Health Insurance (Amendment) Bill, 2000: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time".

Mr. Browne

(Carlow-Kilkenny): When I spoke on the Bill previously I referred to the service the VHI has provided, the scarcity of nurses, the demand for speech therapists who are being lured away from this country because of the low wages they are paid, the delay in obtaining treatment, especially MRI scans and brain scans, experienced by public health patients. In the Leas-Cheann Comhairle's absence, I said that on one occasion I was lucky to receive excellent advice from him. I acknowledge, in his presence, his help in allowing me to continue with more ráiméis here today.

In addressing health insurance, the necessary facilities must be in place. I mentioned the havoc in hospitals due to the scarcity of nurses. Since I last spoke on the Bill, a State enrolled nurse – a nurse who has completed two years' training – approached me regarding the issue of training. One year training courses are run in England to bring trainee nurses up to the standard of a State registered nurse or its equivalent, at which stage they can take up nursing posts. Some trainee nurses pursuing that training course must pay between £6,000 and £10,000 depending on the time they have to spend abroad and whether they can get accommodation with a relative, etc. A group of 30 trainee nurses are participating in such a training course. Those trainee nurses will be qualified to take up nursing posts in a year. There are approximately 3,000 State enrolled nurses here, although not all of them are free to return to nursing.

In response to a parliamentary question I tabled regarding the course in England and the provision of financial aid for those participating in it, the Minister said that while he was not in a position to provide funds to assist enrolled nurses working in the Irish public health service in non-nursing capacities to undertake that course, he intends to explore with An Bord Altranais and other relevant bodies whether it would be possible to deliver such a course here. While I am not referring to the Minister, there seems to be no forward planning or thinking in this area in the Department of Health and Children. If courses have been run under the English system for such a period that Irish trainee nurses are enrolling in them, why have we not copped on to that, sent our experts to England to investigate it and set up a course here when there is such a demand for nurses? What is there to investigate with An Bord Altranais when this course exists in England? Why are we not grasping the opportunity to set up a similar course here?

The Minister of State, Deputy Moffatt, was present when I raised another matter on the Adjournment. I tabled three parliamentary questions regarding help for those suffering from attention deficit disorder and hyperactivity disorder. Because of the gobbledegook answers I got, I raised it on the Adjournment and expressed my delight that a medical doctor was present to reply to it and that I expected he would not read out gobbledegook, but he did. He said the Department will do A, B, C, and D. The person from Carlow on whose behalf I raised this matter went to Canada and to London at her own expense and found systems of treatment there that work. From my experience in the classroom when I was not aware of ADD, I thought young lads who could not control their impulses and were not quiet in class tended to get into trouble and end up in jail. Why can we not ensure such children have access to the necessary treatment? When I raised this matter on the Adjournment, I got three pages of a reply about health boards. The health boards should be abolished because they are used as an excuse for pretending we deliver a service that does not exist. The mother, to whom I referred, went to Canada and to England. She knows the cause of her children's difficulties, yet we have no facility for helping such children. It is disappointing there is not a think tank in the Department to plan ahead and deal with matters, such as training for nurses and the treatment of ADD and ADDHD that other countries have mastered. That should be addressed.

I tabled a parliamentary question on the delay in the provision of hearing aids, to which I got a reply today. These seems to be no problem with providing them in two months, three months or four months. I tabled this question on behalf of a 90 year old constituent who told me that when he applied for medical aid he was told it would take 12 months for him to be seen by the ENT consultant. That was enough to knock him over, although there was a sensible senior official in the South Eastern Health Board who said that nonsense must be stopped. The concept was that this man would wait a year to be told by a consultant that he was deaf. One would not need a consult ant to know this man was deaf; one would know it from talking to him. That was left out.

I wonder if the answers we get are as clear as they might be, as this man's case was not an exception. There is a long waiting list for consultants' appointments and I am not satisfied that some of these services are as up to date as they appear to be.

Regarding treatment for ADD, the last reply I received stated:

My Department is currently considering whether there may be a case for the further development of the adult psychiatric services in this regard. However, the development of appropriate services for children is a priority and, as I have outlined, that is being addressed by my Department at present.

The statement that "there may be a case for the further development of the adult psychiatric services in this regard" is dreadful. Two different consultants dealt with this person. He told one of them when in jail that he suffered from ADD and needed help and he was told by the consultant, "We all suffer from ADD". The other consultant said he should go to England because people like that all finished up in jail. Those were consultant psychiatrists.

The Minister says his Department is considering whether there may be a case for the further development of the adult psychiatric services in this regard, but there is no doubt that it is time a group of specialists in the Department should be nominated to visit Canada or England to catch up with the medical practices there. It is appalling that we are just now thinking of doing something in this area when we should have services in place. It is bad enough to have an ailment that does not respond to treatment but it is awful when one has an ailment and people do not know what one is talking about, particularly when that ailment may mean one ends up in jail. Then, when one is in jail somebody masquerading as a consultant psychiatrist says everyone suffers from ADD. If one of my family members were involved I would take drastic action.

The Department will have to come to life and get a research unit going to stay up to date on this issue; it should be ahead of other countries instead of being left behind on such serious matters.

Mr. Ardagh

I welcome this Bill. It copperfastens certain aspects of private health insurance, which is very welcome given that so many people depend on it.

The first issue is community rating, where insurers set and charge their customers the same price irrespective of their age, sex, health status, prospective health status or medical history. This is a large part of the reason young people have taken up private health insurance in such numbers and without quibbling about the costs. They know that in the future, as they get older, that they will get the benefit of it at the same price as when they entered the system at the beginning, except of course for inflation costs. There is also the issue of open enrolment, which means that insurers must accept people of any age or health status without any penalty. That gives great confidence to people when they get to the stage where they can afford private health insurance. When they reach 25 or 35 and feel they can afford private health insurance they can afford to do so without penalty.

Lifetime cover gives great security to people, particularly those getting on in years, as they know that if they join a health insurance company at a young age, whether that is under 30 or under 60, that they can continue with that cover for the rest of their lives. The feeling of security is very important to people as they get older, particularly our senior citizens. Minimum benefits, which must be given by insurance companies, cover stays in hospital and most of the medical costs.

I acknowledge the effort the VHI has put into developing private health insurance. It has made a phenomenal contribution and has given great peace of mind to its 1.5 million subscribers. I have been a member of the VHI for many years and I have always felt the charge to me and my family was reasonable. The VHI set the scene with regard to community rating, open enrolment and lifetime cover. Its package was comprehensive, with plan A, plan B and so on. Plan B was the most widely used plan in the system and one felt very comfortable with it.

I also acknowledge the work done by BUPA since entering the market. It has brought competition to the market and the synergy between BUPA and the VHI has brought the number of people using private health insurance up to 46% or 47% of the population. It was good for consumers to have an alternative which could match the products already on offer from VHI; the product was similar because the Government was determined that there would be a package of comprehensive minimum benefits. BUPA helped to increase the market dramatically by creating that awareness and also improved the product range, as there are subtle differences between the schemes that are available. BUPA's essential and essential plus schemes are broadly similar to the plan B schemes of the VHI, but there are small differences which give people a choice.

The fairness of risk equalisation is a big problem in the Bill. Some companies say that without risk equalisation effective risk rating will come about. Risk rating means that those between 20 and 30 will get a lower premium because the risk of them getting sick is lower than for those between 60 and 70, who would pay a far greater premium. We do not want that here; everyone is agreed that we want community rating. We want the same premium paid by the 20 year old and the 50 year old. It has worked well for us in the past and I see no reason why it will not work well for us into the future. If there was no risk equalisation young people would be attracted to companies coming into the market to charge a lower rate. The concept of risk equalisation, where companies which have a huge preponderance of people who are liable to have large claims, should be levelled out by companies that are not likely to have a preponderance of large claims because of the age distribution among their clients.

It was implied to me that the full cost of the C, D and E schemes would be included in the costs to be equalised. Another source informed me, however, that only plan B content of the VHI's C, D and E schemes would be included in cost equalisation. This is important and I see some merit in this process if only that the plan B content will be equalised in respect of the entire population.

In addition to equalising the costs and giving a greater amount of money to the company with the larger number of high cost clients, one must consider the administration expenses incurred by these companies. If we consider a company with 1.5 million customers and another with 180,000 customers, there is no doubt the administration expenses per customer will be significant in respect of the company with the smaller customer base. Unless we help the company with the higher administration costs per capita in some way, it will not be able to develop its presence in the marketplace and provide the type of service offered by the larger company. Effectively, there would be a subsidy from the smaller company to its larger counterpart which would not be fully warranted in terms of cost equalisation because the smaller company's administrative costs would be far greater. This matter must be considered in that context.

I do not know the administration expenses of the VHI or BUPA. However, if the VHI's expenses are £10 million I have no doubt BUPA's expenses are at least £3 million to £4 million. In light of their customer bases, BUPA's costs are considerably larger in proportion to those of the VHI. I agree with the concept of risk equalisation but it must be tempered by taking account of the other items of expense of the companies involved.

I wish to refer now to the incidence of diabetes type 2. I recently visited the diabetes day centre at St. James's Hospital which is an inspiring place. The care and attention being given by the doctors and nurses working in the centre is phenomenal. I was extremely impressed by what I saw. Following my visit I received a visit from one of the consultants who stated:

I know you are aware of the "explosion" of Type 2 diabetes . . . our new patient referrals (mainly with Type 2 diabetes) have increased year-on-year by about 40% in both of the past two years. This is a huge problem. Many of these newer patients are middle-aged or young people, working – with young families . . . all speciality areas continue to clamour for Government support – diabetes is a genuine area of need with potential to prevent cardiovascular disease in young people in particular . . . we need to increase the profile of this disease, and bring it into the mainstream of the hospital, and Irish medicine . . . It has been shown very clearly that the costs of good diabetes care and preventive medicine is much less than the cost of treating patients with complications, particularly cardiovascular disease.

My purpose in quoting from this letter is to bring this matter to the fore in the hope that the Minister might take action in respect of it.

I am vice-chairman of St. James's Hospital and I can state that the Minister recently gave approval for a significant development of its accident and emergency facilities. The hospital serves a significant area of Dublin which is home to many senior citizens and elderly people. The accident and emergency unit at St. James's, like other hospitals, is over-stretched. I am delighted the new multi-million pound facility is expected to be in operation before next winter because it will help to improve matters dramatically.

I welcome the fact that the Bill deals with a number of issues. The first of these involves the section which retains the provision requiring insurers to operate significant premium costs in respect of children. It is good for people with either the VHI or BUPA to know that they can include their children on their health insurance at a reasonable cost. I welcome the fact that the age at which the lower price premium will cease to apply to students will increase from 21 to 23 years. Increased numbers of children are entering third level education because of the motivation given to them by their parents and the current economic boom and the increase in the age limit is a welcome development.

Community rating provides an incentive for individuals to take out health insurance at a young age. That is also a welcome development. The power to apply late entry premium loadings to persons of over 35 years of age should encourage people to start early. I suggest that people in this age category should get in on the act now.

Section 10 inserts an exemption from risk equalisation in the case of new insurers entering the market. The period of such exemption will be three years from the date the insurer concerned commences the carrying on of health insurance business. We need competition because it is good for the marketplace. At present, almost 1.7 million members, or 47% of the population, have private health insurance. Everyone would like to see that increase to a figure as close as possible to 90%. To achieve that we must encourage competition in the marketplace.

It would be extremely difficult for a new competitor to enter the market, because of the costs of setting up and maintaining operations, if the scheme was not tempered in some way to cater for them. If the new insurance companies entering the market do not have a customer base, they will find it very difficult to spread their administration costs over all their customers. Their costs will be very high. Rather than specify a period of three years, the Minister should consider indicating that once a company reaches a certain number of customers, say, 400,000, it will be included in the risk equalisation package. Even at that stage companies should still consider taking into account the extra administrative costs involved over those of a major player in the industry.

Mr. Ring

I am glad the Bill is before the House. I agree with the previous speaker that there is a need for competition in the marketplace as it leads to cheaper prices. We all know what happened when we had monopolies.

I heard a representative of the Irish Blood Transfusion Service complain yesterday on radio that there was a shortage of blood. As a consequence, operations in a number of hospitals in this city and in Castlebar have had to be postponed. Will the Department consider requesting the Irish Blood Transfusion Service to come to Leinster House for a day either next Wednesday or the following Wednesday to give the substantial number of people who move around the complex daily an opportunity to donate blood? We do not always have the opportunity to do so as we are busy in our clinics, doing constituency work and moving around the building. I have no doubt Members would show the right example in dealing with the current crisis.

The Bill, which deals with private health insurance, is timely. The health service is a sick joke. There is no doubt it is in disarray. If one does not have the pounds, shillings and pence, one is in trouble. Money talks in seeking to have a hip replacement, heart or cataract operation performed. As someone who comes from a working class background, this is wrong. We should not have a two tier health system, rather we should have a system which is open to everybody. Perhaps the time has come for some radical thinking and action in the Department. Rather than have public and private consultants and doctors working side by side in the one hospital, given the performance of the economy, perhaps the time has come to consider the establishment of private hospitals, of which there are a number in the State. Perhaps the time has come to refuse to allow consultants employed and paid by a health board to engage in private practice. The public and private mixture has not worked. Public waiting lists are getting longer. We have reached the stage where patients have to wait before being placed on the waiting list. This is wrong. If one has the pounds, shillings and pence one can have whatever operation one needs performed in whatever hospital and at whatever time one likes. This is wrong.

I know of a gentleman in my county who in recent weeks arrived at Galway Regional Hospital at 9 a.m. As there was no family member at home, the hospital rang a neighbour's wife at 9.30 p.m. to say he would not be kept in overnight. He had to be rushed from home at 7 a.m. the following morning to Mayo General Hospital from where he was transferred to Swinford. He was still there last week. I tabled a parliamentary question in this regard and this morning received a reply from the health board in my office in Westport. The last two lines – I will not read the entire letter as I do not want to identify the official in the health board from whom I received it – read as follows:

According to the nursing staff on duty, Mr. X was indeed very distressed and upset that he was not remaining in hospital. If I can be of any further assistance, please do not hesitate to contact me.

The gentleman concerned who had a very serious infection was sent home to an empty house in which there was no fire lit. He had to ring his neighbour at 7 a.m. the following morning to be rushed to Mayo General Hospital. This proves the point that we have a two tier health system. If on the evening concerned he had said he was prepared to pay for a private bed and a private consultant, he would not have been sent home, rather he would have been given the best bed in the hospital and received the best of attention. There is something wrong in the health service.

I know of another gentleman who was waiting two weeks to be transferred to St. James's Hospital to which he was transported by his two daughters to insist that he be given a bed. He is no longer with us, he is dead. There is something wrong in the health service.

I know of a 57 year old woman awaiting admission to the National Rehabilitation Hospital. I was informed by the manager of the hospital by letter last week – I have since tabled a parliamentary question – that there are three patients in the hospital from the Western Health Board area as there are no day care services available in the province. What has gone wrong in the health service?

The Irish Independent, Sunday Independent, The Irish Times and Irish Examiner daily carry advertisements for programme managers, assistant programme managers, press officers and assistant press officers, despite the fact that there is a shortage of nurses and beds and waiting lists are getting longer. The best the people concerned can do is give up to 50 patients hospital appointments at 11 a.m., some of whom will have to wait until 10 p.m. before being seen. Those employed by the health boards are trying to create chaos to justify their jobs, upsetting the general public in the process. They are saying to the Minister and the health boards that they are running the service. If these people were working for an international company, they would lose their jobs very quickly. There is something seriously wrong with the manner in which hospital services are being run. I would like to see a service in which everyone would be treated equally and where those in need of attention would receive it promptly. That is not happening; people are becoming increasingly angry and upset and are beginning to wonder why they are paying taxes.

I intend to table a parliamentary question next week to find out how many programme managers and assistant programme managers have been employed in the hospital services over the past ten years and what increases there have been on a year by year basis. I also intend to table questions to find out how many nurses were employed over that period and what increases there have been in the numbers of doctors, consultants etc. It appears the hospital services are becoming increasingly top-heavy in regard to the ratio of officials to medical staff. The health service is not operating as it should and the Minister for Health and Children has responsibility to rectify this imbalance.

I am sure the Minister has written to the chief executive officers of the health boards seeking new guidelines for medical cards. The decreasing level of medical card provision constitutes a further attack on the weak and poor in our society. I tabled a parliamentary question recently seeking information on the number of medical cards held throughout Ireland. Up to June 2000, 87,256 cards had been issued. In June 1996, some 91,500 people held medical cards. An increasing number of people are losing medical cards because the chief executive officers of the health boards, who have responsibility for this issue, do not seem to have any understanding of people's needs. Last year, a single person who lived alone was entitled to a medical card if he or she had an income of £92 per week but he or she was not eligible with an income of £93. The cut-off limit was increased later in the year by £1.50 to £93.50 and by £2 per week for a family unit. The Minister should come into the real world. A person in receipt of the minimum hourly wage rate who works for a few hours per week would not qualify for a medical card. I call on the Minister and the health boards to introduce realistic medical card guidelines this year. The limit should be substantially increased because the current limits are insulting to people. People are essentially being told that they will not receive hospital services unless they can pay for them. They are even being denied access to their GPs on whom an increasing number of them rely in the absence of hospital services. Hospital waiting lists are increasing and we now have waiting lists for waiting lists. I hope the next budget will result in substantial increases in medical card guidelines.

The Department of Health and Children has launched an attack on tobacco companies. As a non-smoker, I feel this is a cowardly attack because the Department is afraid to attack drink companies on the same basis. We witness the abuse of alcohol daily on the streets of our towns and villages. We see people under the influence of drink becoming involved in increasingly vicious assaults. The Government has reneged on its responsibility to address this problem. It is not prepared to take on either the drink companies or big business. I agree that the tobacco industry should be dealt with but it should not be isolated. That is cowardly and hypocritical. If we are not prepared to allow tobacco companies to sponsor Formula 1, we should not allow Guinness to advertise in Croke Park or Lansdowne Road. We must be consistent.

Alcohol abuse and alcoholism are scourges which affect every family in Ireland. Moderate alcohol consumption can be a very sociable activity. However, when alcohol is abused, families suffer. I often think that instead of imposing huge fines on men for disorderly behaviour or drink driving, judges would do better to send them to jail. These people will go out drinking again the following week. Their wives will have to find the money to pay the fines and their children will suffer.

I wish to raise an issue which is close to my heart and that of the Minister of State, Deputy Moffatt. A debate has raged in recent weeks in County Mayo and Connacht in general in regard to the provision of breast cancer services. The health board is due to make a decision on this matter in the coming weeks. Why must all specialist services be located in cities such as Dublin or Galway? Why will the Department not consider locating these services in the regions? There is a proposal to move the existing cancer services in Castlebar to Galway with the result that people in need of treatment must travel to Galway, Letterkenny or Dublin.

Why will the Department not consider making Mayo General Hospital a specialist centre? Different centres could offer different specialties but services should not all be concentrated in the same areas. People in Galway could travel to Castlebar for treatment. After all, it is the same distance from Galway to Castlebar as it is from Castlebar to Galway. Why should the people of Mayo be treated as second class citizens? Why does the Department not consider locating specialist services in Roscommon or Sligo?

Consultants, not hospital consultants, are only good for making money. All Government Departments are filled with consultants' reports. As long as the Government keeps paying them, consultants will tell it what it wants to hear. I do not know where these people get their titles but they can pull the wool over the eyes of departmental and health board officials. I do not understand why consultants always recommend the location of services in bigger population centres. The services should be spread out. The people of Castlebar and County Mayo do not want the breast cancer services to be withdrawn from Mayo General Hospital. We would like to see the specialist service being transferred to Castlebar rather than locating it in a larger population centre.

Regarding the elderly, ourselves and Italy were always respected for looking after family members – mothers, fathers and grandparents – but we seem to have lost that touch. We have become more like America, we are too busy and are working harder and longer hours. The Minister has responsibility for the elderly. I am concerned at the abuse of the elderly which has been evident from recent court cases and reports. The Minister has established a committee and I hope he will introduce the necessary recommendations and that a helpline will be put in place so that those being abused at home, in State care or in nursing homes can report it. The elderly are vulnerable and when they are in a supervised place they can be afraid. They must be protected and it will be a sad state of affairs if that is not done.

Cecilia Keaveney

I am delighted to have an opportunity to contribute to this Bill. It affords providers of health insurance an opportunity to respond to the growing and urgent demands for additional products and services. This is a most significant Bill.

Despite the most stringent and close questioning at a recent meeting of the Committee on Health and Children, which was attended by representatives of BUPA and VHI, the concepts of community rating and risk equalisation have continued to evade clarification. I trust that by the time the Bill is taken through Committee Stage, my knowledge will be broadened. In this respect I ask the Minister of State, Deputy Moffatt, to talk to the Minister given that risk equalisation was taken out in 1998 by the former Minister, Deputy Cowen, and the huge increase in the number of people being insured. Prior to competition market cover was 33% but it now covers 46% of the population.

I ask the Minister for his reaction to various comments made by BUPA on risk equalisation. It claims it is happy the proposed health insurance authority would have the freedom to recommend a risk equalisation scheme if such a scheme was independently considered necessary by the authority to maintain market stability and if in the view of the authority it would be desirable taking account of the impact of any such scheme on damage to competition in the market and implications for inflation in the health sector. It claims any threat to market stability should be assessed on objective criteria in terms of down-sizing the market, the exit of older age policy holders and-or the pending financial collapse of one or more insurers. While it feels no insurer could compete in a market if the authority did not consider these issues, but focused solely on an unknown academic mathematical review of risk profiles, perhaps the review as proposed in the Bill could be undertaken as an input to the authority's evaluation and only in relation to the relevant market segments. I trust these points may be addressed in the Minister's closing speech on Second Stage.

Private health insurance has had a big impact in Ireland. VHI covers 40% of the population, with 1.5 million members, while BUPA in a very short time has reached 180,000 customers. This increasing sector is providing an important service for many people every year. Competition in the sector is healthy, as it is in most sectors, and I trust this legislation will not only widen the level of service being given via the incorporation of primary medical care, but will maintain the scope for true competition to flourish and not impede any aspect of the community rating system which is vital for fair play throughout the sector.

In respect of the primary health care market, the Minister in his speech on Second Stage confirmed that the new proposal does not affect the existing eligibility arrangements for health services under which persons are given access to primary care services on the basis of need. It is aimed at giving people who fund their primary care needs on a pay as you go basis the choice of financing their care by means of insurance. This was initiated in the Government White Paper, which stated the evolution of private insurance was to include steps to promote the position of the primary care sector within the system.

I agree with the Minister's comment that health insurance is geared to expensive hospital based treatments to the disregard of more minor but very pertinent areas of dental or other primary health care, which tends to leave the consumer open to sizeable expense. It is welcome that within the new remit there will be scope for the development of preventative and early detection services. These have not had a significance in insurance to date. The focus has been on times when things have reached a serious stage and people are in hospital.

Everybody should be in a position to access health care. It is regrettable that any person, even one with private health insurance, should feel he or she could not afford visits to a doctor. There are many such people who leave their health care on the long finger until such time as they can no longer ignore the aches and pains. At that point their health insurance may kick in, but their medical difficulty could be quite serious. In this respect, the development of the primary care sector is extremely important and may be a measure which will save lives alongside its delivery of a range of greater services and providers through which they can access the services.

There is also a change in the provision of services to people aged 65 and over who have not previously taken out community rated insurance in that insurers will be obliged to cover this age group, a most welcome addition. The elderly in our communities have helped through their lifetimes to build the country and have contributed over many years to the State. It is therefore essential that when they age and become more vulnerable all levels of health care are available to them. This should include the option of private insurance. I know the Minister of State, Deputy Moffatt, will be geared particularly towards the concerns of the elderly given that he has responsibility in that regard.

Given that many people speaking on the Bill may not address the details but will bemoan the fact that our public health system should cater for all and that there should be no need for private health insurance, I wish to say there are aspects of the health system which have developed under the current Administration which must be acknowledged. I congratulate the Minister and the Ministers of State on the very important progress which has been made, particularly in relation to breast cancer. Through the co-operation of Europe Madona and the Reach to Recovery group I have gained a small level of knowledge in this field and know that early detection can lead to great success. People are not getting the positive message of early detection. I commend the Minister, Deputy Martin, on the Breast Check initiative and request that everyone involved continues with the development of the project to ensure people in the north-west can avail of this most valuable service. This has real life saving potential and nobody should ever be forced into private health care to deal with such things as breast cancer.

I commend the existing cross-Border services which the North Western Health Board operates with hospitals throughout Ulster. This co-operation makes geographical sense at a time when the road network from Donegal to Dublin continues to grind to a halt. What was a car journey of three and a half hours now takes five hours, and in this context I ask the Minister to continue the great work which has begun in terms of cross-Border services. Most of us can understand the frustration of being in a car for five hours, but not all of us have had the experience of being ill and in a vehicle, be it a car or an ambulance, for this time. It is heartening to know there are specialist hospitals within two hours of us for most if not all ailments. This journey makes an appointment at 9.00 a.m. much more manageable. I cannot over-emphasise this point. The work of the Minister with his colleagues on the Northern Executive, particularly Bairbre de Brún, must continue and advance for the sake of the people of Donegal.

In this context I also wish to refer to the breast care programme. I visited London and met experts from St. Bartholomew's, Guys and other hospitals and the message was clear – the women of Ireland need a number of well resourced locations where multi-disciplinary work can be carried out. Only with this serious approach to breast cancer will we reduce the high incidence being presented in the country. Therefore, that puts immediate stress on the ability to successfully treat the cancer. I congratulate the Donegal hospice on the recent turning of the sod for the new facility in Donegal. It works alongside the Foyle hospice in Derry with which my family had direct contact. It is outstanding for both patient and family. I cannot speak highly enough of their role in looking after cancer sufferers in the county.

Therefore, given the journeys involved for people in such large rural counties for major centres, in this case because of the proximity of very good facilities at a near destination we must maximise the resources within a minimum distance. Having spoken to medical experts it is clear that the decision in relation to the location of breast care services should not be politicised or be a geopolitical decision. Making a geopolitical point, when I first came into this House the national cancer strategy had been drawn up by the previous Administration and there was a great hullabaloo about the fact that the whole country would be covered. When I asked about the centres I was informed they were in Dublin, Galway, Cork and Athlone. There may have been another which I cannot recall. When I asked about coverage for my area I was informed that I was close to Galway. To put matters in perspective, my home town is 20 miles further from Galway than from Dublin. I am pleased things have changed and that people are beginning to realise there are hospitals throughout Ulster that could provide work. It has to be done on a cross-Border basis. When it comes to breast cancer the best facility must be put in place and within a minimum distance if possible. The patient must come first.

I trust that any alteration we make to our health insurance cover will take into consideration the new arrangements that exist at a political level throughout the island of Ireland and that people who, for whatever treatment, might wish to attend a facility in Derry or Belfast will not be hindered by the rules of the health care cover. Ultimately if there is something that can be done to assist people to remain healthy that would be the best course of action. In this respect I congratulate the Minister for Tourism, Sport and Recreation on the number of grants he allocated in July for sporting facilities. This is an important resource for young and old. I trust the Minister, Deputy McDaid, will continue to acquire adequate funds from the Department of Finance to complete the many projects that remain outstanding. It would be good if the health insurance companies expanded the services they are beginning to offer. The vhihealthe.com and the "Go for it" and "Get Unstressed" healthy lifestyle initiatives are important. The latter provides a 24 hour nurse-medical information line.

I congratulate the Government on its support for voluntary housing and associated support units. In Donegal there are many examples of these which help to keep people out of hospital. Similarly the supports provided to the mental health and carers categories under this Administration have greatly assisted those in most need. I encourage the development of more support units, more help for carers, more respite and more support for home helps. I thank the Minister for sanctioning the Alzheimer's facility in Carndonagh. It is important that patients with these types of illnesses are covered by their health care insurance. Section 8 of the Bill will probably assist this age group.

Not everyone can afford private health care insurance and it would be wrong to assume they can. In the context of the forthcoming budget I ask the Minister to look at medical card eligibility and either increase the income limit substantially, to take the net rather than the gross income level, and-or develop a tiered system whereby a certain basic income would allow one to have a full medical card. If one had a certain amount above the limit one should be allowed a certain number of doctor visits and prescriptions free of charge. As one's income increases the number of doctor visits and prescriptions free of charge would decrease. I acknowledge the significant increases in the limit for the elderly. This has happened over the last couple of budgets and it is an important achievement.

We have had a serious difficulty with the number of younger and older people smoking. Deputy Ring referred to this and made a half-hearted attempt to slap the Government over the wrists for trying to deal with the position. This matter is being addressed by the Minister and the Joint Committee on Health and Children. I am of the view that the nicotine replacement packs and-or the new treatment aimed at supporting people to quit smoking should be brought under the medical card system. Where does this topic stand in respect of the private health insurance and the concept of preventative action? I agree with Deputy Ring that drink related illnesses should be brought under the system also. Ultimately prevention would lower health costs in the longer term.

A friend of mind who should have been admitted for a serious operation tomorrow is being sent home because the blood bank does not have a supply of blood. I agree with Deputy Ring's suggestion that we should have a facility here for people to give blood. There should always be a contingency plan for emergencies on which the blood bank can call for blood. This is a serious situation. When representatives of the blood bank came before the committee they asked us to encourage blood donors. I am asking people to give blood because others cannot get the services they need over the next few days. That should not happen. I encourage the blood bank to look at its long-term strategy in times of flooding or other catastrophes when people cannot get blood transfusions.

I could go on about the waiting list for public versus private patients. Initiatives are being introduced in my area. Whether these are in the orthodontic service or hip replacements the cross-Border element could assist in reducing those waiting lists. While the shortage of nurses needs to be sorted out I believe the Minister is working towards that end.

Speech therapists, orthodontists, physiotherapists and all those specialities that do not seem to be coming to Donegal do not know what they are missing. I encourage those with a speciality in the field to give it a chance because we have much to offer. I ask the Dublin hospitals to think about those travelling long distances, from Donegal or west Cork, and to give reasonable appointments. If they cannot deal with the person on the day I ask them not to call them to Dublin and send them home again.

I congratulate my own health board, the hospitals and the medical staff who do a tremen dous amount of work. We always hear the negative aspects and seldom the positive aspects of what they do. It should be acknowledged that they work hard. In respect of people who work hard in the Department of Health and Children I wish to acknowledge one person within the system. I pay tribute to the significant work done by Gobnait O'Connell not only as a health care professional but in her role as an adviser to the Minister. Ar dheis Dé go raibh a aimn dílis.

While not every issue will be solved by this Bill, it is a positive step. If competition can be kept in the market place and if the insurance market place is driven there will be advantages for those availing of it. Almost half the people have private health insurance. I look forward to dealing with this Bill on Committee Stage.

Mr. Farrelly

I welcome the fact that I can speak for a minute on the Health Insurance (Amendment) Bill. The Bill does not direct the VHI to actually—

Debate adjourned.

Dáil Éireann debate - Wednesday, 8 Nov 2000