Dáil Éireann debate -
Tuesday, 4 Jul 1995

Vol. 455 No. 4

Adjournment Debate. - Psychiatric Services.

Mrs. Geoghegan-Quinn

I raise this matter this evening because the draft regulations, as they stand, have very serious implications for the welfare of psychiatric patients and for the future of public and private psychiatric services. The draft regulations include one providing a minimum cover of 40 days psychiatric in-patient treatment per year be provided by any health insurer wishing to operate here.

There are considerable worries among the public and in the institutions involved in the provision of psychiatric care that this minimum will become the norm. I understand that preliminary discussions between many of these institutions and the Voluntary Health Insurance Board suggest that is likely to be the case. For example, the present cover provided for psychiatric in-patient treatment is 180 days per year, no different from that provided for physical in-patient treatment.

If one looks at the recommendations concerning patients suffering from substance abuse, like alcohol, drugs and so on, the position is even worse. At present the VHI cover is 90 days every five years but the draft regulations propose 40 days only within a lifetime. As we are all aware — and here I am sure the Minister of State will agree with me — neither alcohol dependence nor substance abuse is reducing here, if anything, the opposite is the case.

The introduction of a 40 day minimum limit constitutes a most serious discrimination against psychiatrically ill patients, no other type of patient is singled out for such a limit. It will result in approximately 30 per cent of patients currently being treated within the private psychiatric sector having to seek care from the already over-stretched and seriously strained public psychiatric services. The patients who will be most affected by these changes will include those who suffer from serious psychiatric illness, such as manic depression, schizophrenia, anorexia nervosa, psychiatric disorders associated with physical disease and with ageing, for example, Alzheimer's Disease.

In relation to those people suffering from substance abuse and alcohol dependence, these regulations will reduce the role of the psychiatric services from that of providing what they do at present, which is a valuable, professional, in-patient treatment and after care, to a very short term system of detoxification programmes and crisis management. In an era in which both alcohol and substance abuse are on the increase that is not acceptable.

The real impact of these changes in the draft regulations will be borne by the patients most seriously affected by psychiatric illness and, of course, by their families who are extremely worried. I understand that representatives of St. Patrick's Hospital and St. John of God's Hospital sought a direct meeting with the Minister because of their huge concerns but were informed that he was too busy to meet them. I appreciate that the Minister has a very busy schedule. I understand those hospital representatives met his departmental officials but, because of the level of care they provide, they feel they deserve a meeting with the Minister and I ask the Minister of State to bring that request to the Minister's attention.

I ask that the psychiatrically ill be treated no differently from patients suffering from physical illnesses. I also request that the present levels of VHI cover for psychiatric in-patient treatment should be the recommended minimum level for inclusion in the new regulations about to be signed by the Minister. If those regulations are implemented, as drafted, they will have far reaching, serious, negative effects for patients and psychiatric care generally.

Minister of State at the Department of Health (Mr. O'Shea)

I thank Deputy Geoghegan-Quinn for having raised this issue. I welcome the opportunity to explain to the House the background to the proposed psychiatric cover in the minimum benefit regulations pursuant to the Health Insurance Act, 1994.

The acceptance by the EU Commission that our legislation is valid is dependent on them being satisfied that we are genuinely creating an open market in health insurance. The proposed arrangements for psychiatric cover must reflect this.

The minimum benefit regulations require insurers to provide minimum benefit in respect of in-patient psychiatric treatment for a period of 40 days in any one year. In addition, the regulations originally provided that insurers may require treatment plans to be submitted for approval prior to admission, other than in an emergency.

The prescribed minimum payments set out in the regulations for prescribed health services — which are in-patient services provided by a private psychiatric hospital — is £35 per each in-patient day.

The prescribed minimum payments for prescribed health services which are day-patient services provided by a private psychiatric hospital is £15 for each day-patient day.

Departmental officials have consulted widely a range of interest groups, including public and private service providers, and a number of meetings have taken place. Private psychiatric service providers have raised issues of concern specifically to their services and the implications of these issues for the public sector. I would like to take this opportunity to clarify these issues.

First, concern has been expressed at the provision allowing insurers to seek prior approval for admissions to non-emergency psychiatric in-patient treatment. After careful consideration of the submissions made by the providers this provision was withdrawn.

Second, certain private hospital providers have submitted that 40 days' minimum cover is insufficient to meet patients' requirements. The minimum benefit regulations provide that insurers must provide a minimum of 40 days in any one year. This is the first time that psychiatric cover will be on a statutory basis and the 40 days will ensure that some level of such cover is available to members of insurance schemes. This will prevent a situation developing whereby, as in many schemes abroad, insurers refuse to offer benefit for psychiatric care or offer it at a level below 30 days. I again emphasise that this is the minimum benefit and that insurers will be free to offer any higher level they wish.

A number of private psychiatric hospitals have also expressed concern at what they see as very low levels of benefit payable to them for in-patient treatment. The hospitals in question have argued that they should be treated differently on the grounds of offering a more comprehensive service. In particular they regard payment of £15 for day-patients as being too low. The minimum benefit levels are necessary to underpin community-rating and to provide a degree of consumer protection. They have been set at the lowest possible market price to avoid being inherently inflationary. If they were set any higher a situation could arise whereby a hospital which charges rates lower than the minimum benefit would be paid at the higher rate. To treat the hospitals in question in a different manner from other psychiatric hospitals would have a knock-on effect in the general acute area where the major high-tech hospitals would then require that they be treated differently and the payment of benefits under minimum benefit would then become unmanageable.

With regard to the specific issue of day-care cover the Department of Health is currently examining the components of day-care in psychiatric hospitals. However, the area is ill-defined at present. The Department is currently examining the possibility of dropping the requirement for day-care cover in the regulations and examining it in the review of the minimum benefit regulations which will be undertaken by an assessor.

Finally, a number of private psychiatric hospitals have indicated concern at the arrival of for-profit insurers to this country on the grounds that these insurers will put profits before patients' welfare and will lead to spiralling costs. However, in reality competition must be accepted as an inevitable consequence of the requirements of the single market and the Government's objective, which has been achieved, is that competition takes place on terms which ensure the greatest possible equity for all patients concerned. Where possible, the Government has taken account of the concerns of the private hospitals but the fundamental part of the Government's strategy is to clearly demonstrate to Brussels that we are genuinely creating an open market in health insurance.

The Health Insurance Act provides for the appointment of an assessor whose role it will be to review the minimum benefit regulations. He or she will review the regulations to take account of developments in the market, new technology and procedures and inflation. The regulations will be changed to incorporate the recommendations made by the assessor to the Minister for Health and it is intended that the assessor will be appointed in the autumn.