Health (Amendment) (No. 2) Bill 2010 [Seanad]: Second Stage

I move: "That the Bill be now read a Second Time."

I am pleased to have the opportunity to address the House today on Second Stage of the Health (Amendment) (No. 2) Bill 2010. The Bill provides for the charging of modest fees in respect of prescribed items dispensed by community pharmacy contractors to persons who have full eligibility under the Health Act 1970, that is, medical card holders. The Bill provides for a charge of 50 cent per item prescribed by a registered medical practitioner, dentist or nurse and dispensed by a community pharmacy contractor. The maximum amount payable will be €10 per family per month. The charges are being introduced on foot of a budget 2010 decision to address the rising costs in the general medical services, GMS, scheme. The scheme also seeks to influence demand and prescribing patterns in the GMS, in a modest way.

We have not set out in the Bill to make the level of savings of the order of €200 million and more which we are already achieving in respect of the price of drugs and the cost of distributing and dispensing drugs. Nor is it of the scale of the savings we expect to achieve in coming years by introducing reference pricing and generic drug substitution. However, every saving and every contribution counts. This change could raise approximately €2 million per month. Every saving achieved by and for the HSE Vote will reduce, though not eliminate, the pressure on funding for front line services, from hospitals, home help and home care packages to mental health services and services for people with disabilities and their families.

It is important given our current financial situation that we take every possible step to provide public services efficiently, to limit costs to the greatest extent possible, and to involve users of resources in a better understanding of the value of those resources and their appropriate use. We are doing this very much in a pragmatic way in the context of Ireland today, including not only the national finances, but also our own patterns of prescribing and usage of drugs and the costs we face.

Almost 1.55 million people, or 35% of the population, are medical card holders. Payments to pharmacies under the GMS scheme increased from €748 million in 2004 to €1.129 billion in 2008. This cost increased by a further €50 million to reach €1.179 billion in 2009, despite a reduction in the fees paid to pharmacists from July last year and ongoing reductions in the prices of off-patent medicines.

On a point of order, I apologise for interrupting, but will we get a copy of the Minister's speech?

There is a tradition of making available the speech but no requirement as such. I am sure it will arrive. The Minister should proceed in the interim.

The cost of the GMS scheme, including payments to pharmacists and general practitioners, in 2010 is projected to be more than €2 billion. The rate of increase, an average of 12.5% each year over six years, in the cost of supplying drugs and medicines is not sustainable. The number of prescriptions issued under the GMS increased by almost 4 million between 2004 and 2009 to more than 16 million. The number of items dispensed during this period increased by more than 15 million to just over 50 million. The average number of items per prescription has also increased from 2.74 in 2004 to 3.11 in 2009.

Section 1 provides for the amendment of section 59(1) of the Health Act 1970, which requires the Health Service Executive to supply drugs, medicines and medical and surgical appliances to persons with full eligibility without charge. This will be amended by section 1(a) to provide that, where prescription items are supplied by a community pharmacy contractor, they shall be subject to the charges as provided for in subsections (1A) and (1B)(a) subject to the exemptions provided for in subsection (1C).

Subsection (1A) provides that a person who is supplied by a community pharmacy contractor with a drug, medicine or medical or surgical appliance on the prescription of a registered medical practitioner, registered dentist or nurse who is entitled to prescribe shall be charged 50 cent per item. It also provides that any variation in this amount may be determined by regulations subject to certain conditions, set out in the amended subsection 59(4) of the Act.

Subsection (1B) provides that the maximum amount payable by a person and his or her dependants in any month will be €10. In addition, provision is made for the HSE to refund, credit or otherwise relieve any amount paid in excess of the maximum aggregate amount. Any variation in the maximum aggregate amount will be determined by regulations subject to certain conditions, set out in the amended subsection 59(4) of the Act.

Subsection (1C) provides that two classes of persons will be exempt from the charges. These are children in the care of the HSE under the Child Care Acts, 1991 to 2007, and persons who are supplied with specific controlled drugs such as methadone. The section also provides for the making of regulations to exempt other classes of persons from charges, subject to certain conditions, set out in the amended subsection 59(4) of the Act. The prescription charges will not be payable by holders of long-term illness cards. In addition, charges will not apply to persons who are covered by the Health (Amendment) Act 1996, that is, persons who contracted hepatitis C through the use of certain blood types.

Subsection (1D) provides that, notwithstanding the contract between community pharmacists and the HSE, the amount paid to a community pharmacy contractor by the HSE will be reduced by an amount equal to the amounts collectable by that contractor in charges. The amount collected in charges will be retained by the community pharmacy contractor. Subsection (1E) provides for a definitions of "community pharmacy contractor" and "dependant" for the purposes of section 59(1).

Section 1(b) inserts a technical amendment relating to the existing subsection 59(2).

With regard to the conditions for the making of regulations, section 1(c) replaces the existing section 59(4) and provides in the new 59(4)(a)(i) and (4)(b) that, in deciding whether to make regulations to vary either the amount of the charge per item or the aggregate monthly amount, the Minister will have regard to such of the following, as considered appropriate: information on the consumer price index; information on expenditure and the number of items prescribed to medical card holders; the medical needs and financial burden on persons who avail of the services; and the necessity to control health service expenditure.

Section 1(c) also provides in the new section 59(4)(a)(ii) and (4)(c) that, in deciding whether to make regulations specifying classes of persons to. be exempt from the charges, the Minister will have regard to such of the following, as considered appropriate: the medical condition, disability or medical needs of persons in that class; the number of the prescription items required in respect of those medical needs; information on expenditure and the number of items prescribed to medical card holders generally or in respect of the specific class; the necessity to control health services expenditure; and whether the overall financial situation of the proposed class is worse than that of other persons who are charged for items supplied on prescription.

Section 1(c) also provides in the new 59(4) (iii) that the Minister may make regulations relating to refund, credit or other relief arrangements where he or she considers it necessary. Section 1(c) provides that regulations made under section 59 shall be made with the consent of the Minister for Finance.

Section 2 provides for the Short Title, construction, collective citation with the Health Acts and commencement. The Bill is part of a set of actions the Government has taken or is taking to address increasing costs in the general medical services, GMS, scheme. These actions include the introduction of off-patent price cuts, reductions in wholesale and retail mark-ups and the introduction of generic substitution and reference pricing. Significant progress has been made in recent years to improve value for money in the area of pharmaceutical expenditure. Off-patent price cuts have been implemented and wholesale and retail mark-ups have been reduced. As a result of off-patent drug price reductions in February, the cost of prescribed medicines measured by the Central Statistics Office as part of the consumer price index dropped by more than 12% in that month alone. Discussions are under way with manufacturers of generic medicines and lower prices for them are expected to be introduced in September this year.

Despite these reforms, pharmaceutical expenditure continues to pose a challenge because of our ageing population and increased usage of medicines. Further changes are required to secure a sustainable system of pharmaceutical expenditure while, at the same time, ensuring patients can continue to access necessary and innovative medicines. On 17 June last, I published a report on the proposed model for the substitution of generic medicines and reference pricing. Generic substitution and reference pricing represent significant structural change to the system of pricing and reimbursement of medicines in Ireland. As more medicines come off patent, the introduction of generic substitution and reference pricing will ensure both taxpayers and patients will benefit from increased competition in the pharmaceutical market.

Giving patients more choice and promoting price competition between suppliers will help reduce the overall drugs bill without compromising the efficacy or safety of the treatment that patients receive. Savings will be achieved by limiting reimbursement to the reference price, allowing patients to opt for less expensive versions of the prescribed medicine and promoting price competition between the manufacturers of interchangeable medicines. The savings will be dependent on a range of factors, including the number of medicines included in the reference price system, prescribing practices and the behaviour of manufacturers of interchangeable medicines. The system will be introduced on a phased basis and, therefore, savings will be achieved on the same basis. An expert group will provide guidance on which medicines can be safely substituted. Exemptions will be required in some instances for individual patients for clinical reasons, for example, if a patient has difficulties swallowing.

The maximum monthly amount payable under the legislation is €10 per family. Payment of the maximum amount will only arise where a family receives 20 items or more in a month. In 2008, just over 2% of medical card families had 20 or more items per month prescribed to them. More than 35% of families had no items prescribed, while almost 18% had one or two items prescribed. It is expected, therefore, that only a small minority of medical card families will have to pay the €10 per month maximum charge. Based on trends in previous years, it is expected that the prescription charges will yield €24 million in a full year.

I expect that the primary care reimbursement service of the HSE will roll out the charging system from 1 September. Once the legislation is passed, my officials, the HSE and representatives of the pharmacy contractors will enter into discussions to make this happen. Some adjustments to the IT systems both in the HSE and on the pharmacy side will have to be made to allow for implementation, including calculation of data to provide for refunds. Issues such as how often refunds will be made, for example, on a quarterly basis, will be worked out. I do not expect this will have a significant ongoing resource implications in terms of cost or staffing. I will keep the implementation and the impact of the changes under constant review. As I said in the Seanad last week, I will report back to both Houses of the Oireachtas and the Joint Oireachtas Committee on Health and Children. I commend the Bill to the House.

On a point of order, I still have not received a copy of the Minister's speech.

I have asked that the Minister's office be requested to at least circulate copies to spokespersons and the Chair. They have not arrived yet.

Some have been circulated.

Two copies were available.

The Bill is vehemently opposed by the Opposition with good reason. It will be aimed at the most vulnerable, sickest and weakest in our society and, yet again, as I pointed out to the Taoiseach on the Order of Business yesterday, he has long-fingered, along with the Minister, the tough decisions that have to be made about generic prescribing through which hundreds of millions could be saved and goes after an area where the Minister might save €25 million in a full year. I wonder whether she will and whether this legislation will transpire to be penny wise and pound foolish because it puts an obstruction between those with chronic illnesses and their medication.

Anything that discourages people from taking their medicine results in them falling ill, developing complications and having to attend hospital, often being admitted. A single day in hospital more than wipes out the cost of drug treatment for an entire year for the vast majority of people. These might be savings in theory but, as has so often happened previously, they might transpire not to be savings at all.

The Minister said: "Section 1(c) provides that any regulations made under section 59 shall be made with the consent of the Minister for Finance." Again, more control will be devolved to the Minister for Finance and his Department, as if they do not have enough control already. I remind the House that this is the same Department of Finance that got all its predictions wrong on both our way up and our way down. It is the very Department that led us blindfold into the current mess, no doubt encouraged by the Government. The cost of our economic mess should not be laid on the people who are least able to bear it.

The Minister spoke about off-patent price cuts and the reduction in mark-ups, saying significant progress had been made in recent years. It is only in the last year that any improvement has been made with the main manufacturers of the drugs they produce off-patent. Why is it the case that a cholesterol-lowering drug in this country was costing €28 per month for the brand leader and €27 per month for the generic product while a mere 45 miles up the road in Newry it could be bought for £1.40, or €2? That is one-fifteenth of the price. Clearly, there are huge savings to be made in that area and that is where our focus should be.

This 50 cent charge might not appear to be much to the Minister or me, but it is for many low income families. International research shows that any disincentive for people to take medicines should be avoided, as certain patients will inevitably end up in hospital. The nearest jurisdiction to Ireland, Northern Ireland, has abolished prescription charges. We are going in the opposite direction. Wales has also abolished these charges and the Welsh Assembly document called "Helping to improve health in Wales" found there was no increase in the number of prescriptions dispensed in Wales following the removal of the charge. One wonders why this country is going in the opposite direction. In the remainder of the United Kingdom where these charges still apply, and when they did apply throughout the United Kingdom and Northern Ireland, they have never applied to the lowest one third of income earners, the people who comprise the vast majority of the people in this country who hold medical cards. There is no precedent for this in these islands or elsewhere. By taking this course, the Minister will discourage people from taking their medicines, with dire consequences for them and serious financial consequences for us. It really makes no sense.

The Bill provides for some exemptions. As a general practitioner, I am aware of people with long-term illness cards who subsequently receive medical cards while retaining their long-term illness card. These people will not have to pay for medicines relating to their illness. What about those who have a medical card but have never had a long-term illness card, and never saw the need for one due to having a medical card? They will be subject to the prescription charge. Surely that is inequitable. The Minister's list of exemptions should include the entire list of illnesses on the long-term illness card, such as mental handicap, mental illness, phenylketonuria, cystic fibrosis, spina bifida, hydrocephalus, diabetes mellitus, diabetes insipidus, haemophilia, cerebral palsy, epilepsy, multiple sclerosis, muscular dystrophies, Parkinsonism, acute leukaemia, high blood pressure and cancer. The last two are not on the long-term illness card, but they should be, as well as Crohn's disease and asthma. It is well known that if people stop taking their asthma therapy, they will feel fine for a while but that predisposes them to an acute attack which could be fatal and in many cases will hospitalise them.

The Minister referred to the 50 cent and the consumer price index. The Taoiseach this morning made it very clear where this is going. He was patting himself on the back for starting the charge at 50 cent when Mr. Colm McCarthy had recommended €5. However, it is clear that once the Minister gets this charge under the door, it will continue to increase. Is the Minister prepared to give an undertaking to the House that it will not happen? Even if she gave that undertaking, what would it be worth? The Minister referred to the Health (Amendment) Act 1996 which provides the equivalent of a medical card and free health care to those who suffered hepatitis C infection through contaminated blood products. Of a total of 54 women who were in the course of attending that tribunal, 24 were accepted as having hepatitis C even though their titres were not measurable. The Act was changed in 2006 and now they cannot get a Health (Amendment) Act card. I met those women this morning and was told that the Minister had given them her word that she would address that, but they are still waiting for her to keep her word.

It is not my intention to use the full 30 minutes as there are important amendments to examine. How will the Minister administer this? How will she administer reclaims? If I have a medical card and am on holiday with my family, and all I can afford is a trip to Kerry, Cork, Monaghan or Cavan, and one of my children gets sick or I run out of my medication and have my prescription with me or I go to a local general practitioner and have the medicine prescribed for me, how will I reclaim that if I am not at my regular chemist? There are all sorts of logistics involved. What price has been put on that? Please do not tell us it will not cost anything to administer this because we know there will be a cost. Administration comprises a large part of the bill for the black hole known as the HSE. The putative savings of this scheme are questionable and the cost of administering it is unclear.

In the provisions of the Bill dealing with exclusions and definitions, section (1E) states: "In subsections (1A) to (1D) . . . . ‘dependant' in relation to a person with full eligibility, includes an adult person with full eligibility, so long as that adult person is under the age of 21 years and receiving full time education and is wholly or mainly maintained by the first-mentioned person." Where does this leave parents on medical cards caring for disabled adult children who also have a medical card? They are not part of the maximum €10 charge because they will be outside it. I humbly suggest the Minister modifies the Bill to avoid this.

I spent half an hour outside the gates of Leinster House today with parents of disabled children who are having their respite services removed. I spent Monday evening at the Brothers of Charity care centre in Galway with Deputy McCormack and it is very clear that these parents are under terrible pressure. Due to a penny wise, pound foolish HSE initiative, which the Minister approves, they will lose their respite care. Parents who are getting on in years cannot cope without it and will give up, much and all as it will hurt them to do so, and these children will end up in full-time care, costing the State many multiples of the money required to provide respite care. I ask the Minister to consider using her prerogative on Committee Stage to ensure that adult children with disabilities are included with the remainder of the family in the maximum payment of €10 per month.

I have received representations from Nursing Home Ireland whose members are very concerned about the impact of this charge on nursing homes. They are concerned that patients with medical cards who are also in receipt of the old-age pension will have to give up 80% of that pension under the Fair Deal arrangements. They will be left with a very small sum of money and up to €10 a month could be taken from their remaining €40. That is not fair and the Minister should examine this area.

I am utterly opposed to this Bill as it is penny wise and pound foolish. It hurts the weakest people in society. The amount of money it will save is questionable while the amount of money it will cost to administer the scheme is unknown. Ultimately, the Exchequer will lose out, as people end up in hospital because of difficulties with affording their medication.

I wish to share my time with Deputy Ó Caoláin.

The Labour Party will be opposing this Bill. The people who will be affected by it are the poor and the sick and they are not the people who should have charges imposed on them because of the drastic situation in our public finances. They are the very opposite of those who should have to pay.

The Bill copper-fastens the inequalities in our society. It is a bit rich for the Minister to state that she was imposing this charge so that there would be more money for front-line services such as respite care and home help services. The very people who are being asked to pay this prescription charge are the people who need the home help and the respite care and all the other supports because they are the poorest people who qualify for a medical card on income or illness grounds. They are, by definition, already the most vulnerable people in our society. They are being asked to pay a charge of 50 cent on every prescription, subject to a maximum charge of €10 per month per family. A sum of €10 per month might not seem like a big deal to the Minister or even to those of us in this House with a reasonable income, but the people we are talking about had their incomes reduced in the last budget, in many cases, down to €196 per week, a reduction of €8 per week. The people in that category according to the list of social welfare cutbacks are those who are either widowed, ill, disabled or blind. Those people are now living on €196 per week. Carers and old-age pensioners are very slightly better off at just over €200 per week. These are the kind of incomes we are talking about.

These people already have heavy demands on their income because they are ill or disabled. They will also be facing a carbon levy in the near future and we still await details of the Government's plans to ensure that fuel poverty is not added to the burden of the poor. Already the cost of fuel is high but the introduction of the carbon levy will cause it to rise.

These people are the poorest of the poor. This is an unequal society that is becoming more unequal. Many of us will have read the book which shows that the negative effects of inequality are seen across a range of indicators, including physical and mental health. It should be noted that the wealth of the country is improved if society is more equal.

The Government is imposing cuts on the poor but it is noted that other, better-off sectors seem to get away with things. I refer to the information from NAMA yesterday about the amount of money that will be recovered. The predictions of return for the public purse are way lower than original estimates. These figures are blithely thrown out in their billions of euro. The charges proposed in this Bill may be very small money but it is money that can make the difference between being able to balance one's budget at the end of the week in the case of the people affected.

The Minister said in her contribution that €2 million per month would be saved by the imposition of this charge. This amount of savings is directly on the backs of medical card holders because nobody else will be paying it to the Exchequer.

It has been argued that this charge is an attempt to reduce the bill for medications and stop people over-using prescribed products. The Minister stated that 4 million extra prescriptions have been written in the period 2004 to 2009. This charge is not the way to address that problem, in my view. The very fact the Minister admits it will save €2 million per month does not indicate it will address that problem but rather it will be a money-spinner to bring in extra money every month.

The Minister often accuses the Opposition of not supporting her on initiatives but the Opposition supported the Minister's introduction of generic substitution and reference pricing as this is a good idea and a good way of saving money on prescription drugs. The pharmacists have suggested having a medicine use review which they say would considerably help to reduce dependency on drugs. Patients need to be educated and informed about the use of drugs. It should be explained to them why they may not need to take so many prescribed drugs. We need to focus on those who prescribe the drugs, the doctors and in some cases, nurses. If too many drugs are being prescribed, the focus should be on those who prescribe the drugs rather than those who take the drugs.

This is a case of using a sledge-hammer to address a problem that a sledge-hammer has not a hope of solving. People on drugs for cancer, diabetes or other long-term illnesses as listed by Deputy Reilly, have no choice but to take their drugs. They need them, yet it is proposed to incorporate most of them into this system of charges. The Minister said there would be exemptions for children in care and with regard to controlled drugs such as methadone and for those with hepatitis C. There is a provision to make further exemptions. I have tabled some amendments about homeless people and those whose lives could be in danger if they do not take medication. We need to see a lot more exemptions if this Bill is not going to be of serious concern with regard to a number of categories of people. Under section 1(4)(a)(ii), the Minister is permitted to make regulations to exempt other classes of persons but I ask the Minister to outline the kinds of classes of persons for whom she will consider making exemptions. The list in the Bill is inadequate to deal with categories of vulnerable people. I received an e-mail from the nursing home organisation, which makes the valid point that people in nursing homes have only 20% of their disposable income, which is usually 20% of the pension, left for all personal needs. This includes therapies, an expense they did not have before. Previously, therapies were provided by nursing homes but in most cases people must pay for therapies from the 20% of their disposable income that remains. People in nursing homes are very vulnerable.

International evidence on the impact of the prescription levy indicates it places a financial barrier on the poorest in the community in terms of accessing vital medicines and has a negative effect on the health of the population. As mentioned by Deputy Reilly, Northern Ireland and Wales have got rid of prescription charges. We are going in the opposite direction to other countries that have tried it and decided it is inappropriate and has a negative effect. If people do not take drugs because they cannot pay for them, it endangers their health and will probably impose extra charges on the hospital system because people will not be able to control their illnesses in the community and are more likely to go to hospital. There are many reasons the Labour Party will vote against this Bill.

The question of how this will be administered and collected also arises. It will be an administrative nightmare. It will be difficult for pharmacists, who are now effectively becoming tax collectors. The amount of money will be taken from the sum paid to them and they are expected to collect it from the medical card patient. What will pharmacists do if a person says he or she cannot pay, will not pay or should not have to pay? Will the pharmacist contact the Garda Síochána, take the burden of the cost or fight with the patient? Generally pharmacists develop long-term relationships with regular patients in the community. This will fundamentally change the relationship and could create difficulty. I do not know what pharmacists are supposed to do because they are not tax collectors or the Revenue Commissioners but they must collect this tax. This measure is fraught with difficulties and many problems will arise with regard to the practicalities of the Bill. I am not sure the Minister will save the amount of money she believes.

It is true that we must save money on drugs. Reference pricing and generic substitution, along with other measures suggested, could achieve this. We need every single penny we can get in the health services for the delivery of frontline services. I support the Minister in this respect but this is despicable legislation in some ways because it targets those least able to pay.

I met the families outside Leinster House today. I have met many of them in the past weeks because the respite centre in my constituency has been closed for the past three weeks. Those with adults with intellectual disabilities in their homes who care for them 24 hours a day have lost their respite. We must restore that respite before we leave here tomorrow. It is as simple as that. Those people and vulnerable sectors must pay this levy. It is inequitable and will be extremely difficult to collect. It has been tried and has failed in other countries. It targets the most vulnerable and for those reasons the Labour Party will vote against this Bill. We will try to amend it but, even if we succeed in the amendments we propose, it remains a Bill that is wrong and should not be imposed on the poorest in our community.

I move amendment No. 1:

To delete all words after "That" and substitute the following:

"Dáil Éireann declines to give the Bill a Second Reading as prescription charges represent an unjust imposition on medical card holders and undermine the General Medical Services Scheme.".

Sinn Féin totally opposes this Bill, which enables the Minister for Health and Children of the day to impose prescription charges on medical card holders. It is a disgraceful item of legislation that targets the least well-off in Irish society. As I indicated on the Order of Business, it is a sneaky and dishonest Bill. When initially signalled by the Minister for Health and Children, it was listed as the Prescription Charges Bill. This was changed to the Health (Amendment) (No. 2) Bill in the vain hope of taking the bad look off it.

The legislation sets a charge of 50 cent per item up to a maximum of €10 per month. The Bill has been sold politically and in the media on the basis that the charges are small. The opening contribution of the Minister for Health and Children on Second Stage referred to the charges as being modest. The most dishonest thing about this Bill is where the fees are cited. It is a smokescreen, a device to get the Bill passed. When Government representatives are challenged their main argument has been that it is a charge of only 50 cents and a charge of only €10. However, that is pure deception because section 1 empowers the Minister at any time in the future to make regulations to vary the charges. We know this Minister and future Ministers will increase the prescription charges for medical card holders. I warrant that will happen if this Bill is passed.

At the end of last year it was leaked to the media — deliberately perhaps — that the Minister's officials were seeking a charge of €2.50 per prescription. This was after Mr. Colm McCarthy recommended a €5 flat fee for every prescription in the notorious report of an bord snip nua. I might add in passing that Mr. McCarthy's prescription for the ailing Irish economy was a strong dose of deadly poison across the board. The Government deserves no credit for prescribing a slightly lesser dose because it is deadly poison nonetheless.

On 19 November last year, the Minister addressed a body much in the news lately, the Fianna Fáil Parliamentary Party. She floated the 50 cent prescription charge and it was reported afterwards that Fianna Fáil Deputies and Senators supported the proposal. Only one Deputy was reported to having expressed concern and, to give credit where it is deserved, he hit the nail on the head when he said he was worried the charge could be increased in future years. At least someone saw the train coming down the track.

The Minister, Deputy Harney, saved the day because, we were told in a newspaper report, "Observers said Ms Harney made clear that no final decision had been taken", and the Cabinet was saved from rebellion in the ranks once again.

Then came the budget with its savage cuts to public services, including health, and its confirmation that prescription charges would indeed be imposed. Did one hear the faintest protest from the ranks of that Fianna Fáil Parliamentary Party? Not a whimper. After all the talk of rebellion in the Fianna Fáil Parliamentary Party in recent weeks, where are they when a Bill comes before the Dáil that clearly and undoubtedly will affect the least well-off and the most needy in Irish society? I note that not a single member of that party is present. The Minister is an independent member of the Cabinet but not a single member of either of the two parties in the coalition is represented in the Chamber during this Second Stage debate. Will even one of them stand up for the people who are being penalised by the prescription charges provided for in this Bill? The backbenchers have been much concerned lately about hounds, stags, hares and related matters but it seems that last night, the sheepdog from Clara barked at them and the sheep now are being herded exactly where he wants them to go, that is, voting as he, the Minister and the Government dictate. There is not a bleat out of any of them regarding this Bill.

One should make no mistake but that any Deputy who supports this Bill is opening the way for higher prescription charges in the years to come. Moreover, Members will not be obliged to wait too long before the first evidence of this will present itself. This Bill, therefore, undermines the general medical services scheme in a fundamental way. Access to essential medication free of charge always has been a cornerstone of the medical card scheme. It has lifted a potentially huge financial burden from people on low incomes and especially from families with young children. It not only has lifted a financial burden but undoubtedly also a great concern regarding the challenge with which any family struggling to make ends meet can cope or can afford at any given time.

In addition to being penalised financially, people with medical cards are being scapegoated for the high cost of medicines in this State. As previous speakers have indicated, all Members agree that the cost of medicines to the State and to individuals is unacceptable and simply is too high. Everyone acknowledges there is wastage and over-prescription of medicines and all agree that measures must be undertaken to address these problems. However, the very last way to address this is to punish those who are least able to pay. I agree with Age Action Ireland when it states:

Over-prescribing and inappropriate prescribing is a problem in Ireland but the Minister needs to address this issue with the doctors who write the prescriptions, rather than hitting their patients. The patient is not the person writing the prescription so . . . penalising them will do little to change prescribing practices.

For many older people in receipt of a State pension who are reliant on medication, this Bill will mean an additional annual burden of €120 each. Moreover that is only the initial cost, as there will be an as yet unknown higher amount when the Minister or her successors or both inevitably increase the charges.

These prescription charges on low-income individuals and families come in the wake of the abolition of the social welfare Christmas bonus and the reduction in social welfare payments generally. Furthermore, this is only on the payment side as services for people with medical cards and for all who rely on the public health system are being reduced on a weekly basis. Dental treatment for medical card holders has been confined to what are called emergencies but the HSE has failed to state what constitutes an emergency in the context of dental treatment. That said, I have met many people who have suffered and who consider that their situation was an emergency but for whom the system no longer provides. Public hospitals are in deeper crisis now than ever. Waiting lists and queues are worsening, the promised primary care network has not been delivered and now this disgraceful Bill has been introduced. This is hardly a record of which the Minister should be proud.

The Government claims that the purpose of this legislation is to make savings and to reduce the State's drugs bill. For years, Sinn Féin Members and others in this House have called for greater use of generic drugs and for control of the gross profiteering by pharmaceutical manufacturers and distributors. The Government and successive Ministers for Health and Children from 1997, throughout this existing Government formation anchored by Fianna Fáil, have failed repeatedly to act. Belatedly, the Minister for Health and Children has moved on the issue of generic substitution. She also has promised to introduce a reference pricing Bill but it has not been published. Instead, she has rushed in with this legislation to penalise the least well-off for a problem that clearly is not of their making. There was no equality in the Minister's intent or endeavour to bring forward the reference pricing Bill as this was the easy option.

As I stated earlier, there is widespread agreement that the cost of medicines to the State must be reduced but it already has been shown that huge savings can be made without imposing prescription charges. Last February, an agreement between drugs manufacturers and the Minister for Health and Children made projected savings of €94 million in a full year. One should add to this the further savings that will be made through the use of generic drugs and reference pricing and then set that against the estimated €20.5 million that will be raised by these charges. While the figure of €20.5 million has been cited repeatedly, I note from the Minister's contribution at the outset of the Second Stage debate that she has added a further €3.5 million to it and now claims the figure will be approximately €24 million in a full year. These charges are, in my view, that of the collective Opposition and I daresay of at least some of those who sit on the Government benches, totally unnecessary from a budgetary point of view, as well as being unjust and unfair.

The Government would accuse the Opposition of not coming up with alternative proposals. However, Sinn Féin and the other parties have indeed come forward with such proposals. In Sinn Féin's pre-budget 2010 submission, The Road to Recovery, the party proposed measures to reduce the cost of medicines in the health system, including the establishment of wholesale distribution of drugs by the State. Based on figures provided to Sinn Féin by the Department of Finance, these measures would have saved €200 million annually, which is nearly ten times what allegedly will be raised by the prescription charges being introduced under this legislation. Ending the notorious co-location scheme would save €100 million in 2010 alone or nearly five times the revenue from the proposed charges. Moreover, I understand the figure would rise to approximately €400 million over a seven-year period. I note these are figures provided by the Department of Health and Children. Instead of making real savings and targeting the profiteers in the drugs industry, the Government once again has gone for the easy targets, namely, the elderly, the infirm and low-income families with children. All of this has been seen before and Sinn Féin has cautioned against it. We have repeated our challenge to it repeatedly and it is as shameful now as it ever has been before. It is doubly disgraceful in the face of all that already has happened to those families and individuals who are struggling to make ends meet.

Even at this late stage, on my own behalf and that of my colleague Deputies in Sinn Féin, I call on the Government and specifically on the Minister, Deputy Harney, to withdraw the Bill. If the Government does not do so, I call on every Deputy with a conscience to vote against this Bill at every point of its passage today. I want to see the same commitment to the interests of the 1.3 million medical cardholders in this State as was exemplified in recent weeks by Government backbenchers regarding other issues. It is time that Members began to address in a real and effective manner the terrible vista the Government has imposed and continues to impose on the lives of so many. Members will see whether the Fianna Fáil backbenchers have any backbone. While I do not know what to expect from their Green Party colleagues in government, 1.3 million people expect a result that will give them some breathing space and relief and that will not effect a further imposition and penalty for them to bear in an economic situation that is not of their making. I reject this Bill outright.

Much of the debate is focusing on broader issues than those with which the Bill is concerned. I might take the odd liberty myself in that regard. On medical cards and charging for prescriptions, my colleague, Deputy Reilly and others outlined what is happening in other countries where the trend is to row back on such an approach. I would like to know on what evidence the Minister based her decision.

When the possibility of a charge was first mooted in the past year, I agreed with it on the basis that it made sense and it might stop people from abusing the system. We are familiar with people who end up with too many unused medicines at home under the bed or on the locker. Those drugs go to waste. However, when I heard my colleagues speak at our parliamentary party meeting and in the House I realised that the research shows that certain people would be prevented from getting the drugs they need. We cannot allow that to happen as the consequences of it would be serious, especially for a person with a long-term illness. If such a person does not take his or her prescribed medication, he or she will end up in the accident and emergency unit. The Minister's approach is not correct. Perhaps she will respond to me on the matter when concluding Second Stage.

The addition of 50 cent to each prescription has been mooted but the fear is that the charge will not remain at that level. In the past three terms the Government increased most of the existing charges by means of stealth taxes in every budget. People did not realise how much stealth taxes had increased until 2008 or 2009 but it happened incrementally from 2002 up to the present. The fear is that the same thing will happen in this case; that the charge will start low and rise to perhaps €4, which adds up to a lot of money. Last year, we saw the effect on people's livelihoods of losing €3 or €8 in social welfare payments. It is a lot of money. In general, medical cards belong to people who are in the lowest income bracket. Others have it that probably should not have it and some people do not have it who should have it but the majority of people with a medical card are on low incomes so we are again hitting people on low income in this case.

I listened to a comment yesterday about general Government decision-making policy. Due to bad management in the Health Service Executive or a Department, we often introduce policies to correct bad management rather than fixing the management. In this case it is a combination of patients being allowed to abuse the prescription system and to get more if they get a chance. That could be the fault of the doctor, the Health Service Executive or the pharmacist. There are other ways of fixing the problem rather than introducing a charge. The response of most people is to introduce more legislation rather than to solve the problem in the first place. The other argument is that this is really only a sneaky way to make more money. Either way it is avoidable and does not necessarily need to be done.

I have seen many cases of that happening. Another example is where a Minister makes a statement that he is going to slash travel expenses for civil servants even when common sense might dictate that it should be done for a certain percentage. When one works out the travel arrangements in each office, it turns out that sometimes the rules are stupid and lack common sense. Money could be saved but the quick fix is to bring in a cut across the board. That is bad decision making policy to solve bad management rather than fixing the problem. We must address that issue as well.

I do not wish to say people have been conned for a long time in terms of medical cards and access to them but the doctor-only medical card is a good service if one still has income. People were led to believe that getting it would solve the problem but they must cope with exorbitant charges for drugs as well. The cost of drugs in this country is off the wall. I have listened to the Minister explain that it is the fault of the pharmacies or others. I cannot get my head around whose fault it is but if I am in France, Spain or another country, one can buy the same medicines for a quarter if not a fifth of the price. Something is wrong and I do not believe it is all due to the pharmacies making money. I have gone to pharmacies, talked to them and looked at their books. I agree that some make a lot of money but others do not. However, someone along the way is creaming it and people are suffering as a result. That must be examined.

I accept progress was made with the purchase of drugs by the Health Service Executive but, in general, people are not getting value for money and they are losing out. We must examine the matter. It is all very fine to say we will fix things. When the Minister was first appointed she talked about addressing the issue but I have not seen much progress in the area. This is an important issue. Members regularly have people come to their clinics who cannot afford to buy the medicine they need regardless of the drug payment scheme or the medical card. If one is on long-term medication, one has to spend €120 a month before one can avail of the free drugs scheme, which is a lot of money. It is €30 per week. If one is on the minimum wage that is almost 10% of one's take-home pay. We must examine the issue.

I understand there are budgetary constraints and that the Minister is trying to match everything up but ultimately we must look after the most vulnerable in society. We must also consider prevention. If a person becomes ill because he or she is unwilling or unable to spend money, the State will lose out because it will cost us more in the long run. The Minister knows that because she is an intelligent person when it comes to economics and figures.

My final point relates to health although not necessarily to the Bill. The Acting Chairman, Deputy Charlie O'Connor, who is from Tallaght, will understand why I must mention Navan. We have discussed the hospital in Navan many times through correspondence and in debates, not always directly with the Minister. It is an issue of great concern to people in the area. The Health Service Executive and the Department had a good plan to build a new regional hospital for the north east which makes total and utter sense. As a Deputy for the town I fully backed the proposal. I even agreed that if it meant that the hospital moved up the road or down the road I would accept that because it was the right thing to do for the north east. Now that project is on hold even though a site was picked. A lot of work was done and money was spent in order to make the decision. The project should be going through the planning process. It is capital expenditure, not current expenditure. We should not necessarily be cutting back on capital expenditure in times of recession. The work could be done easily through a public private partnership or through other mechanisms to raise funding. The construction of the hospital would not be a waste of money because that would provide jobs and one would get good value for it at the moment.

My party is in agreement that one has to cut back on current spending but not on capital spending. In the meantime, one has to keep five hospitals open whether one downgrades services or not. The Health Service Executive and the Department of Health and Children are all the one. At the end of the day the Minister pays the bills. It is taxpayers' money. The Health Service Executive is the Government. It is a pity that the impression has been created that there is a separation in that regard when it is not the case. It is clear that they are one and the same. The plans for the hospital should be going ahead in terms of planning permission. A public private partnership could be easily put together and the hospital could serve the people of the north east. If half the people of Meath, Cavan, Louth and Monaghan who need an operation must be put on a waiting list for a hospital in Dublin, there is something wrong. It is improper that people are waiting for two or three weeks in hospitals in Navan, Cavan, Drogheda, etc., before being given a bed in a Dublin hospital. The Minister knows it is wrong. We should try to make progress in this regard.

I accept it will take a number of years to build the facilities I propose. Let us engage in the planning process and commence construction. The facility will be good for the taxpayer and the economy because it will save money in the longer term, in addition to saving lives and making life much more convenient.

There are plans to reduce the accident and emergency services in Navan hospital over the coming months or year because of the opening of the new accident and emergency unit at Our Lady of Lourdes Hospital, Drogheda. I have always held the view that if a service is better and worthwhile, we must accept change that allows it to be put in place. However, nobody in my area believes the accident and emergency unit at Our Lady of Lourdes Hospital, Drogheda, can handle the numbers the HSE will try to put through it. Up to 30,000 pass through the unit in Our Lady of Lourdes Hospital, Drogheda, approximately 10,000 or 11,000 pass through the unit in Louth County Hospital and up to 20,000 pass through the unit in Navan hospital. This amounts to nearly 60,000, which is far too many to try to put through one accident and emergency unit, namely, the unit at Our Lady of Lourdes Hospital, Drogheda. The latter cannot cope with that.

In the past few weeks, when the accident and emergency unit in Louth has been closed, Navan has been used as a backup to the facility in Our Lady of Lourdes Hospital because the latter cannot cope with the numbers. I accept this matter is not part of this Bill and, therefore, I do not necessarily expect the Minister to address it today. I ask her to examine it in any case. It is not right that so many patients are being asked to attend one accident and emergency unit, thus extending waiting lists and generating the possibility that certain patients may not be treated on time. There is a perfectly functioning accident and emergency unit in Navan hospital, albeit in a cardboard box. The staff and the service they provide are excellent. The unit should be kept open for 24 hours per day. The Minister has a say in this and I ask her to intervene because my argument is common sense.

Is Deputy Durkan offering to speak?

I never refused an offer. If I am being offered time, I will be delighted to oblige. How many minutes do I have?

My colleagues are looking at me with disapproving glances so I had better not speak for 20 minutes. Does the Minister have a preference?

I ask the Deputy to stick to the Bill.

If the Chair wants me to contribute on it for 20 minutes, I will have no difficulty doing so.

It is always a pleasure.

This Bill is innocuous in theory. That is what it is meant to be because it is part of the PR exercise that now occurs daily in this country. The pretence is that it is but a small imposition that will not be felt by those for whom it is intended. The theory is that it is to generate greater respect for the services we provide, but that will not really be the effect. The Bill will generate even greater despair among a cohort who have been under attack for the past two and a half years. With each passing day, the cohort is attacked with increasing severity and consistency, each time with a more debilitating impact. One must consider this from the point of the view of the individual who may need to have recourse to a medical card or pharmacist, for reasons beyond his control, because he has contracted a particular health problem.

As I stated previously, the HSE has very many dedicated staff. There are many dedicated facilities which have had a particular task over the years. Some of these facilities are not being run to address the issues they were intended to address. I will not elaborate on this. There are facilities all over the country that are not being utilised. Hospital wards and beds have been decommissioned, as have various other facilities that were paid for by the taxpayer and which the taxpayer should now be enjoying by way of just reward. Instead of enjoying them, the public is now being admonished once again in respect of services it does not have and being told it should have respect for a particular service when it gets it. The public fully respects the services that exist and is grateful for them. It is when a service disappears that the public gets worried. That seems to be with increasing rapidity, or on a daily or weekly basis.

I do not want anyone to provoke me into a long rant on this matter. I have held the view for a long time that the HSE is now dysfunctional. We hear the continuous mantra that tough decisions must be taken. Decisions must be taken but they must be the correct ones. Sometimes decisions appear to be tough but they still must be correct. The kind of decision envisaged in the Bill does nothing more than pile more coals on the heads of those who are already being hammered daily. This is unfair and it would be wrong of Members on either side of the House not to acknowledge it.

Over the past two weeks, the consciences of Members on the Government side of the House were troubling them in respect of certain issues. They struggled with their consciences outside and inside the House and struggled within the parliamentary party and on the plinth. Gladly and gratefully, they overcame their consciences; their consciences do not exist any more and that is the sad part. The Bill before us demonstrates this.

All Members know from their constituencies that the people being punished daily can take no more. They have had it up to their eyes. Every time they get out of bed in the morning, if they can do so, they wonder what else is in store for them. They wonder whether they will be able to see and pay through the day and be alive at the end of it. They wonder whether they will be left waiting for a service in a hospital corridor, in spite of the fact that all the services are readily available if they were switched on.

The Acting Chairman will be glad to know I will not use my 20 minutes but I could do so.

The Chair has no view on that matter. The Deputy may proceed.

I believed the Chair was going to encourage me to conclude as quickly as possible.

Others would want me to but that is not my role.

This is not a personal matter. I concluded a long time ago that the HSE is not the ideal body to administer health services. I ask the Minister to revert to the old system, which was at least accountable to some extent. It was transparent to some extent and could be challenged. Members were able to receive answers to parliamentary questions on vital issues in the House daily. They did not have to wait three months for the parliamentary affairs division of the HSE to respond. Why there is such a division in the HSE, I do not know. This is the House of Parliament, where answers ought to be given and where information is supposed to be challenged. We should not have to wait at all.

I strongly opposed every measure in this Bill, as I opposed virtually every measure proposed by the HSE through the Minister, or by the Minister through the HSE, over recent years. I have long since concluded that the HSE is an unwieldy body. It is supposed to do a job that should be straightforward, simple and targeted, but it is not doing so.

Let nobody suggest that centres of excellence will solve all our problems. Every facility provided by the health service is supposed to be excellent. There is supposed to be no second, third or fourth level, or a level for the poor or others. All the services are supposed to be universal services of a high standard and readily available.

Over recent months, we noted the added irony of backlogs. There was a backlog for medical cards and one had to wait three or four months therefor. The Minister used to state that, due to an industrial dispute, it was impossible to answer parliamentary questions at the time they were asked.

In many cases, the unfortunate person on whose behalf a Deputy raised the question died in the intervening period. The Minister would add that, if the matter continued to be an issue, the Deputy could raise it with her again. Was this a suggestion that one would be inspired to the point of no longer feeling sufficient urgency about raising the matter in the House again?

I am glad to say that the Minister is even longer in the House than I am, but I am willing to follow in her footsteps. When someone raises by way of a parliamentary question an issue that affects the community at large or an individual, it is urgent and needs to be addressed with respect and within a specified period. There are no excuses for doing otherwise. Since entering the House, I have known of no answer being deferred because of a dispute. At every dispute during my time in the House, provision was made to ensure answers were given when required. This time, it suited the Government not to give answers because it did not need to spend money. It could postpone or adjourn everything. The books were better balanced, but only by not providing the services intended for a particular cohort of the public.

I pay tribute to the many great people and professionals within the HSE, but they are frustrated. They threw up their hands long ago and asked why they should be the ones carrying the responsibility when no one else seemed to be doing so.

In this and other services, the number of forms that must be filled up by an individual to get a basic service could be included on a single A4, but there is duplication and triplication. If anything is wrong, forms are returned after two or three months. More often than not, they are not returned to the Deputies who raised the questions, but to someone else. Eventually, the whole system will break down. More people are involved in recycling mounds of paper that are in danger of going on fire if they are not dealt with, but some of them have been sitting there for the past three months. I have not mentioned the issue of supplementary welfare, as it is not contained in the Bill, but it is a classic example. Supplementary welfare, rent support and so on are being recirculated in such a way as to make it impossible for the public to access a service that is justly theirs. The Acting Chairman will be delighted to know that I will not continue. This is my submission.

The Deputy should not believe that.

It is in deference to the Acting Chairman's wisdom that I will sit down.

Deputy Coonan is next and can also take 20 minutes.

The Acting Chairman is kind, but I do not intend to take 20 minutes. On behalf of the people I represent, I wish to register my protest against these proposals, in particular the imposition of 50 cent on prescription charges. While I do not want to go over old ground, the Minister referred to an overall ceiling of €10. I do not doubt her sincerity, but the Acting Chairman knows as well as I do that something might start at 50 cent, then rise to €1 in six months time. By this time next year, it could be €2. Equally, the cap could be increased.

We are getting off on the wrong foot. I agree with the sentiments expressed and I do not want to repeat anything, but this is another attack on the most needy in society. Lousy and mean spirited, it is intended to raise money, but money can be raised in other ways within the health services — for example, through savings, better management and efficiencies. I would prefer it were the Minister to tackle these problems. Many people who pay for medicine encounter a problem. After a certain period, sometimes a short one, their medicine becomes ineffective.

I will provide an example in which these problems — inefficiencies and ineffective medicines — are combined. An 11 year old named Jack suffers from autism spectrum disorder, ASD. Despite his age, he is taken by many to be 13, 14, 15 or even 16 years of age because he is a big guy. He is becoming more prone to violence towards himself, his family and his community. The medical experts realised that the drugs he was on were not working properly, so he was sent to a centre of excellence, namely, Limerick Regional Hospital, last April for an electroencephalogram, EEG. His mother had difficulty restraining him and getting him to the hospital because he goes berserk when he sees hospitals, doctors and so on. When he arrived, the EEG had suddenly become an electrocardiogram, ECG, because someone made a mistake. After the effort of getting to the hospital and staying there for most of the day, this difficulty could not be overcome, so he was sent away with a new appointment for last Monday. Jack was brought by his mother and grandfather to the hospital. Four people were needed to restrain him so that the doctor could administer a sedative. He was then left on his own for a considerable period. His mother was told that it would be at least an hour or an hour and a half before the effects of the sedation would wear off, but no one checked on him and she duly became concerned after 40 or 45 minutes about the sedation wearing off. She called a nurse, who informed the doctor, but the doctor believed otherwise. Jack came around after an hour or an hour and five minutes, could not undergo his test, became violent in the hospital and needed to leave again.

How will this child be brought into a hospital again? Is this the best way to administer assistance? Will the Minister investigate this case and the plight of people like Jack? In north County Tipperary, three people are in dire need of care. According to the experts and professionals, they should be on a shared care system, but the HSE cannot afford it because of cutbacks. There is no place for those people in Nenagh hospital and no one can administer the care because of the Government's cutbacks. Is this the type of service that the Minister is recommending to the public and over which she can stand this afternoon?

The service in the example was provided by one of the centres of excellence that we are told are the future, but Jack's mother was black and blue and bitten and his grandfather was in a similar condition when they got home. His mother is in dire straits. The HSE is providing Jack with three hours of care per week during June and July. If matters improve, something better might be provided in August. Three years ago, professionals stated that Jack should be on a shared care programme. Under such a programme, he would spend four days in and three days out of care one week and three days in and four days out the following week. Why can we not provide this service to people like Jack? Why must the other three people in my constituency who urgently require this service undergo the trauma of being left without it? These situations must not be allowed to occur and we must look after the most needy and vulnerable in society. I asked the Minister not to dismiss my contribution. She can check that the story is real. I am sure it is replicated in every constituency.

We need efficiencies in the service. We need a service that can be given to the people on the day they need it, not three, six or 12 months later. The proposals in the Bill are mean spirited and penny pinching. They try to attack the most vulnerable in society, the easy targets. The Minister should go after the people who have money and leave those on the bread line alone. The Government did enough to them in the budget. At this stage I ask the Minister to rethink her proposal in relation to the health services.

I am pleased to reply to the debate, because it was rather wide-ranging, and I want to thank all the Deputies who contributed.

I understand the position of the Labour Party and of Sinn Féin. However, I find the position of the Fine Gael Party incredible for the following reason. Fine Gael keep telling us that its FairCare health policy will implement in Ireland the system of universal health insurance that operates in the Netherlands.

It is only part of the system that operates there.

I protected Deputy English, so the Minister is entitled to make her contribution without interruption.

Deputy Kenny, for whom I have a good deal of respect, and Deputy Reilly, the Fine Gael spokesman, told us they visited the Netherlands and they intend to implement in Ireland the universal health care system that operates there, where all the hospitals are privatised and the insurers purchase services from the hospitals. Even in the Netherlands, however, people at the very bottom make a co-payment. I had this discussion only this week at a European Council Meeting with my Dutch colleagues because I wanted to ensure I fully understood what their proposals were. Those at the very bottom pay an annual sum of something in the region of €600 per family.

That is the Fine Gael plan for Ireland and it has not yet been costed. We were told there would be free primary care, which I estimated would add another €1.3 billion to the annual cost. There is an enormous hole in the Fine Gael plan. For the Fine Gael Deputies to say they would oppose a prescription charge of 50 cent per item, capped at €10, when they want to introduce the Netherlands plan into Ireland that has co-payments for every single person——

That is wrong. The Acting Chairman must correct this.

The Minister is entitled to make her contribution.

Deputy Reilly is now the deputy leader of his party. In the Netherlands, everybody makes a co-payment, as he knows. No group, no matter how low down the income ladder, gets its care totally free, and everybody makes a contribution. Families at the bottom make a contribution in the region of €600 per year, which is far in excess of what is being imposed here. I shall be honest and say we would probably not be doing this if we were not facing tough financial challenges.

This morning Deputy Kenny raised the subject of the McCarthy report and said it had put up a plan of €1.2 billion in the health area. We have not gone for everything in the report. One of its recommendations was to tender for GP and dental services, where it was estimated there would be savings in the region of €200 million to €300 million per annum. We have not done that, but it may be something that will have to be considered.

The McCarthy report, as has been acknowledged, recommended a €5 charge per prescription, which would have raised considerably more money, around €70 million. What we are proposing to raise here is €24 million. The purpose of this is not to stop people taking their essential medicines. Again, a 1998 Dutch study — and I commend the Oireachtas Library for the great research it has done on this — showed that a small charge of €91 a year did not affect people taking their essential medicines and did not have much of an effect on prescribing.

The difference between the two jurisdictions in Ireland, North and South, is considerable. In the South we prescribe more than three items per prescription. In Northern Ireland, which has the same demographics and the same type of population, they prescribe 1.79 items——-

That is for the entire population in Northern Ireland, not just one third of the sickest. Stop trying to be mischievous.

They cover the same number of people.

Yes, but it is for all the population, not the sickest one third.

Deputy Reilly will find it interesting that the out of hours service in Northern Ireland is about 30% of what we pay here for the same number of people.

What has that to do with prescription charges?

I am simply making the case that there are enormous cultural and other differences, even between North and South, where there is a similar population, in terms of——

That is a management issue.

——the number of items prescribed, whether it is on DPS or GMS. That is a fact.

Surely it was the Minister's responsibility to introduce that, and she has not done it.

Equally, they prescribe 83% generic medications, as distinct from 11% and 18% here.

Whose fault is that?

We have reduced the cost by about €350 million a year. There is a reduction in the wholesale margin, down from 17.6% to 10%.

I support the Minister on that one.

There is the reduction in the manner in which we pay pharmacists, which was introduced last summer. Again, that was opposed with both parties opposite arguing that it would close 400 pharmacies. It saves about €132 million a year. We negotiated a 39% reduction in off-patent medicines, which will save more than €100 million in a full year, and the last time the contract was negotiated, last year, with the pharmaceutical companies, more than €100 million a year was taken out of the sector.

The irony is that generics are more expensive on the Irish market than off-patent products.

We can use a lot more generics.

The contract is up for negotiation in September. For Deputy Reilly to suggest that we will save hundreds of millions of euro on generics is ludicrous, since the whole market in Ireland is €300 million. Unless the companies give us all the drugs free, we could not save hundreds of millions of euro.

It should be much more than that.

If we got everything free, then we would save €300 million. The total market for generics in Ireland is €300 million, equivalent to the total production.


If the Minister makes her remarks through the Chair, I can protect her. She is entitled to make her remarks without interruption.

She is not entitled to mislead the House.

She puts a spin on everything.

Spin away over there, but not while the Minister is speaking.

I did not interrupt anybody and I am more than happy to respond to all the points that were made.

No one stopped the Minister from interrupting.

In regard to reference pricing and generic substitution, we are going to legislate for that. Generic substitution in itself would not be adequate because as I indicated, we now have an ironic situation with generics being more expensive since our agreement with the pharmaceutical industry this year than the off-patent prices. That is a ludicrous situation and it will be dealt with in September when the contract is up for negotiation.

To be fair to the generic manufacturers, when we grow the market here through reference pricing, hopefully we shall see a much greater impact with regard to generic substitution in the Irish market. We have a very high level of prescribing by brand, compared to Northern Ireland, Britain and other European countries. That is why we need to give pharmacists the power to substitute, where the branded product is prescribed when there is a much cheaper clinically acceptable alternative that can provide the treatment for the patient.

There will be exceptions, as I mentioned. I understand there are issues highlighted by people with clinical expertise in this area with regard to people's swallowing capacity in respect of some generic alternatives. This will of course be facilitated. We do not want to put patients at risk but rather to drive down costs so that all the money we can assemble for the public health services can go into providing them.

On the question of how we shall reimburse the patients, the GMS Payments Board has data on all patients. If somebody, for example, is accustomed to going to a pharmacy and is, say, in another part of the country the computer system will make the link between the medical card patient and what he or she will have paid. The intention is that there will be a reimbursement. If somebody goes over by just 50 cent or a euro, will he or she be reimbursed on a weekly basis, or should it be quarterly? My officials, the pharmacy representatives as well as the HSE and GMS officials will discuss the mechanism to be employed from a patient protection viewpoint.

With regard to the issue raised by Deputy Reilly about the adult disabled, if somebody is financially independent, he or she is assessed for a medical card based on the financial circumstances. If somebody, such as a child in education or whatever, is not financially independent, he or she remains part of the medical card of the family and is included in the €10 cap scheme that is being imposed in this legislation.

With regard to groups such as the homeless — I am sure we shall deal with this on Committee Stage — it is not possible for a pharmacist or, indeed, a medical card to identify somebody in this position. Therefore we are not in a position to say whether a person is homeless. Sometimes people are homeless for temporary periods and it is not possible to identify the position. I should like to convey that to Deputy Jan O'Sullivan.

In regard to the wider issues that were mentioned, Deputy English referred to the hospital for the north east. The intention is to have a single new hospital for the north east. It was never the intention to have it before 2014-15, in fairness, and the economic circumstances have pushed it back, for obvious reasons. However, the short-term plan was to consolidate five into two, and have two hospitals in the region which would provide critical and acute care. Very few health systems in the world would provide five hospitals for the population base we have in the north east. To be frank, we could not provide the quality care one is entitled to expect if resources were spread across so many different sites. It would become impossible from a skills and competency perspective for those working in such a system.

Yet the doctors are moving from hospital to hospital between Navan and Drogheda.

I do not have recent data on patient volume but five years ago it showed 60% of patients went to Dublin hospitals for surgical procedures, bypassing their local hospitals. That is why we have to build up capacity in the north east.

That is over half the patients.

I have been reassured by the clinical directors, Dr. Brannigan, and Dr. Power and Dr. O'Neill that the new accident and emergency facilities at Our Lady of Lourdes Hospital will be capable of dealing with increased volume.

Can I just come in on this?

Now that the facility is open, the figures attending it will be high. I accept the doctors the Minister referred to believe it will be able to cope with these numbers. Will the Minister, however, take a fresh look at it as the numbers may be too high?

The Deputy should look at the throughput at Waterford Regional Hospital which has the busiest accident and emergency department after Tallaght hospital.

That is a very different case.

Yes, but we need all our hospitals to operate to best practice if we are to get the best possible care for our patients.

If Deputy Coonan sends me the details of the complaint concerning the family he raised, I will investigate it.

I must correct him on another matter. Limerick hospital is not a centre of excellence but a specialist centre. We want everywhere to be a centre of excellence and our health care system to operate the excellent standards we are entitled to expect, whether it is a GP's practice, a community long-term care facility or an acute hospital.

Is the Minister saying that Limerick hospital is not operating to excellent standards?

I said it is a specialist centre and everywhere should be a centre of excellence. Deputy Coonan implied there were only eight centres of excellence. He seems to be confusing the term "excellence" with "specialist".

There will be challenges in health service provision. Ireland spends 11% of its national income on health services, going by GNP data as GDP data is somewhat unreliable due to the large multinational presence in the economy. By international standards, Ireland's spend on health is very high. While we may not be at the top of expenditure league tables, we are still high up. We must continue to seek value. This year €1 billion was taken out of the public health service which will put enormous pressures on services delivery. The priority must be to minimise any impact on front line services.

Today, I had a frank meeting with the Brothers of Charity. It must be remembered the organisation has seven chief executive officers, however. We must look at overheads in providing services without being critical of any organisation.

Funding for the organisation's Limerick respite service is €25 million and the challenge is to find €150,000 for the service to be kept open. I hope it can be restored but it will be a subject on the Adjournment tonight which the Minister of State at the Department of Health and Children, Deputy Moloney, will address. I support his efforts to drive better value in that sector among public and voluntary providers. I know the organisations involved are keen to make that happen too.

The Health (Amendment) (No. 2) Bill 2010 is being introduced to raise a modest but not inconsiderable amount. The €24 million it will raise is twice the increase we were able to provide for home care packages this year. It is not unreasonable for medical card patients to make a small co-payment on their prescription medicines. The reason it will only apply to medical card patients is because other patients pay €120 a month under the drugs payment scheme. An exception has been made for those on the long-term illness card scheme which would not include diabetics. No new illness has been added to the scheme since the mid-1970s. Eligibility legislation is being prepared which will bring greater coherence to the medical card and long-term illness regime as there are anomalies with those illnesses defined in the 1970s and the emergence of new long-term ones.

The Minister has the capacity in the legislation to make exceptions but it is more appropriate that it is done by regulation. One area, for example, that I would like to cover but that is difficult to define is palliative care. Another possible exemption would be for women who had suffered symphysiotomy. I will examine these matters with my officials and deal with them through ministerial orders.

Question put: "That the words proposed to be deleted stand part of the main question."
The Committee divided: Tá, 77; Níl, 68.

  • Ahern, Bertie.
  • Ahern, Michael.
  • Ahern, Noel.
  • Andrews, Barry.
  • Andrews, Chris.
  • Aylward, Bobby.
  • Behan, Joe.
  • Blaney, Niall.
  • Brady, Áine.
  • Brady, Cyprian.
  • Brady, Johnny.
  • Browne, John.
  • Byrne, Thomas.
  • Calleary, Dara.
  • Carey, Pat.
  • Collins, Niall.
  • Connick, Seán.
  • Coughlan, Mary.
  • Cowen, Brian.
  • Cregan, John.
  • Cuffe, Ciarán.
  • Curran, John.
  • Dempsey, Noel.
  • Devins, Jimmy.
  • Fahey, Frank.
  • Finneran, Michael.
  • Fitzpatrick, Michael.
  • Fleming, Seán.
  • Flynn, Beverley.
  • Gogarty, Paul.
  • Gormley, John.
  • Grealish, Noel.
  • Hanafin, Mary.
  • Harney, Mary.
  • Haughey, Seán.
  • Healy-Rae, Jackie.
  • Hoctor, Máire.
  • Kelleher, Billy.
  • Kelly, Peter.
  • Kenneally, Brendan.
  • Kennedy, Michael.
  • Killeen, Tony.
  • Kitt, Michael P.
  • Kitt, Tom.
  • Lenihan, Brian.
  • Lenihan, Conor.
  • Lowry, Michael.
  • Mansergh, Martin.
  • Martin, Micheál.
  • McEllistrim, Thomas.
  • McGrath, Mattie.
  • McGrath, Michael.
  • McGuinness, John.
  • Moloney, John.
  • Moynihan, Michael.
  • Mulcahy, Michael.
  • Nolan, M.J.
  • Ó Cuív, Éamon.
  • Ó Fearghaíl, Seán.
  • O’Brien, Darragh.
  • O’Connor, Charlie.
  • O’Dea, Willie.
  • O’Donoghue, John.
  • O’Flynn, Noel.
  • O’Hanlon, Rory.
  • O’Keeffe, Batt.
  • O’Keeffe, Edward.
  • O’Rourke, Mary.
  • O’Sullivan, Christy.
  • Power, Seán.
  • Ryan, Eamon.
  • Sargent, Trevor.
  • Scanlon, Eamon.
  • Smith, Brendan.
  • Wallace, Mary.
  • White, Mary Alexandra.
  • Woods, Michael.


  • Allen, Bernard.
  • Bannon, James.
  • Barrett, Seán.
  • Breen, Pat.
  • Broughan, Thomas P.
  • Bruton, Richard.
  • Burke, Ulick.
  • Burton, Joan.
  • Byrne, Catherine.
  • Carey, Joe.
  • Clune, Deirdre.
  • Connaughton, Paul.
  • Coonan, Noel J.
  • Costello, Joe.
  • Coveney, Simon.
  • Creed, Michael.
  • D’Arcy, Michael.
  • Deasy, John.
  • Deenihan, Jimmy.
  • Doyle, Andrew.
  • Durkan, Bernard J.
  • English, Damien.
  • Enright, Olwyn.
  • Feighan, Frank.
  • Ferris, Martin.
  • Flanagan, Charles.
  • Flanagan, Terence.
  • Gilmore, Eamon.
  • Hayes, Tom.
  • Higgins, Michael D.
  • Howlin, Brendan.
  • Lynch, Ciarán.
  • Lynch, Kathleen.
  • McCormack, Pádraic.
  • McGinley, Dinny.
  • McGrath, Finian.
  • McHugh, Joe.
  • McManus, Liz.
  • Mitchell, Olivia.
  • Morgan, Arthur.
  • Naughten, Denis.
  • Neville, Dan.
  • Noonan, Michael.
  • Ó Caoláin, Caoimhghín.
  • Ó Snodaigh, Aengus.
  • O’Donnell, Kieran.
  • O’Dowd, Fergus.
  • O’Keeffe, Jim.
  • O’Mahony, John.
  • O’Shea, Brian.
  • O’Sullivan, Jan.
  • O’Sullivan, Maureen.
  • Penrose, Willie.
  • Perry, John.
  • Quinn, Ruairí.
  • Rabbitte, Pat.
  • Reilly, James.
  • Ring, Michael.
  • Shatter, Alan.
  • Sheehan, P.J.
  • Sherlock, Seán.
  • Shortall, Róisín.
  • Stagg, Emmet.
  • Stanton, David.
  • Timmins, Billy.
  • Tuffy, Joanna.
  • Upton, Mary.
  • Wall, Jack.
Tellers: Tá, Deputies John Cregan and John Curran; Níl, Deputies Aengus Ó Snodaigh and Emmet Stagg.
Question declared carried.
Amendment declared lost.

I declare the Bill read a Second Time in accordance with Standing Order 121(2)(i).