Amendment No. 1 is in the name of Deputy Ferris and I am proposing that we discuss together amendments Nos. 1 to 5, inclusive, by agreement. Amendments Nos. 2, 3, 4 and 5 are alternatives to amendment No. 1. Is that satisfactory? Agreed.
Health (Amendment) Bill, 1991: Report and Final Stages.
I move amendment No. 1:
In page 3, to delete lines 21 to 42.
This amendment proposes the deletion of a section.
Amendment No. 2 is a replica of the amendment I moved yesterday just before the Committee Stage debate was guillotined. The amendment states:
In page 3, to delete lines 33 to 35 and substitute the following:
"(2) Except in the case of an emergency, nothing in this Act shall permit the Minister, or Health Boards, or others to redesignate public beds in public hospitals as private beds.".
During his Second Stage speech the Minister stated:
When the Bill has been enacted I will immediately be making the regulations in question and my intention is to provide for the designation of public beds as public and private and that public patients must be accommodated in public beds and private patients in private beds.
He went on to say that in preparation for this new system his Department have been involved in detailed discussions with every health board and public voluntary hospital, who have been asked to draw up proposals for the designation of public and private beds for a three-year phased implementation of the modified system of access to these beds. My concern is to protect the existing entitlements of public patients in public hospitals.
This amendment seeks to ensure that the numbers of public beds will not be interfered with and they will not be redesignated as private beds with a view to overcoming the loss of income to the public hospital from the VHI, which is considerable, and to deal with some of the problems the consultants had in making the case for the increase in their remuneration recommended in the Gleeson report. The Minister stated that he would ensure that the number of public beds available would remain the same.
It is almost impossible then to reconcile his statement on Second Stage with regard to the purpose of the Bill and his approach to my amendment unless, of course, the Minister wants to accept the amendment which would ensure that he and his successors or any health board or hospital agency could not then interfere with the existing list of public beds. If the Minister gives that commitment he should accept the amendment, If he does not accept the amendment there will always be a question mark over his intention for public beds.
The Minister is aware that there are closed public beds in existence in public hospitals throughout the country—some 1,000 beds altogether. Will the Minister admit that it is his intention to reopen those beds and redesignate them as private beds since there would be no additional cost to the Department? I am specifically concerned with the existing open public beds. I do not want to see a diminution in them or to see them redesignated. If that happens this Bill will have been a shambles. I want to protect the existing public beds of which there are not enough, as is obvious from the length of the waiting lists. There seems to be disagreement as to whether the Minister knows how many public and private beds there are, as of today, in any hospital. I have a list from the health board in my own area, which is compiled annually and submitted to the Minister, of the total number of beds available in each faculty in all the hospitals.
It is amazing that the Minister for Health, who has overall national responsibility to the Government and to this Parliament, says he does not have the information. He must know, for example, that Waterford Regional Hospital has 64 medical beds. Can he tell me how many of those are public and how many are private? There are 67 surgical beds, five gynaecological beds, 50 paediatric beds and 15 ophthalmic beds, although under an asterisk which is at the bottom of the report they are called authorised. I could give the figures for every hospital in the region. I could even give the rate of occupancy of beds. The health boards submit all this information to the Minister every year. Surely if the Minister looks at all this information and at that supplied by the VHI he should be able to say how many private beds there are at the moment.
The Minister said yesterday that he was satisfied that he would not lose any public beds in this process. I would like the Minister to clarify this. Deputy Bruton has a similar amendment which is not as specific as mine because it looks for equality between the two. In a public hospital we must discriminate in favour of the public patient because it is a public hospital intended for public patients and in which the majority of beds are public beds. I do not want to see equal access in a public hospital for public and private patients. I want the present discrimination in favour of public beds to continue. I take it that in private hospitals all the beds are private beds and it is presumed that anybody who goes to them has to pay privately or through the VHI.
I am speaking specifically about public hospitals. I am aware that the number of private beds in public hospitals is small: I gave an example yesterday, maybe four or five beds. The Minister is aware also that, since the implementation of the common contract which is at present in operation by the consultant surgeons, they renegotiated with the Minister for additional beds to be made available for consultants for private patients. That could account for Deputy Allen's comment that up to 40 per cent of public beds were occupied by private patients. This was an arrangement of bed days being made available to consultant surgeons in hospitals to enable them to continue to have some private practice in a public hospital. Perhaps the numbers I gave the Minister yesterday were on the low side and the situation may have changed. If so I would like to know today how many private beds are in all the public hospitals before this Bill passes through the House, by guillotine again, at 1 o'clock. I want to know now and I think I am entitled to know. I want to retain that number, and if there is a change in that number in the future we will have something to argue about because we will have the Minister's commitment on the record. I rest my case.
I have tabled this amendment overnight as a middle ground between the Minister's position and that of Deputy Ferris. I understand that one of the difficulties the Minister has with Deputy Ferris's amendment is that as of now we do not have a precise indication of the number of public beds. The Minister has instituted an inquiry with the health boards who will, in time, be coming back to him with what they regard as the necessary complement of public beds. Whenever I have asked questions about the number of public beds I did not get a reply. I presume the Minister does not have the information at his disposal and in that situation it would be hard to make Deputy Ferris's amendment work.
Instead of concentrating on the allocation of beds, which we do not have sufficient information at our disposal to do, I am proposing that where the Minister is taking responsibility to decide about access to private care and is in a position to decide between private and public beds in effect, the regulations should provide for sufficient public beds to provide care for all those who seek access as public patients in an equitable manner with those provided for those seeking private care.
The Minister must recognise that any hospital which is, in the Gospel terms, a wise steward would write up its number of private beds to the highest possible level because it gives it an opportunity of some flexibility on funding. That is a real danger we have to be alive to. We have to build into the legislation protection for the public patient from the situation where a health board or a hospital finds itself under financial pressure, and, as a way out, designates extra private beds.
Let me say that that would not necessarily be offensive in the same sense that they could still, under the Minister's regulations, put public patients into those private beds. There would be nothing to stop the authority putting public patients into the private beds, so having them designated private is a win/win situation for health boards in that when they have private patients to put into them they can get revenue but when they have public patients they can put them in also. What we need is not some sort of crude fossilisation of a ratio between public and private beds that would be there for all time, because that does not reflect the sort of changes that health boards and hospitals would have to deal with as the years go by.
We want an assurance that, first, in the earmarking of beds as public and private in any one year, there will be fair access for public patients; in other words equal waiting times for public and private patients. That is the sense of subsection (1). The sense of subsection (2) is that, recognising that we live in a changing world, year on year, both the bed mix and the case mix should be reviewed to ensure equity between public and private patients and a reasonable equality in waiting times for surgical treatment. That is the most sensible way I can see to put into the legislation what I think the Minister and all of us want to see copperfastened in legislation.
There is a danger if we adopt the notion that you designate a certain number of private beds so that they are more or less fixed for all time, not subject to annual review. Then consultants may see they have, so to speak, property rights in those private beds, that those are their beds, and no growth in public need, sudden emergency or increase in the number of people opting for public care can take those beds from them. I think no consultant should be given that sort of property rights in beds in a public hospital. Under the present regulation it would be extremely difficult for a hospital to row back in the event that, say, they found suddenly that the services were not there for public patients or they could not give acceptable waiting times. Where would they then turn if a sort of property right was given away in private beds? There must be the flexibility to review on a year by year basis and to say, "Okay, last year you had so many private beds but because of the pressures of public care and the needs of the public patients we cannot provide those"
A consultants' contract has recently been signed. The Minister will correct me if I am wrong in what I am about to say because he is much closer to it than we get from the odd newspaper clip. I understand that under the new contract the hospital consultants have a commitment to certain hours at the hospital. They do not have an explicit commitment of hours to public patients, they have an overall commitment to the hospital. If there was a fixed property right in private beds and if the health boards over-designated the private beds, given clinical independence and so on which the Minister pointed out, it would be very difficult for the hospital authorities to prevent those private beds being used up to a level that might leave the public service inferior. The consultant would still be honouring his contract, coming in, working the 33 hours, but there would be a tendency to over use the private side of his practice. I understand that the element in the Gleeson report that seemed to be trying to deal with that, namely that consultants' pay would be reduced in proportion to private practice, is not in the renegotiated contract. Under Gleeson's original proposals as I understood them, if 25 per cent of a consultant's workload was private there would be a comparable reduction in his public salary. That element is gone in the consultant's contract. There will be an incentive for the hospitals to play safe and designate a high number of beds as private so they will have the flexibility to earn revenue in years to come if certain things happen.
To avoid all those risks we need an amendment such as I have put in here. We state clearly that the basis of allocation between public and private beds is to ensure fair waiting times between the two extremes. Secondly, we insist there be an annual review and no property rights given to anyone as to the number of private beds. If circumstances change and there is more need for public care the hospital has the ability to see to that. I feel my amendment fits in with the way the common contract seems to be negotiated and it gives the authorities, the Minister and the public patients a better chance of a fair shake out, which we are all trying to achieve.
It is easy to understand why these are being proposed. In amendment No. 5 I propose that the regulations should be brought before the House. We still have the question of private practice. Over the years and in the past decade particularly the bone of contention was the use of public beds for private patients in our public hospitals with no control over that. I thought this amendment would eliminate that completely. I am beginning to have doubts. The Programme for Economic and Social Progress indicates that the Government are committed to maintaining the position of private practice both within and outside the public hospital system. Why is it emphasised so much if the Government's intention was not to eliminate entirely but to reduce the level of private practice in public hospitals? The abuse of that system over the years was horrendous. Consultants are paid their salaries to do the job but because no resources were provided by the health boards patients who had VHI cover were admitted as private patients, so the consultants were paid twice.
At the last meeting of my health board I received a copy of a document issued to the boards which indicated that the designation of day beds between public and private is necessary as for other beds available to elective patients. That is mentioned as is the issue of involvement of consultants. On the one hand we are now giving consultants an increase. Some of them got from £13,000 to £17,000 as well as salary increases of 30 per cent to 50 per cent and we are still giving the same consultants the right to a say on what private beds will be available. It seems each hospital has been requested to ensure its consultants are fully involved in drawing up these proposals. The proposals will have to be agreed by the Department of Health.
Why is there still such emphasis on private practice in our public hospitals if the whole purpose of this measure is to eliminate the problem that arose over the years? I am beginning to wonder whether the points made yesterday evening have more validity than I attributed to them when I listened to the debate then. Is there an intention to introduce a system whereby the resources being provided for health care are so restricted that the health boards will use the beds in our hospitals for private care and VHI cover will be availed of? That is a real danger unless the Minister gives a categorical assurance that that is not the case and specified the ratio in hospitals. In a 100-bed hospital what would he see as a fair ratio of private/public beds? The Minister also needs to come clean on the number of beds per thousand of the population in the State generally. I think a figure of three beds per thousand of the population was given four or five years ago. However, I think that figure has gone out the window at this stage. I should like the Minister to reply to these questions.
Amendment No. 5 proposes that:
Where it is proposed to make regulations under this Act, a draft of each regulation shall be laid before each of the Houses of the Oireachtas and shall not come into effect until a motion approving of the draft has been passed by each such House.
Amendment No. 2 in the name of Deputy Ferris proposes that:
Except in the case of an emergency, nothing in this Act shall permit the Minister, or Health Boards, or others to redesignate public beds in public hospitals as private beds.
This is a specific proposal. Deputy Bruton's amendment No. 3 proposes that the regulations shall inter alia“provide for the provision of sufficient public beds to provide care for all those who seek access as public patients...”. I also support this amendment.
I want to refer to the situation where public-voluntary hospitals in Cork city receive more attention than the hospital in Mallow. The hospitals in Cork city are given a subvention by the Department and as far as I am aware unlike other hospitals which receive subventions, they do not have to account for this money. I should like to know if regulations will be introduced to rectify this anomaly. Does the Minister have any power over such issues? These are the main points I wanted to make and I hope the Minister will reply to them.
In his response yesterday the Minister attempted to attribute to me something I had not said. I have never held consultants up to ridicule. However, while the vast majority of consultants are conscientious and hard working, a number of them are abusing the system. As the Minister knows the common contract was so designed that it lent itself to serious abuse. He was wrong to stand up in this House and say that I was making wild allegations. If the Minister knew his brief, he would know that three years ago the Southern Health Board, at my request, carried out a survey of the level of private practice in hospitals in their area. That report clearly showed that there was widespread abuse in a number of specialities in hospitals in that area. I do not think hospitals in the Southern Health Board area were unique in this respect. By coming into this House and saying that there are no facts to substantiate my statements, the Minister has shown a lack of will to confront the abuse in some sections of the consultancy profession.
The Minister is also aware of the merry-go-round syndrome which exists in hospitals where people are subjected to a battery of tests so that everyone gets a pluck at them. I hope that the introduction of this legislation will eliminate such abuses. I want to give two examples. If a person who is involved in an accident goes into hospital for an X-ray he is asked whether he is a member of the VHI or if he has a medical card or hospital services card. The magic words are "Voluntary Health Insurance." If the person is a member of the VHI two or three weeks later he will get a bill from a radiologist or a group of radiologists he never saw. Eventually they will threaten legal action if he does not pay. I hope that that type of activity will be eliminated under this legislation. Analysts and pathologists can also get their pound of flesh for tests they have not carried out. Technicians who are employed by the health board carry out the tests and the analysts and pathologists can also issue a bill for this service.
The VHI have been bled almost dry by a small select number of consultants. We have never tried to come to grips with this problem. I believe there are still wide loopholes in the legislation. I referred yesteday to the loophole in regard to bed complements. The reply given by the Minister yesterday to this point was not satisfactory. If, for example, I have a back problem, under the new legislation, I will have to wait for up to nine months for an appointment with an orthopaedic surgeon in the Cork Regional Hospital or any public hospital. However, if I go privately I will be guaranteed an appointment with him within two or three weeks and if I am diagnosed as having a serious medical problem I will be admitted to hospital immediately. However, if I cannot afford to pay for a private examination I will have to wait a considerable period for my initial examination so that my complaint can be diagnosed. Under this legislation the backdoor avenue into hospitals will continue to be open and people who visit consultants in their private rooms will be able to get into public beds. The legislation will be meaningless unless the Minister plugs this loophole. If the backdoor avenue into hospitals continues to be open it will be academic whether we are talking about public or private beds and the quality of treatment one receives will depend on their resources.
Hospitals do not have sufficient beds at present to deal with the demands on our health services. This is a fact, and the waiting lists prove it. The Minister may trot out impressive percentages here — 20 and 40 per cent decreases in waiting lists — but he should give us the true figures and indicate the number of people still waiting for public beds. A five year old child who is waiting for a tonsillectomy whose hearing and performance at school are impaired will be condemned to wait for two years for this surgery if his parents cannot afford to pay for a bed in a hospital. An elderly person in severe pain who is waiting for a hip replacement operation is condemned to wait for a considerable time for the necessary surgery — depending on the region it can take up to two or three years. This proves that there are waiting lists and a shortage of beds at present. That is the reality.
If this legislation is to have any meaning the loophole I have pinpointed has to be dealt with by the Minister, something he has not yet done. The Minister should quantify for us the number of public beds in public hospitals as of 31 May 1991, tomorrow. He should tell us the number of public beds and private beds there will be so that we can decide whether there will be a change of use in regard to public beds. I believe public beds will be used as private beds because the Minister is not giving any extra resources and he is not opening beds. Therefore, if he is allocating private beds they will have to come off the public list. The Minister should quantify the number of public beds in public hospitals so that we can be satisfied that the public will not be taken for a ride as regards this legislation.
I ask the Minister to set up immediately a national hospital bed register so that we can monitor the performance and effectiveness of the new legislation and regulations and keep an eye on what is happening. The Minister is killing two birds with the one stone with this legislation.
As I said on Second Stage he will bring in £90 million by the increased charges. There will be an extra cost to each person earning in excess of £16,500 and they will not receive a better service in fact, I contend they will get a worse service. By redesignating public beds as private beds the Minister is effectively saying to the hospitals, you go away and generate your own revenue. Will the Minister reduce the allocations to those hospitals eventually? Will the hospital replace the allocation they received from the Minister with revenue they are forced to raise by transferring the use of beds from public to private? These questions are the nucleus of his legislation and are not being answered by the Minister. I ask the Minister to give us the figures as we do not have them; we are depending on the Department to supply them. When we table Dáil Questions we are told that figures are being compiled, are not readily available and will be supplied later but they do not arrive. I urge the Minister to give us the facts and figures so that we can judge the legislation.
In considering these amendments we are getting to the nub of the Bill and, therefore, we are getting to what the health services are supposed to be about. In his lengthy speech the Minister has not stated clearly the basic principle on which we must operate, that everyone here from the most disadvantaged — the travellers or single parents — right up to Dr. Michael Smurfit and Dr. Tony O'Reilly is entitled to the same standard of medical and nursing skills. I do not think that can be said often enough. Of course, Dr. Michael Smurfit, Dr. Tony O'Reilly or anyone else is entitled to go into a private nursing home or a private bed in a public hospital and have a huge room with nice curtains, adequate visiting hours and have flowers put in the vase every day and pay dearly for it. However, there should be no question of that person being able to jump the queue — as at present — or, having jumped the queue and being admitted to hospital having a higher standard of medical or nursing skills. I do not think this problem is being addressed here.
Deputy Bruton's amendment No. 3 refers to more flexibility. In practice it is unlikely that there are too many public beds in hospitals. Everyone knows that there are too few public beds in hospitals. I know a person who, since March, has been waiting for a public bed for major heart surgery. About a week ago he had a severe cardiac arrest and I do not know if he will survive to avail of a public bed; he may even be dead by now. This is appalling.
Amendments Nos. 4 and 5, tabled by Deputies R. Bruton and Sherlock, are similar. In section 6(3) the Minister proposes to lay resolutions before the House and unless they are negatived by the House within 21 days they will come into effect. That is a very bad way of doing business as there could be a U-turn; a regulation introduced by the Minister, or the health boards, may suddenly be reversed by the Dáil. Surely the House should have responsibility for these matters. If the Minister were to put a reasonable resolution before the House the Dáil would deal with it expeditiously and in a reasonable manner. The more we can do in the House and the less we leave to the Minister the better for democracy.
This section is the kernel of the Bill. How one views it depends on the perspective one brings to the debate. From the point of view of the Department of Health that perspective is financial in the sense that it leaves a door open to health boards to use this section in determining the mix of public or private beds for revenue raising purposes to make up a shortfall. The Minister has not given any assurance in this debate as to how that avenue will be blocked off from health boards and how the proper mix will be reached.
A number of pertinent points must be made. After three years we will have the solidification throughout the country of the number of beds, public or private. That is regrettable because we cannot say from one year to the next what will be the mix of public and private beds. That will not work. Age structures and demographic trends will have a critical impact on that equation. The percentage of the population who have VHI cover is critical. In the post-1992 era if other health insurance companies are allowed into Ireland to compete with the VHI it is likely that the percentage of people with health insurance will increase. I am not suggesting for a moment that the breakdown of beds should be based on the number of people who have health insurance.
It should not be beyond the capacity of the Minister, and his officials, to arrive at a base line figure beyond which health boards cannot proceed. There is evidence to suggest that the take-up of beds by people who are fortunate enough to be able to afford voluntary health insurance is not in the same proportion as the take-up of public beds by people who do not have that insurance. In other words, the people who have VHI cover are healthier because of their status and their financial well-being in the community. The perspective the Minister brings to the debate is not one of health care but rather one of financial considerations which will leave an avenue open to health boards to raise funds to make up a shortfall.
A big question mark has been put by Deputies Allen and Bruton on a public information campaign regarding eligibility. There is evidence to suggest that people who are entitled to free care are being charged for the services. In the event of this legislation being passed there is a need for a public information campaign about people's entitlements.
The Minister is not preparing any guidelines for health boards on the bed mix complement. That is a deliberate ploy by the Department and is seen for what it is. The revenue raising issue in the debate is misplaced in that any health legislation should be about improving health services and not motivated primarily by financial considerations.
I have listened attentively to what the three spokespersons have said. I do not intend to accept the amendments for a number of reasons. The first point I would like to make is there is no mystery about what is happening in this legislation. As I pointed out on Second Stage and again yesterday, this legislation has come about as a result of a study by the Commission on Funding. It was recommended by NESC and sought by the Irish Congress of Trade Unions.
Billy Attley is not too happy with the Minister now.
It was agreed by the Government and the social partners that we should bring forward this legislation. I want to assure the House that the legislation is in keeping with what the social partners wanted. There is a commitment in the Programme for Economic and Social Progress to introduce a change in the present arrangements for admission to public ward accommodation in public hospitals. I propose to make regulations — I have a copy of the draft regulations in front of me — under the section Deputy Ferris's amendment proposes to delete, which would restrict the admission of elective private patients to public beds to emergency admissions. This is the whole basis of the legislation, to restrict the admission of elective private patients to public beds except for emergency admissions. This would free up public beds for public patients. The deletion of this section as requested by Deputy Ferris would mean that the key element of the new arrangements could not be implemented.
The designation of beds as private or public is essential to the new arrangements given the existing ambiguity which exists in a number of hospitals arising from the current practice where public patients may be accommodated in private beds and private patients accommodated in public beds. The requirement to designate beds more clearly will also be included in the regulations as well as the requirement that I must approve all such designations. I have already instructed health boards and hospitals that there is to be no reduction in the number of public beds when beds are being designated. Furthermore in cases where beds are regarded traditionally as private or semi-private but have a high occupancy of public patients, I will ensure that an appropriate proportion of these beds are designated as public beds.
At present there are public patients in public beds, private patients in private beds and private patients in public beds. The difficulty arises with the private patients in public beds. It is not possible to state how many private patients are in public beds for the simple reason that the patients change on a regular basis. If you were to carry out a census on 31 May, as somebody requested, certainly we could provide the information for 31 May but it would not be the same as for 29 May, and that is understandable because of the present system. One of the prime objectives of this legislation it to make sure that in future private patients will not take up public accommodation in public hospital and that those public beds will be freed up for public patients.
On a point of information——
There will be no point of information.
Deputy Bruton's amendment contains vague aspirations to provide sufficient beds in an equitable manner without saying how this might be done.
How is the Minister going to do it?
The regulations which I propose to make under this section will introduce concrete measures for improving equity of access to hospital services by ensuring that publicly funded beds are available for public patients. The designation of beds as public or private, which will be required under the regulations, will require my approval. I have already given a clear commitment to the House that there will be no reduction in the number of beds available to public patients.
The Minister does not know the number.
He is bluffing.
I want to tell Deputy Bruton — to use his terminology — there will be no fossilising of beds for years to come. Each agency has been asked to submit to us the number of beds they intend to designate as public and private, and we will ensure that the number of public beds available will be maintained. As I have said, by changing the position where private patients occupy public beds we are ensuring that those public beds are freed up for public patients.
We are not seeking a maintenance of the number but rather fair access.
The beds will be available, as I have guaranteed to this House.
The Minister's guarantees are worthless, and have been worthless.
As I said, this legislation will be operated within the spirit of what the social partners requested. The Government made the decision to introduce the legislation after consultation with the social partners, and it appeared in the Programme for Economic and Social Progress. There is no mystery about it.
The Minister should consult with them again.
Billy Attley is not very happy with the Minister now.
Even those groups can make mistakes.
We will make no mistake, I can assure the Deputy of that.
The Minister is sleep-walking.
On the question of persons visiting out patients departments, you cannot prevent somebody from going privately as an out-patient to a consultant. If the consultant finds that the patient should be in hospital the patient may decide to go private or public. If the patient goes public I assure the House there will no back door entry. He will take his place on the public waiting list where he would have been placed had he waited for a public appointment. It might be two or three months down the road——
It might be 12 or 18 months.
That might be so in certain instances, but they are few and far between.
At least these people are on the list.
Deputy Allen, I will not tolerate this baying across the floor.
The Minister is misleading the House.
The Deputy is not entitled to interrupt.
The Minister is misleading the House.
Everybody has his own view as to who is misleading whom.
I take exception to the Deputy's remark and I would like him to withdraw it.
The Deputy is not entitled to make such a charge.
I believe it.
That does not make it in order. The Deputy must withdraw the charge that the Minister is misleading the House.
I object to it.
The Deputy will withdraw that remark.
I will not because I believe it.
Then you will leave the House.
I will not withdraw what I believe to be the case.
The Deputy will leave the House.
It does not make it right because the Deputy believes it.
The Deputy will leave the House.
Is that the way we are silenced, by way of guillotines or of being asked to leave the House?
Leave the House, please, Deputy.
As I was saying——
The Deputy will leave the House.
I am gathering my papers.
I am not putting any pressure on you, but business will not continue until you leave.
The public have no rights now.
Deputy Allen withdrew from the Chamber.
As I was saying, if a patient goes to a consultant privately for an out-patient consultation, finds that in-patient treatment is required and opts for public treatment, we will ensure that that person will not have an advantage over the public patient. His place on the waiting list will be the same as if he had waited for a public consultation at the out-patient department. I am sure the House will agree it would not be reasonable if a person who goes for a private consultation, finds he needs to go to hospital and opts to go as a public patient, has to go back on the waiting list to be examined by the consultant when his turn comes around. It is reasonable that he takes his place in the queue, let it be a month or two months down the road, without having to wait for a further examination.
That is nonsense.
That is the way it is going to be.
That does not make it right.
It does make it right. He will have the same place in the queue as if he had waited for the public appointment.
That is not possible because the other person is not even in the queue yet.
It is possible. It is quite simple.
The person who has not seen the consultant has not even joined the queue.
The person who cannot afford a private consultant——
Is Deputy Bruton seriously suggesting that this is the way to conduct business?
The Minister is asking——
He is not asking, he is addressing me.
That does not appear to be the case.
I am surprised that Deputy Bruton, in his capacity as spokesman, continues to bay across the House. If he continues in this manner I shall ask him, too, to leave the Chamber. This is not the way to conduct business, especially on Report Stage, and Deputy Bruton knows that. I shall not repeat eternally the rules that have been drawn up for me to carry out, only to have Deputies persist in breaking them.
On a point of order, a Leas-Cheann Comhairle, surely you cannot rule that one would be asked to leave the House for responding to a comment——
The Deputy will respond to comments in accordance with the Report Stage. He is entitled to make his contribution and to listen while others make their contributions.
Yes, but——
And he is not entitled to interrupt me, he knows that as well as I do. I shall not wear myself out in carrying out the rules of the House only to have the Deputy or anybody else perpetually break them.
I shall give an example of what might happen in practice. If on 1 June a patient goes to a consultant for a private consultation as an outpatient, the consultant decides that the patient should be in hospital and the patient opts to avail of his or her right to go as a public patient, then the hospital concerned will provide the patient with the next available public appointment, whether that appointment be in six weeks' time or, as is more usual, two or three weeks' time. I accept that for certain disciplines the waiting lists are longer and patients might have to wait for three months.
There is no mystery about what will happen. I assure Deputies that there will be no unfair advantage given to patients who go to a consultant and then avail of their right to go public. It is right in the interests of patient care that a patient should not be asked to go to a consultant and have a full physical examination and then be told that if he or she wants to take up the right to public accommodation he or she will have to go through exactly the same procedure again. Nobody in the House would wish patients to be subjected to a second full physical examination unnecessarily. I repeat my assurance that there will be no unfair advantage given to those who attend a private consultant.
The review body on higher remuneration made recommendations in relation to consultants. Their salaries and conditions of service were sent to the review body on higher remuneration, which is appropriate for highly paid senior public servants. The negotiations that took place were based on that report and were in keeping with the recommendations in it.
An amendment has been proposed in the name of Deputy Sherlock. Deputy Garland also spoke to the amendment. I shall first deal with the point made by Deputy Garland that everybody is entitled to the same standard of medical skills. I agree with the Deputy. It would be fair to say that everybody receives the highest standard of medical and nursing skills in hospitals under the Irish health system. The difference for private patients was referred to by Deputy Garland when he spoke of comfortable private wards and the provision of flowers in private accommodation. It is very important to recognise that the standard and quality of medical and nursing care is of the very highest level and that all patients receive that when they go into hospital. Everyone in the House would agree on that point. The standard of care provided deserves the payment of great tribute to the health care staff who are responsible for it.
I cannot accept either the amendment of Deputy Sherlock or Deputy Bruton's similar amendment that relate to regulations coming before the House and being passed by the House before coming into operation. The course taken by the Government is the usual practice with such legislation. It is not the practice and it would not be desirable that a debate in each House of the Oireachtas be required every time it was necessary to make variations, no matter how minor. Under section 6 (3) the Oireachtas will be able to annul any regulations should it choose to do so and I do not consider it necessary to make provisions as proposed in the amendment. Deputies would agree that for every piece of legislation coming before the House enabling regulations to be made the Opposition always put down an amendment to ensure that the regulations come in to be debated in the House. Deputies opposite would also agree that were that practice accepted the Houses of the Oireachtas would do nothing other than debate all the regulations and all the changes in regulations going back over many years. During the Order of Business this morning Opposition Deputies were very anxious that a long list of legislation be passed through the House. In fairness to the House, it would be unreasonable to ask that every minor detail and every change in regulations should be brought before the House. Deputy Garland said that the House should have responsibility for change in the regulations. The House will have responsibility for change in the regulations in that under section 6 (3) the regulations will be laid before the House and the House will have an opportunity to annul those regulations if Members so desire. That position accords with standard practice and it is appropriate with this legislation.
Again, I assure the House that beds designated private beds will be available for private patients and beds designated public beds will be available for public patients. There will be no reduction in the number of public beds available. No longer will private patients go into public beds, and that will free up public beds for public patients. I assure the House that patients have the right to go to a consultant for a private consultation as outpatients, and I assure the House that that will not give advantage to such a patient ahead of a public patient who waits in turn to go to a public outpatient appointment.
I thank the Minister for at least putting on the record of the House responses that have removed some of my worries in this regard. However, I would genuinely have preferred it if the matter had been legislated. I wish to speak on three points made in the Minister's reply to my amendment and the other amendments.
The Minister said that public patients would have the oportunity to go to a private consultant in his private rooms for an opinion on the basis of the waiting lists — we already have more than 5,000 in our own health board area — of people waiting to see public consultants working for the State, consultants who also do some private work. I have no problems with the consultants. They are a very special group of people. I admire the way that the Minister dealt with their problem, which was examined by Gleeson and in negotiations with the Department. I said in my Second Stage speech that, although I was concerned that the new contract would not be accepted, I hoped it would be. Consultants are very important people and they must be paid adequately, but I also have a responsibility as a public representative to ensure that public patients are protected in new legislation. The Minister suggested — and, in fairness to him, I think it is his belief — that someone who goes to a private consultant in his private rooms for an opinion will not gain backdoor entry to hospital, that the patient will have to go back into the queue even if a decision is made to go into hospital as a public patient, which everybody is now entitled to do. The Minister has missed the point of Opposition Deputies' arguments.
Deliberately.
Somebody who pays for a private consultation, whether they pay £15, £40, or more, will at least get a medical, clinical opinion from the consultant on whether they need hospitalisation. If one is waiting on a public list to get an appointment with a consultant it surely affects the waiting time for hospitalisation, if needed. One cannot get a hospital bed without having been seen by a consultant, either publicly or privately. The only alternative to that is to allow the GP the decision as to whether or not one needs a bed.
I gave an example of a medical card holder, the wife of a pensioner, who had been waiting for two years to see an eye specialist. She went to a private optician and an opinion was given that an operation was needed urgently. She was admitted to hospital, practically blind, and was successfully operated on. Had she continued to wait for the public service she would still be on the waiting list. That is my only argument in relation to people going privately for the initial consultation. The sooner the consultant's decision is given the sooner one can get into hospital, whether it be a public or a private bed. There might be people on the waiting lists who do not need hospitalisation, but how do we know? All we know is that until they get a definitive decision after a clinical examination by the consultant a decision is not made. Unless the Minister allows the GP to make a decision there is not any way out of the problem.
I am glad that the Minister has prepared regulations but I would like him to make those available to us as quickly as possible so that we can see if they address the problem about which we are talking. Time is of the essence. The Minister in his Second Stage speech said that in preparation for the new system his Department had been involved in detailed discussions with every health board and public voluntary hospital. He said they had been asked to draw up proposals for the designation of public and private beds and for a three-year phased implementation and that the proposals were being examined by the Department of Health, who are responsible for the overall coordination and monitoring of the new arrangements, as required under the terms of the Programme for Economic and Social Progress.
It is important to get the balance right in the designation of beds so as to reflect fairly patterns of public and private practice. There is nothing to stop health boards from redesignating existing public beds before the legislation is enacted and submitting a list of them to the Minister. On what basis does the Minister give his definitive response that there will not be a reduction in the number of public beds? Is the Minister basing his response on a redefined list submitted to him by chief executive officers in health boards? At the moment people are going around hospitals with measuring tapes trying to work out which beds can be made private so as to submit this redesignated list to the Minister. We are losing public beds while we are discussing the legislation. That is a big problem. I accept the Minister's assurance that there will not be a loss of public beds but I would like the Minister to tell me from what date he is working. I want to be assured that the number of public beds will meet the demand.
The Minister did not address the question of reopening closed public beds. They might be reopened as private beds. I would not have a problem with that because the more effective beds in the hospital the better. Perhaps the Minister has already agreed with the consultants to do that. Private beds are supposed to be self-funding through the VHI, but I would like to know if the staffing of these private beds would be self-funding. To open more private beds in this way would increase availability of beds without disturbing the existing designation of public beds about which I am concerned.
In emergencies public patients can avail of private beds. If private beds were available in a non-emergency situation and if there was public demand for them, would they be available for public patients in the interests of improved health care? The Minister has said that the beds cannot be mixed around. I want to make sure that public patients will not be disadvantaged due to the lack of a bed.
I have not deviated from the principle of the legislation throughout the debate here. I will accept the Minister's reassurance that there will not be a reduction in public beds, but I would like to know from what date the Minister is talking. I would also like to look at the regulations governing hospitals and health boards. The Minister said that regulations would be subject to amendment by the House. The Minister is incorrect in that regulations cannot be amended by the House. They can only be rejected or approved.
On a point of clarification, Deputy Ferris has concluded. There was an agreement before I arrived that amendments Nos. 3, 4 and 5 would be taken together. Therefore Deputy Ferris' conclusion represents the final comment. I am saying this because I see later on that there is a suggestion that two amendments, Nos. 6 and 7, will be taken together. I am advising Deputy Bruton, in whose name the second amendment appears, that if he agrees to the request that amendments Nos. 6 and 7 be taken together for discussion, he is automatically accepting that he would not have the right to reply.
We are being treated disgracefully. We raised very serious points about this measure but the Minister has not replied to any of them. Deputy Sherlock and I have amendments down which we want to press and we deserve the right to respond to the Minister's points. Our agreement to take these together did not represent an agreement——
I cannot introduce a new Standing Order to accommodate your misunderstanding of it. I must proceed, as we have proceeded in every case since I had the honour of taking this Chair, on Report Stage. I cannot adjust orders to accommodate people who are not familiar with them.
Under what Standing Order has that ruling been made?
You can find out under what Standing Order it is wrong.
The Members are entitled to know the position.
The position is as I tell you and if you discover I am wrong there is a mechanism whereby you can have it changed.
It is disgraceful.
We have a right to protection from the Chair. If you are taking a casual, throw-away remark by the Ceann Comhairle when the House was full as an agreement to be muzzled in a debate on Report Stage of a Bill which has been guillotined, it is very unfair and does not provide adequate protection.
I am telling you what is provided for in the Standing Order and I will not change it. I have alerted you as to how you can protect yourself in respect of ensuing amendments if you want to avoid this. I would not say this unless I was convinced it is true. It applies to all amendments where they are taken together. On Committee Stage the person can reply, as there is cross-talk. However, on Report Stage there is only a question on the amendments taken together.
There was no understanding that we would be muzzled in that way and we are not getting fair protection from the Chair if he interpreted a throw-away remark in the middle of a hurriedly assembling Chamber——
I was not here at the time and I take the word of the Ceann Comhairle in respect of what was agreed.
I did not give any such agreement.
We were not asked.
Deputy Ferris, are you anxious that I should put the question in relation to your amendment? I indicated that amendments Nos. 2, 3, 4 and 5 would have to be taken with amendment No. 1 and that a decision on amendment No. 1 could mean that amendments Nos. 2, 3, 4 and 5 could not be moved.
I appreciate the difficulties of my colleagues. It was suggested that for the purpose of discussion all these amendments could be taken together, although we realise that only one can be moved. There was not a suggestion that people who had tabled individual amendments would not have an opportunity to reply. However, I accept your ruling, but I do not want to be seen as having disadvantaged my colleagues.
I should like Members to appreciate that what I say is a decision of the Chair. Only one amendment has been moved and, although it was agreed to take other amendments with it, only one amendment can be replied to. It is as simple as that.
Can the amendments which have not yet been put to the House be replied to?
No, only one amendment has been moved. I will put the question in that regard. If it is negatived the others will not arise because they all refer to the same matter. In that case the other amendments could not be moved.
Question: "That the words proposed to be deleted stand" put and declared lost.
Did the question relate to No. 1?
Deputy Bruton will appreciate that if amendment No. 1 is negatived, amendments Nos. 2 to 5, inclusive, cannot be moved.
If amendment No. 1 is defeated can we still press amendment No. 3?
No, you cannot.
Why?
The Deputy should look at the terms of——
Amendment No. 1 proposes to delete the section and amendment No. 3 proposes to amend the section.
The Deputy should know that if amendment No. 1 is negatived there is no point in having subsequent decisions in relation to the same matters.
One option is to throw the whole lot out, but my proposal is to modify it.
I cannot keep explaining to Members the orders which were made. Deputy Bruton must accept that if a decision is made now that the words proposed to be deleted stand there is no point in having a subsequent question on any part of the same question.
I do not accept that.
Well, Deputy Bruton, if you do not——
On a point of order, surely it is the case, if Deputy Ferris's amendment is carried and the section withdrawn, that it is gone. In that case I cannot press my amendment because I am seeking to amend the section. However, if Deputy Ferris's amendment is not defeated and the whole lot is not thrown out I am perfectly entitled to press an amendment to have a modification in what is left.
The House has already decided that the words proposed to be deleted stand. What would be the point, two minutes afterwards, in asking a question on whether any part of those words should be altered? In case there is any misunderstanding I will again put the question.
Question: "That the words proposed to be deleted stand" put and declared carried.
Amendment declared lost.
An bhfuil tú sásta leis sin? Therefore, subsequent amendments Nos. 2, 3, 4 and 5 cannot be moved. We now move to amendment No. 6 in the name of Deputy Ferris. There was a proposal that amendments Nos. 6 and 7 should be taken together. I am now alerting the House to the fact that if there is agreement in that regard the Deputy in whose name amendment No. 7 appears will not have the right to reply.
Did you say that the Deputy who moves amendment No. 7 will not have the right to reply?
If he agrees to take amendment Nos. 6 and 7 together.
There is no question of agreeing to that.
Amendments Nos. 2, 3, 4 and 5 not moved.
We now move to amendment No. 6 in the name of Deputy Ferris.
I move amendment No. 6:
In page 3, to delete lines 43 to 45 and in page 4, to delete lines 1 to 9.
The reason I should like to have this section removed from the legislation is because it states on page 4:
Regulations under this section may also specify the circumstances in which a person's entitlement to out-patient services shall extend to services provided by a registered medical practitioner engaged in a consultant capacity in the provisions of hospital services and may provide that, where a person's entitlement does not so extend, the health board concerned may charge for the provisions of out-patient services such charges as may be approved of or directed by the Minister.
I am worried about that regulation because it complicates the GP's role in admitting patients. The GP referred to here is a consultant GP and the phrase "subject to regulations by the Minister" is ambiguous in relation to when a decision will be made as to whether somebody pays for the services. For that reason I am unhappy with the section as worded. I previously suggested that I would oppose it but on Report Stage I am suggesting that we delete it, the only other option open to me.
With regard to amendment No. 6, this element of the Bill is also flawed. The Minister has refused to face up to the principle outlined in the report of the commission, even though he has cited it frequently. The principle espoused by the commission was that people should have equal access to services. Each time they mentioned the need to extend full eligibility they also said there should be a common waiting list. They went on to state that "any danger of preferential access for patients in private accommodation would be counteracted by a common admissions policy". They alerted us to the problems which the Minister has refused to address in deciding how private services should be made available. The regulations to which the Minister has referred, which we have not seen and are not allowed to debate, do not address the principle espoused by the commission that an objective system of assessment should be introduced covering access to publicly funded hospital services and that there should be universal criteria governing admission to these services regardless of the patients' status.
What the Minister has proposed in these two sections, which deal with in-patient and out-patient services, flies in the face of what the commission put forward. The Minister has offered a smug, ambling and shambling defence. Not once did he mention the threat to the community rating for the VHI which the commission put forward as a justification for extending eligibility or the question of balanced billing. Neither did he properly defend his decision to abandon the idea of a common waiting list for hospital services. The Minister will not come clean. He keeps saying that this has been accepted by the Irish Congress of Trade Unions and by the Commission on Health Funding but a kindergarten child could read the report of the commission and see that the Minister's actions are not in keeping with the spirit of that arrangement.
The Minister has also described the alternatives put forward as vague aspirations, but he is distorting what we are trying to achieve. We are trying to ensure that public and private patients will be treated fairly, but he has dismissed this as being vague. He is going to rely instead on regulations which he will not allow us to debate. The Minister is treating the House with disdain, which does him no credit. We will learn in time to come that this Bill will cost the public patient dear.
First, with regard to the VHI, I have spoken at length about the Government's policy on the community rating but that matter does not arise under this section of the legislation. I am not going to debate the matter for that reason. That is the correct approach to adopt. I do not want to be accused of running away from the issue simply because I will not debate it as it is outside the scope of the Bill.
With regard to the question of a common waiting list, I have already referred to the recommendation of the Commission on Health Funding and the reason we have not gone for a common waiting list, which is, as I made clear on both Second Stage and Committee Stage yesterday, that it could place the public patient at a disadvantage. The commission's recommendation relied on admissions being monitored to ensure that private patients were not admitted to available beds ahead of public patients with greater medical need. As Deputies will understand, this recommendation would present great difficulties in practice since the decision to admit a specific patient must always rest with the consultant concerned.
Based on medical need.
We have already heard Deputies make reference this morning to the case of a patient visiting a consultant as an outpatient. Deputies on the opposite side of the House have accepted that it is possible to have a fair system under which the public patient is not placed at a disadvantage. In this case the decision would rest with the consultant, who would have responsibility to draw up the common waiting list and decide where a patient should be placed on that list. That is a very important point. The Government and the social partners believe that the public patient would be best protected by ensuring that for non-emergency treatment public beds are available exclusively to public patients.
It is also true that a patient on a common waiting list would have to take the next available bed, be it public or private. That would defeat the main objective of this legislation, which is to ensure that public beds are only available to public patients. As I said, it is in the interests of the public and private patient to maintain the mix of public and private care in our public hospitals. Public patients benefit from the availability of the best and most skilled consultants who can be retained in the public hospitals because of the opportunities to continue a private practice there. Under the new arrangements any increased demand for private care can be met by expanding the number of private and semi-private beds in the public hospitals without placing the public patient at a disadvantage. Such an expansion will be possible because it will be self-financing. Indeed, Deputy Ferris said earlier that he would have no objection to this provided it was self-financing.
If there was a common waiting list such an expansion would not be possible and the likelihood is that the focus of private practice would begin to move away from the public hospital system and in the long term this would not be to the advantage of the public patient. It is important, in my view, to ensure that the very best consultants are available to public patients in public hospitals and are on the campus for as long as possible during the day and not carrying on a private practice elsewhere.
Section 7 of the Bill deals with out-patient services and amends section 56 of the Health Act, 1970, to enable regulations to be made specifying how consultant outpatient services are to be made available to eligible patients. The amendment also provides for charges to be approved by me to be levied by public hospitals for services they provide to private patients of consultants. I have in mind charges for the use of X-ray equipment and laboratory facilities which are very expensive services for which no specific charges are currently made. I do not propose to introduce charges immediately but will continue to review the situation. I might point out to Deputy Bruton that there will be an ongoing review of the implementation of the changes. It will not be a question of an annual review but an ongoing review of the mix of beds. I want to assure the House that there will be no reduction in the number of public beds available to public patients.
The first regulations that I intend to make under the new provisions dealing with outpatient services will cover the provision of consultant services. It is my intention to confirm the existing practice in relation to public and private out-patient services where the tradition has been not to mix entitlements. It is my intention that the regulations will provide that a person availing of outpatient consultant services as a public patient will be deemed to be the public patient of all consultants providing outpatient services in relation to that particular consultation. Similarly, a person availing of outpatient consultant services as a private patient shall be deemed to be the private patient of all consultants providing outpatient services in relation to that particular consultation. The approach set out in section 7 in relation to outpatient services, and which I propose to follow through with regulations, is consistent with the general principle that patients should not mix their entitlements. This underlines the new arrangement for achieving greater equity, which is the main objective of the legislation.
I have already dealt with the argument that the regulations applying to inpatient service should come before the House before they are implemented as it applies to inpatient services. The same rationale stands. I do not think it appropriate to make provision in this legislation that all regulations should come before the House. I accept the point made by Deputy Ferris that the House does have an opportunity to annul the regulations, if Members so wish, under this legislation. However, I do not think it is appropriate that the regulations should be brought before the House, as is the case in other legislation, before being implemented.
(Carlow-Kilkenny): I have listened to this debate yesterday and again this morning. Now I think life is getting curiouser and curiouser — the Minister says there will be no reduction in public beds, but will the number be increased? In Kilkenny Hospital people are out on the corridors and it is an absolute shambles at present.
On the question of appointments to see a consultant, there is at least a 12 month waiting list to see the ENT consultant in Ardkeen Hospital, Waterford. I know of cases where a 20 year old patient and 70 year old patient have been waiting at least 12 months for an appointment. Will the Minister say if things are going to improve because otherwise we will have no service. In Kilkenny hospital people are being left out on the corridor. In fairness to the staff, it must be said that there is a great medical service, but the conditions are hopeless. The Minister's assertion that the number of public beds will not be reduced is not worth a tuppenny curse to the people who are still waiting for a public bed.
I appreciate Deputy Browne's comment because it is so valid. The legislation provides that everybody is entitled to a public bed and in the process of extending this to everybody we want to ensure that no existing public bed would be lost to private practice. Section 7 provides that section 56 of the 1970 Act is amended by the addition of a new paragraph after paragraph (c) which states:
"(d) Regulations under this section may also specify the circumstances in which a person's entitlement to out-patient services shall extend to services provided by a registered medical practitioner engaged in a consultant capacity in the provision of hospital services and may provide that, where a person's entitlement does not so extend, the health board concerned may charge for the provision of out-patient services such charges as may be approved of or directed by the Minister.".
This means that if a person's entitlement does not extend to hospital services their entitlements to all services is gone and this can be covered by regulations made by the Minister. We would want to be absolutely clear about what we are trying to do. I would like the Minister to agree that the general practitioner working on the ground would have more right to admit patients to hospital services and would be in the first line of defence in the fight against disease. Their word should decide when a person is seen at outpatients or admitted for hospitalisation where there is already a long waiting list. There is no need for a consultant's opinion in that process. If this was taken on board I would not be unduly worried about the section, but as the section is presently worded there is a possibility that a person's entitlement to public services could be lost in the process of going from outpatients services to hospitalisation.
It is essential — and the Minister is correct in stating this — in the interest of the public patients that consultants remain on the hospital campus and they should not be forced by this legislation to go elsewhere for their private practice. I want to ensure that in the agreement between the Minister and the consultants the consultants will be available 100 per cent to public patients and that it is only when they have the time available that they will be free to see their private patients. Many doctors believe in treating all their patients on the same site and in the same way and I welcome the ethos of commitment that has been built up over the years.
There is a risk that the regulations might offer consultants who now see their patients in public hospitals the incentive to do more and more of their work in private rooms or in private hospitals. That is a risk, unless the Minister can assure us that in the negotiations with the consultants the increase in salary offered will mean a total commitment to the public patient so that everybody is entitled to a free consultant service in a public ward in a public hospital. If this is not so, there is a great risk that we will remove the expertise that has been built up over the years and that consultants will congregate in places such as the Blackrock Clinic or other private hospitals where the real money can be made, whether from health insurance or the private cheque book. It is a fact of life that the consultants now require additional payments over and above the fee the VHI pays them. We should remove that anomaly as well.
These are the reasons I am concerned about this section and I am still not satisfied that it is worded in such a way that protects the principle that I have espoused over the past three days. In order to register my concern I would like that my amendment be formally put.
Question: "That the words proposed to be deleted stand" put and declared carried.
Amendment declared lost.
I move amendment No. 7:
In page 4, between lines 9 and 10, to insert the following:
"(e) Where it is proposed to make regulations under this section, copies of them shall be laid before each House of the Oireachtas and the regulations shall not come into effect until a resolution approving of them has been passed by each such House.'.".
It is vital that we have the opportunity to see the regulations before they come into force. The Minister has incorrectly suggested to the House, in reply to Deputy Ferris, that this Bill provides for a system of annulment, because it is quite clear from reading section 56, as amended in this Bill, that there is no such provision for laying these regulations before the House. The regulations will be made by the Minister, with the consent of the Minister for Finance, under section 56 of the 1970 Act, as amended in the 1987 Health Act. The Minister is not giving accurate information to the House about our rights to rescind this.
It is very important that we do not only have the right to rescind but that we have the right to have a debate on the issues, as Deputy Sherlock suggested on an earlier section. The importance of that is quite simply that the Minister is asking us to buy a pig in a poke in terms of the protection of public patients. The Minister has admitted that he does not know the number of public beds in the system, but he is going to preserve their number even though he does not know that number. The Minister cannot put his hand on his heart and expect us to accept that he can preserve that number. Indeed, the Minister recognised in the regulations to which he referred briefly, but did not have the courtesy to let us have, so that we might have had the opportunity to debate them that there were many beds designated as private where there was heavy usage by public patients. This is a grey area where public patients would rightly have fears that their usage of those beds could be usurped. The Minister said he was worried that this might happen and that he would seek to have a proportion of the beds redesignated into the public area. We do not know the numbers of beds involved and whether public patients will be guaranteed right of access on an equitable basis with private patients. It is the Minister's vagueness which makes it so important that the regulations should come back to the House for a proper debate. The Minister said he will have an annual review.
I did not say I would have an annual review.
I suggested an annual review and the Minister said he will have a review from time to time. If the Minister has given away as property rights a quota of private beds to consultants, he cannot withdraw them; yet if there is a growth in public patients he must recognise that he will have to use some of those beds which were wrongly designated as private and bring them back to the public sector. The Minister is asking us to accept regulations, which he will not show to us today, without having the right to annul them if they are not satisfactory.
The regulations under section 56, as amended, will deal with the point raised by Deputy Allen concerning people seeing a consultant as an outpatient who will subsequently have the right to go as a public patient. A person who opts to see a consultant as a public patient may wait perhaps six or nine months for an opportunity and only then would his name be included on the list for hospital admission. If a person goes to see a consultant in his private rooms he can get on the waiting list straight away. The Minister actually said that when a patient is approved for urgent medical care by the consultant he may wait only three weeks to get into public care. The person who cannot afford to see the consultant on a private basis may have to wait six months to see him for the first time. There will be a huge inbuilt gap between the person who can go to the private consulting rooms for the initial assessment of his case and get on to the public waiting list for the earliest possible vacancy and the person who does not have the money to go to the private rooms who will be languishing without any consultant knowing the urgency of his case. That case could be a great deal more urgent than the case of the person admitted quickly. This area is riddled with problems.
The Minister is not being fair in looking for the power to make regulations. He has the draft regulations in his hand but he will not let us see them before the debate concludes. We are expected to vote through sections enabling regulations — regulations which will be fundamental to equity of access of public and private patients — without a chance to see the regulations. That is not fair play. The Minister cannot but expect a lot of cynicism about the effectiveness with which these regulations will deliver public care to public patients when he has not the grace to give the regulations to us. We could have seen the regulations last night so that we would know the Minister's intentions with regard to these sections. That would have allowed a much more reasonable debate. The Minister has stuck his head in the sand and he is insisting in driving ahead with his ideas. He is not willing to listen to amendments which could modify and improve the Bill.
It is important to enshrine in this Bill the notion that there should be an equitable allocation of beds for public and private patients within a reasonable waiting period. That principle should have been statutorily underpinned but it is not in the Bill. The Minister is making a fundamental change in the way we run our services. He dismissed my amendment as a vague aspiration. This Bill is not a charter of equity. There is no mention of equity. The issue should be brought back to the House when the Minister has introduced the regulations to see they are meeting the standards we expect and catering adequately for public patients who cannot afford private care.
This is a valid amendment. Any section of this Bill already agreed which involves regulations provides that such regulations made by the Minister under the section will be dealt with in a particular way. The Minister will publish them and allow the House afterwards a chance to annul them within a certain number of sitting days. No such provision is made in respect of these regulations. Since the House has agreed that there should be regulations, Deputy Bruton's amendment should be accepted. The Minister has promised that the regulations are in hand and that he will give us a copy. All the regulations to be made under this Bill will be before this House except the regulations under section 6. This leaves us no opportunity ever to debate these regulations.
Section 56 of the 1970 Act contains no mention of regulations. Now we are adding regulations to the section with the provision that they need only be approved by the Minister for Health and the Minister for Finance. That is not a good way to legislate and this amendment is legitimate. The Minister should accept the principle of this amendment and perhaps introduce an amendment along these lines in the Seanad which we could approve later. Regulations made under any legislation should be subject to the overview of the House.
Having enacted legislation to deal with public and private patients at the time of admission to hospital, it is also important to extend this to outpatient facilities. Consultants with public appointments should see and treat all patients, public and private, in the same manner, in the same room or outpatients' department and under the same conditions and from the same waiting list. GPs in the general medical service already have this contract and what is being requested in this amendment is that the regulations giving effect to that section would be brought before the House. I would support that, a Leas-Cheann Comhairle.
(Carlow-Kilkenny): I also want to support this because I am very much worried by the way the Minister is carrying on here today. He is more or less telling us that if he says it is right, it is right. He is giving himself the cover of bringing in regulations that will automatically be right if he brings them in and we can do nothing about them.
The Minister's argument, which has been going on here yesterday and today, about patients going privately and then coming back into the public service is so wrong that it defies any understanding. As Deputy Bruton has pointed out, if a person cannot get into a clinic to be assessed — and I have given an example myself of two people waiting to get into Ardkeen with ear problems where the specialist's secretary told me that there was at least 12 months' delay — how can he get treatment? I am quite sure, in the case of at least one of the people I am talking about, that if they could get into the clinic they would be taken in for treatment immediately. On the other hand, somebody else can get in in a fortnight, as happened in my own case. I rang up to find out what the position was in regard to an appointment I had for myself and the secretary told me I would have to wait until February. I asked her if private medicine had gone as bad as that and she said that since I was going privately I could be called in on the Friday week.
The same thing will happen with this system that the Minister is talking about at the moment. People will be called in privately if the consultant sees them and decides they need emergency treatment. He will bring them in immediately. The Minister's argument on that is so wrong that I am worried about all the rest of the legislation. That is why regulations should be under some kind of control so that the Minister does not have carte blanche to bring in what he likes.
It is very hard to know how to deal with the arguments that have been raised by Deputy Bruton. I cannot understand why Deputy Bruton comes in here and totally distorts what I am saying. At no stage did I say that there would be an annual review. I said that we would be continuously monitoring the situation. At no stage did I say that a patient who opted to go to a private consultant for an outpatient consultation would be in a position to jump the queue. I said that they would take their position on the waiting list at the point where they would have taken it had they gone for a public outpatient appointment.
Is that not queue jumping?
What I said was that if the patient went on 1 June and had a private consultation with the consultant, the consultant having decided the patient needed hospital treatment and the patient having opted for public service, they will go on the place in the queue where they will get the next available appointment with the consultant at the public clinic whether that is three months down the road or three weeks down the road. It is important to assure the House that the vast majority of appointments in our public hospitals for public patients come within two to three weeks. When Deputies refer to longer waiting times they refer specifically to orthopaedics and to ophthalmology; and measures have been taken over the last 18 months to improve these services with quite substantial and spectacular results. There are still waiting lists, but we are dealing with them.
Deputy Bruton accused me in regard to the regulations. This is the first time I have spoken on Deputy Bruton's amendment in regard to the regulations. What is happening here is that in-patient regulations will come before us here and the House will have an opportunity to annul them. The outpatient regulations, in accordance with section 56 of the Health Act, as amended by the Health Act, 1987, provides that various regulations for outpatient services do not require to be laid before the Oireachtas, but I want to assure all the Deputies in the House that we will indeed lay the regulations before the House.
In regard to the point raised by Deputy Ferris about the regulations that are in draft at the moment, I do not think that, in fairness, the Deputies can complain. I insisted that I would have draft regulations here before me with this legislation so that I would be in a position to deal with points raised by the Deputies. When the regulations are completed the spokespersons for the Opposition parties will have a copy of them. They should be available by Tuesday next, or Wednesday, if the Dáil is not sitting on Tuesday.
On the question of access to hospital by patients it is important to point out, because Deputy Ferris raised the point, that the first point of contact with the medical element of the health service is generally the general practitioner and that is as it should be. I have expressed my concern in this House at the number of patients in the greater urban areas, particularly in Dublin, who bypass their general practitioner and go directly to the hospital. That does not happen to any great extent outside the larger urban areas. However, it is appropriate that the first point of contact with the medical end of the health services should be the general practitioner. If patients are concerned, their general practitioner is in a position to advise them, and if it is an emergency the general practitioner is in a position to admit them directly to hospital.
On Deputy Ferris' point about giving more authority to the general practitioner, all matters in regard to medical treatment are matters for clinical judgment on the part of the doctor. As Deputies know, where there is an emergency a general practitioner can refer the patient direct to a hospital. The classical example is the case of an acute appendicitis. The person is sent directly to the hospital and is admitted to a bed and has surgery.
What we are talking about in the main in this legislation is elective procedures, non life threatening procedures, because emergencies will be admitted to whatever bed is available. If all the beds in the hospital are full, arrangements are made to ensure that emergencies are admitted. For example, nobody with an acute appendicitis has ever been sent home from a hospital. So what we are talking about here is elective procedures.
I want to assure the House that this legislation was brought in on foot of recommendations by very prestigious bodies and it was sought by other bodies and organisations including the Commission on Health Funding, NESC and the Congress of Trade Unions. It has probably the greatest consensus that one could expect from any legislation brought before the House, consensus between the Government and the social partners. As far as I am concerned, the legislation will be implemented in accordance with the law before us and in accordance with the spirit in which it was recommended and sought and the spirit in which the Government and the social partners agreed it.
I want to assure the House that the main objective is the delivery of service and that public beds will in future be available for public patients. That is in it. I have already referred to the fact that there are three groups of patients in hospital. There are public patients in public beds, private patients in private beds and there are private patients in public beds. After 1 June that will not be the case. The private patients will no longer be entitled to avail of a public bed — in other words, to be a private patient of the consultant and a public patient in a bed. When that change, which will be phased in, takes place that will ensure that beds that are occupied by private patients paying their consultant but being maintained as public patients by the State will be freed up for public patients. It is quite simple. There is no mystery about it. We will be implementing it in accordance with the law and with the spirit in which it is agreed by the Government and the social partners.
I am disappointed that the Minister will not accept this amendment or undertake to offer a modified version in the sense Deputy Ferris suggested. I am disappointed because under section 56 heretofore the only issue was charges being made for services that were being provided. Now we are into a very different area. In this legislation the Minister is substituting what used to be the principle of common waiting times for services in public and in private, which we know did not work, by an alternative system which he is going to enforce by regulations. The regulations are to bring about separation of public and private. What we want to achieve with that separation is equity in services to the public patient compared to the private patient. That is a fundamental break in what was in section 56 previously. We are breaking new ground in section 56 and the House deserves the courtesy of having the regulations laid before it and if necessary under the 21 day rule having the right to annul. It is a major change in the way we run things.
Referring back to the old drafting of this section when it did not carry this extra baggage the Minister is loading on it, the Minister said there were no regulations then because it was simply a matter of the Minister for Finance and the Minister for Health getting together to decide on a set of charges. To date, the Minister has not given a fair response to this amendment. Telling us the regulations will be with us next Tuesday is only rubbing salt into the wound. We are asked to accept that we should vote the whole thing through now without seeing the regulations. Admittedly, we will see the regulations in four days time but if they were available now they could be debated in conjunction with the Bill. That would have shown respect for the House. To tell us he will post them out to us when the Bill is passed is not good enough. We should get an opportunity to debate a fundamental change that not everyone agrees with. We have the right to tease this out in detail.
I must go back to the issue of a patient going to private consulting rooms in order to get access. As I understand the Minister, when a patient on the public waiting list cannot go to the private rooms he will have to wait his turn to be assessed but when he goes to the private rooms and is assessed and is decreed to be in urgent need of hospital care, he will be told he has to wait until the public patient who applied at the same time for a public patient assessment has been assessed for public admission to a hospital. In that case the consultant is not living up to the Hippocratic oath. The Minister is saying the patient who went to see the consultant privately will not be admitted to hospital before the public patient who joined the queue the same day he saw the consultant as a private patient.
Yes, for something that is not life threatening. I have made a distinction between life threatening illness and acute emergencies. People are going in every day with appendicitis.
The man on the public waiting list with a life threatening illness will not even have been seen at that stage. He cannot afford to go to the private consulting rooms.
He will not be there. His general practitioner will ensure that if he has a life threatening illness he will go into hospital.
His general practitioner will not be paying for it.
On a point of order, I am concerned about my amendment. This amendment is about regulations being brought in or not being brought in. I see quite clearly that we are going back over another section. I do not agree with that.
It is a fundamental issue dealing with outpatient service. This section is all about going to an outpatient clinic, and it cannot be said that is not intimately involved with what happens after that outpatient consultation. I have to take issue on that. I still want to press this amendment. We are asked to accept that these regulations will be posted to us next week, but that is not good enough.
Amendment put and declared lost.
Amendment No. 8. I understand it has been agreed by the House that amendments Nos. 8 and 9 will be taken individually.
I move amendment No. 8:
In page 4, to delete lines 10 to 16.
I will have due regard to my colleague Deputy Sherlock who also wishes to speak on this. I want to remove this section because I am not satisfied with it as worded, especially since the other amendments were ruled out of order. One of them related to the amount allowed under health contributions at present. The tax relief for PRSI contributions is a flat figure of £286. With the limit removed, the people paying an additional £19 million to the Exchequer through PRSI and PAYE will get no recognition for that in the income tax code. I know the figure cannot be put into this legislation, but I suggest that the Minister for Finance should take account of it.
The other amendment dealt with changes in the 1987 regulations which penalised people paying PRSI and PAYE by bringing in charges of £12.50 a day. That is double taxation. For that reason I want this section removed from the legislation.
Acting Chairman
Is the Deputy pressing his amendment?
I want to register for the record that I am opposed to the section.
Acting Chairman
Are you withdrawing your amendment?
No, I wish it to be put to the House.
Question: "That the words proposed to be deleted stand" put and declared carried.
Amendment declared lost.
I move amendment No. 9:
In page 4, between lines 16 and 17, to insert the following:
"(2) The income accruing as a result of subsection (1) shall be used to fund the country's health services."
The Minister must accept that introducing legislation without making the necessary financial provisions will not bring about the desired effect. I understand £19 million will accrue to the Exchequer as a result of measures taken in this legislation. The health board in my area face a shortfall in excess of £4 million. An assessment of the amount required to keep an adequate and proper level of service has been made, and agreed, by the officers of the health board. In 1989 the Southern Health Board recommended 20 additional beds at Mallow General Hospital to bring the number up to 84. That is a double consultant hospital and to this day there has been no increase in that number of beds. Also a number of appointments are awaited.
This amendment is entirely unnecessary as under section 13 of the Health Contributions Act, 1979, all income accruing from health contributions is paid over to the Minister for Health. The additional income resulting from the abolition of the income limit will, therefore, automatically be used to fund the country's health service.
Amendment, by leave, withdrawn.
Acting Chairman
As it is now 1 p.m. I am required to put the following question in accordance with a Resolution of the Dáil of this day: "That Fourth Stage is hereby completed and the Bill is hereby passed."
Question put.
The Dáil divided: Tá, 72; Níl, 43.
Tá
- Ahern, Bertie.
- Ahern, Dermot.
- Ahern, Michael.
- Aylward, Liam.
- Barrett, Michael.
- Burke, Raphael P.
- Byrne, Eric.
- Calleary, Seán.
- Callely, Ivor.
- Clohessy, Peadar.
- Connolly, Ger.
- Cowen, Brian.
- Cullimore, Séamus.
- Daly, Brendan.
- Davern, Noel.
- Dempsey, Noel.
- Dennehy, John.
- de Valera, Síle.
- Ellis, John.
- Fahey, Jackie.
- Fitzgerald, Liam Joseph.
- Fitzpatrick, Dermot.
- Flood, Chris.
- Gallagher, Pat the Cope.
- Garland, Roger.
- Geoghegan-Quinn, Máire.
- Gilmore, Eamon.
- Harney, Mary.
- Haughey, Charles J.
- Hillery, Brian.
- Hilliard, Colm.
- Hyland, Liam.
- Jacob, Joe.
- Kelly, Laurence.
- Kenneally, Brendan.
- Kirk, Séamus.
- Brady, Gerard.
- Brady, Vincent.
- Brennan, Mattie.
- Brennan, Séamus.
- Browne, John (Wexford).
- Kitt, Michael P.
- Kitt, Tom.
- Lawlor, Liam.
- Lenihan, Brian.
- Leonard, Jimmy.
- Lyons, Denis.
- Martin, Micheál.
- McCartan, Pat.
- McDaid, Jim.
- Mac Giolla, Tomás.
- Molloy, Robert.
- Morley, P.J.
- Nolan, M.J.
- Noonan, Michael J.
- (Limerick West).
- O'Connell, John.
- O'Dea, Willie.
- O'Donoghue, John.
- O'Hanlon, Rory.
- O'Rourke, Mary.
- O'Toole, Martin Joe.
- Reynolds, Albert.
- Roche, Dick.
- Sherlock, Joe.
- Stafford, John.
- Wallace, Dan.
- Wallace, Mary.
- Walsh, Joe.
- Wilson, John P.
- Woods, Michael.
- Wyse, Pearse.
Níl
- Barrett, Seán.
- Barry, Peter.
- Belton, Louis J.
- Bradford, Paul.
- Browne, John (Carlow-Kilkenny).
- Bruton, Richard.
- Connaughton, Paul.
- Connor, John.
- Cosgrave, Michael Joe.
- Creed, Michael.
- Crowley, Frank.
- Currie, Austin.
- D'Arcy, Michael.
- Deasy, Austin.
- Doyle, Joe.
- Durkan, Bernard.
- Farrelly, John V.
- Ferris, Michael.
- Finucane, Michael.
- Flaherty, Mary.
- Flanagan, Charles.
- Higgins, Jim.
- Hogan, Philip.
- Howlin, Brendan.
- Kemmy, Jim.
- Kenny, Enda.
- Lee, Pat.
- Lowry, Michael.
- McGrath, Paul.
- Mitchell, Gay.
- Mitchell, Jim.
- Noonan, Michael.
- (Limerick East).
- O'Brien, Fergus.
- O'Keeffe, Jim.
- O'Shea, Brian.
- O'Sullivan, Gerry.
- Quinn, Ruairí.
- Ryan, Seán.
- Sheehan, Patrick J.
- Spring, Dick.
- Taylor-Quinn, Madeleine.
- Timmins, Godfrey.
- Yates, Ivan.
Tellers: Tá, Deputies V. Brady and Clohessy; Níl, Deputies Flanagan and Howlin.
Question declared carried.