 16, which deals with maternity treatment, be put into operation, for example, within six months after the passing of the Bill?
Mr. Baxter: Perhaps the Minister would also tell us whether the sections dealing with maternity will be brought into operation simultaneously all over the country. Will he, after consultation with the representatives of the health authorities, decide to make an Order that maternity facilities will be available to all those who are entitled to receive them in every health area through the country from Cork to Donegal on the same day?
Dr. Ryan: It is possible that some of these provisions may not come into operation for all authorities on the same day. It is provided that they can be brought into operation for a certain number of authorities, perhaps a few months before the others, if the others are not altogether ready. As regards Section 14, that is only continuing what is there already. I do not think it will make very much difference at what time it is brought in because it is only continuing the dispensary  and medical services as they are there at present. With regard to maternity and hospital services, I expect, anyway, that a number of local authorities will be able to put them into operation on 1st April next, the beginning of the financial year. If some of them were in a position to do it even earlier than that I would be very glad. I should like to be able to say definitely that they would be able to do that. If they are in a position to do that the necessary Order will be made.
Professor Hayes: Is there power here to put the Bill into operation regionally—to put it into operation, for instance, in one region first and later on in another region? I do not think the power is in Section 2.
Mr. Baxter: The Minister said he hoped he would be able to bring the section of the Bill dealing with maternity services into operation by the 1st of April next. That is rather interesting and surprising news because the point of view held generally is that so far as maternity beds are concerned they are not anything like adequate to our means. Could the Minister give us an indication as to how he hopes to be able to bring the section of the Bill dealing with maternity services into operation by the 1st April? As far as my own area is concerned I would be very much surprised if this could be done owing to the lack of facilities.
Professor Hayes: Is it not doubtful whether Section 22 gives the power to which I referred? As I read the section, it deals with the regulations which will only be made when the Act has been brought into operation by Order?
Professor Cunningham: This question as to when this Bill is to be brought into operation is very important. It has been found from experience in other countries that when a Health Bill of this type is being brought into operation it is often better for many reasons to introduce it gradually. It has been the custom to introduce that part of the Bill which covers the major expenses of an individual or a hospital. In other words, they frequently bring in the hospitalisation part of the Bill first. It is easier to do the hospital side first. I should like to know from the Minister if he has any idea in his mind as to what he is going to do first about this Bill? If he intends to bring in the hospital side first, does he intend to bring that in soon?
We are up against certain difficulties. I have been associated with the staff of a voluntary hospital in Dublin since 1919 and I can claim to know something about the difficulties under which these hospitals have worked since that time. Although there have been in a few cases some small additions to the numbers of beds  in hospitals in Dublin and throughout the country, we are all labouring under the same difficulties at the moment—we are very short of beds, not only in Dublin but everywhere else, particularly with regard to maternity beds. What I am going to say now holds good for all hospitals but especially for maternity hospitals.
Let us take one hospital in Dublin, the one with which I am associated— the National Maternity Hospital, Dublin. That was built and opened in 1935 and it was not completed until 1938. That hospital was built with the idea of accommodating 2,500 maternity patients per year. Last year, 4,500 patients were delivered in that hospital. It is grossly overcrowded. I think that overcrowding has a bad effect on the structure of the hospital itself in regard to wear and tear and it has a bad effect on the patients who go there. A number of these patients are obliged to leave the hospital as early as the fourth day and a number are obliged to leave on the fifth day. The same thing holds good in regard to the Rotunda and the Coombe hospitals.
In these hospitals we have tried as far as we could to get patients who live near the hospitals—people who we think will have normal deliveries —to stay at home and we send out the nurses and the staff of the hospitals to look after them in their own homes. In that way we are at the moment refusing admission to the hospitals of certain patients. Under this Bill every woman in the country is entitled to free treatment and so are people in the upper income class if they pay a guaranteed maximum of £2 in the year. Of course, that was a subterfuge on the part of the Minister to overcome a moral difficulty to which grave objection was raised. It has not overcome that moral issue. It is merely a subterfuge and pretence. From that point of view the Bill is just as bad as ever it was.
I object to the Bill because it is fundamentally wrong. I also object to the Bill because it is really very bad medicine from the medical point of view. If all these women are going to  have access to hospital treatment under the Bill, they have the right to demand treatment in these hospitals which are already overcrowded. Where is the Minister going to put the patients? We will now have patients who have been accustomed to staying in their own homes and patients who went to the smaller nursing homes and paid their own way demanding treatment in hospitals so that the numbers looking for admission to the hospitals will be greater than ever before. Some of them will get in but who will suffer if they do? The poorer patient. There are a number of poorer patients who find it necessary to go to hospital because they have not the facilities in their own homes. Sometimes they apply for admission to the hospital just at the last moment and the hospitals are not able to take them in. That is going to happen in every hospital throughout the country. That is all I want to say about the maternity services.
The general hospitals, especially in the city, are overcrowded and there are not enough beds. We are going to allow in a huge number of patients who previously went to a nursing home or stayed in their own homes. They will want to be admitted to the hospitals and get X-ray facilities and all that. I want to know how the Minister intends to provide for that? Of course, it will be all thrown back on to the governors and staffs of the hospitals to make whatever arrangements they can. I think that is unfair. If this Bill is going to be implemented we are going to be swamped out with patients.
Senator Hayes raised this matter about the commencement date. I have some experience as a member of a local authority, and when I turn to Section 16 I find the words “where the local authority shall provide”. What is bothering me is that the section provides that the health authority shall provide so-and-so. Senator Cunningham  has referred to the fact that people paying £2, no matter what their income may be, will be entitled to treatment. Suppose, for example, somebody goes into a hospital as things are at the moment and alleges negligence against the hospital authorities. We see cases of that kind reported fairly frequently in the newspapers. These cases go into court and sometimes damages are awarded. In some cases, a death may have resulted from what is alleged to be negligent treatment in a hospital. Suppose somebody seeks admission to one of these local authority hospitals in which the local authority is obliged to provide accommodation for those people who have paid a fee. The fact that they have paid the fee entitles them to accommodation in the hospital. If, however, as a result of a bed not being available in the hospital for a patient to be treated in time and a death occurs or a more serious condition develops as a result of the local authority's inability to take the patient in in time to give the treatment which it is obliged under the law to give, where will the local authority stand in a case of that kind? I am sure I do not know. I should like to hear from the Minister what the legal position will be so far as the health authority is concerned if the case be that it was physically impossible for it to provide the accommodation which, under the law, the Minister demands it must provide.
That is why I say that the question raised by Senator Hayes is of considerable importance—that is as to when the commencement date is to be. I pointed out on the Second Reading of the Bill that, in my county, you may have 100 people on a waiting list who want a bed in the surgical hospital which cannot be provided for them. Some of those people may die because that accommodation is not available. There is that problem to be considered. I do not know that there is such an obligation on a local health authority at present, but I am anxious to know what the position will be if this Bill becomes law. Does not that raise the whole question of the commencement date? I suggest that it does, and that  it is a matter of fundamental importance.
Dr. Ryan: Senator Baxter has mentioned the County Cavan. I think that the County Cavan is exceptional. At least, for some months back anyway, I have been coming across complaints from the Country Cavan about a long waiting list for the county hospital. I have not got the same complaints from other counties. We must not, therefore, take it that the whole country is in the position of having 100 on a waiting list so far as the county hospitals are concerned. It is regrettable, of course, that there should be waiting list at all, but even if there was a waiting list of 100 in the case of every county I do not see why everybody should argue from that that this Bill is impossible or unnecessary.
What we are providing here is that we will pay the hospital bills for certain people which are not being paid at the moment. If any Senator argues that because we are going to pay the hospital bills for people who will accept hospital treatment, for people who otherwise would not accept it, I think that is a very good argument for the Bill. It proves that there are people in this country—and I believe it to be so—who need hospital treatment but cannot afford to get it. If the fact that we are providing hospital treatment free for them will mean that there will be a rush to the hospitals well that, I think, is a very good argument that the Bill is necessary.
We have been providing additional hospital beds all the time. I have not the figures with me at the moment. I quoted them several times in the Dáil debates on the Bill and I can quote them again before the debate on the Bill concludes here. The fact, however, is that several thousand hospital beds have been provided within the last ten, 15 or 20 years, and I am quite sure that we will have to provide plenty more. We have a number of hospitals under construction at the moment, regional hospitals in different places, and county hospitals. We are dealing with that matter as quickly as we can. The same thing, to some extent, applies to maternity beds. What we are doing in this Bill is, we  are providing that we will pay the maternity bills for certain women who have to pay them at the moment themselves, but we are not in any way encouraging these women to go into hospital. There is no reason why they should not stay at home. If they do stay at home we will pay their bills, and I do not see why they should not stay at home. Therefore, I do not see why the hospitals should be in any way more crowded than they are at the moment.
I would like to say that when the present scheme of hospital building is completed, that is, the hospitals that are at present authorised or under construction, we will have beds for 65 per cent. of the maternity cases in the country, and, in addition to that, 24 per cent. in private hospitals which are not under the local authorities. These two figures give a total of 89 per cent. That figure is far and away higher than the accommodation that is provided either in Great Britain or in the Scandinavian countries. We know that the Scandinavian countries are often held up to us as models of hospitalisation, but the fact is that we are going to provide more maternity beds here than they provide in those countries.
I think that the objections which are being made to this Bill, as regards the impossibility and so on of what it proposes, arise from hostility to the Bill—because we are providing these facilities. Under this Bill, we will pay the bills of certain people which are not paid at the moment.
As regards this £2 per person, I want the sympathy of the Seanad on this. I met the Catholic Hierarchy and they agreed to a certain thing. In spite of that, I am told by Senator Cunningham that it is immoral. Therefore, Senator Cunningham is not only accusing me of doing something immoral but he is also accusing the Catholic Hierarchy of conniving at something that is immoral. I cannot deal with anything like that. What I mean is that if any ultra Catholic here wants to be more Catholic than the Irish Hierarchy, well all I can say is  that I cannot come up to his standard. I think I am doing fairly well in coming up to the standard of the Catholic Hierarchy. I do not propose to come up to Senator Cunningham's standard of Catholic morality. This is not a subterfuge. I believe myself that, under this provision, the women who come into it will be paying half the cost and the Catholic moralists I was dealing with said that was fair enough. They thought that was fair enough from the Catholic point of view. Senator Cunningham does not think it is fair enough. As I say, I cannot come up to Senator Cunningham's standard. I have to be satisfied with what ordinary people like the Catholic Hierarchy and myself agree is fair enough, and I have to do with this £2.
Why should the type of woman who hitherto has had her baby at home want to go to hospital? When this Bill is passed we will pay her bill for her, and why should she want to go to hospital? Why should she not continue to have her baby at home? The only explanation that I can see for the arguments that are made is that they just indicate hostility to the Bill. There can be no other explanation. Whether a woman stays at home or goes into hospital, her bill will be paid for her. If she has been having her babies at home, why should she now make a change and say that she will go into hospital for the next baby unless she has the idea of Senator Cunningham of making the Bill impossible? But common-sense people do not do that kind of thing. I do not think that the hospitals are going to be overcrowded. In any case, when our present programme of maternity hospital building is through, we will have more beds for maternity cases in this country than there are in any other country that I know of and definitely more than they have in Great Britain or in the Scandinavian countries. I think that is fairly good.
Professor Cunningham: The Minister put forward the argument that from the time this Bill is brought into effect people who have not been able to get medical treatment previously will go to hospitals and that that is a very good argument for the Bill. He  must know as well as we all know that that is not accurate. No patients at the moment are deprived of medical treatment of any kind because of expense or because of their inability to pay. They are all provided for either in hospitals, as semi-private patients or in private nursing homes.
On one occasion when I met the Minister I asked him if it had ever been reported to him or to the Department of Health within his knowledge that any maternity patient had suffered or had died because she could not find a doctor or could not get proper medical attention and he very truthfully said to me: “No, it had not,” and that holds good for everything else. We have had a lot of nonsense talked in this country about people not being treated and not being looked after because of their inability to pay. I visited most countries in Europe and recently I visited hospitals in America. I know exactly what provisions are there and I can say without any fear of contradiction that as far as maternity services are concerned the people in this city are as well looked after as anywhere except for one thing and that is the shortage of hospital accommodation. They are better served by the doctors and at a lower rate; the standard of medical treatment they get is renowned everywhere. I think the same thing applies to the majority of our hospitals.
The Minister also raised the point as to why a patient who formerly had her baby in her own home should now want to go to the hospital and why the maternity hospitals should be more crowded. I will deal with that on another section of the Bill when we come to it. The Minister says that when the hospital scheme of building is completed we will have beds for 65 per cent. of maternity patients and that nursing homes will provide 24 per cent. of maternity beds. If that number is provided it is far too many in my opinion. There will always be a certain number of patients who will have their babies in their own homes and he is overestimating in this respect. I do not know how it is proposed to provide these beds in hospitals for 65 per cent. of maternity patients, where the hospitals will be  or when they are going to be built. However, if they are going to be built at the rate hospital building has gone on in the past, neither ourselves nor our children will live to see them. Planning has been proceeding in this connection for 20 years. New plans are being brought up year after year and nothing is being done. The whole thing is disgraceful. I just want to say one word about the morality question.
Mr. Hearne: On a point of order, we are dealing with this Bill in Committee and although we are supposed to be discussing a particular section it appears that there is going to be a roving commission all over the general principle of the Bill which has been accepted. Second Reading speeches are being made on a section which merely provides for the coming into operation of the Bill. I feel that the Chair should rule firmly that speeches will be relevant to the section under discussion.
Professor Hayes: The question at issue is whether this section makes provision for powers for the Minister which are, in fact, powers the Minister can exercise. Surely a member is in order in asking the Minister how he proposes to exercise them, when and under what conditions, and is revelant in indicating that it would be very, very difficult for the Minister to exercise these powers. I agree entirely with Senator Hearne that the Bill has passed the Second Reading Stage and that we should not have Second Reading speeches but I do suggest that the speeches so far have been concerned with powers which it is proposed to give the Minister under this section and how and when they are going to be exercised.
Mr. Baxter: I put a question to the Minister to which he has not yet replied. I am concerned as to when  the commencement date of this will be. The Minister said a few moments ago that when the present building programme is completed there will be ample maternity beds in the country. He also said that he hoped that the section of the Bill dealing with the maternity service would be brought into operation by the 1st April. Does that mean that his building programme will be completed by the 1st April? If not, is he going to impose on local authorities the obligation to bring into operation the service which people are entitled to have on the payment of a consideration and, if the service is not available, where does the local authority stand? Have those people who have paid for this service and who are unable to obtain it cause for action against the local authority? This is a very grave matter.
The Minister says he thinks Cavan is unique in the difficulties it has experienced with regard to hospital accommodation for patients. May I say that we have probably spent more money out of the ratepayers' pockets in our county on the reconstruction of our hospitals than has been spent in many more counties, counties that are more wealthy? Nevertheless, the accommodation is not available. Therefore, as a member of the local authority, I am concerned as to when the commencement date is to be. The Minister may bring the Act into operation in certain areas where there is accommodation but it does not seem from anything which has been disclosed by him in his speech or from anything Senator Hayes is able to elicit from the Bill as it is that the Bill is to be brought into operation for three, four or five counties on this date while other counties are excluded. Would the Minister clarify that vital matter for me on this section?
Dr. Ryan: I am assured by my legal advisers that it is possible to bring different provisions of this Bill into operation at different times, hospital treatment, one time; dental treatment, another time; maternity treatment, another time; and so on. It is also possible under Section 22 to bring it in  at different times for different areas. Even though it does not appear that way to Senators, I am advised legally that it is possible. What I intend to do is to make an Order when I think certain counties are ready, let us say, to bring in hospital treatment. The Order having been made, the counties can adopt it at their own will. I do not say that we will allow them to delay too long but after a reasonable time we will urge those lagging behind to come along and put it into operation.
Professor Hayes: I asked the Minister on the Second Stage whether the provision of the Principal Act which says that regulations made under the Principal Act must be tabled and may be annulled by resolution of the Dáil or Seanad applies to this Bill, and he said it did. Is sub-section (3) of Section 3 the part he is relying on now for that; that is to say, is the Minister advised that any regulations made under this Bill will be laid upon the Table of the House and may be annulled? This Bill provides for regulations and Orders. Will Orders as well as regulations be tabled? Speaking subject to correction by the Minister—I am not familiar with the matter—I do not find any Orders in the Principal Act.
Professor Hayes: Regulations and appeals, but not Orders. There are important powers of the Minister in the way of making Orders under this Bill in many places—all kinds of Orders, even the Order mentioned in Section 2, which is very important, and other which are very important  for various people. It is only the regulations that will be tabled, not the Orders?
Professor Hayes: Take Section 9, the power of the Minister to make an Order there. It gives complete power to him over hospitals to divide them in any way he pleases; to define the particular treatment which may be given in a particular hospital, or the particular treatment which may not be given in a particular hospital. All these Orders will not appear at all on the Table of the Dáil or Seanad.
Dr. Ryan: I could not answer that question offhand. Orders will have to be published, I take it, in Iris Oifigiúil or in the daily papers. I think the principal object in publication is to make the local authorities aware of what the Order contains. They will naturally get a copy of the Order. It depends to a great extent on what the Order is, of course.
Professor Hayes: If I may say so to the Minister, I do not think he is right. I think Orders in Iris Oifigiúil are published in accordance with the provisions of a section of an Act, but there is no such provision here. I take it that an Order under Section 9 will be sent merely to the health authority concerned and will not be published to anyone else. It is difficult enough to keep track of all the Orders, but if they were here in the Library anyone interested could do something about them. There is a great number of Orders made here, apart from regulations, and it seems to me they should come under the same rule as regulations under the Principal Act.
Dr. Ryan: The usual practice is to publish Orders in the daily papers. Some of them are published in Iris Oifigiúil. I am told that even that is not absolutely necessary. I think Senator Hayes is right there, in regard to Section 9. An Order of a type that concerns only one local authority probably would not be published but sent only to that particular authority.
Mr. Douglas: I can say that so far as the Department of Industry and Commerce is concerned the practice is to publish a notice in the newspapers which no one can understand—but if you send to the Publications Office you can get a copy of the Order.
Mr. Baxter: The Minister makes an Order and it is dispatched to the local health authority. They meet once a month. The document may be received two or three days after the meeting of the body concerned, so it will not come to the notice of the local representatives until the next agenda comes out in three weeks' time. The Order is in operation and nothing can be done about it after 21 days. Even the Minister may at times be glad to have certain things brought to his notice and to have an opportunity of withdrawing or amending an Order. There ought to be some provision made for that. The Minister finds fault with people who are raising questions about this Bill. There are so many things which are not clear in it and which none of us can understand that naturally we are questioning about them. If the Minister is able to inform us reasonably about them, it will go some way to a  better understanding and appreciation of the position.
Dr. Ryan: I am only too anxious to give the Senator any information I can, but some of the questions are rather hard to answer straight off. The general practice with regard to Orders is to have them published in the daily papers if they are of general application, but where they apply to one local authority only they are not published but are sent to that local authority. It would be an enormous task for Senators to deal with all the Orders made by all Ministers. If they all make as many Orders as I do, it would be very difficult. We make an enormous number of them every year, some of very minor importance but others of more importance. As in the case of Section 9, to which Senator Hayes refers, an Order may be a serious matter, I admit.
Dr. Ryan: No, that one would be of particular application. It is not so easy to get over these matters. I do not know whether we could get over this in any way. I should say that it would scarcely be possible for members of either House to follow all the Orders that are made.
Mr. Douglas: I was not saying these should be published but simply that they should be put in the Library. Then any member of the House can, if he likes to go to the trouble, get a copy. I think that is reasonable, that it would not cost much and that it would be worth while. SECTION 4.
Mr. Douglas: Sub-section (3) provides that “a reference in the Principal Act to that Act,” etc. Then I begin to wonder what a reference in this Act means in relation to something done under the Principal Act. I think the intention is to cover all the health services as operated by the two Acts. The matter should be looked into to see if it would be necessary to add “or in the Principal Act”.
Professor Cunningham: This Section 4 is intended as a general saver for the patient. In itself it cannot achieve that end, as very often the patient does not know what is going on; something may be done which interferes with his principles and the patient does not know about it. It is difficult to have a saver of any kind and make certain to cover everything. There is one great omission, that is, the doctor.
There is no saver for the doctor in this and there ought to be. After all the doctors are the people who, if they decide to do so, will work this Bill and I think it is very important that the  doctors should also be protected. Psychiatry has become a very important feature of the medical practice at the moment. It is a feature far more important in some countries than it is here and from the point of view of saving the doctor it is very important that there should be protection because he may be called on to carry out certain matters in accordance with the Freudian theory to which he may himself object, but there is nothing to protect him. Furthermore, the doctor may be told by the Minister—I am quite sure Dr. Ryan would never tell him but after all Dr. Ryan will not always be the Minister for Health in this country and we might have somebody who would adopt these ideas and a doctor might be told to conduct a birth-control clinic or that he must carry out an investigation, for example, of sterility in certain ways which might be objectionable although there are several other ways of doing it which are not objectionable. The doctor gets no protection under the Bill and I think a small clause which includes the doctor as well as the patient should be introduced. I think it is rather an advantage, as it were, and I think it would be on the part of the Minister a friendly gesture towards his colleagues.
Mr. Hearne: Might I suggest to the Senator that if the day comes when such directions will be given by a Government it will not matter a hoot what safeguards are in this Bill or any other Bill to safeguard the doctors or anyone else because then you will have a Government in power able to enforce its will on the country irrespective of what anybody wants?
Mr. Baxter: Senator Hearne knows as well as anyone else that there are Orders being made to-day by Government Departments and by Ministers and if the Oireachtas and members of the Oireachtas appreciated what they were doing when the legislation was being passed many of these. Orders would never see the light of day.
Mr. Hearne: That, I say, is a complete reflection on a body established by this House, the Statutory Rules and  Orders Committee, and the chairman of that is a member who sits on the Senator's side of the House. The active members who are terribly anxious to protect the people's rights are on the other side of the House, and if such Orders are being made the Statutory Rules and Orders Committee is not doing its job.
Professor Hayes: If Senator Hearne's point has any validity in regard to doctors, it also has validity with regard to patients and sub-section (2) should not be in at all, and therefore no safeguards should be in. Probably, the Minister will take the line that Ministers nearly always take, that the Minister is a reasonable man who will not do anything unreasonable and everything will be all right.
Dr. Ryan: I was not going to take that line at all. The same question was raised in the Dáil as has been raised by Senator Cunningham. I do not think it is necessary to protect the doctors. If a doctor says he will not do a certain thing, he will not do it and nobody is going to make him do it by putting something in here. That would not make the slightest difference. Senator Cunningham mentioned the carrying out of psychoanalysis on the Freudian theory. I do not know much about the Freudian theory—I did read something about it —but if a doctor is going to do these things whether we put it in here or not he will do them, and if he is not going to do them he will not do them. I think a doctor is quite well able to look after himself. That is the only answer I have.
Professor Fearon: I would like to ask the Minister a question I indirectly asked him during the discussion on the Second Stage of the Bill: Is he really averse to the idea of setting up a national consultative council to help in the making of these regulations? We are assembled here to do the best we can for the health of our people but also to protect democracy, and under this section, the Minister of the day may make any regulation he thinks fit in his absolute discretion for the management and conduct of health institutions. I believe it is contrary to democratic principles to entrust such enormous— such unlimited—power in the hands of a single individual, and I suggested during the Second Reading that a consultative council should be set up which would consider any far-reaching and momentous regulations, and where a Minister disagrees with the findings of a consultative council he might submit the controversial matter to both Houses of the Oireachtas giving the arguments put forward by the council and his reasons for not accepting their decisions. I think that would be a very great help at this very difficult stage—the birth pains of the Bill—if there were a national central advisory council of some sort to deal with these regulations. I understand that regulations are always available for us, whereas Orders under regulations may or may not be available. I am referring here to regulations the Minister will make under this Bill. I feel if the regulations were made with the co-operation and assistance where necessary of the advisory body it would strengthen the Minister's hands and it would make us as guardians of democracy easier in our minds and would facilitate the initial period of the Bill. I know the Minister has several expert advisory bodies at present, but this would be a body set up for this purpose, for the drafting of these regulations, and I would be very glad to know if the Minister has any real objection to the establishment of such a council.
Dr. Ryan: I think the Senator is advocating a reversal as it were of  what is provided here. Section 41 provides for the amendment of the National Consultative Council that was there under the Principal Act, and it suggests very many amendments which give that council a fair amount of power—not to make a final decision, but of being independent of the Minister. More than half of the members are elected representatives. They meet independently of the Minister, and he is not present at their meetings. He must submit all regulations to them for their comments and if he ignores their comments their annual report will probably tell all about it. That report will be published so that members of the Dáil and Seanad will get to know what their comments were on any matter the Minister might turn down. That is where the Minister takes the initiative. The Minister makes the regulations and they comment on them. The council might make the regulations and the Minister might adopt them or change them and then—well, the difference of opinion would come out and be eligible for discussion before the Dáil and Seanad. I do not think it makes much difference except that being a Minister rather than a member of the Consultative Council, I think it is quicker the way it is in the Bill, but the net result would be much the same as far as disagreement goes.
Professor Fearon: That may be, but it seems to me that in Section 8 sub-section (1) the Minister can have his own way entirely and completely and I think that co-operation such as I advocate at this stage would be very valuable indeed.
Dr. Ryan: Of course any regulation made under sub-section (1) will be submitted to the council for its comments and if the Minister does not adopt the council's suggestions, then that will appear in the annual report and members of the Dáil and Seanad will have an opportunity of criticising the Minister.
Mr. Baxter: I approach this matter from a different angle from that of Senator Fearon. This section is the pivotal section of the whole Bill. Under this the Minister will run the entire health services of the country. He will make regulations applicable to every health institution. I think that a health council is a valuable institution. This section empowers the Minister to make regulations as to how every health authority in the country will conduct its business and as to how every institution will be run and managed. Senator Fearon used the word “undemocratic”; I think this section is thoroughly undemocratic but there is even something more than that to it.
The Minister must appreciate the fact that under the health services the ratepayers in every county will be responsible for 50 per cent. of the expenditure on such services. Quite frankly I object to any Minister in the Custom House determining how every institution will be run and making regulations in connection with such institutions. I object to any Minister determining how the money will be spent. That is what this section amounts to. I firmly believe that there should not be taxation without representation. Under this section the Minister is taking powers to determine how money provided for health services will be spent. I think that is thoroughly unsound. But it even goes further than that. It shows a lack of confidence in the competence of our people to make any contribution as to how their affairs should be managed. I am not one of those who has so little faith in the ability of local representatives or so little faith in the future of our country as a whole that I am not prepared to say there is no one who ought to be taken into consultation with the Minister when he is making regulations as to how our health services should be run. Those of us who live in close proximity to the people and to those who man our health services—the local surgeon, the county medical officer of health and their assistants—ought to be called into consultation because it is our money that will be spent plus any grants that may  come from the Minister or his Department.
I view this approach with grave concern. The Minister may tell me that this is being done to-day. We may be making regulations to-day but under this section the Minister intends to go much further than that. If all these health services are to be run from Dublin is that not a confession of bankruptcy so far as the rest of the country is concerned? Is it not a confession of bankruptcy if the country representatives here are not prepared to stand up and speak against the introduction of this entire principle? I believe that any Minister for Health can get valuable advice and counsel from those who are associated with local authorities and who know the difficulties and the problems confronting those who finance and manage these institutions. I am convinced that the Minister will help the development of health services here if he is prepared to set up some organisation or group of representatives to co-operate with him in the framing of regulations for the running of these institutions because in that way he will be in a position to call upon the experience of local people who can give valuable counsel in problems of this kind.
Professor Hayes: This is the most tightly drawn Bill I have ever seen. Section 8 gives the Minister power to make regulations. The Minister says that in his point of view this will be the swiftest method. It certainly will be. That is, of course, an argument for dictatorship: it is a swift method. It may within certain limits be extremely competent but the Minister also states that even if, as Senator Fearon has suggested, there was a consultative council the result would be the same: that is to say, the Minister would listen to what the council had to say but take his own line after all.
Taking Section 8 with the other sections in the Bill I think it should be made clear that the Minister will under regulations made by himself completely control the local authorities. They will have no power to make any orders, regulations or arrangements save under regulations made by the Minister or  with the consent of the Minister. In that way he will completely control local authorities. He will go a long way, too, towards completely controlling all kinds of hospitals because other sections of the Bill provide that a hospital may make an arrangement with a local authority. If it does not make an arrangement with a local authority under regulations made by the Minister, then it may be squeezed out of existence.
Other sections of the Bill provide that doctors may make agreements with local authorities, again under regulations made by the Minister and not under regulations made by the local authority. Charges and everything else will be defined by the Minister. If a doctor does not make an agreement he may find his livelihood gone. The only way in which he will be able to live will be by making an agreement with a local authority under regulations made by the Minister.
Hospitals are in the same position. Ultimately patients will be in the same position because they will have to go where they are sent. Everything comes back to the Minister. While that may be swift from one point of view it will certainly lead to an extraordinary bottleneck in administration because it will fill the new building in Store Street with files. As I read the Bill, the most minute details will be decided at headquarters in Dublin and nowhere else.
This is the operative section of the Bill and the Minister gets power under it to do anything and everything he pleases. He makes provision in Section 41 for consulting a particular council but he will have made his regulation prior to that consultation and the regulation will have come into operation before anyone knows what the council thought in the particular matter.
This section will give birth to the most rabid centralisation. The Minister will have control of local authorities, of hospitals, of doctors and ultimately of patients. The section is strengthened by other sections, such as Section 22 which the Minister has already quoted. Even under Section  20, if a person has received some kind of medical appliance and that appliance has to be replaced a peculiar position will arise. If the county manager or the local authority thinks there has been negligence on the part of the person using the particular appliance it can only be replaced at such charge as may be approved of or directed by the Minister. I gather from that that the Minister will have power to decide how much Paddy Murphy in Ballyporeen will be charged for some kind of appliance if someone thinks there was negligence in the user of that appliance. I have never seen such extraordinary powers taken by a Minister hitherto. Section 8 is the section upon which this Bill is built. It gives all power to the Minister and nothing can be done about that power.
Dr. Ryan: I am afraid the Senator is exaggerating somewhat. To some extent this Bill introduces new provisions. It is also, however, replacing provisions already in existence. We are, for instance, repealing the Public Assistance Acts and re-enacting in this measure certain provisions in those Acts. This re-enacts what was in Section 34 of the Public Assistance Act, 1939, and also Section 18 of the Health Act of 1947. So, it is only renewing a power that was already there. I think I am right in saying that if we go back to the 1939 Act that was repealing the Poor Law Act that had been in existence for some 50 to 60 years before that, it is carrying on the same power that has always been there.
Since 1947 there would appear to be more force in giving this power to the Minister than there was before, because since 1947 the Minister is paying half the costs of these services to the counties and he naturally should have some say, therefore, in how the money is being distributed.
Mr. Baxter: Does the Minister challenge the truth of what I say, that there are in this House representatives of local authorities who know as much about the business of managing a local authority as any Minister who has sat in the present Minister's chair or any of his advisers know? I do not think that can be challenged. They are men who are unselfish and who have given a great deal of time to building up local institutions. I do not understand the mentality. I confess I do not understand the present occupant of the office. In my long experience, I have always found him at least ready to listen to what people have to say. If, under this Bill, you are now going to draft regulations and are setting out on a new and wider field, can the Minister see any objection, before he puts regulations for the management of any particular institution into operation, to providing that a copy of the regulations would come to the responsible local authorities and that they would be asked for their comments before the regulations would be implemented? That is the least that people who are paying half the cost should expect. It would be common courtesy. If you want good administration and the aid and co-operation of intelligent local administrators, that can be attained by the Minister approaching the problem in that manner. In that way he will get intelligent assistance from members of local authorities in regard to the administration of health services in future. If the health services are to be developed and built up on the work of an inspectorial staff coming from the centre down to the local institution for a few hours in the month, the service will not be what any of us would like it to be.
The Minister ought to approach this matter from the point of view of building up in the remotest corners of the country the people who will be intelligently  interested in the development of public work. There is not much point in intelligent people attending meetings of local authorities to discuss health service affairs if they have not any right whatever to make any suggestion, if all their activities are governed by regulations made by the Minister or by his staff and about which they have never been consulted until they see them being implemented. It is all wrong. It is unsound. It is bad from the point of view of developing in our people that spirit and character and will to do better which we want to cultivate so that the country may progress.
Dr. Ryan: The Senator may not realise that in practice what the Senator has just asked for is what happens, that these general regulations are sent to the local authorities. In fact, they are given sufficient time to consider them fully and to get their comments back before the final regulations are made. If the Senator said to me: “Why not put that in the Bill?” my answer would be that I could not because it is necessary sometimes—not very often indeed—to make some particular regulation that may not be of great importance but that must be made with a certain amount of speed and it might not be possible to consult everybody about it. Generally speaking, the Senator can take it that the local authorities will be consulted very, very fully about the regulations.
Mr. Baxter: The only additional comment I would make is that, when the Minister speaks about the local health authority, he should ensure that the machinery will operate in such a way that the members of the local health authority will see some of those regulations. We never see any of them until we come up against a problem which we find we are unable to resolve because the regulations were made without our being consulted.
Professor Hayes: Is not it true that the British system is very considerably decentralised and leaves regional committees considerable autonomy whereas this system is entirely centralised? That is putting it in the mildest possible way. The power is centralised in the Minister. The British, who know something about democracy in England—in England—have decentralised their system to a considerable extent, have they not?
Mr. Baxter: Could I repeat my query to the Minister, that where regulations are made about which the local health authority is being consulted, the Minister would ensure that the members of the local council would be made aware of the existence of these draft regulations? It is not enough to consult somebody in an office if none of us ever see the draft regulations. I do not know what happens in other counties but I have an idea that it is very similiar to what happens in my experience. We have never been consulted.
Question proposed: “That Section 9 stand part of the Bill.”
Professor Cunningham: Section 9 again gives the Minister complete power, not over the hospitals, but over the doctors practising in the hospitals and over the patients who may go to those hospitals. In effect, the Minister tells the doctors in these hospitals: “In this hospital you can treat this but you cannot treat that. You must not admit this patient; you can admit the other patient.” That is really what it amounts to. It gives power to the Minister as to what kind of work the doctors will do  in the hospitals or what kind of patients they will treat or what kind of patients they will admit and, in that way, it interferes with ordinary medical practice. I raise a very strong objection to this section of the Bill on these grounds, that the Minister is now dictating. He is not only dictating to the hospital management but he is also acting as dictator to the doctors and to the type of patients they will treat.
We understand perfectly well and everybody knows that we will not admit to a maternity hospital or a surgical and general hospital infectious cases, fever cases. Neither will we admit mental patients. We like to keep clear of all these types of cases. But the Minister here is seeking powers to tell hospitals what they can do and what they cannot do. A previous Minister for Health in this country sent instructions to hospitals in this city about the type of patients they were to treat and certain conditions which he wished them not to treat in the hospitals. He had, of course, no powers to enforce that Order and it was ignored. Now, in this Bill, our present Minister is seeking the powers that the other Minister tried to usurp and it is very undesirable. Some members of the House may not know that already there has been a certain direction in this way about hospitals and the type of cases they will treat. The Department of Health has been responsible, the Minister for Health—I do not say the present Minister—for the establishment of a State hospital in this city for the treatment of cancer. There were two already but he overlooked that and established a State hospital for the treatment of cancer, and cancer cases from the hospitals in the country are directed to this hospital in Dublin. It is a State hospital. State hospitals in the country are directed to send patients to it. The Minister may deny that that is so, but we have every evidence that they are. Those patients from the country or from county hospitals requiring special treatment by specialists in the city are economically compelled to go to that hospital. I do not think that the Minister will deny that.
 Now, this kind of thing is going to progress into a lot of other branches of medicine, and a future Minister may say: “In this hospital you must not operate on this; we will send all those cases to another hospital,” or “In this hospital you must do this; this hospital must not treat fractures; this hospital must be for any operations on the neck” or something of that nature. They tried to do it before in this country—a former Minister, not the present Minister—tried to direct cases and to tell hospitals what they were to do and what they were not to do. Now, that power is being sought in this Bill. I object to it very strongly and I think it should be removed.
We do not mind, as I say, limiting certain types of cases to which there are objections in hospital, like fevers, mental diseases and such cases, but we do object to these powers being given to the Minister. It will lead inevitably to trouble and heart-burnings for the hospitals and for people who wish to go to hospital. A patient may wish to go to one hospital and may be told that he cannot go there; that the doctors there are not allowed to do that kind of work. He may be told: “You must go to such a hospital, the only hospital where that type of work is done.” An attempt, as I say, has been made to do that in the establishment of the State Cancer Hospital.
Dr. Ryan: First of all, I want Senators to realise that this particular section only applies to local authority hospitals. It does not apply at all to voluntary hospitals. As far as they are concerned, I have no control over them and I am not seeking any control over them at all. As regards the cancer hospital, I was not directly responsible for that, but I certainly approve of the action taken by my predecessor. I think that, as far as the general public are concerned, whatever the doctors may think about it—perhaps the doctors are right; I do not know—whatever the doctors of the voluntary hospitals may think, they were rather critical that we were doing nothing about cancer because it  appeared to them that the death rate from cancer was going up. Now, really, I think what happened was that the death rate from other diseases went down and cancer held its own, because if we eliminate all other diseases we must die from something and that was the reason why the death rate from cancer appeared to be going up. Relatively, it did go up, of course. The general public were rather puzzled why we did not do something about it, and I think that my predecessor was quite justified in setting up a special hospital.
He did try to set up that special hospital on the lines of a voluntary hospital. Now, how would one set about starting a voluntary hospital at the moment? I am quite sure that if you said to ten or 12 people: “Will you start a voluntary hospital as they did in the old times by putting a lot of money into it?” It would not be very easy to get the ten or 12 people. To start a voluntary hospital of this kind it appears to me that the State would have to find the money, and the only way you can make it a voluntary hospital is to set it up and say: “Will you take charge and run it on the lines of a voluntary hospital?” That was done. My predecessor, if you like, first of all pandered to the general clamour that something should be done about cancer. Secondly he tried to set it up on the lines of a voluntary hospital. Thirdly, he did not, neither did I, ever offer any instruction whatever to any local authority that it should send its patients to that cancer hospital. I defy anybody in this House or in any other House or anybody else to trace any instruction or any advice to any local authority or to any county manager that they should send their cases to that cancer institute. They are quite free to send them to the voluntary hospitals if they want to, and that position will remain.
Mr. Baxter: The Minister indicates that this refers purely to hospitals in our counties, under local authorities.
Dr. Ryan: Local authority hospitals, yes.
Mr. Baxter: Now, I would like the Minister to give us some illustration of what he means, what sort of institutions he is visualising are to be built up in our counties where certain classes of diseases are not to be treated and certain others may be treated. After all, I suppose that some time, some day, some doctor had to carry out an operation which had never been performed before. I do not understand what is in the Minister's mind with regard to these local hospitals. If he is going to confine their activities to a certain field I would like to have more information about it. It is not clear from the section, but we should at least know because it is vital, I am satisfied, to build up skill on the part of our medical and surgical people with opportunity and with training to our local hospitals which cannot be developed if their activities are going to be restricted in a particular way and you are going to build up these specialised services—one there, one there, and one beyond. Are we then going to think of our local hospitals as a sort of clearing house for treatment farther away? I do not know what the Minister has in view. I looked at that section and the first thing that struck me about it was that the Minister could order the kind of institutional services which were to be given. Here again, the local authority, who are going to pay half the cost, have nothing to say about it and were not going to be consulted at all. That is what I feel very strongly about.
Another aspect of it has now been revealed, and I would be glad to hear from the Minister what he visualises, what kind of treatment is going to be given, and so on.
Professor Fearon: Is Section 9 necessary? Surely the Minister has sufficient power under Section 8.
Professor Cunningham: The Minister, speaking of the voluntary hospitals, said that he had no control over them. If a voluntary hospital agrees to work under this Act will he then have powers to tell them what type of work they should do?
Dr. Ryan: No.
Professor Cunningham: About his statement with regard to the establishment of the cancer hospital which occurred just a few years ago, there were two voluntary hospitals in Dublin at the time, both specialising in the treatment of cancer, and they also did a certain amount on skin diseases. Those two hospitals were long established and well known. They refused, I think, to comply with certain specified conditions that were laid down by the Minister at that time, and he completely ignored them, and although other hospitals in this country have been crying out for years for money and could not find the money he built that cancer hospital and equipped it very rapidly; that is, he completely overlooked the two voluntary hospitals and built a new hospital.
Dr. Ryan: This also continues powers that were there already. Senator Baxter asks in what particular case they would be used. So far as I understand, this power was there for district institutions—not, I think, fully for county hospitals. I submit this as an instance. It was reported to the Department of Health that the physician in a certain county hospital was treating open T.B. cases in the wards—a thing which was very dangerous to the other patients. Naturally, he had the patients persuaded that they were better under him than in the sanatorium. Therefore, nobody could get them to give their consent to go to the sanatorium and they continued in these wards. You may come across a crank of a physician like that. Do Senators think that we should let them do what they like? Do Senators think that we should let them injure other patients? That is really the issue. I do not think these powers will be used very often. They will be used only in very extreme cases but they may be necessary at times. That is the only case I can call to mind at the moment. That power was there always. I do not think it was ever used. It may not be used in the future.
I have often had the experience of people coming to me and asking me to do things for them. When I reply that I have no power in the matter  they ask me why I do not take such power. When I come to the Dáil and the Seanad, a different view is taken because you have not in mind these sorts of cases that may crop up.
I think the view we should take is that these powers are not likely to be used but that they may be necessary. I think the case I instanced is one in which they should be used but I had not the power at the time.
Question put and agreed to.
Question proposed: “That Section 10 stand part of the Bill.”
Mr. Douglas: There are a few questions which I should like to ask the Minister in relation to this section. I take it that the section refers mainly to voluntary hospitals and is intended to provide an arrangement between the local authority and the voluntary hospitals whereby they may undertake certain services. It has been suggested to me as a possibility that one of the effects of this section may be to reduce the benefits—or whatever you like to call them—of a person insured under the National Health Insurance Service. I understand that, as things are at present, a man or woman who is insured under the National Health Insurance Service can go for treatment to any of the voluntary hospitals and that payment will be made but that after this Bill becomes an Act such persons will not have these benefits unless it is a voluntary hospital with which the local authority concerned has made an arrangement. I am not sure that what I have said is correct and I should like the Minister to clarify the point.
My second question concerns sub-section (2) of this section. The sub-section provides that the Minister will approve or direct the amount which the health authority may pay to the hospital. I imagine that that will be a matter for negotiation. Is it intended to provide a sum which will provide for payment of the doctors in the voluntary hospitals where they are not being paid at present or is it intended that they will give their services free, as they do at present?
 I am not quite clear about sub-section (4), which reads:—
“Any arrangement which was in force immediately before the commencement of this section and which could be made upon such commencement under this section shall be deemed to be an arrangement made under this section.”
I take it that there may be cases where an agreement exists between a health authority and a voluntary hospital and that if it is in effect at the time the Minister brings this particular part of the Act into operation, the agreement still stands. Does that mean that the voluntary hospital would have to cancel the agreement before this part of the new Act came into effect, if they did not like the agreement?
Dr. Ryan: I am not taking the replies in the order in which the questions were put. The Minister confirms the amount to be paid. I think that that is necessary. I feel that it is advisable to have the same uniform rate paid by local authorities to all voluntary hospitals for a particular class of patient. You would have the same rate in the general hospitals; perhaps a different rate for children and also in respect of a sanatorium. Therefore, the Minister fixes the rate. Apart from that, the local authority is quite free and the Minister has no say in the matter at all. The local authority can choose whatever hospitals they like for the purpose of sending patients to them. That is a matter for themselves.
Mr. Douglas: Provided the hospital will accept the Minister's rate.
Dr. Ryan: That is right. The Senator will realise that, as the hospitals are circumstanced at the present time, they can very well accept it because their deficits are paid afterwards. As a matter of fact, the question of the deficit must be dealt with some time, too. At the moment, the doctor's fee is not included. I told the members of the Irish Medical Association that if the local authorities and the voluntary hospitals thought fit to fix a sum which would include a fee  for a doctor, I was quite prepared to agree to it in principle. I might have something to say with regard to the amount but I am quite prepared to agree to that in principle.
I do not see why doctors in voluntary hospitals should work for nothing. If they think they should be paid for their services that is all right with me. It is a matter for the voluntary hospitals and the Irish Medical Association or the doctors concerned, to negotiate before they come to me.
Senator Douglas asked about a National Health Insurance patient. At present—as the Senator says—the patient is quite free to go to a voluntary hospital on the panel of hospitals drawn up by the Department of Social Welfare. In fact, they include every general hospital. Their definition of a “general hospital” is very liberal: I think that it is at least one ward of five beds. If that condition is fulfilled, the hospital is put on the panel. The National Health Insurance patient is free to go to these hospitals and to get a certain subvention, over a certain period, for treatment. That will be changed. When this Bill is adopted by the local authorities, the insured person will either get free treatment, if he is in the lower income group, or he will get free or partially free treatment according to the income group to which he belongs, whether it be the higher income group or the middle income group. He will have to abide by the rules laid down in respect of these two groups and he will not have a choice of hospital unless he is prepared to pay anything over and above a certain stated sum which, at the moment, will be £3 10s. per week. Therefore, there is definitely a change as regards the National Health Insurance patient. In the first place, he will not have a choice of hospital unless he is prepared to pay a certain amount but, against that, his wife and family will, like himself, get free treatment. At the moment he can only get free treatment for himself under the National Health Insurance scheme.
Sub-section (4) is merely a clause that is in many Acts. It is a sort of  transition clause. When the old Act is rescinded and the new Act comes into operation, agreements under the old Act do not necessarily lapse, but are carried on. The parties can discontinue the contract whenever they like.
Mr. Douglas: Providing the existing agreement is not in respect of a period of years.
Dr. Ryan: Whatever the agreement may be, it is carried on.
Mr. Douglas: Would it not be necessary that the agreement would already have been approved of by the Minister? The sub-section states: ...“which was in force immediately before the commencement of this section and which could be made upon such commencement under this section...”. Only an agreement with the consent of the Minister can be effective under Section 10.
Professor Cunningham: I was interested to hear the Minister say that if the question of payment to doctors in voluntary hospitals arises, it is the local authority and not the Minister who will decide whether they will pay anything or what should be paid. Why does the Minister shift responsibility in this case? He takes the responsibility for everything else but he leaves the responsibility to the local authority when it comes to the question of payment.
Dr. Ryan: I may have made a mistake there. I meant to say that if the voluntary hospital and its staffs agree. Perhaps I said “local authority” but I did not mean to say so. If the voluntary hospital and its staffs agree that payment should be made, then I see no objection to it in principle.
Professor Cunningham: I think that the Minister recently promised, in the Dáil or somewhere else, that, in addition to the £5 12s. which is now paid by the local authority to the voluntary hospital for the maintenance of a patient, he would add 10/- ——
Dr. Ryan: I said “for instance, 10/-”.
Professor Cunningham: ——to cover such things as were not already covered: in other words, to cover various equipment and appliances that may be used. That was also to cover the fees of the doctor. You have very big staffs in a voluntary hospital. There may be anything from 30 to 50, or more. There is a very good reason for that. Consider the position even if all of the 10/- went to the doctors. Bear in mind that these are complicated cases. A very severe operation may be involved and perhaps three, four or even five doctors may be in attendance. The doctor may, perhaps, get 2/- as a fee in respect of the patient. By the time the Minister for Finance extracts income-tax from that it is really a very small fee for the amount of work done.
At present, the sum in respect of maintenance paid by a local authority to a voluntary hospital is £5 12s. I could never understand why it is always less than the actual cost. I remember years ago it was £2 2s. a week and we knew then that it did not cover the expenses involved in maintaining the patient. After a lot of agitation, we got it increased slightly, but the hospitals are still behindhand in the amount of money they receive, because the amounts which come from local authorities, and from other organisations for that matter, do not cover the cost of the patient in the hospital. At the present day in a Dublin hospital, maintenance, which means the housing, feeding and so on of the patient, costs about £7 7s. per week, or £1 1s. per day, and if you add to that the cost of the upkeep of other parts of the hospital, the cost of drugs and appliances—there is no question of doctors' fees because we are speaking of voluntary hospitals where doctors are not paid—the actual expenditure by a hospital on behalf of these patients runs from £12 to £15 per week depending on the type of case.
Senators may think that extraordinarily high, but I can tell you that, in England, at present, the expenses of these hospitals run into £20 per week for a patient, and, in certain London hospitals, into £30 and over per week. Here the hospitals are paid  a good deal less—nearly £2 per week —than it costs to keep a patient and this has kept the voluntary hospitals in tremendous difficulties. They always have deficits and are not able to spend money on the other things which are so necessary. That is what we have been crying out for for so long and now the Minister has offered an increase of 10/- to cover the cost of other appliances and doctors' fees.
The Minister has never made a distinction, so far as I know, between the voluntary hospital and the voluntary teaching hospital. These are two different things. Perhaps I might explain to the Seanad what a voluntary hospital is. A voluntary hospital is one which is run mainly by voluntary subscriptions and in which doctors operate on their patients without charge. A voluntary teaching hospital is very much the same, except that students are admitted for training as doctors. They are given lectures in the hospital and therefore a teaching hospital will require—because its men have to teach—a bigger staff. In these voluntary teaching hospitals, not only in Dublin and in England, but all over the world, there is always the biggest staff, the biggest number of specialists who carry out the most intricate investigations and who are accustomed to deal with all the most difficult cases that cannot be treated elsewhere, and therefore the cost of running a voluntary teaching hospital is very much higher than that of running a voluntary hospital. For that reason, the voluntary teaching hospital should get special consideration.
Instead of that, what is happening here is that they are being kept in a state of permanent deficit. They tried to help themselves out of that situation some years ago. They established the sweepstakes which were taken over by the Government and the money spent elsewhere. The voluntary teaching hospitals got nothing out of it and they are still in the state they were in 25 or 30 years ago. There has been very little improvement and they have been treated badly. Here the Minister proposes to continue that state of affairs. Every patient is going to cost the hospital nearly £2 per week for  maintenance and if a patient requires a big operation—these operations are expensive because a lot of material is used up—it involves expense for the hospital, or if he requires two pints of blood, it means that the hospital has to pay £4 4s. for a point of blood. The Minister is not making any provision for that in the Bill.
We have been told that the other hospitals in the country are cheaper to run, but no figures have been published for the State hospitals throughout the country, so far as I have seen, and I do not know what they cost to run. I have been told, however—the Minister may correct me—that they are even more expensive still. The figures have not been published and if there is a deficit, it goes on the rates and nobody is told about it. I should like to see the figures for maintenance and upkeep of patients in the county hospitals. The reason why these county hospitals and county homes are so expensive is that they are not of an economic size. They are too small and they cannot make them an economic size without making them too big for their requirements. They were built in the wrong way.
I want to put this to the Minister in all sincerity and seriousness: If he wishes the voluntary hospitals to continue as such and if the voluntary hospitals come into this scheme, there are two things which will face the Minister and the Department and the people of the country in general. The first is that the patients must be paid for in full—that is essential. The Minister may promise that we will get money from other sources. We are paying on the overdraft in the bank and losing money in that way and the Minister may say that we will get money from other sources and that we need not bother about it, but there is another point and a point which is of equal importance: You will have to pay the staffs of the hospitals.
I do not like raising this question of money but it all boils down to finance in the end. In a voluntary hospital, a person in my position will work four mornings a week—five mornings some  weeks—in the out-patient department or operating theatre of the hospital. That work is done free for these poor patients. I get no fees, no salary, no remuneration of any kind. I have certain afternoons and perhaps other mornings in the week, or part of a morning, when I can operate on or treat private patients and on that I make an income on which I am able to live. If the Minister puts this Bill through and it becomes an Act, he will be taking from the doctors in this country, doctors like myself and others in private practice, somewhere between 50 and 60 per cent. of our private patients. Remember that all farmers—farmers under £50 valuation, many of whom are much better off than I am—are all going to be treated free and all maternity cases are going to be treated free, so that between 50 and 60 per cent. of their private practice is going to be taken from doctors.
The Minister has made no promise to pay the doctors in any voluntary hospital for the work they are going to do for the patients. If he does pay them, I wonder have you any idea of what it will run to? Remember that in the voluntary hospitals we get all the difficult cases that cannot be treated elsewhere. A county surgeon will deal with a great deal of the ordinary run of surgery cases. He will remove an appendix, for instance. In that case the patient will be able to leave hospital in seven or eight days and it will not cost very much but he has got neither the equipment, the staff nor the technique to deal with difficult cases. He has no way of dealing with difficult cases. We, therefore, get all the difficult and obscure cases in the voluntary hospitals. One of these cases may require the attention of three or four specialists before they can come to a conclusion as to the best line of treatment for that patient. That may involve extensive investigation in the laboratory. Then it may be discovered that the patient may require a big operation in which you will have, not one or two doctors, but perhaps five or six or even seven doctors participating. That all adds to the expense.
Unless the voluntary hospitals are  put in a position in which they can maintain and continue that type of work, there will be nobody to do it. That type of work will disappear. The voluntary hospitals at present are doing the most technically difficult work in the country. They deal with all the most difficult cases; they treat all the cancer and brain cases. All the most difficult operations are carried out by the voluntary hospitals. If you have not staffs with the requisite skill to do that work, it cannot be done in this country and the patients requiring such treatment will either have to cross the Border and go into the Royal Victoria Hospital in Belfast or go to England or to the Continent to have the operations carried out there. There will not be anybody to do that work here because if the income which doctors at present receive from certain patients is taken from them, the doctors will not be able to survive. The senior doctors will, perhaps, be able to survive for a while, but they cannot carry on indefinitely. The young specialist who is trying to establish himself will have no private practice and he will not be able to live. These young men will leave the hospitals or they will not seek appointments in them. We shall be left without staffs for our hospitals and we certainly shall not have in these hospitals the best brains in the medical profession, because they will not work under these conditions. The Minister has got to face that fact. The voluntary hospitals, as such, will disappear unless he faces that fact.
This is a question of tremendous importance for the future of medicine in this country, because the standard of medicine depends on the voluntary hospitals. Go anywhere you like, visit the voluntary hospitals and you will know from them the standard of medicine in that country. The Minister has to accept the responsibility for the prospect which now faces this country and all those who vote for this Bill must share that responsibility. I appeal to the Minister, in all sincerity, to give this matter his earnest consideration, because it does involve the future of medicine in this country. I ask him, and all those who support  this Bill, not to destroy what is left of what is good in the country.
There is one other point that the Minister must face. That is that he must not, if the voluntary hospitals agree to work this Bill and come in with him, attempt to interfere with the autonomy of these hospitals. It has been the experience in other countries that if you have State interference and State control the value of the work done in the hospitals is considerably dimished. We do not want that to happen here. We are very jealous of our hospitals and of the work done in them and we do not want any interference. It is essential that there must be no interference. I am sorry that I have to mention England again but after all I am compelled to do so as this Bill is rather a poor copy of the English Act—an inferior copy. There are many good things in the English Act as well as bad things but there is not very much good in this Bill. However, in England, the former Minister of Health, Mr. Aneurin Bevan, realised the value of the voluntary hospitals and he gave them complete autonomy. The voluntary hospitals there carry on their work under their governors as they always did. They make out an estimate of the amount they require for a year or for some specified period and they send that on to the Department from whom they obtain the necessary funds. I have been informed —I do not know how accurate it is— that the Governors of the Royal Victoria Hospital in Belfast are given a sum of £1,000,000 every year for the running of the hospital.
The Minister has got to face this question of expense. He will tell me that he does not want to interfere with the voluntary hospitals but he is interfering with them under this Bill very considerably. This Bill will interfere with them and unless some justice is provided for the hospitals in this Bill the hospitals will eventually disappear and the standard of medicine in the country will fall.
Dr. Ryan: I suppose it is up to me to reply to Senator Cunningham, even to his sneering references to this Bill as being a poor copy of the British Act.
Professor Cunningham: It is not a sneer: it is true. I do not want to sneer. I am quite sincere.
Dr. Ryan: It makes matters worse if the Senator says he is sincere in that statement. There might be some hope for him if he spoke with his tongue in his cheek but he is hopeless if he says he is sincere in that statement. Where did I say that 10/- a week would cover medical expenses as well as other things? I never said any such thing. When the Senator started his speech and referred to the 10/- I interrupted him to point out that I had merely said “10/-, for instance”, but he had prepared his speech on a certain basis and he made it in spite of me. He wanted to make these unfair points.
Professor Cunningham: What did you mean by “for instance”?
Dr. Ryan: I interrupted the Senator in the course of his speech to say that I merely gave that as an instance but the Senator ignored it. He had his speech prepared and he wanted to establish that I stated that the 10/- was intended to cover other services as well as medical services. I never said any such thing. This destructive criticism of the Bill is not helpful in any way and it is not going to make the Bill any better. I suppose the Senator does not want to make the Bill any better. I suppose that is his attitude and the attitude of the Irish Medical Association but now that the Bill is becoming law, I think they should change that attitude and try to make the Bill better. They have been beaten and they should recognise it.
Mr. Baxter: Does the Minister think that helpful?
Professor Cunningham: I do not speak for the Irish Medical Association. I speak for myself only.
Dr. Ryan: Even if the Senator is speaking for himself only, I appeal to him to try to improve the Bill rather than to try to ridicule it.
Professor Cunningham: That would be impossible.
Dr. Ryan: If that is the position why does the Senator come here at all?  Why does he not stay away? Why does he come in here and try to hold up the Bill to odium?
Professor Cunningham: I am anxious to show why the Bill is so wretched and bad. It is only a remnant of an old Bill; it is wretched.
Dr. Ryan: This is a Bill that was first introduced in 1945. That shows that it is not a copy of the English Bill. You cannot have it both ways. If it is a remnant of another Bill introduced here, it is not a copy of the British Act. I said that I was quite prepared to provide for paying doctors in voluntary hospitals. Somebody then asked how much. I said: “For instance, 5/- or 10/-.” I did not know what it was. I say definitely that I am quite prepared to have this examined by any impartial investigator, to ascertain how much the county hospitals and local services are costing per bed per week and that we will give the same to the voluntary hospitals. They may say that they have better services and that sort of thing, but we may not all agree with them that they give better services.
Professor Cunningham: I did not say that we had better services, but that we had more intricate cases to deal with and that makes it much more expensive.
Dr. Ryan: Voluntary hospitals ought to put up some little element of voluntary service, because the men in the county hospitals do not claim to be giving voluntary services; they admit that they are paid for their services. If we pay the men in the voluntary hospitals at the same rate they ought to be satisfied. I am prepared to abide by that. We will take the medical costs in the county hospitals per bed per week and offer the same to the voluntary hospitals.
Professor Cunningham: That is not justice.
Dr. Ryan: You want a little more. Senators know now how hard it is to deal with the Irish Medical Association. Another thing which the Senator said has been often misrepresented  in spite of the facts being stated so often. It is true that the Sweepstakes were started to benefit the voluntary hospitals. But a Bill was put through this House and the Dáil in 1933 and I went to the trouble of reading the debates on that Bill very carefully. There was no objection to that Bill; nobody in any Party objected to it. That Bill gave the Minister power to distribute those funds to both the voluntary hospitals and the local authority hospitals. The reason why Senators and Dáil Deputies agreed to that is that the income from the Sweepstakes was far and away more than was expected when the original Bill was brought in. The Minister was asked if he would not agree to a certain proportion being fixed. He said he would not and it was not pressed. The proportion suggested, I think, was two-thirds. In fact, when the present programme of building is completed of all the hospitals which have been approved of by the Minister for Health, including the new St. Vincent's Hospital, two-thirds of the proceeds of the Sweepstakes will have been given to the voluntary hospitals. I have stated that over and over again and it is true, but people like Senator Cunningham get up and try to give the impression that the voluntary hospitals practically got nothing out of the Sweepstakes funds. Those are the sort of statements which are being made by Senator Cunningham and members of the Irish Medical Association who are trying to give the impression that the Department of Health—whatever Minister is there— is not giving a fair show to the voluntary hospitals; that the Minister is always favouring the local authority hospitals. There is no truth in that.
No Minister for Health tried to interfere with the voluntary hospitals. They are finding it hard to make ends meet. They must blame somebody and they blame the Minister for Health. The Minister has done his best for them. All these grants are going to them. They get what is considered a fair amount from the local authorities for their patients, but they are not able to make ends meet and the Minister for Health comes along and makes up the  deficit. But the Minister for Health here is only an Irishman; he gives them whatever they want. But the Minister of Health in England is an Englishman. He is a gentleman, according to Senator Cunningham, and he says: “Boys, what do you want and you will get it?”. The Englishman gets all the praise. He does not do it in a different way from the Irishman, but he gets all the praise. The poor Irishman says: “What do you want? You will get it,” but he is only an Irishman. That is the sort of criticism you have about this from Senator Cunningham and members of the Irish Medical Association.
Senator Cunningham complains that there is nothing in the Bill to enable the Minister to give more help to the voluntary hospitals. There is not, but of course we only bring in a Bill to give us power to do the things we want to do and power which we have not already. I have any amount of power to give money to the hospitals and I do not want any legal power to do it; I only want the money. Therefore, it is not necessary to put it into the Bill. What more money can we give them? If I come along at the end of the year and ask them: “What did you spend?” and I give that, what more can I give them? Surely I cannot say: “There are a few thousands for yourself,” if that is what the Senator expects I should do. They are getting all they are spending at the moment and we cannot give them any more.
I ask Senators—because I suppose there may be innocent men among them—not to listen to the story that the Minister for Health is hard on the voluntary hospitals. They get anything they want. In fact, I have offered to give them more to pay their staffs. The position will be then that the voluntary hospitals, if you pay their staffs, will be getting the deficits paid as well and I do not know what else we can do for them.
One point made by Senator Cunningham was that the Minister has not distinguished between the voluntary hospitals and the voluntary teaching hospitals. I do not think we could. What distinction can we make? We pay the deficits and what more can we do? I suppose that is  all we can be expected to do. The voluntary teaching hospitals may have a little more expenditure. If they have, they are getting it back by having the deficits paid. As far as their staffs are concerned, they at least have some income, because the voluntary teaching hospitals—Senators may not be aware of this—collect fees from the students and those fees are distributed to the staffs for lectures. That, of course, is quite correct and I am not objecting to that. The men who give these lectures get some small remuneration. I am not sure what it works out at, but they get some small remuneration per student. Therefore, they are somewhat better off than the voluntary hospitals which are not teaching hospitals. I do not know what distinction the Senator wants made between the voluntary hospitals and the voluntary teaching hospitals. From looking at their bills, it would seem that the teaching hospitals have more expenses and the deficits are bigger, but if they are bigger they are being met and that is all we can do.
Mr. Baxter: A mere layman is hesitant about entering into this discussion, but people who speak on behalf of the ratepayers, who, in turn, have to bear the cost of sending patients to Dublin hospitals, must be concerned about the arguments over this section. I must confess that I cannot commend the Minister's speech. I think it was the most unhelpful contribution he has yet made. I must say that Senator Cunningham put his case reasonably, and he had a case. The Minister points out that he has offered to give the voluntary hospitals the same amount per patient as is given in local authority hospitals. Senator Cunningham indicated his concern because of the new section in this Bill to which we will come in a few moments and to which I have put down an amendment, and which in his judgment, apparently, and the judgment of those associated with him would change the character of the work in the voluntary hospitals and reduce very considerably the incomes of the practitioners  there and, of necessity perhaps, not only alter the personnel, but alter the approach of young men who would enter into the profession if the opportunities were sufficient to encourage them to do so.
I do not intend to deal with the situation under Section 15 until I come to it, but Senator Cunningham has raised the issue now and cognisance must be taken of that. He made reference to the payment of doctors in voluntary hospitals and his reference brought to my mind an experience of our local authority at a recent meeting when a managerial order made reference to the appointment of a house surgeon in the local hospital and the failure to obtain such a person. We were actually proposing to pay him the magnificent sum of £150 per annum, but he could not be procured at that money. For a figure like that, I do not know what sort of a person you can expect to get. After all, it is important to maintain the self-respect of our young professional people and that is the figure which was determined by the Minister's Department. We are deprived of the services of the county surgeon because of this figure. If a figure like that enters into the costings in a local authority hospital and if these costings are put against the costings in a voluntary hospital in Dublin, obviously it will be to the disadvantage of the voluntary hospital in Dublin.
The whole problem of building up health services in this country has been raised by the speech of Senator Cunningham and the Minister. It does not matter how you juggle with words and it does not matter whether you are cross or pleasant in making your statement about it, the truth of the matter is that the building up of health services in this country to the level desirable by the Minister or Senator Cunningham is going to cost an enormous amount of money—much more money than the country has available to spend on the building up of a health service. While Senator Cunningham is concerned about the contribution of local authorities to send patients to voluntary hospitals in Dublin, those of us who spend money on behalf of the local authorities and  who have to put upon the rates the liabilities that accrue because we must send patients to the voluntary hospitals in Dublin have to be concerned about that aspect of the case too.
There is no use whatsoever in the Minister's showing displeasure at the case made by Senator Cunningham. In my opinion Senator Cunningham's case was very reasonable. He was seeking an understanding of a situation which exists and there is no use in the Minister showing displeasure. The fact is that this Bill will not be worth the paper it is written on unless we can provide millions and millions of pounds more for health services than we have ever provided before. Where these millions are going to come from none of us can say. It does not matter whether Senator Cunningham hopes to get the Minister to decide that many more patients should be free to go into the voluntary hospitals and pay for the services which they get or whether the Minister is going to provide that these people are going to be treated free. There is a certain amount of money which we can afford to spend on health services in any particular year—a certain amount of the national income— and there will be considerable impoverishment if more than that is spent in that particular way. That is the real problem and nothing which the Minister will say or do in this Bill will solve the difficulties which will confront him and all of us when the Bill is implemented.
Professor Cunningham: The Minister tried to get annoyed over what he said was the comparison I made between him and the former Minister of Health in England, Mr. Bevan. I made no comparison whatsoever. I merely stated certain facts concerning the method of paying money to hospitals here and elsewhere. I think the Minister understood that very well. He knew I meant no reflection whatever. I never mentioned Mr. Bevan being a gentleman or otherwise and I never mentioned the Minister being a gentleman or otherwise. I do not take all that very seriously.
This is a very serious matter and  there are a few statements which the Minister made to which I must reply. He said that the voluntary hospitals were getting all the money they needed and that when they were in debt he paid off the debt. The accounts of the hospitals are very carefully checked and the items which are purchased are very carefully checked. If there is an item purchased in respect of which the Department or the Minister does not agree, then they will not pay for it. The voluntary hospitals at present are in the position—and the Minister will bear me out in this—that when they require certain apparatus or require to extend a room, an operating theatre or a laboratory they must apply to the Department of Health first. If they spend the money without doing so and put it on the deficit for the year it will not be paid. I can quote numerous instances of my own experience. I am the governor of one hospital in the city and I am on the staff of another and I know we are waiting for a certain apparatus in our hospitals for at least two years and the Department of Health will not sanction the purchase. The Minister may gloss over these things. He said he is giving the voluntary hospitals everything they want. They have not got it.
We have been agitating for years for all the necessary things. They do not do me any good to have them but they benefit the patients and give us better facilities for teaching students but the Department of Health wants to keep down expenses and we do not get them. The Minister also said that two thirds of the money has been given to the voluntary hospitals but only one voluntary hospital has been built in Dublin out of the sweepstake money. How many hospitals have been built in the country? There were local subscriptions for these also. Why have we been kept waiting 20 odd years?
The Minister also said that we get fees from students. That is true. The students pay fees to the hospitals for their teaching and these fees are divided according to the arrangement that existed years ago amongst certain members of the staff. These fees do not amount to very much and for that reason we have never bothered to  change the system. The men who do most of the teaching are surgeons and physicians because it is they who deal with the major subjects. They get the fees which do not amount to much. I teach two days in a hospital and so do my assistants and all the other voluntary surgeons and physicians, but we do not get one penny for that. So much for the fees.
The Minister, again, asked for some explanation of the difference between the voluntary hospital and the voluntary teaching hospital. I tried to explain it. The voluntary hospital has not got the same expenses as the voluntary teaching hospital because in the voluntary teaching hospital you have specialists of the highest degree. They get all the difficult cases and it costs for each patient more on the average than it does for a patient in a voluntary hospital or in a State hospital, and from the point of view of investigation it costs a great deal more.
We get the difficult cases, the cases that are bad risks for operations. The patient may require three or four pints of blood, certain apparatus may be required, and all that has to be paid for and it costs a great deal more than it costs for the removal of a simple appendix. We have a lot of that difficult work to perform because the patients are sent from the country where facilities to deal with them do not exist. That is why the voluntary teaching hospital is much more expensive to run.
Furthermore, we require laboratories where students can be trained. Of course, they get most of that training in the universities, but we require a little more room from the point of view of teaching also. I hope I have made it clear why a voluntary teaching hospital is more expensive to run. This is a most serious matter and it affects the whole future of medicine in this country.
Question put and agreed to.
Sections 11, 12 and 13 agreed to.
 SECTION 14.
Government amendment No. 1:—
In sub-section (1), page 5, lines 47 and 48, to delete “ophthalmic and dental” and substitute “ophthalmic, dental and aural”.
Dr. Ryan: In dealing with this amendment, I think I should say a few words on it and on amendments Nos. 2, 5, 6, and 7. Perhaps I could put the matter shortly this way, that there was some doubt as Section 14 was cast as to whether aural appliances and aural services were both free as, of course, they should be under Section 14 because it is the section which is to continue to give free services to the lower income group, known at the moment as the public assistance group. We want to make it clear that they are entitled to free services of all kinds. These amendments propose to make it clear that they are entitled to aural appliances as well as aural treatment. There was some doubt, and hence these five amendments—1, 2, 5, 6 and 7—propose to put aural treatment and appliances on the same level as ophthalmic but not dental. The effect of the five amendments for the lower income group will be that there will be free treatment for the ear and free appliances. As regards the middle income group, where they are entitled to specialist services they will be entitled to free advice but not necessarily entitled to free appliances. There may be a charge made for the appliances. That, briefly, is what these five amendments mean.
Mr. Douglas: As regards the amendment to sub-section (1) of Section 14, I read it in a completely different way from the Minister. I read it to mean as including aural, as far as treatment is concerned, but excluding aural as far as appliances are concerned. It is significant that you put in the word aural, as provided in the amendment, and leave it out in the last sentence of the sub-section where there is reference to appliances. I suggest, therefore, that you are excluding appliances. There is the danger of putting in the word aural in one place and leaving it out in the other.
 There is the general principle to be borne in mind that the more you define the more danger there is of excluding. I looked up the dictionary and found that aural appertains to the ear and nasal to the nose. Nasal treatment would be excluded because it is not mentioned. I mention this to show that there is a possible danger in this arising from the general principle which is fairly well recognised. Eye treatment and dental are being described as medical. If a person gets a pain in the ear must he, in the first instance, go through the ordinary doctor? I am doubtful of the wisdom of adding this word in these amendments and then excluding it in the last sentence of sub-section (1) of Section 14. I think that under the amendment, as it stands, aural appliances would be excluded.
Dr. Ryan: I must say that this is very puzzling. It got a good deal of study both from myself and my legal advisers. As the section stands, medical appliances would cover aural appliances also, but that makes it doubtful as to whether aural treatment is included or not. We must make sure that aural treatment is included.
Mr. Douglas: I think that the Minister should look into this again. The word is excluded in the last part of the section.
Professor Hayes: I suggest to the Minister that he should look into this. There is the well established principle that if you mention A, B, C and D, you exclude everything else. If you use a general term it may be interpreted generally to include a great many things, but if you define a general term and specify it as A, B, C and D you may find yourself doing the very reverse of what you had intended. It would appear to me that, since you specifically mention ophthalmic, dental and aural, and then leave out the words after the word “dental” in the last line, you are excluding this from appliances. Once you specify, everything must be in, and everything else is excluded.
Mr. Douglas: I think that when the Minister is dealing with the treatment of those under the age of six he will  find that there is specific provision for aural appliances. These are mentioned specifically.
Professor Cunningham: Sub-section (2) of this section says that
“The persons referred to in sub-section (1) of this section are persons who are unable to provide by their own industry or other lawful means the medical, surgical, ophthalmic or dental treatment or medicines, or medical, surgical or dental appliances necessary for themselves or their dependents.”
I should like to ask the Minister whether this new card system operates under this section? In other words, must a patient apply for a card and, if so, must he go to the local health authority, to the county manager, and declare to him that he is in need of public assistance—in other words, that he is unable to pay and, therefore, is entitled to a card?
An Leas-Chathaoirleach: The Senator can deal with that point on the section when we have disposed of amendments Nos. 1 and 2.
Professor Hayes: Perhaps the Minister would agree to leave the amendments over to the next stage?
Dr. Ryan: If the House will accept amendments Nos. 1 and 2 now, I will look into that point.
Amendment No. 1 agreed to.
Government amendment No. 2:—
In sub-section (2), page 5, line 51, to delete “ophthalmic or dental” and substitute “ophthalmic, dental or aural”.
Amendment agreed to.
An Leas-Chathaoirleach: Senator Cunningham can now continue on the section.
Professor Cunningham: If a patient has not a card and requires immediate treatment, must he then apply for a red ticket? If a person who declares himself to be of this class has not gone to the trouble of getting a card and  gets suddenly ill, or if some member of his family gets suddenly ill, must he then apply for a red ticket to get assistance? In other words, does the red ticket system remain, or has it been completely abolished?
Dr. Ryan: No. The position with regard to that is as I mentioned in the Dáil. We intend to introduce what we call the card system. In saying that, I may be giving a wrong impression. What I mean is, to introduce a card rather than a ticket, the card having a permanent applicability. A person who thinks he is in the lower income group would be entitled to apply to the local authority for a card which would entitle him to free medical services of all kinds. If he gets that card, then he will be entitled to these services without any further application. I do not know how long it will remain in force, but probably 12 months. He would, of course, have to satisfy the local authority that his means entitled him to this card. The person having a card would not be put to the inconvenience, if something occurred either to himself or some member of his family at night, of having to seek out a warden and of getting him out of bed to sign a red ticket to present to a doctor. Instead, he would go with the card to the doctor. The doctor would attend on it rather than on the red ticket. That was merely a suggestion for the convenience of the patient. It was in no way an attempt to do away with the red ticket, although it has been represented to be that—with the degradation, if you like, of the red ticket. It was merely suggested as a matter of convenience.
I quite recognise that everybody in the lower income group may not have the foresight to apply for a card, and so may be caught out. Therefore, we must continue the red ticket as well because we cannot very well say to a person: “If you do not supply a card, then you cannot get a doctor.” We must, I suppose, allow the red ticket to continue for a long time, until such time, at any rate, as everybody will be provident enough to have a card in his possession. That is as far as that system is concerned.
 On the question of means, the local authority would have to be satisfied that the person is entitled to the card. They are entitled now to make inquiries with regard to the red ticket and be satisfied that the person is entitled to it.
Professor Cunningham: I understand we will have now both a card and a ticket.
Dr. Ryan: Yes.
Mr. P. O'Reilly: I wonder if when this Bill becomes law some method could be evolved whereby the present red ticket system could be eliminated. The Minister suggested a few moments ago that he could foresee a position in which the red ticket system would continue and that it would take time to replace it. Do I gather from that that it would be replaced by cards? Could some system not be organised to ensure that the class referred to in Section 14 could be supplied with those cards? I can see a very awkward situation arising if some people apply for these cards to the health authority and more people do not. The Minister must envisage a position in which the head of each family feeling that his family was entitled to services would apply to the health authority for these cards. Some person will ultimately have to decide whether a person is qualified under Section 14 or not. As far as I know in rural areas the person who will have to decide that issue is the home assistance officer and the report which the home assistance officer would make in any particular case would be the deciding factor in connection with the manager's decision as to a person's entitlement. Therefore, if you had co-operation between the Department of Health and the health authorities a system could be operated in which the home assistance officer would be regarded as the person to decide. This, in my opinion, would eliminate the necessity for continuing, except for a very short time, the red ticket system. Quite a lot of the people who would normally apply could be supplied with these cards and it would make for a smoother operation of the Bill and avoid overlapping as between the issuing of the card by the local  authority and the continuation of the red ticket system.
Section, as amended, put and agreed to.
Mr. Baxter: I move amendment No. 3:—
In sub-section (2), page 6, paragraph (b), to add at the end of the paragraph—“and who in the opinion of the health authority are not in a position, without undue hardship, to contribute to the cost of the institutional and specialist services referred to in sub-section (1)”.
On the Second Reading of the Bill I addressed myself to this aspect of the Minister's proposals and I want again to ask the House to consider the implications of what is contained in this section. I have a similar amendment for sub-section (2), page 6, paragraph (c). This is an effort to change the character of this section so that it will apply to those and only to those who are unable to pay for their own institutional and specialist services without imposing undue hardship upon them.
Earlier in the debate arguments were introduced on the morality of the Bill as a whole and in relation to certain sub-sections. I feel that the health services must be regarded in the main as resembling other public services and it is from that angle we ought to attempt to approach this section. The Minister now is extending a health service to the people of the country and broadening it so that when this Bill is passed an enormous number of citizens will be entitled to claim free institutional and specialist treatment in our hospitals.
I went to the trouble of looking over some statistics to see in relation to our farming community what this was going to entail. I have discovered that out of a total of 380,000 odd holdings in the country, 346,000 are of £50 valuation and under. Therefore under this legislation 346,000 families out of 380,000 will be entitled to free treatment in our hospitals and free specialist services. Then we have the portion of it which deals with families with £600 incomes. I do not want to be misunderstood  in this matter. I believe that in so far as we can provide it, we ought to have the best medical and surgical attention available for our people that we are able to provide. I realise there is a type of treatment both in the surgical and the medical sphere which no money can purchase. You do not make a good surgeon because you have a lot of money. A man must have the skill in his fingers and the capacity in his brain and you just do not make that with money.
The Minister indicated in the debate earlier, discussing an objection by Senator Cunningham, his disturbance of mind about the financial implications of the measure and the problem confronting us in regard to the whole service of health. If he were making a sound approach to building up an efficient health service, realising the difficulties going to confront him or his successor in providing the money to do the job well, I would have thought he would do his utmost to see that the burden of payment would be distributed reasonably and equitably. The Minister may reply that I am arguing a type of morality to which he cannot subscribe. There are very few families in this island which have not had the experience of having hospital treatment and meeting hospital expenses. Most of us know what this means. Any citizen who is earning an income which makes it possible for him to make a contribution to a service which he secures from a health authority ought to make that contribution. It would be just as invidious for me to go into a grocer's shop and bring home food necessary for the sustenance of myself and my family and expect a neighbour or a collection of neighbours to bear the obligation of paying for that wholly or in part, as it would be for me to go into a hospital and expect service there from the public which I was able to pay for myself. That would be a perfectly indefensible attitude for me to take up.
The standard which the Minister is applying in this section is not based either on equity or on justice. In one case you base a man's capacity to pay on the cash income he receives. When you come to the farmer you base it, not on his income but on the value of  the property he holds. Which is the correct standard on which to judge his competence to pay? At times there is nothing more popular than to say you are giving everybody everything for nothing and that nobody has to pay. That is sheer nonsense, but it is what we are writing down on paper in this Bill, although someone has to pay. None of us can disregard the consequences of purporting to give a service free while we know in our hearts it just cannot be given free.
In the first place, I think this is an extension of the dole system. There are many people who subscribed to the implementation of that policy originally who have lived to regret it. Once you enunciate the concept, and implement it, that people can get something for nothing, there is no country in the world where the people are as ready to rise to that bait as they are in this country, relative to our population. That is something I do not want to inculcate to a greater extent. It is unsound and, in the last analysis, they will all discover it is not free, that these services must be paid for somehow, somewhere, by the people.
I do not believe that a farmer of £50 valuation in any county to-day is so impoverished that he is unable to make some contribution for the service he gets in our health institutions. Whether he is a wool or sheep farmer in Galway, a pig and poultry man in Cavan, a grassland man in South Tipperary, or some other type in West Kerry or Cork, he is able to make some contribution. I believe a considerable number of these people are prepared to make that contribution. This section, introducing it in this way, brings in a new idea amongst a new class, who have pride of race, who have considerable industry in them and who are the most solid force in the social and economic life of the country. You are going to destroy something that is terribly precious when you make these people feel they are entitled to something from the community which they could buy, in whole or in part, themselves, for themselves, out of their own money.
 I do not understand the principle that in one case you can judge a man's competence by his cash income while in another case you judge it by the value of the property he holds. There are many people who know that a valuation of £50 is no criterion as to a man's income. There are men with £50 valuation to-day and probably a gross income of £2,500, while I know there are men of £50 valuation who probably have not a gross income of £400. The competence of such people to make a contribution for a particular service that they require ought to be the basis as to whether they should pay and, if they should, how much they should pay. I do not want to be a party to introducing the idea amongst a new group of our citizens that there is something for nothing. We all know there is nothing for nothing.
With the limited income available to the nation, we must pick and choose as to the services that are most desirable and as to who are to enjoy them and at what price they will get them. Considering the Minister's difficulties in financing the many schemes he hopes to operate under this legislation, I cannot understand at all his anxiety to spread his net so wide. We all know quite well that there can be two families each with £600 income and no comparison whatever between the standards of living they enjoy. There may be a young lady with a salary of £600, or a school teacher, single, with a salary of £600; and another man with a wife and six or seven children and £600. Who is going to argue that there is equity or distributive justice in giving the same type of health service to all these people? I do not understand that at all. I think it is something that we will live to regret. If somebody will stand up and say that in one case the lady in question is making her contribution to the exchequer and circuitously to the maintenance of health services because she pays income-tax, I would say: give her the chance or the opportunity to get an allowance in her income-tax against the institutional treatment which she may require in a hospital, if that should arise, but let her realise that  she must pay for that service, which the public in a way provide, and for medical service to her. Let her pay for it, because she is able to pay for it.
I think when you realise, from the figures I have given, that out of the people in this country there are 380,000 people of £50 valuation or under, it shows you the dimensions of the Minister's proposal. Where is the money going to come from? By what other means is the Minister going to obtain the finances that are to run this measure? I know my amendments, if you analyse them and tear them to pieces in the literary sense, may not withstand attack, but I have put them down to indicate the point of view I have on this and which I am certain many other people have, and I think it will be more appreciated as the days go by and the sense that underlies it.
Mr. Hawkins: Senator Baxter drew the attention of the House to this question of the extension of the public health services on the Second Reading. He has—I must give him credit for having done something more than other Senators who spoke against the Bill on the Second Reading—at least gone to the trouble of tabling an amendment. I regret very much that he thought fit to table the amendment to this particular section that he has tabled it to. I always looked on Senator Baxter as the champion of the small farmers. This is the first occasion on which Senator Baxter has addressed this House to tell us that the farmers of the country are so prosperous, that almost every farmer of £50 valuation had an income now of some thousands of pounds per year and that the very worst farmers, the men who idle away their time and make little use of their 50 acres, or whatever is the acreage of the holding of which the valuation is £50, have not less than £500 a year. I was still more surprised when I examined the proposal and found the distinction that Senator Baxter was prepared to draw if the House accepted his amendment as between working farmers in Cavan, Galway or Mayo and the town dwellers who have £600 a year income or that other type of person who will be entitled when this Bill becomes law to  free medical services and specialised service which Senator Baxter would deprive these 340,000 farmers of.
When we realise that every insured worker in the country—and a worker is entitled to be an insured worker up to £650—has provision made for him to benefit under this section, and also take with that the fact that small shopkeepers and people working on their own behalf whose income is not over £600 will be entitled to benefit, and the only one group of people that Senator Baxter would degrade and send to the county manager or the home assistance officer for this red ticket or card or green card or whatever colour it might be, would be these 340,000 hard working farmers, I fail to understand Senator Baxter's outlook in such a case unless the amendment was put down just for the sake of having some amendment and justifying postponing the Committee Stage of the Bill on the last occasion.
I think our main consideration should be the concern of the people throughout the country who are going to seek medical assistance and aid. I quite realise, and I am sure other members of the House also realise, what the medical profession, like all other professions or bodies of organised persons, are quite capable of, and will not in any way be lackadaisical in looking after their own interests. I failed for quite a considerable time to understand the hostility of many sections and particularly that of the medical profession to the introduction of this Bill, until I listened for some short time here to-day to Senator Cunningham.
Professor Hayes: On this amendment?
Mr. Hawkins: On some previous amendment, but it has a bearing on the question and I am sure if Senator Cunningham rises to speak on this section that he will refer to it.
Mr. O'Higgins: Why not leave that to him?
Professor Hayes: Is the Senator entitled to make Senator Cunningham's speech in advance?
Mr. Hawkins: I do not propose to do any such thing. The case Senator Baxter made was—and I, like Senator Cunningham, referred to it earlier to-day—where is the provision to be made? Examining their outlook one would come to the conclusion that what the Minister should have done was to await the introduction of this Bill and have advertisements issued in all our daily and weekly papers announcing that there were so many vacant beds in each hospital throughout the country and urging that something should be done to induce people to occupy these beds, and until that situation had arisen there should be no attempt to extend or improve our present medical system.
Senator Baxter has spoken on other occasions in this House about the encouragement that has been given to the farming community to leave the agricultural areas and go into the towns, but here is one suggestion that was put forward and which, if accepted, would work in that way. Surely, if you are going to deny young people in the country, whether farmers or farm-workers, or those people of £50 valuation the same facilities and services that you are going to give their brothers in the towns in regard to medical services, then you are giving another encouragement to these people to leave the country areas.
Business suspended at 6 p.m. and resumed at 7 p.m.
Mr. Douglas: I support the amendment moved by Senator Baxter; I support, at any rate, the principle underlying it. Quite possibly it may require some modification since it gives a very wide discretion to the health authority, but I think it was worth while putting the amendment down because it draws attention to what is in my opinion one of the most serious flaws in this measure. I think most people accept the principle that we want the best possible health services and that these services should be provided free of charge to those who are not able properly or reasonably to provide such services for themselves or their dependents.
 It is inevitable that under that principle there should be some means test, and it is this section in the main that provides that means test. I think it is tragic that we are not able to devise a more equitable or fairer means test than that provided in this section. A single man or a single woman earning £600 a year is well able to provide and pay for health services. A married man, with a number of children, earning £625 or £650 may find it extremely difficult, and from that point of view he should be treated in a different fashion.
Senator Baxter has pointed out that to arbitrarily take a valuation of £50 will mean that some people who could well afford to pay may get free services. There is a possibility that the reverse may also occur in the farming industry where people with a valuation of over £50 will not be in a position to meet the cost of health services for themselves or their families. The Minister may say that he can think of nothing better, but it seems to me to be a mistake to pass a Bill of this kind without protesting that this is not an equitable means test.
I am puzzled by a provision which, on the face of it, is reasonable enough but which in its details appears to be both unworkable and impracticable; I refer to the decision to include in yearly means the income of the wife, of the young married son or daughter. I do not object to that inclusion but, on the other hand, they are only included if the wife lives with her husband and not otherwise. The income of the son is included if the son normally lives with his father, but not otherwise. If the father and son each earn £500 per year and live in two separate houses they can both avail of free medical services under this Bill. If they live together and are in receipt of a lesser income they cannot. That is a mistake. There could be some way by which the existence of a family and children below a certain age could be taken into consideration in determining how the local authority will decide who cannot afford to provide medical services for themselves.
Although I am criticising this, I do recognise that it is a very difficult  problem and I do recognise that you will not get any system that will not have some anomalies and difficulties. It seems to me, particularly in regard to the single men and women and families, that this is wide open to criticism and that it should not be impossible even at this late stage to improve it. I suggest to the Minister that it will cause a good deal of dissatisfaction, that there will be a feeling that people who could very well afford to pay are getting away with free services while others have to pay simply because their income reaches a nominal figure which is in excess of £600.
While I am on this section, I should like to ask the Minister has he considered the phraseology? The section provides that a health authority shall, in accordance with the regulations, make available institutional and specialist services. The words “they shall” mean that they are obliged to provide institutional services for people of a certain class. If they have not enough hospital space immediately available is there a possibility that they could be sued in the courts, as occurred in the case of the Dublin Corporation where a firm got a mandamus because the corporation had not carried out an Act that contained a proviso that they should provide a city plan? There is that possible danger and it should be provided against. I may be wrong. There may be a proviso. It seems to me that you are giving certain people rights as against the local authority which they may be able to enforce in law if they want to be troublesome. If there is anything in that point, it should be dealt with in the Bill.
Mr. O'Higgins: I would urge the Minister to give very serious consideration to these amendments set down by Senator Baxter. I recognise, as did Senator Douglas, that the questions of particular means tests running throughout this Bill are matters of some difficulty and possibly some delicacy for the Minister. There are various means tests in the Bill. Senator Baxter is suggesting a rational way in which the means test to govern Section 15 should be applied. He has  made a very reasonable case for his amendments. He has pointed out that there will be glaring examples of persons having the same income but having completely different family and home circumstances and that it is merely a catch-cry to talk about free for all. Nothing is free. Someone will pay for it. If a person can well afford to pay for his own specialist treatment or institutional services, there seems to be no reason why others in less comfortable circumstances should be taxed, as they will be taxed under this Bill, to provide treatment in those cases. That, in a nutshell, is the point of view advanced by Senator Baxter and I consider it to be very reasonable.
Senator Hawkins attacked the amendments and attacked Senator Baxter's speech on the basis that Senator Baxter was trying to take something away from the farmers with a valuation of under £50. He got very indignant about these people who would get free institutional treatment from the Minister and about Senator Baxter, who should be representing the farmers, trying to take it away from them. I do not think Senator Hawkins meant that. If he did mean it, I do not think, with all respect to him, that he read the section. The Minister does not give these people a right to free institutional treatment under this section. I do not think there is any doubt about that. If Senators will study the section they will see, in sub-section (3), that the only people entitled as a matter of right under this Bill to free institutional treatment are those who come within sub-section (2) of Section 14 of the Bill, that is, persons who are unable to provide by their own industry or other lawful means the medical, surgical, etc., treatment set out in sub-section (2) of Section 14. In every other case—in all the cases included in sub-section (2) of Section 15—these people, small farmers, the people with means under £600 a year, and so on, will only get free institutional treatment provided it is determined by the health authority that they are to get that treatment. Unless something active is done by the health authority to declare them entitled to free institutional treatment, they will not get free  institutional treatment. I think my reading of the section is correct. If I am wrong, I am sure the Minister will put me right. As I read the section, it is nothing but the greatest bluff to pretend that this section gives free institutional treatment to all the categories of persons set out in sub-section (2). It does nothing of the sort. I emphasise the fact that I am talking of institutional services. It does give the right to specialist services without charge but it does not give the right to institutional services without charge.
If I may be allowed to follow a point raised by Senator Douglas, I want to say that in connection with this method of assessing joint income, I agree with what Senator Douglas has said. This also is a matter to which the Minister should give very careful consideration. I think he is on the right lines in the Bill, in sub-section (6) of this section. The principle, if there is any principle in it, in sub-section (6) is on a par with the principle which Senator Baxter asks to have introduced by means of his amendments but it will raise problems.
Senator Baxter referred to the case where a husband and wife living apart, each with incomes of, we will say, £500 per year, become each entitled to the benefits under this section, but if they live together they are not entitled to it. You are going to have in Dublin City, particularly, very many cases where you have different families or different members of the same family, married members, living in the same house in what are known under the Rent Restrictions Act as separate and self-containued dwellings. They are flats in the same house; and you are going to have a problem arising out of tenement houses in the City of Dublin and elsewhere where different members of the same family, having married, brought their wives and their own family into another room in the house. There should be something to define whether or not those people are going to be considered as living together or living apart. I do not see an effort made in the Bill to clarify that matter and I would like the Minister to look into it.
 Going back to the proposals made by Senator Baxter, I pointed out the position in relation to institutional services. It seems to me that the Minister has already provided for the principle contained in Senator Baxter's amendment in section 3 of sub-section (15) so far as it refers to institutional services. Is there any good reason, is there any reason at all, why the same principle should not be extended to the specialist services referred to in the section? It is quite clear, I think, as I say—the Minister will correct me if I am wrong—that under sub-section (3) of the section the various categories of persons set out in sub-section (2) will only get free institutional treatment if the health authority so decides. Why is not the same provision made in respect of specialist treatment?
Mr. McCrea: I rise to oppose this amendment, I would say, because if the Minister were to accept the amendment as it is worded there, then he would kill the whole principle of our institutional treatment under this Bill. I have been a member of a public authority all my life and I have been associated with health committees all during my life, and knowing home assistance officers, superintendent assistant officers and county managers as I know them, if this amendment were accepted even recipients of home assistance would not be sure that they would get institutional treatment. They always seem to find some invisible income coming into the home unknown to everybody except themselves. That is my experience of them, and it would be better for the Minister, if he accepted this amendment, to put a maximum in this Bill so far as institutional services are concerned. Every case, as it is worded here, would be investigated—not the person with the £50 valuation but the person with the £10 valuation and the person living in the labourer's cottage, for that matter. I think that there is one thing that commends itself in this Bill —that it caters for farmers living on uneconomic holdings. I have always advocated that not alone should the medical services have been extended to people in that category, but even at one time I thought that the Labourers  Acts should be extended to farmers with a valuation up to a certain point. If Senator Baxter considers £600, say, or £50 valuation, too high, then he should have engraved that in this amendment and let us have some discussion on it, but as worded there it would kill the whole principle of this Bill so far as institutional services are concerned, and I certainly oppose it.
Professor Cunningham: Senator Baxter raised one point of great importance which has received far too little attention, I think, both in the Oireachtas and outside, and that is, the effect on the character of the people of this Bill. It was rather disheartening for me when this measure was being discussed in various county councils and elsewhere to see how few people—there were only very few exceptions—considered this aspect of the free, or so-called free, medical treatment that was going to be given by this Act, but it is one of the most important aspects of the whole thing. When people get something for nothing, first of all they do not value it. They take advantage of it and they abuse it. It has a bad effect on themselves morally and in every other way.
A young man, for example, who earns £550 a year is not badly off in this country. He is able to provide for himself. He probably will get married in a few years' time when his income may be £650 a year if he improves himself. When he has been on his £550 a year salary he has been given free medical attention, free hospital treatment, everything done for him free. Now he is married, he has a wife to look after and in time he will have some children to look after. Now anybody who is worth his salt is able to provide for himself out of an income of that type. A single man on £550 a year can provide for himself. It is very good for his character that he should do so, that he should be able to pay his way. It makes him appreciate the value of money.
Mr. Baxter: He is probably driving a motor car already
Professor Cunningham: He certainly is. He certainly has to appreciate the value of money and what he is capable of doing with money. If you give him all that free you do a certain amount of damage to his character. When he is married and has two or three children or perhaps four and his salary may be £1,000 per year he is now outside the category, but he is in a position where he is less able to pay for this treatment than he was before; and even if he is able to pay for it or has £1,000 a year then on account of the way he got it free before he will approach the county manager or somebody else, the health authority—that is the county manager, of course—and he will make out a very strong case as to why he should get this free. This whole business is going to have a very demoralising effect on young men. If they had to subscribe to it and knew that they were paying so much a week or so much a year for a health scheme, then that is an entirely different matter; but where they are told they are getting it free, that it is being paid for by the wealthy people in this country, whoever they are, and by the very small percentage of taxpayers in this country, they are glad to accept that, and that is very bad for them. That is one point.
The other point, the whole difficulty about this particular matter, is this dead-line of £600 per year. I do not know how the Minister or his officials arrived at that figure of £600 per year. Below that you are a medical indigent; if you are just above the line you are well able to pay for yourself. The thing is perfectly absurd, and this thing could have been easily avoided if the Minister had only taken advice, the advice that he was given by people who had studied this, or if he had only taken cognisance of what had happened elsewhere. I think it is not too late still for the Minister to change his mind, because this is a matter of such great importance, not only for medical circles and for the health of the people but for the character of the people. I do not think it is too late even now for the Minister to change his mind, drop the whole thing, and adopt the system which has proved so successful  in a country which compares with ours, like Denmark or Belgium or France or Australia, where they have introduced it in the last year or two.
I do not know if any of you read an address that was given by Sir Earl Page, Minister of Health for Australia and a man of great experience, at the World Medical Meeting at The Hague, recently, where he was the principal speaker and gave an accurate and detailed description of the system that they had adopted in Australia in the last two years, a system which is working so well; and it worked well in European countries. It is a system which has been recommended early this year by the Truman Commission in America, which sat and considered this whole matter for about two years, published their report this year, and have recommended exactly the same thing.
Some two years ago we had a meeting with the Minister for Health. He was very kind and courteous to us. We went as representatives of the doctors, as representatives of the Irish Medical Association. We told him that we had formulated a scheme which was started at the time his predecessor, Deputy J. A. Costello, asked us to draw up a scheme for everybody—not a mother and child scheme but a scheme to cover every person in the State. We drew up that scheme and, in time, submitted it to the present Minister. He turned it down and gave his reasons for so doing. However, you will find that none of these reasons will stand careful examination. We submitted exactly——
An Cathaoirleach: The Senator is getting away from the amendment.
Professor Cunningham: I am pointing out how this can be avoided.
An Cathaoirleach: The Senator will have to relate his remarks to the amendment before the House.
Professor Cunningham: So long as this deadline of £600 a year is maintained, there is a means test the whole way through this Bill. There will be difficulty about the people who are just over the £600 and who cannot afford to pay. The man who will decide whether they can or cannot pay will,  apparently, be the county manager. That puts him in a very unfair position. Therefore, I support Senator Baxter's amendment.
Professor Stanford: I think the House would like to hear what Senator Cunningham suggests as an alternative. Does he suggest that we should have no means test or does he suggest that the means level—that is, the operative figure of means—should be lower? Would Senator Cunningham reveal that to us? Is he in favour of no means test or of a lower means level?
An Cathaoirleach: That question does not arise on this particular amendment.
Professor Stanford: Personally, I shall be interested to learn Professor Cunningham's view at a later stage.
Dr. Ryan: I think that this particular amendment affects fundamental questions underlying this Bill. It might, indeed, have formed the basis of a Second Reading debate.
When I first came to consider a Health Bill of this kind—it is some years ago now—I had in mind that there were certain people who could afford to pay the family doctor but who could not afford to go further than that. These people could not afford the big hospital bills that were sometimes served on them. With that in mind, in the Department, we decided to draw up a scheme to help people above the lower income group to meet bills that were intermittent and, if you like, that were exorbitant from their point of view. I am not saying that the bill would be exorbitant from the point of view of the hospital or of the doctor but only from the point of view of the person who received it. We sat down to consider how that could be done and we decided on a certain thing. I suppose that if Senator Baxter or Senator Cunningham had been in my place they might have decided otherwise.
When you are considering a scheme like this, naturally you have to take into account how things are at the moment. You have the insured classes. Every manual worker working for  another is insured. Every non-manual worker under £600 a year who is working for another is insured. Up to this, they were entitled to hospital treatment—somewhat limited, I admit, but in any event they were entitled to it. It is not so easy to take away a thing like that. It is easier to say: “Let that be, and let us see if we can bring other people into line with it.” Naturally, you bring in other people under £600 a year. Take, for instance, a man working for himself. He could get sick and need treatment just the same as a man working for an employer. It is only reasonable to take the same level of income. We took £600. That makes the second class.
In 1947, when Fianna Fáil was a Government, we first published this scheme. At that time we had the insured worker—the person up to £600. Then we asked: “What farmer would correspond to that level?” At the time, we put down a farmer of under £50 valuation. May be we were wrong but that was put down in the White Paper which was issued in 1947. We took that White Paper up again in 1952 and proceeded to incorporate the scheme in a Bill. It is in this Bill in that way. I think it would be rather difficult to go back on the insured class and say: “We will cut down on you. You may have been entitled to free treatment up to this but you will not any longer”. It would be a very difficult thing to carry and I suppose people would argue that it would be unjust, too. The other things follow logically. We may have put the valuation too high. Perhaps a valuation of £30 or £40 would be nearer the equivalent of £600 a year. If we made a mistake like that, all I can say is—and I suppose Senator Baxter will agree with me—that farmers do not always get the best of it in these things and that if they are getting the best in this case then let them have it.
Mr. Baxter: Who is going to pay the money?
Dr. Ryan: Somebody is going to pay it. Nobody ever claimed that it was free in that respect. I come now to the question of means test. There are several means tests in this Bill because we did not claim to have a free service  for everybody. For that reason, we set up several means tests. For instance, there is the lower income group and, above that group, everybody must pay the family doctor. Everybody in the middle income group must pay their hospital expenses and if they want to come into the maternity scheme they must contribute. Therefore, there are several means tests.
One thing which I was rather keen on was to stop, if possible, means investigation. Probably the suggestion was made to me—because various suggestions were made—that the means of farmers should be investigated, but I thought it was better to say: “Take us up to a certain valuation and then there is no means investigation.” If we err a bit on that side, I think it is better than to have investigation in every case. As Senator O'Higgins pointed out, there will be investigation in the case of the farmer and in the case of the person under £600 where institutional treatment is concerned because the local authority may, if they think fit, charge up to £2 2s. per week, that is, 6/- per day. Therefore, if you like, there is a means test there. The farmer with a valuation of under £50 who is told that he has rather a serious ailment and that he must go to hospital for treatment or for an operation can be told by the family doctor that it is free or practically free. The most they can charge him is £2 2s. per week, and there will be no surgeon's fee. The family doctor can tell such a man that even if he is in hospital for five or six weeks the bill will come to only £10 10s. or £12 12s. Even that will not frighten off the small farmer.
I think that what set me going in the beginning about this matter was letters which I was receiving. I remember distinctly one letter in particular from a woman who described herself as a widow with a big family. She said she was living on a farm of £15 valuation and that she had received a bill for £115. Possibly she did not pay that amount. I am sure that if she went to some kind friend in the county council, he would approach the county manager and get the bill abated somewhat. However, such bills  were sent out. I quite admit that there is room for any amount of differences of opinion on all these various questions. I think, however, we can argue that it is better to try to lessen the cases where investigation must be carried out on means, as far as we can. Even if we err a little bit by giving free treatment where it is not absolutely essential, let us face that.
The next case that is put up is that you have the man with a family and who has over £600 a year. He is provided for under sub-section (2) (d). If he makes the case that his is a case of hardship, that he is not able to pay, the county manager is the person in that case who can investigate it and, if he thinks fit, can pay the bill or partially pay it for him.
We tried so far as we could in drawing up the Bill to see that there would be no case of hardship. Perhaps I should put it this way—we tried as far as possible to see that no man would be denied treatment because he was not able to pay or would be frightened off treatment by his fear of what the bill might be. That would be a better way of putting it, because there may be some payment to be made but not sufficient to frighten a man off. If Senator Baxter were very anxious to save money for the local authority and, incidentally, for the Department of Health, because the Department pays 50 per cent., it would have been better to deal specifically with the poor law valuation of the farmer. I do not know that we would be inclined to support him at this stage, seeing that the Bill has gone so far, and in any case bringing the valuation down to £40 would take in only a very small section of farmers. The figures Senator Baxter gave were for holdings.
Mr. Baxter: Valuations of holdings.
Dr. Ryan: Many a farmer has more than one holding. So far as I could get the figures from the Statistics Office, there are 250,000 farmers, of whom 220,000 are under £50 valuation, so that there are only 12 per cent. over.
Mr. Baxter: About the same proportion.
Dr. Ryan: Much the same. Senator O'Higgins asked me about these specialist services. I think it would be more costly on the local authorities to make charges for these specialist services. Remember that ophthalmic and dental services are excluded from these specialist services and are dealt with in a special way. The services then left would be orthopædic clinics, mental clinics, X-rays and other clinics for ear, nose and throat treatment. That is the type of specialist treatment we have in mind and many of them are the types of treatment we would like very much to encourage people to seek advice on. Even if we were to make a charge, we would not collect very much, and we thought it better on the whole to make that a free service and try to get the people to attend the clinics.
I find it very hard to understand Senator Cunningham's last sentence. He said the county manager is going to decide who shall get this free treatment and therefore he supports Senator Baxter's amendment. He meant to be against the county manager, but, as he put it, it would appear that he had such confidence in the county manager that he would support the amendment, because under the amendment somebody must decide means, must decide who shall pay. I fought this principle very hard in the Dáil—that it is wrong to let the county council, as such, decide it. I do not think that many people—some people do not mind, we know—would like to have their case discussed at a public meeting of the county council, with the Press present. They would rather have one officer who would examine their case and say yes or no, everything being done in private, with no publicity.
It is the only instance in this Bill, I think, in which the county manager is definitely brought in as the person to do a certain thing and he is the person to decide, in all cases where the question of means arises, whether the applicant is entitled to the treatment or not. I think Senators will agree at least to this—one person should decide  it rather than that it should be decided at a public meeting of the county council or of the Corporation of Dublin, as the case may be. We do not want to appoint a special arbitrator or umpire for the purpose and we think the county manager should do the job as he has been doing it up to this. Since county managers were appointed, they have done that job and have done it, on the whole, very well. I have never heard any complaint about them.
Mr. Baxter: I have to express regret that the Minister failed to face the fundamental fact. He has not attempted to answer the question I put to him: is there a responsibility on me, on any member of this House or on any member of our community to bear his own burdens where he is able to bear them in regard to hospital charges? Senator Cunningham brought this discussion rather farther than I attempted to bring it in my opening remarks, but I want now to reiterate what he has said. The family is at the base of our society. The head of the family has his responsibilities and obligations and they ought not to be lifted off him, if he is able to bear them.
I dislike the Minister's attitude in relation to this matter, that we are all going to be lumped together and that we must all be lumped together because we cannot find a better way. That is what he has done in regard to this section. A person with £600 income gets a certain treatment, but the person with £605 cannot get that treatment. The Minister is against probing into people's means, but how are you going to discover what the means of a family are without probing into them? Any of us who have experience on local authorities which operate a differential system of rents know the difficulties which are created, because we find one man paying 10/6, another man 5/- and yet another 15/6 per week. When the matter is raised at the county council, you are informed that the rent is based on the earnings of the family, the total moneys going into the home. The Minister has exactly the same principle embodied in the section in regard to people with a cash income of £600. That is the family income, so there has to  be, and there is, a probing into their means there.
One thing with regard to this figure of £600 is that all sorts of subterfuges are going to be adopted by people in regard to their incomes—covering up wherever they can—to ensure that they come within the category specified in the section. If it is possible, they are going to keep their income at £600, no matter what it is, and they will find devious methods of doing that. We are quite good at that. Take the case of the man with £50 valuation. He ought to do some things about his house— ought to improve his place, to build something additional. Every time he comes to do anything like that, his valuation is going to be raised and he is then outside the free category. He goes to £50 10s. or £51 valuation and is then in a class apart. The whole thing is really inequitable and I am not satisfied that there is not a better way.
I come back then to what is the fundamental issue. Where people can pay the total charge, I think it is their moral obligation to pay it. Where they are not able to pay the total charge, there ought to be a means whereby they will be released from some of the charges simply because it is going to weaken society at its roots when the family is weakened. If you put a burden on the family that is going to weaken its capacity to live and progress, society is the worse for that, and if we do that over a wide range of our families, the strength of our society is weakened at its very foundation. Then society collectively through some organised body, like our local authorities, must come to the aid of individuals, heads of families and so on. Until it is necessary for society to act like that, there is no obligation whatever on society to do so. The obligation is on the head of the family.
I should like the Minister to address himself to that point and then come back to the practical issue. I have not troubled to see what exactly the figures are in my own county, but the only way in which, if we want to see how a measure like this is going to operate, any of us can have any appreciation of it, is to try to apply  it to the conditions as we know them in our own surroundings. That is what I tried to do. Taking my own county again, probably 90 per cent. of the valuations there are under £50. The local authority there will get a certain grant—50 per cent. of the cost of the health services—from the Exchequer. The other 50 per cent. will be borne or paid for somehow locally. In the main we are a farming community. If certain numbers of our farmers are released from the obligation to pay for health charges, the liability will be spread over the whole body of ratepayers. It is not going to be carried for us by the Minister. Where then do we stand?
I know that it can be argued that the total amount that accrues to the rates in this respect is rather small. We got this information from our own county manager when we were levying the rate at the beginning of this year. We were told that the total amount accruing to the relief of the rates in payment of our hospital services was £10,000 in the year. Some people have a queer sense of standards of value. The total amount that comes to the relief of rates in Cavan in one year in respect of people who received treatment in our institutions would, as I say, be £10,000. If Cavan were in the All-Ireland Final last Sunday, the amount spent by people from that county attending the match, no matter how small an estimate might be put on the amount spent by each person attending, would be at least between £15,000 and £20,000. When you look at the matter in that way, you wonder what are the implications of a section like this at all.
I think that in our legislation we should try to educate our people to have a real sense of values and to pay for the things that are of real import. If people have money to spend on services that are not essential, on pleasures and gaiety of various kinds—I do not want to deny people any of these things; if they can pay for them out of their own resources let them have them—why should they not pay for things that are essential to their well-being and existence? In so far as they are able to pay for these things themselves they should be told that  that is the first obligation just as I pay for the bread I need.
Mr. O'Donovan: It is subsidised.
Mr. Baxter: It is subsidised for everybody. How long the subsidy will continue is another matter. I do not want to be drawn away from my main argument. The Minister said that because he had already taken a certain line in this matter he did not want to retreat from it. There should, I think, be no difficulty in any honourable man admitting when necessary that he had made a mistake. There should be no difficulty if we felt that we had made a wrong turning, in our stopping, hesitating and changing our direction. While up to the present only a limited number of people were entitled to certain services, it is rather a different question when the bulk of the people are being brought into that category. A self-employed person in Great Britain has to pay 7/9 per week for his health services. Here a self-employed person having less than £600 income will not pay anything. I am convinced that the issues raised here are of such importance that we should not assent to this principle lightly.
I must say that however reasonably the Minister argues his case I am not convinced. He has been agreeable in the way he has argued it, but he has not convinced me. The Minister mentioned that he might have fixed the qualifying valuation at £30 or £40 instead of £50, but I would point out to him that there are men in my county with valuations of £30 and £40 who would have from 15 to 20 milch cows. They would be entitled to free services under this Bill, while people with a valuation of just over £50, who would not be so entitled, may have only seven milch cows. The incomes into the two homes are very different. Again, in the case of the non-farming community, you have a situation where a man with a family income of £600 will get this treatment while a man with a family income of £605 cannot get it. Where is the consistency in the whole thing or what is the principle underlying it, if there be any principle in it at all?
Mr. O'Higgins: I want to put just a few queries to the Minister. I asked  the Minister if there was any difference in principle as between the provision of institutional services and the provision of specialist services and if there was no difference in principle, why the two services were treated differently. The Minister in his reply gave two reasons, and I should like to know which is correct. He started off in replying to that point by saying that he had come to the conclusion that the imposition of a charge in respect of specialist services would be more costly to the State. I want to ask the Minister is he serious in that? Has he any figures which he can put before the House to demonstrate the accuracy of that claim? If it is an accurate claim, I am not going to argue any further with him. I think that he is showing an unaccustomed concern for ratepayers and taxpayers if that is his approach to the differentiation between the provision of institutional services and specialist services.
He got away from that and said that the real reason why no charge was being made was because in the specialist services they were of a particular kind. He instanced mental treatment where the aim was to encourage people to take the treatment. I should like the Minister to be clear as to which of the two reasons is correct. My argument to the Minister is that if services are going to be provided, whether they are institutional treatment or specialist services, there is in fact no difference in principle between the two. I cannot see why the imposition of a charge in one case is going to be more costly than in the other. I may be wrong in that but I just cannot see it. I cannot see either why in one case it should be the desire of the State to induce citizens to take treatment and not in other cases. I cannot see why there should be the application of the rule in one case and not in another case.
In connection with another matter, the Minister mentioned in reply to Senator Cunningham two cases of people on the £600 line—one possibly a single man or a single woman with an income of around £600 who was entitled to the benefits of the Act and the other the case of a person with £650 or £700  who happens to have a family of three or four children and who is not entitled to the benefits of the Act. The Minister's reply to that was that paragraph (d) of sub-section (2) is designed to cover these people. I accept it that that is the reason why this kind of omnibus section was included.
I want to ask the Minister, however, is it intended in cases which will be admitted under paragraph (d) that the same treatment will be accorded to them as in the case of categories (a), (b) and (c). My difficulty is that the Minister issued a White Paper in connection with the Bill and it seemed to be quite clear, in fact it is made clear, I think, in Section 15, that so far as institutional treatment is concerned people who are admitted to benefit under paragraph (d) may be treated in a different manner. There may be a higher charge than the two guineas a week imposed for institutional treatment, for instance. I want to know how does the Minister reconcile that with what he gives out as the broad principle running through the section, that while he recognises there must be a means test, he wants to eliminate the investigation as much as he can.
It seems to me that in connection with these borderline cases not only is there to be an investigation, which the Minister deplores or at any rate is reluctant to encourage, but that he is, in the wording of the section and as explained in the White Paper, providing for different treatment, certainly for different charges for those people. Once the Minister gets into that sphere he is opening up a completely new field. I am not sure that the new field he is opening up would not be a better pasture than the one in which he is grazing. It might be well worth the Minister's while considering if that rigid line of £600 could not be replaced by a sliding scale according to clearly defined classes or categories of persons. A single person earning over £300 a year might be in a much better position to pay for his own medical treatment, whether institutional or specialist, than the married person with a wife and no children with £400 a year or the married person  with one child with £500 a year and so on. The Minister's remark with regard to paragraph (d) brings this point to my mind. I think it would be worth the Minister's while giving that some consideration. I should like to know if he has given it any. Certainly the way in which the matter is dealt with in the section is definitely objectionable.
While joining with Senator Baxter with regard to the Minister's complacent demeanour in reply to the remarks made on amendments, I am completely unconvinced. I do not think the Minister has answered the case fully. He gave me the impression that he recognised that there was a case there but that it did not matter a whole lot one way or the other, that he could be right or he could be wrong and someone else might be right or someone else might be wrong. With all respect to the Minister, I do not think that that is the proper approach for a Minister dealing with such an important and intimate matter as this Health Bill. I think the Minister should be able to tell the House that he has gone into the matter very thoroughly, not only with representatives of the Medical Association and public representatives but with every section of the people who will be affected by it and that as a result of these consultations he is satisfied that he cannot improve on this section.
Dr. Ryan: Perhaps I should deal first with the point made by Senator O'Higgins towards the end of his speech. I can truthfully say that all these suggestions were examined very fully and very carefully. Any Senator will see that in thinking over this the sliding scale idea would occur to anybody. It certainly occurred to me, and we examined it carefully. We did not take any particular case because we rejected it. But supposing we put down £500 for a single person and added £50 for each dependent instead of having this £600, the big objection is that you get away from a simple scheme. The Senator may laugh, but he must admit that it is making it very complicated. If a person has four or five children he has to add up the  various £50's, and that certainly makes it more complicated. I do not know whether the Senator mixes with ordinary people, but he probably knows that a lot of people are not capable of adding up such figures. Therefore, they may get mixed up and may think they are entitled when they are not entitled, or perhaps come to the conclusion that they are not entitled when they are.
Mr. O'Higgins: Is not that the principle which was adopted in the Workmen's Compensation Act?
Dr. Ryan: Yes. I quoted the International Labour Office, which laid down three principles for a good social scheme, one of which was simplicity. I think it is a very good idea that everybody should understand the scheme. A person will at least understand what £600 a year means. Anyway, that is the big objection to the sliding scale, that you are getting away from simplicity and that it would be a bit involved. Apart from that, we would have a good deal of trouble making out who were dependents and who were not. I know that on the social welfare side they are very clearly defined, but even there, there is often trouble in deciding whether an aunt is a dependent or not. If the aunt has been depending on a person all the time and is living in the same house and has no other means of support, it is obvious that she is a dependent. But that may not be the exact position. She may be getting money from some other relative as well. You will be up against very difficult problems if you have a sliding scale. Therefore, I think it was better to do it in this way and at the same time to put in the saving clause contained in paragraph (d). I was asked certain questions about that by Senator O'Higgins. Such a person may be asked to pay more than £2 a week. There is no set amount laid down, but he may be asked to contribute some proportion of what the hospital is costing, say one-half or one-quarter.
I should like to emphasise that my anxiety was to investigate as little as possible. I admit that we cannot get away from it completely. But let us take three sections of the population. First of all, there are the insured  people, who are a very big proportion of the population. There are about 700,000 insured people employed, and if you take the families of these they must run into 1,000,000 or more than 1,000,000. Then take the farmers under £50 valuation. I think there are about 22,000 such families. We probably have half the population when we take the two of these. Then we have those whose income is over £600 and who are neither farmers nor insured people. We have, therefore, a very big slice of the population in regard to whom no investigation is necessary and it is simple to that extent. We cannot, however, get away from the investigation completely unless we have a free scheme for everybody. When we come to paragraph (d) and say that a person with over £600 income or a farmer over £50 valuation might get free treatment or partial treatment, you must investigate it.
Mr. Douglas: Will you not have to investigate whether a farmer's main income is from agriculture or not?
Dr. Ryan: I think that would scarcely arise. It will not arise very often. If the county manager is to get a report—I do not know from whom he will get the report; that has not yet been decided but possibly it will be from the home assistance officer—I take it that the home assistance officer will be able to report to the county manager without the slightest trouble “yes” or “no” in that case as to whether a particular farmer is living alone or otherwise on a farm. That farmer's income is not investigated. That will not take place very often. It will only occur in very few cases.
Senator Baxter, I think, put me a moral question. I will answer it as well as I can. It is quite true that the obligation is on the head of the family to look after his family. The community or the State as such is not only entitled but is bound to help if help is necessary.
Mr. Baxter: Agreed, so far.
Dr. Ryan: All we decide is who needs the help. That is a matter for the civil authority, the Oireachtas and  the Government to decide between themselves. In my opinion, these are the people who need help.
Mr. O'Higgins: We are not deciding it. We are leaving it to someone to investigate.
Dr. Ryan: I am only answering the point put by Senator Baxter. If the Senator was in my place he might have a different outlook on that and would be bound to follow it from the moral point of view. Anyway, I believe that those people who are enumerated in sub-section (2) are the people who need help and, therefore, I think we are not doing anything wrong by saying we must help those people in regard to hospital and specialist services.
The last question about specialist services was put by Senator O'Higgins. He said I gave two reasons. You can have two reasons for doing a thing. It was partly one and partly the other. For instance, I gave one example, that in regard to mental treatment. There are others. If a child has a defective nose or a bad throat I should like to see the parents getting that looked after. It will only be diagnosis in this case. In regard to specialist treatment, we encourage the parents to find out what is wrong with the child. If is comes to an operation, it is decided under other sections whether the parents have to pay or not. There is a good case for encouraging specialist services and for encouraging people to take advantage of them. Apart from that, I said that the local authority might lose. I suppose that is putting it a bit strong but let me put it this way. The amount they would collect would be small and if you take into account the time of an official in looking after these cases and making some attempt to investigate them and so on, there will be very little left when his time has been paid for. That is what I meant. They might lose rather than gain. The time and trouble taken to investigate would hardly be repaid by the amount they would collect as the amount would be very small.
Mr. O'Higgins: When the Minister was dealing with what was the moral principle involved, that the head of  the family is responsible for the health and maintenance of his wife and children, he said that the State was not only entitled but was bound to help where help was necessary.
Dr. Ryan: That is right.
Mr. O'Higgins: I think that will be accepted by all.
Mr. Baxter: We all accept that.
Mr. O'Higgins: I accept it but in the next breath the Minister explained that in connection with these specialist services he was not going on the principle of the State helping because help was necessary and because these people needed it but because he thought these people should be encouraged to see that their children got the treatment. I should like the Minister to reconcile these two points of view.
Dr. Ryan: If we are going into the moral issues we may take a long time to decide them. Take the specialist services. Morally, I think you are not bound to collect off a few individuals if it is going to entail a great deal of administration. If there is going to be a great deal of trouble to collect it off the few it would pay the local authority to drop it and they would be quite entitled to drop it from the moral point of view. The administrative difficulty must be taken into account. That is the point. I think we are all right there too.
Mr. Baxter: We are in agreement that there is an obligation on the individual to do his best to pay for his own services. There is an obligation on the community to provide certain services if the capacity of the individual concerned cannot rise to that level. Let us come to the other point. If we  believe people can pay, where do we stand? I believe that if people can pay, there is an obligation to pay. I want to challenge the Minister on that. He has admitted, apparently, if I followed him rightly, that the obligation is there for people to pay for what they can. I want to put that to the test in this House because I am satisfied that it is the vital thing upon which we ought to pass judgment.
Dr. Ryan: The Senator was interrupted with a remark about bread. He said everybody was getting the subsidy on bread.
Mr. Baxter: Senator O'Donovan said that.
Dr. Ryan: Everybody is getting a subsidy on bread because it would be administratively impossible to have it otherwise. Senator Baxter might not need it as opposed to a poorer man like Senator Quirke. For administrative reasons, it is given to everybody.
Mr. Baxter: That is too tendentious. The Minister is not really serious now.
Dr. Ryan: Take housing. Everybody who builds a house is entitled to a grant. According to Senator Baxter, a man who takes that grant and who does not need it is committing an offence.
Mr. Baxter: Provided he is going to build a house of certain dimensions.
Dr. Ryan: According to the Senator's philosophy or theology one should not take it if one did not need it.
Professor Stanford: Primary education is free for everyone in this country irrespective of his means. Is there any moral obligation involved there?
The Committee divided: Tá, 13; Níl, 30.
|Baxter, Patrick F.
Cunningham, John F.
Douglas, James G.
McFadden, Míchéal Óg.
McGee, James T.
|McGuire, Edward A.
Meighan, John J.
O'Donovan, Timothy J.
O'Higgins, Michael J.
Ruane, Seán T.
Clarkin, Andrew S.
Farnan, Robert P.
Gorry, Patrick J.
Honan, Thomas V.
Lynch, James B.
Lynch, Peter T.
|McCrea, James J.
Ó Ciosáin, Éamon.
Ó Donnabháin, Seán.
Ó Grádaigh, Seán.
Ua Guilidhe, Seán.
Ó Siocfhradha, Pádraig.
Stanford, William B.
Teehan, Patrick J.
Tellers:—Tá: Senators O'Higgins and S.T. Ruane; Níl: Senators Hawkins and Ó Ciosáin.
Amendment declared lost.
Amendment No. 4 not moved.
Government amendment No. 5:—
In sub-section (10), page 6, line 59, to insert “or aural” after “ophthalmic”.
Amendment agreed to.
Question proposed: “That Section 15, as amended, stand part of the Bill.”
Professor Cunningham: Under this section people who are entitled to this treatment are specified first of all as persons under the Social Welfare Act. The socially insured person at present may go to any hospital he or she wishes and they receive maintenance from that hospital. The hospital is partly paid for that maintenance and the patient is treated free by the staff of the hospital. When this Bill is enacted his position is very much worsened because he may be asked to pay up to £2 2s. per week for his hospital treatment and maintenance and this occurs at a time when he is not receiving any wages; yet this Bill is supposed to be for the improvement of medical services. If any member of his family is ill he may be in exactly the same position. He may be required to pay £2 2s. per week for any member of his family who is receiving treatment in a hospital. As has already been pointed out a single man who is earning £600 a year is quite well able to pay for his treatment at present, but a married man with £610, £750 or even £800, may be quite unable to pay if he has a family to support.
Under (c) the farmers of this country whose valuations are below £50 a year will receive free treatment. That covers, I believe, about 83 per cent.; I think the Minister's figure made it somewhat higher, so that 88 per cent. of the farmers of this country will receive free treatment. At a recent by-election in Galway the Minister for Finance informed the people that the farmers have never been so well off and that last year the agricultural exports of these farmers amounted to something over £151,000,000. These are the people who are so badly off that they must receive free hospitalisation and treatment.
The last occasion on which land was valued in this country was about 98 years ago, in 1855. At that time land was valued in a peculiar way. For example, land that produced wheat was valued at a much higher rate than land which did not produce wheat; so we find now the position that the valuation of the property of a farm in Ireland has no relation whatsoever to its earning capacity. A man may have a small farm and he may earn more than a man with a large farm. He may have a poor dwelling house and be financially better off than a man with a bigger house. We know there are some small farmers with, for example, a valuation of about £15. Anybody who has been through the country, especially in the more remote places, knows that there are a number of small farms; you look at the holdings and the fields around  them; you wonder how they live. If you make inquiries you will find that a particular farmer has a very big range of mountain on which he may graze sheep. If you inquire further you will find out how much he is able to make from those sheep. Some of those farmers running sheep on the mountain, for which they pay very little— only a nominal rent—make £1,500, £2,000 or more than that a year. That is not my idea; that is a fact.
Mr. Quirke: Why are there practically no sheep on the Wicklow mountains?
Professor Cunningham: It may not be suitable for them.
Mr. O'Higgins: There are plenty of sheep on the Wicklow mountains.
Professor Cunningham: I am not a farmer. Do not ask me that question. Furthermore, a farmer may run a poultry farm from which he may make money, a pig farm or even a stud farm, and he only pays income-tax, so to speak, on his valuation. Although he may be very much better off than the city dweller who has £700 a year that farmer is going to have this free medical treatment.
In this whole Bill it is those earning around £600 a year, the middle-class people, who are completely neglected. Nothing whatsoever has been done for the people who pay income-tax, the people who pay the higher rates of taxation. The Bill is entirely unjust in that way and that could have been avoided if a different system of rating these people had been adopted.
To return for a moment to the farmer, an increase in local taxation, that is, in the rates, is bound to occur and I believe it has been estimated that in a number of places when this Health Bill has been implemented it is going to cost them at the rate of 10/- extra in the rates. A farmer who has a farm of, say, £48 valuation will now have to pay £24 a year for a service which he may not require. He may be a poor farmer or he may be well able to pay that. In that respect the farmers will not get off quite so well as they think. It will be a hardship for some although it will not interfere  with others because possibly they can afford it.
This stipulation in regard to £600 a year and £50 valuation is going to give rise to all this trouble. The Minister has said that the important thing about a Bill of this kind is to make it simple. In the working of this measure I can see nothing that could be more complicated and more difficult. Look at the position as it affects the local health authority and the county manager. The county manager may be asked to decide what people will be free from this medical expense if they are above £600. The Medical Association wrote to the Minister asking him a question on that. His answer was that the local authority would have to decide. That puts them in a very difficult position. The county manager will have many people with incomes over £600 who will apply to him for relaxation from paying their hospital expenses. He will be very bothered especially by people from his own neighbourhood or town, people whom he knows. If he is conscientious, as I have no doubt they are, he will have to turn down a number of applications. On the other hand, if he is careless or sympathetic towards these people, pressure may be brought to bear on him from certain quarters to allow free treatment. We can very easily see how clause (d) may be very much abused.
When you come down further to sub-section (5) you find a peculiar position. It says that specialist services under sub-section (1) shall be made available without charge. That links up with Section 25, where we find these people can choose to go to another hospital, to their own hospital, or they can choose a nursing home. If they do, £2 2s. will be deducted from their allowance of £5 12s., so they will get a subvention of £3 10s. per week. If the patient goes to a nursing home which charges ten or 12 guineas a week, he has to pay the difference. Section 25 mentions, under (4) (b), (5) (b) and (6) (b), that there is no restriction on what the nursing homes may charge. They are protected and can charge anything they like. Under this Section the patient may claim he is entitled to specialist services free  under sub-section (5) of Section 15. In other words, the patient goes as a patient who is being paid for; he agrees with the nursing home that he will pay the difference between £3 10s. and whatever they charge—it may be 20 or 30 guineas a week—but he can claim that he is still a person who is getting this subvention and therefore he is entitled under Section 15 (5) to free medical treatment. Therefore, he may refuse to pay his doctor's bill, although he had been treated and looked after in a nursing home and he may tell the doctor he can apply to the local health authority for the money.
It is difficult to understand in this Section why it is that the nursing home is being protected. It has been mentioned specifically. In other words, there is a saver for a nursing home or private hospital but there is no saver for the doctor. The doctor has not been mentioned. The patient can claim that his doctor is not entitled to any payment, although he has been treated and operated on in a nursing home. This Section 25 appears to have been introduced at a later stage in the Bill and I think the draftsman made some mistake. I do not like to suggest that the saver was deliberately left out, but I would like to ask the Minister if a mistake has been made, as it is a serious flaw. Patients may elect to go to nursing homes and pay the difference between £3 10s. and their charge. A doctor may take in a patient believing it is a private patient and the patient can refuse to pay. Then the case may come to court. An eminent leader of opinion has said that he would be very pleased to take the patient's case in court; in other words, the patient would have an excellent chance of winning the case. That means very unpleasant law cases on this point. As a saver is put in there for the nursing home there should also be a saver for the doctor or doctors who are dealing with the case. I would ask the Minister specifically why the nursing home is specifically saved but there is no mention of the doctor at all.
Dr. Ryan: I am edified by the Senator's anxiety for the fate of the  National Health Insurance people. The Senator must remember, as I explained already, that the person who is now entitled to a limited period in a hospital—six weeks free—will be entitled to free hospital treatment, in most cases, anyway—I will deal with that in a moment—without a limit, and also that same free treatment will apply to his wife and family or any other dependents. On that alone, the person now insured under National Health Insurance will fare very much better under the new scheme than he did in the past. It is true that under this Bill he could theoretically be made to pay a certain amount in hospital. I would say the majority of those insured would be in the lower income group and, therefore, entitled to free service of all kinds, and I would say that of the minority left it is unlikely any of them would reach the category where the county manager would think they should pay something in hospital; so the Senator's anxiety for those people is misplaced.
The Senator has more than once tonight hinted at a scheme put up by the Irish Medical Association. We cannot discuss that scheme here, as it would not appear to be in order. I want to say it was a voluntary scheme. We all know that certain people would not bother about paying 9d. or 1/- a week or whatever it might be and, therefore, would not be covered for medical benefits. Then I or somebody else would have to bring in a scheme to cover those improvident members of society. I have done that, and I have told the Medical Association more than once that they can go on with their schemes if they like. They can take on anybody that joins their scheme and this Bill can deal with those that stay out because we must, or somebody must, deal with those who stay out.
It is true that the farmers will have to pay a certain amount in rates, but under the Irish Medical Association scheme they would have to pay a certain amount each week. Take the £50 valuation farmer, which is the worst case I could take against myself in this argument, and let us assume the  rates go up 2/- in the £, which I think is the maximum under this scheme. That is 2/- per week for which the farmer will be covered for himself and his wife and family. The £20 valuation man will have to pay 9d. per week by paying an extra 2/- in the £. The farmer has to pay, it is true, but he would also have to pay under the Irish Medical Association scheme. The only difference is that the better-off farmers would pay more than the lesser farmers under our scheme, and that is a principle we cannot very well object to. So, I think while we admit the farmers must pay for this scheme, it is a more equitable scheme for everybody than the scheme suggested by the Irish Medical Association which scheme would not cover everybody and therefore the Bill is necessary.
The Senator also quoted from a letter which I, or my Department, wrote to the Irish Medical Association in answer to queries on certain points they raised regarding this Bill. I mentioned the case of—I think it is Section 25—where I protect the nursing home and do not protect the doctor. I suppose I have to bear with the attack of protecting vested interests although I am sometimes attacked for not protecting them. But in this case we are protecting them and that stands. Why do we not protect the doctor? Because it is not necessary. It is clearly pointed out in this letter I sent to the Irish Medical Association that sub-section (5) in this Section 15 relates only to special services provided under Section 15, not to services provided under Section 25, and if a person chooses his own hospital and pays the home some very colossal amount because I have protected the homes and told them they can charge what they like and I am attacked by Senator Cunningham for doing that——
Professor Hayes: No, the Minister is not being attacked at all.
Dr. Ryan: Anyway he is being charged some colossal amount but when the doctor comes the man claims he is entitled to be free. He is free under Section 15 but he will not be entitled to free services under Section 25. I have got legal opinion on this  on at least three or four occasions because the Irish Medical Association raised it three or four times. I am quite satisfied with the legal opinion I got that a person would not have an action as suggested by Senator Cunningham. He says there is some legal person who is prepared to contest that case in court. Of course you will always get people prepared to contest things in court but they do not always succeed. After all, what can I do except take legal opinion as I get it and it is very clear in my case and it would not bear out at all what Senator Cunningham suggests with regard to a patient going to choose his own hospital and refusing to pay the doctor.
Professor Cunningham: Why was the nursing home specifically mentioned and a saver put in for them and not for the doctor? The legal opinion we have got does not agree with the Minister's.
Dr. Ryan: Section 25 deals with hospitals and private homes and therefore we talk about hospitals and private homes.
Professor Cunningham: But it relates back to Section 15.
Dr. Ryan: No. Not so far as my advice goes.
Mr. O'Higgins: There are just one or two matters which I would like clarified on this section. One of them has been raised by Senator Douglas and myself already in connection with Senator Baxter's amendment. I do not think the Minister dealt with the point when he was dealing with the amendment. It is in relation to the method of assessing joint income under sub-section (6) of Section 15. It does seem to me that there is a matter here which the Minister must consider assuming that the principle of a rigid line of £600 is going to be adopted by the Oireachtas. The section goes on to provide that the figure of £600 in the case of a married man will also take into account the income of his wife residing with him, and it goes on further to say it will include the yearly means of any unmarried son and daughter of such person or the spouse of such person  or any deceased spouse of such person where the son or daughter is normally resident with such person. I can see cases arising, particularly in the corporation areas in the City of Dublin, where a case might be made out in law. If the Minister and his advisers or the health authority as the case may be decide to do it they could make out a case that people were residing with their parents when it might be a case of separate dwellings in the same house. I would urge on the Minister to give that matter consideration and to have some method arranged even in his Department as a guiding rule for questions of that kind.
Dr. Ryan: The Senator has in mind the married son or daughter?
Mr. O'Higgins: That is so.
Dr. Ryan: Well, they would not come in.
Mr. O'Higgins: I know, but I can visualise cases particularly in corporation areas in the City of Dublin where you have all sorts of family entanglements and arrangements, where I think, it would be worth trying to clarify the meaning of this section.
The other point arises under sub-section (4) and again it is on a point of clarification. I find it extremely difficult to read sub-section (4) or to understand it when reading it. It starts off: “Where institutional services are made available under sub-section (1) of this section, in cases not governed by sub-section (3) of this section,....” It certainly is not readily apparent to the untrained mind as to what cases are not covered by sub-section (3). Remember the Minister's guiding principle in this section is simplicity. So he says. I gather that what is intended—and I may be wrong in this—is that the sub-section means where institutional services are made available in cases not entitled to free institutional treatment under sub-section (3). If I am right in my interpretation of that I would like the Minister for the sake of people like myself to put it in that form rather than to use the words “not governed  by sub-section (3)”, because it seems to me that all the cases under sub-section (1) are governed, either by inclusion or exclusion, by sub-section (3). It is merely a matter of drafting but it is very difficult indeed, to make out what the sub-section means as it stands at present.
Finally, I want to say a word in support of a point raised by Senator Cunningham, though on somewhat different lines. It seems to me that the Minister by the provision made in Section 25, in relation to nursing home fees, admits the argument put up that there will be many cases which fall within the categories (a) to (d) of sub-section (2) of Section 15 but the people in which will nevertheless be well able to pay for treatment for themselves. The Minister recognises that by safeguarding the fees of nursing homes. He recognises that cases will fall into sub-section (2) of Section 15 in which the people will be quite well able to pay ten or 15 guineas per week to a nursing home. When that admission is contained in the Bill, as it certainly is by the mechanics of Section 25 the Minister might as well recognise that there are cases in which the people, although they come within these categories, should be made pay for their own medical treatment.
Professor Cunningham: The Minister has accused me of attacking him. I am not making any personal attack on the Minister. I am attacking the Bill. I oppose this Bill just as strongly as I opposed a former Bill introduced by a former Minister some years ago. I oppose the Bill because I think it is a bad Bill. It is a tragedy that we should try to introduce a Bill and a health scheme of this kind into this country. The Minister referred to the voluntary insurance scheme put forward by the Irish Medical Association. That association does not claim any great originality for that scheme. That scheme evolved from other countries in which it has been working for years past, and working very successfully. That scheme puts everybody into the same category. Everyone is insured. There is no means test. Those who cannot afford to insure themselves are  insured by the State. If the Minister wants a simple scheme, there it is. Let the Minister read the report given at the World Health Organisation meeting at The Hague about ten days ago, and he will understand what the scheme means. The scheme is simplicity itself. The hospitals working under it are able to show a surplus. It is at once the cheapest and the best possible method of health insurance. It satisfies everybody.
Question—“That the section, as amended, stand part”—put and agreed to.
Question proposed: “That Section 16 stand part of the Bill.”
Professor Cunningham: This section deals mainly with maternity. It covers all classes and all women are virtually entitled to free treatment under this section. Those in the upper income groups above the £600 per year level and those whose husbands are farmers with a rateable valuation over £50 per year will receive free, or almost free, treatment, on payment of a nominal contribution. I can see certain difficulties arising under this provision. In principle, I think the entire idea is wrong. I have already referred to the subterfuge adopted by the Minister to get over one of the difficulties inherent in this provision. Before the Bill was amended in the Dáil it was originally intended that those in the upper income groups should be charged ultimately half the cost of treatment. For some reason—I do not know why—the Minister changed his mind and he amended the Bill on the basis of a maximum payment of £2 per year. The wife of the wealthiest man in this State can, if this Bill becomes law, contribute £2 per year and enjoy free medical and hospital treatment if she is having a baby. This is not a very wealthy country and from that point of view I think this is an absurd suggestion.
I want to ask the Minister some questions. When will the patient start payment? When will she qualify for  this benefit? I am speaking now of those in the upper income groups. Will she qualify if she starts payment when she knows her baby is due to arrive in seven months? Must she start payment when she gets married? Would it be advisable for her to start before she gets married? When will she stop payment? She may decide at some point that her family is large enough: “Thank you very much; I shall not pay any more now; you have given me all you promised and that finishes that.”
The entire situation appears to me to be ridiculous. I should be very much ashamed to show that clause as one adumbrating a maternity health service for this country. I would be ashamed to put that forward as a genuine proposition.
Under sub-section (d), clause (i) and parts (I) and (II) of Section 16, the Minister is encouraging women to join in the first five years when the subscription will be only £1 per year. I want to know from the Minister if the woman who joins in the first five years will have a permanent advantage over those who join later and who pay £2 per year? Will that woman continue to pay £1 per year while those who join five years later will pay £2 per year? Clause (i) says:—
“such amount as may be fixed by the Minister for that period as the amount which will result in obtaining by contributions approximately one-half of the estimated cost, as determined by the Minister, during such period of the provision of the services for women by or on behalf of whom contributions at the rate fixed under this clause of this sub-paragraph are paid, or
That does not stipulate whether it is to be the maximum or the minimum.
Professor Hayes: It does.
Professor Cunningham: It is not to be higher than £2. I do not know if the Minister means to infer that it costs £4, or less, for a woman to have a confinement. That whole paragraph reads so absurd that I think it should be deleted altogether.
 We have in Dublin three maternity hospitals, three large hospitals. These hospitals are known throughout the world and Dublin, as a school for teaching obstetrics, is very famous. We are very jealous of that reputation. We would not like anything to happen to it. We would not like people to say that Dublin has fallen down on that and, therefore we do not want any interference which might bring that about.
I want to know from the Minister what would be the position of a maternity hospital if the governors refuse to co-operate with this Bill. Remember, there are voluntary hospitals. The governors are entitled to refuse or not. If they refuse, what is their position? Will they be cut off from any grant to which they may be entitled from the sweepstakes or any other benefits? Remember, if that is so and if these grants are cut off, that is an indirect way of bringing compulsion on the hospital to enter this service and to do as the Minister wishes with regard to this Bill.
The Minister has said here this afternoon that he did not wish and it was not his intention to interfere in any way with the voluntary hospitals. He said that before. But, here in this very Bill you can see how he can interfere with voluntary hospitals by cutting off their grants if he wishes to do so. If the hospital does not agree to co-operate in this Bill with him, will he continue to pay them these moneys? Remember that the National Maternity Hospital and the Rotunda, each of them deliver in the hospital over 4,000 women a year. The Coombe Hospital is not so large; it does not do so many but, when the new Coombe Hospital is built—when, unknown—it is planned to be a bigger hospital than either of the other two and will deliver far more.
You require a fair number of staff in these hospitals to look after these patients. What will be the position of the doctors in these hospitals? If you are going to have free obstetrics for everybody—and every woman is entitled under this Bill to free obstetrics; it is the old free-for-all, just the same as it was before—if every woman is  entitled to free obstetrics and gets free obstetrics and claims it, who is going to pay the doctors in the maternity hospitals?
Again, in the maternity hospitals, the same as in the other voluntary hospitals, the doctors are not paid but they earn an income outside by doing private obstetrics in nursing homes and patients' houses, and do any operations that may be necessary. If this is going to be free obstetrics and if a patient goes into a nursing home she may still be entitled to free treatment or to treatment at a very minimum rate as prescribed by the Minister—because he is going to fix the remuneration to any doctor as to what he is to get for any patient in her confinement—and it may be impossible for these doctors who now staff the voluntary hospitals to carry on. I am back exactly to the same theme I was on this afternoon when I said that this is where the voluntary hospitals are going to be destroyed. I want to know if it is the Minister's intention to repay the doctors in any way. I do not like to mention England again in case he may be offended, but they have been properly protected by the Minister in England.
We come now to domiciliary midwifery, that is, where a patient is attended in her own home. All kinds of difficulties may arise. The patient may have a doctor engaged. Remember what a doctor has to do—he is supposed to be responsible for the patient and to look after her. It does not specify how many times she is to visit him before her confinement, during, if necessary, and afterwards. In other words, the patient may only be required to pay him two visits, once before her confinement and once after her confinement, and the doctor may not be obliged to be present at the time of her confinement. That is what we find in the White Paper. I do not see any change in the Bill. That, to my mind, is a defect because I think that should be more specifically laid down. But I know and the Minister knows that if the patients have to pay a greater number of visits as it is desirable, it will add to the cost, but, if we are going to have a proper scheme for maternity, it should be properly planned even if it does cost a little  more. Now, this doctor is living in a country town and this patient has him engaged and he has made an agreement to carry out this work under the State and, when he is wanted or is sent for in an emergency, he is away somewhere on another case. It happens not infrequently. Another doctor is called in an emergency. He is told this woman is very ill; they cannot get her own doctor; will he come. The doctor always goes. This other doctor has not entered into any agreement with the State. He still has retained his freedom as far as he can. Will that doctor who, in the emergency, looks after that patient be entitled to payment by the State?
There are no regulations, of course, made about anything like that yet and there are no regulations made about anything in this. It is all very vague, this Bill and all the final regulations are to be made by the Minister, whoever he may be. In other words, he is the dictator. He can specify what fees are to be, what doctors are to do— everything. He completely controls everything and that is very wrong, to put that much power into anybody's hands. We know what happens when we have dictators. We have ample evidence of it. To have a dictator on a matter like this with regard to health is very wrong and will lead to a tremendous amount of trouble always.
We know that in Dublin and throughout the country, especially in the country, there is a great shortage of beds for these patients. The Minister has promised that there will be hospitals built and plenty of beds supplied but for the moment there is a great shortage of beds and the Minister has said that this Bill will be implemented early next year. If so, some patients will be able to get to hospitals and some will not. Who is going to decide what patient is entitled to go to hospital and what patient is not? Remember, if a doctor sees a patient and she says: “I want to go to a hospital for my confinement” and he says: “No, you cannot go; there is no room for you; you had better stay at home,” if anything goes wrong with that patient that doctor will be in for  trouble and responsibility will be put on him.
We try to select cases as best we can but nobody can tell whether the birth of an infant will end up normally or abnormally and a case that is perfectly normal to the very end may develop very serious trouble and the patient may die. That is very well known in obstetrics. You never know that everything is all right until it is completely over. You can select certain cases that we know beforehand will have trouble but the case that appears to be perfectly normal may at the end develop very serious trouble that may cause death. Anybody who knows anything about hospitals or medicine will understand that. I am sure a lot of people who are not doctors—perhaps married men—will have heard some of these stories and will understand it also. Therefore, there is great difficulty in selecting. Is the responsibility going to be put on the county manager or is it going to be put on the doctor? Who is going to be responsible? It has not been specified as to how it is to be done. I think it has been suggested that only abnormal cases go to hospital. When is a case normal; when is it abnormal? Again, you cannot tell until the whole thing is over. Under this Bill remember that a patient has a right to go to hospital, and she may claim her right to go into hospital, and we will have the present, mostly poor, patients in hospital. Where are you going to treat them both if there are not beds there for them provided under this mother and child scheme?
Section 23 also relates to this, and I think it might perhaps be better to leave it over and deal with it later, or I could talk about it now if there was no objection. We will continue with Section 16.
An Leas-Chathaoirleach: Yes.
Professor Cunningham: Sub-section (4) of Section 16, if you read it carefully, compels all doctors who want to practise obstretrics or attend patients for confinement to enter into an agreement with the State. That is a compulsion on doctors. The Minister has said that in principle —I am sure he means well, and he is  perfectly right—he does not want to compel any doctor or any patient; but there is here indirectly a compulsion on doctors because if they do not they will not be able to practise obstetrics, and that is entirely wrong and unfair from every point of view. It amounts to this—it is a conscription of doctors for maternity services under economic pressure. It means that there will be no more private maternity practice and the patient will find it difficult to get attended or to get anything. She would not get anything or any help from the State unless she attends a doctor who has entered into an agreement. That is how the patient is to be treated. Now all these objections to that are very real, and they are numerous as far as maternity patients are concerned. I do not know how they could be amended or how they could be changed under this Bill. I did not introduce any amendments to this Bill because I did not think it could be amended. The whole thing is so wrong from every point of view that I really feel ashamed of this section on obstetrics for a city and a country with a reputation that Dublin has and to find a scheme like this put forward as a good scheme for looking after women who are pregnant and during their confinement. I really feel ashamed of it.
Dr. Ryan: The Senator has asked a number of questions which I hope I have taken a note of as he went along. He started off by saying that even the wealthiest person in the State is given free maternity services by paying this £2 a year which is roughly about 9d. a a week. That is true, of course, but I do not know if there is very much difference between that and the Irish Medical Association scheme. The Irish Medical Association scheme would give a free maternity service. If they were charged a bit more it would not be much so far as I know. There is no great difference, certainly no difference in principle, between paying so much a week——
Professor Cunningham: There is a very big difference in principle.
Dr. Ryan: The difference is that the Irish Medical Association want to run  a scheme of its own. There is that difference, I know.
Professor Cunningham: That is not a matter of principle.
Dr. Ryan: At any rate this contribution is paid yearly because wealthy people could afford to pay it yearly. The Irish Medical Association scheme thinks it should be a weekly contribution. When you add them up they are not very much more. Personally I do not see very much difference. I do not see, anyway, how the Senator can find a great deal of fault with a scheme produced by another person and give nothing but the highest praise to a scheme produced by his own organisation.
The Senator wants to know when these women start to pay. Well, that, of course, will have to be settled by regulations, and those regulations will be submitted to the consultative council, on which the Irish Medical Association is represented, and any reasonable suggestions will naturally be adopted by the Minister.
Mr. Baxter: Who it to determine whether they are reasonable or not?
Dr. Ryan: The Minister must decide that. I think there are a few points that must be obvious. There will be an appointed day. Well, of course, obviously women who are now married must come in at some stated period after the appointed day, whether six or 12 months I do not know. We will have to give some consideration to that point of what would be a reasonable period to allow for entrance into the scheme. Then after that women who get married would have to come in at some stated period from the date of marriage. That, however, can be settled by regulation. If she pays £1 for the first five years and if it is found then that the fee must be put up to £2 I am asked will a woman who pays £1 remain at £1. She will. That is fairly definitely stated—that she will continue on the same contribution all through.
The £2 does not imply by any means that maternity will cost not more than £4. I do not know why the Senator came to that conclusion. On the statistics  there are 25 births for every 100 married women every year. That is an average of a birth every four years for all married women.
Professor Cunningham: Between what ages?
Dr. Ryan: Between the age they get married—I do not know what it is— and up to 44. I think it is 44 but I am not sure if it is not 40. It is what the Statistics Department regard as the child-bearing age. It is they who have given these figures.
Professor Cunningham: Some of them have none at all.
Dr. Ryan: Of course that it true, but in statistics on a scheme like this we must assume that everybody will join. I know that some of them may not, but if everybody joins there will be four married women paying £2 each, that is £8, for the one birth, and I think the scheme is going to be all right on that basis. I know, of course, that some women will not join, and women may after five or six years probably get discouraged and say: “I will pay no more.” We will have cases of that kind. Still we have to go on statistics and to take the figures as they are.
I am asked a question, which of course the Senator will agree with me it is hardly fair that I should be asked to answer right here—if a voluntary maternity hospital refused to co-operate, what action am I going to take? Now, first of all I would like to know in what way would they refuse to co-operate. They will continue, I take it, to take in patients. If they do this, all right, they are doing their job and I cannot see where the non-co-operation comes in.
Professor Cunningham: They might refuse to take patients of a certain financial standing.
Dr. Ryan: I see. Well, we would have to know what the circumstances are. I suppose that is a point; but I am bound to know before I could answer the question of what I am going to do. Personally I cannot see where the non-co-operation could come  in. Perhaps it could. I suppose ingenuity can think of many things I cannot see at the moment.
Now the Senator says to the Seanad here: “You can see now how the Minister can interfere with the voluntary hospitals although he said he did not mean to interfere with them.” I do not see where I am going to interfere with them. Surely if I wanted to interfere with the voluntary hospitals I could do it with the laws there already. I could say, if you like, I suppose: “If you want money I will search among the laws that are there, and I will probably be able to think of means to make you do so-an-so, if not, you will not get any more grants”—something it would be quite wrong for me to do, but which we have not done, and we do not intend to do these things. That is all I can say. Regulations will also be laid down I hope, in general, of the service the doctor will be expected to give under the maternity scheme. Antenatal care—I do not know if one can define it any more than that—will be a matter for regulations, and similarly post-natal care. I think it is not intended that we should insist that the doctor would be present at the birth, though that would be advisable if it could be done. However, that again would be a question for regulation. I have no idea what we should lay down in that case because I do not know enough about the subject to say what should be done. In any event, these regulations will be brought before the consultative council, on which the Irish Medical Association is represented.
The Senator also spoke about a doctor who is engaged by a woman and who is away on another case when she requires him and another doctor has to take his place. That happens sometimes. I do not know what arrangement doctors make between themselves in such cases, but I do not see why the same arrangement should not be carried on, whatever it may be.
Professor Cunningham: Would the second doctor, if he has not signed an agreement with the Department, be paid by the Department?
Dr. Ryan: I am afraid the Senator is putting cases to me which would require  regulation. I think the first doctor is responsible and, if he is elsewhere when he is required, I suppose he settles with the second doctor; I do not know.
With regard to the crowding of hospitals, I should like to read the following extract from the White Paper, which was issued in July, 1952, before this Bill was introduced. Paragraph 24, which is at the top of page 13 of this White Paper, begins as follows:
“The hospital and specialist services will be available for—
(a) All persons in the lower income group.
(b) All persons in the middle income group.
(c) All women outside the lower and middle income groups (already provided for under (a) and (b)) in respect of motherhood. It will be necessary to give priority in admission to hospital for maternity to cases requiring hospital attention on medical grounds or on grounds of social need.”
I remember distinctly that when we were drafting that sub-paragraph (c) “medical grounds” was first inserted. Then I said: “Take, for instance, a woman with a very bad house and bad living conditions. It would not be right that she should be made have her baby in that house.” One might say that that could be covered by the term “medical grounds” but, as it might be straining the interpretation of “medical grounds”, the words “or on grounds of social need” were added. That is the sort of guide and principle that is contained in the White Paper. Regulations will have to be drawn up—regulations to fall in with that guiding principle. If the Senator asks me who is to decide in such cases, then my reply is that I think the man in charge of the hospital must decide. Whether he does so personally or leaves it to his matron or house surgeon, or whoever else it may be, I think the man in charge of the hospital is responsible. The county manager could not possibly do it. The doctor who is sending in the patient could hardly decide, because he might  not have as good a claim as a neighbouring doctor, although we might think that he had a better claim. That is a question that involves regulations.
Professor Cunningham: If the doctor in the hospital sends the patient home simply because they are crowded there and because he thinks it is a normal case and then, if it turns out to be difficult or abnormal and the patient dies, is he protected?
Dr. Ryan: What is done at the moment? Why should there be any change, when this Bill becomes operative, from present practice?
Professor Cunningham: Because more people will be entitled to hospital treatment and will apply.
Dr. Ryan: Yes, but more people will also be entitled to domiciliary treatment. For instance, there are certain people now who might not get free dispensary services in their own homes because they might be over the income, but they would get hospital treatment. I think that, under this Bill, the position will be better.
Professor Cunningham: No.
Dr. Ryan: They will all be entitled to treatment, whether it be free hospital or domiciliary treatment. I think, therefore, that the proportion who will remain at home will be at least as high as it is at the moment. The man in charge of a hospital now is up against that problem sometimes. A couple of cases are offered to him and he finds he can take only one. He can only decide, as best he can, which he will take. He will have to continue to do that, as best he can.
Let me come back now to the White Paper and quote from paragraph 26, which concerns agreements with voluntary hospitals:—
“Payments to the voluntary hospitals at an agreed rate, in respect of the cost of examination, diagnosis and treatment and (where necessary) the cost of maintenance, will be made by local authorities. Services provided by voluntary hospitals will be on a contract basis and the autonomy of the hospitals will not be affected.”
 As far as we can put these thing in words, they have been put in words, as is proved by that quotation. The autonomy of the hospitals will not be affected. The hospitals will be free to make agreements with the local authority on a contract basis.
The Senator said that there is a sort of economic compulsion on the doctor. He said that if the doctor does not join this scheme he will get no work. That does not follow. Undoubtedly, the Senator can argue that but, strange to say, in Britain, where there is a free scheme in operation, a number of doctors can make quite a good living outside the scheme from patients who come to them. Maybe the same will happen here: I do not know. At any rate, I suppose that if this whole scheme is a huge success and if everybody is inclined to join, then the doctors who remain outside it will have a thin time. That is probably true but I am sure that that would not happen for a long time.
The Senator says that a patient cannot get any help if she does not go to a doctor within the scheme. What can we do if a doctor refuses to come into this scheme and if a patient goes to that doctor and is told by him that he will not take payment from the local authority and that she will have to pay him herself if she wants him? It is a free contract and if the patient likes it that way then it is all right. If the doctor wants to remain outside the scheme, it is all right, too. We can only wait and see how things will work out. It is hardly fair to attack the scheme on the allegation that we are imposing an economic compulsion on doctors to join by offering them terms to come in.
Professor Cunningham: By taking the practice from them.
Dr. Ryan: As far as I can see, that really means that you cannot have any scheme at all. The I.M.A. scheme was an insurance scheme. Doctors were expected to come along under that scheme and treat the people. If they remained outside it, they would get nothing.
Professor Cunningham: No. no.
Dr. Ryan: What Senator Cunningham presumes is that nobody would remain outside his scheme but that there would be doctors who would remain outside this scheme. He may be right: I do not know. I have heard some doctors talk about the I.M.A. and my impression is that they would hang it, if they could. I do not say that they would hang the doctors in the I.M.A. but that they would hang the association itself.
Professor Hayes: It is very hard to hang an abstraction.
Dr. Ryan: Having heard these men talk about the I.M.A., my impression is that they would not join the I.M.A. scheme. Senator Cunningham might, on the other hand, say that there are certain doctors who would like to see this scheme hanged and who would like to remain outside it.
Mr. Hearne: That is it. They would like to see this scheme hanged.
Professor Cunningham: I am quite satisfied that the Minister's intentions in regard to the treatment of voluntary hospitals are very good. However, all I say to Senators is that they should read the Bill and see what powers are given. I have not the slightest fear that so long as we have the present Minister in office we will be badly treated, but we must bear in mind that we shall have other Ministers in the future and that the powers are there for a Minister to do certain things and that he can avail of these powers. We cannot forget that we have had the experience of a former Minister for Health who tried to avail of powers which he did not have and who tried to dictate to hospitals. That is what we object to in this Bill, and especially in this clause.
I should like to deal now with the question of a doctor who refuses admission of a patient to hospital. At the moment, very few patients are refused admission but there are some. In the hospital they try to select patients who live near the hospital, patients who, they think, will be normal and who have reasonably good homes, whose homes are suitable, and  they advise them to stay at home; but the hospital is still responsible for the patient and looks after the patient.
If there is going to be, as there is going to be, in spite of what the Minister has said, a bigger influx of patients into hospital, more patients are going to be refused admission. Something may happen to some of these, and I want to know if the doctor who sends a patient away in perfectly good faith is going to be protected in any way. The Minister said he thought that fewer patients would go into hospital. Let us look at it this way. Why do patients go into maternity hospitals or nursing homes for their confinements? Remember that confinement is a physiological process and not a disease, and that 80 or 85 per cent. of confinements are quite normal. The other 15 per cent. may give rise to serious trouble and some patients may die. We have reduced maternal mortality by about 400 per cent. in the past 20 years, and that has been brought about mainly by new drugs and new methods of treatment. A patient in hospital knows that she is protected. A woman knows that if she gets a severe hæmorrhage while in a hospital—it is one of the great killers of women—there are plenty of doctors there and plenty of blood available and she can be treated straightway. The same applies in a nursing home, but not to quite such an extent, because there is not the staff there to assist you that there is in a hospital. That is one reason why people go to hospitals and nursing homes—they know they are safer, that more can be done for them and that there is more than one nurse to look after them. These nursing homes and hospitals have other doctors available in an emergency and so the patient is better looked after. That is one very big reason.
Another reason is the economic or social reason. Many women have no help in their homes these days—they cannot get a mind. A woman may be able to farm out one child with a friend or relative and another with other friends. She then goes into hospital because the husband can look  after himself during that time. She cannot stay at home and have two children running around the house. If she is in bed with an infant, who is going to look after her? That has happened in other countries and it is happening here now. It is a social problem and, with all due respect to him, I think the Minister is quite wrong when he says there would be fewer patients under this scheme going to hospital. Look at what happened in every other country. They are in the same difficulty in England as we are in trying to get patients to stay at home, the reason being that they have not got the hospitals to put them in. They hope to build them, but my whole concern in this matter is that the doctor should in some way be protected. My other point is that the maternity hospitals are going to me more overcrowded than ever.
The Minister also mentioned four women paying £2 per year, which amounts to the large sum of £8 a year, and that one of these four will have a baby that year. Let us hope that they have the baby in turn and do not have them all about the same time. Does he mean to suggest that £8 will cover the expenses of one confinement? It will not cover the hospital expenses. Perhaps he intends to pay the doctor 5/- or 10/-, but certainly there is not very much margin left. The sum of £8 will not cover the hospital expenses of the patient.
The Minister also touched on the voluntary insurance, contributory insurance scheme to which I referred earlier when I spoke about the Truman report and the report from Sir Earl Page at The Hague last week on how it is working in Australia and in various other countries. The Minister said this scheme and that scheme were very much the same, that, if the patient pays £2 a year, it is very much the same as the voluntary insurance scheme. It is not. If a patient is insured under a voluntary insurance scheme, a certain sum will be allotted to her for expenses. In France, the amount is 30,000 francs, or £30, so you can see what this may cost. They are insured in France and the patient gets a grant of 30,000 francs. On that amount she can do what she likes. She  can go to a hospital or to a nursing home, paying the extra expense; she can have any doctor she likes; but under this scheme a patient must comply with certain conditions and must go to a doctor who has signed on. Otherwise, she gets no grant.
That is the big difference between the two schemes. Under the voluntary insurance scheme, a patient has some liberty, but under this she is told what to do, where to go and whom to go to. If you take the trouble to look into this question you will find that people are contributing to the voluntary insurance scheme and even in England at present there is a very big voluntary contributory scheme because so many people are dissatisfied with the State scheme. I am not against a State-aided medical service—I am all for it, and we have been asking for it for years—but we want it done in the proper way. That is the only difference—we want it done properly, so that it will benefit the patients and will provide the best service, without interfering with the proper running of hospitals.
Mr. Baxter: So far the Minister has not given us any answer to the point raised earlier on Section 2 with regard to the date or dates on which the different sections of the Bill will become law. Senator Cunningham has put the point: what is to happen in the event of a woman being refused a bed in a hospital because another woman has been chosen as being more necessitous for one reason or another? Will an action lie against the doctor? I pressed the Minister to say whether an action would lie against a local authority, and I want an answer from the Minister to this question: if a health authority, having done their utmost, fail to provide a service, because of physical limitations of space, which the Minister commands them to provide, and if some woman cannot secure a bed or be given the necessary attention and there are serious consequences, what is to happen? Are there legal liabilities on somebody?
The Minister's line on this is that he does not see any reason for believing that there will be any more crowding  into hospitals than before. I do not accept that point of view at all. Senator Cunningham has given some reasons as to why in his judgment— it is a judgment that any of us who understand what conditions in the country are at the moment will accept —there will be more crowding into hospitals.
There is a domestic problem in very many homes in the country to-day that will force a pregnant woman to go into a nursing home, if such be available. There is another consideration, that if there is hospital accommodation available, most of the dispensary doctors will be disposed to send the mother into hospital for treatment. No dispensary doctor just quite knows what is going to happen or how a case will develop, and it will be his desire to pass the responsibility on to somebody else. You are going, therefore, to have all sorts of difficulties in deciding the question as to whether this or that person is to be taken into hospital where there is limited accommodation. Who is going to determine that question? Is it the doctor in charge of the maternity section? If a patient comes in 20 miles from a country district, is she to be told to go back home when she arrives at the hospital? I do not know how this will be worked at all, but I am quite convinced that the demands on hospitals will be much greater than ever before.
I have here a copy of the London Times of 25th September which deals with an “elaborate survey conducted by a committee of general practitioners for the British Medical Association, the results of which appear in this week's Medical Journal with the committee's own report”. I am not going to quote very much of this, but it goes on to state:—
“The health service, intended to enlarge the competence of the general practitioner, has in fact enlarged his uncertainties. The last of his troubles is the really unreasonable patient who regards him as a servant, not an adviser. More serious is the committee's complaint that patients generally tend to ‘over-emphasise the place of the hospital in medical treatment’ and that ‘patients might become less hospital-minded if they were more aware of the capacity of their own doctors to treat successfully and quickly most of the common illnesses’.”
That is the experience in Great Britain and I believe exactly the same thing will take place here. I believe that when people feel these services are there and that the obligation is on the health authority to provide the services, the people will demand and will expect to get them, whatever the circumstances and conditions may be and they will be very impatient and intolerant if they are not allowed to avail of these services. I believe too, that medical practitioners will prefer to send their patients into hospital rather than treat them in their homes. I think the Minister and local authorities are going to be up against that throughout the country. I should like to hear from the Minister some answer to the question as to where the health authorities will stand when he commands them to provide the services if they are not able to do so or if there are disagreeable or unhappy consequences for certain of our citizens because the services are not available for them.
Mr. O'Higgins: I want to ask the Minister if he would be good enough to give the House whatever figures are in his possession as to the average yearly number of births and the number of maternity beds available throughout the country. I should be very surprised to discover from the Minister that the number of maternity beds now available in any one of the Twenty-Six Counties are adequate to deal with the maternity cases arising in that county at present. I should like the Minister to give the House the number of people seeking accommodation so that the House would be in a position to form a judgment on this matter. I accept the case made by Senator Cunningham that the number of people seeking beds will be greatly increased when this scheme comes into operation. I want to know if the Minister is really serious in regard to Section 16 of the Bill and in his  expressed intention of operating it within the next 12 months or so. I do not believe that it would be humanly possible for the Minister to provide an adequate number of maternity beds to implement Section 16 within the next two, three or four years. In regard to sub-section (4) of Section 16, I disagree with the view expressed by Senator Cunningham because I consider that this talk of a free choice of doctor for every patient is the greatest piece of bluff. I do not believe that there will be any alteration in the present position at all.
If you look at the position in rural dispensary areas you will find doctors in private practice there. The only doctor available there is the dispensary doctor. Neither by his contract nor by law can the dispensary doctor be forced to take a case from another dispensary or to attend a case from another dispensary. If there are people who want a choice of doctor in these rural areas how can that choice be exercised? If the doctor of the dispensary area in question is not by some method forced into seeking an agreement with the local authority, it is quite on the cards that the person who wishes to exercise that choice will not receive any additional benefit whatever. I do not believe that there will be any choice of doctors in the rural areas. Few, if any, of these areas have two dispensary doctors. In city dispensary areas where there may be two or more doctors there will be the same choice of doctor as you have at the moment. I do not believe that sub-section (4) will confer any additional benefit on patients. As I said, it is merely a piece of bluff.
Mr. P. O'Reilly: I should like to get some information from the Minister in regard to sub-section (4) of the section. The sub-section states:—
“(4) Regulations shall provide that any woman entitled to receive medical services under this section may receive them from such registered medical practitioner who has entered into an agreement with the health authority for the provision of those services and who is willing to accept her as a patient as she may choose.”
 Does that mean that a woman is confined to the doctors practising under a particular health authority or will it mean that a woman living, say in Banagher, which is situated adjacent to the junction of three provinces, could avail of the services of a doctor practising in any of these three provinces? I should like to hear from the Minister what would be the position of a woman living there or as to whether she would have the choice of a doctor from County Galway, County Offaly or County Tipperary. If she has not that choice I would suggest that on the  Report Stage the word “the” before the words “health authority” should be deleted and the word “a” substituted because I believe that by that small change, you could provide a woman with a choice of doctors working under any particular health authority in the country.
Mr. Quirke: I move to report progress.
Progress reported; Committee to sit again.
The Seanad adjourned at 10 p.m. until Thursday, 1st October, at 3 p.m.
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