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Dáil Éireann debate -
Wednesday, 7 Jul 2010

Vol. 715 No. 1

Health (Amendment) (No. 2) Bill 2010 [Seanad]: Committee and Remaining Stages

SECTION 1

Amendments Nos. 1 and 2 are related and may be discussed together.

I move amendment No. 1:

In page 3, line 18, after "other" to insert "lesser".

As I said on Second Stage, this is a deliberately deceptive Bill. I emphasise that fact. The Bill's proponents and supporters point to the 50 cent per item charge and the €10 per month ceiling, but deliberately ignore the wording of section 1(1A) of the Bill, which states "or such other amount as may be determined by regulations made by the Minister under this section". The same phrase is repeated again in section 1(1B)(a).

Without question, this is the real meat of the Bill. We know that once these charges are introduced, they will be increased. There can be no question about that whatsoever. As sure as night follows day, there will be increases on the 50 cent charge per item and the ceiling of €10 per month within, no doubt, a reasonably short period of time. The amounts cited in the Bill are intended to be but the thin end of the wedge. The temptation is there, already excited by Mr. Colm McCarthy's statement of what is realisable in his opinion, and the opinion of others of like mind, out of the pockets of the most hard-pressed, deprived and marginalised sections of society. This is absolutely scandalous. While I am totally opposed to the Bill and the charges, if the Government is indeed determined to ram it through, it should at least guarantee that the charges will not be increased and that any change by ministerial regulation will be to reduce them or abolish them altogether.

This is the purpose of my amendments which insert the word "lesser" after "other". In other words, section 1(1A) would state: "or such other lesser amount as may be determined by regulations made by the Minister under this section." The purpose of the amendment is to restrict any change in this charge in the future to either a lesser amount than 50 cent or its abolition. In that event, the worst case scenario that will present with the Bill being forced through here this evening is that the charge will be 50 cent and cannot be greater. This is the challenge facing the Government and the Government backbenchers in particular. They have stated time and again, as has the Minister as I mentioned on Second Stage, that this charge is a modest charge. Let us retain this modesty and ensure we are not looking at something greater than 50 cent and the €10 ceiling per month at some point in the not too distant future.

Let us now follow through on the logic of the Minister's argument about a modest fee and on what Government backbench spokespersons are saying in their constituencies and in local interviews in the print and broadcast media. Let us test that now and let us hold the charge at what it is. We should only facilitate any future change that will either abolish or reduce the 50 cent sum. We must not leave the section open, as the current wording of the legislation does, for the Minister to introduce multiples of 50 cent as a charge on prescription items in the future.

I note from reviewing past contributions that the Minister for the Environment, Heritage and Local Government, Deputy Gormley, who was the Green Party spokesperson on health in the previous Dáil, has defended the charges on the basis that they are "modest". The Green Party and Fianna Fáil should follow through on this and ensure that we are not looking at a situation where this charge which is about to be introduced will end up in multiples in the not too distant future. I listened to the contribution of the Minister on Second Stage in which she mentioned a €24 million realisable return from the introduction of this charge in a single year. I have no doubt that the calculation in her head and in the Department of Finance, to which this matter will be entrusted in the future, is being made. Mr. Colm McCarthy spoke about a €5 flat charge per prescription item. That is ten times what is currently being proposed. Therefore, the sum is bound to be applied to the projected returns. I am sure ten times €24 million, €240 million, is a great temptation for the Government and the Department of Finance. The current thinking within the Government and the Department of Finance is that they should take the money from the pockets of the poorest, the most needy and the most dependent in Irish society. However, the Minister will be taking more than their money; she will be taking their entitlement to health. She will be absolutely breaking the resolve of these people on a range of different levels, even though many of them are already broken by the previous measures introduced by this Government.

Let there be no mistake about it — we must ensure this charge is restricted to this so-called modest amount and that there is no potential for the Minister or the Department of Finance, at any point in the future, to increase it and thereby impose further penalty on the most penalised and most in need in Irish society, that is, the 1.3 million people who are dependent on the medical card. I commend the amendments to the House. I appeal for the support not only of Opposition voices but also of Government voices. If Government Members consider these amendments to be worthy of their support, let them state clearly that they will not contemplate allowing an increase in the charge of 50 cent at any time in the future. It is a test of what they consider to be a "modest" charge. Let them hold to it by voting for this amendment when the opportunity is assuredly presented to them in this Chamber in a short while.

I support the Sinn Féin amendments. I am strongly opposed to the imposition of any charge on medical card holders, but if such a charge must be introduced these amendments would at least ensure the temptation to raise more than €2 million per month from the poorest of the poor and the sickest of the sick, via a charge of 50 cent per prescription up to a maximum of €10 per month per family, cannot be succumbed to by the Minister, Deputy Harney, or any future Minister.

When I spoke on Second Stage I did not realise there would be no Members of Fianna Fáil or the Green Party contributing to this debate. It is reprehensible that the only speaker on the Government side is an Independent Minister. It seems nobody in Fianna Fáil or the Green Party gives a damn about people with medical cards having to pay for their prescriptions. We have been extraordinarily exercised about dogs and stags in recent weeks and Members have received hundreds of e-mails from interested parties on either side of those debates. Yet this legislation is simply being nodded through as if it does not matter.

The reality is that it matters very much to people living on €196 per week, some of them with chronic illnesses and requiring vital medication. Many of these people are already counting their pennies at the end of the week and will now have to pay for medicines prescribed for them by professional medical practitioners who decide in their wisdom that they are necessary. People do not get a prescription from their GP just for the fun of it and doctors do not prescribe medicines for the fun of it; they prescribe them because, in their professional opinion, the patient needs them. As I said, we are talking about people living on €196 per week out of which they must pay for rent, fuel and groceries. In some cases they have higher costs because they have an illness or disability, and all of them will soon face higher fuel bills. Now they are being asked to pay this additional charge. These are people who did absolutely nothing to cause the problems this country is experiencing but they are the ones who must pay. I support any attempt at least to cap the charge at 50 cent per prescription or €10 per month.

Deputy Ó Caoláin referred to the Government's characterisation of the new charge as "modest". I cannot resist the temptation to refer to the savage indignation of Jonathan Swift in his treatise, A Modest Proposal, written in this city several centuries ago. In it he suggested that people might be expected to eat their children given the cost of raising them. He is not so far off the mark in that we are now reverting to a situation where we do not care too much if people have to scrimp and save in order to survive. At the same time those directly responsible for what has happened to our country are still living in their large houses. I am not referring in particular to politicians but to those who made decisions about loans, whether the developers who totally overstretched themselves to borrow vast sums they cannot now repay, the lenders who did not perform due diligence or proper risk assessment in granting those loans or the persons who were supposed to supervise all this activity in their regulatory capacity. All of these people are still living lives of relative comfort but the person on €196 per week is not.

Those who are ill and need a prescription will now have even less comfort because many of them are not exempt from these charges. They will have to find the additional money within very tight budgets. At least if these amendments are agreed they can know with certainty that the charge will not increase beyond €10 per month per family. We should not be dealing with this legislation today. It is absolutely disgraceful that there is nobody from the two parties in government willing to speak about the Bill in the Chamber when they got so exercised about wild animals, tamed animals, farm animals and so on. Animals need protection but so do human beings.

I support these amendments. I wish to refer to some of the points made by the Minister in response to issues raised on this side of the House. I spoke about individuals who may be away from home, on holiday or business elsewhere in the country, and have to renew their prescriptions. The Minister assures us that pharmacies throughout the State will be linked by computer and that the HSE's primary, community and continuing care directorate will be able to look after everything. The reality is that the HSE cannot even give people their medical cards on time or track where medical cards are at a given moment in time. I have very little faith that it will be able to achieve what the Minister has proposed. The Minister also claims there is no way of indicating on a medical card that a person is homeless. However, the old medical cards could be marked "NFA" to indicated that the holder was of no fixed abode. I am sure that system can be reinstated, particularly if we are to have the slick computer system to which the Minister referred.

The Minister spoke about the new accident and emergency department in Drogheda. The reality is that no matter how good the accident and emergency unit, it will not substantially improve the situation for patients if there are no beds for them once they have been assessed. It will not shorten the time spent waiting on trolleys. The Minister says the Government's expenditure on health is something to be proud of. I certainly agree there was a need for increased expenditure, but where is the reform of the HSE, which is the central component in the wastage of money that is occurring in this country? Why is the Minister not focusing on the great black hole that is administration in the HSE — Professor Drumm himself has acknowledged there are 2,500 to 3,000 people who do not even know what their job is — instead of targeting respite care for people with disabilities, the poor and the chronically ill?

I wish to correct the record in defence of the Brothers of Charity. They spend 4% of their budget on administration while the national spend in the HSE is 5%. The Minister is shaking her head but I saw the report yesterday and it is there in black and white. If she wants to challenge that figure, she should challenge it with the Brothers of Charity themselves.

With all due respect, I would believe them before I would believe the Minister.

Health outcomes are worst for the poor; that is a well known fact. It is completely bogus for the Minister to refer to Northern Ireland and to compare the NHS with our medical card system.

Our medical card system covers the one third of the people of Ireland who are among the sickest and lowest income earners, whereas the UK NHS covers all citizens across all income groups. It is outrageous to compare the two with regard to prescriptions.

The Minister referred to Holland. She is remarkably good at reframing the situation. The reality is that our health care policy, Fair Care, transposes some of the system in operation in Holland, not all of it. We have adopted some of the procedures in Northern Ireland with regard to waiting lists and we have adopted some procedures from the UK with regard to the model for giving hospitals and trusts some independence instead of central command and control in the HSE.

I strongly support the amendment. It is clear that billions of euro can be put into the banks at the drop of a hat but the Minister is prepared to use the poor as an ATM, to be raided at will. At €1 it would be €48 million, at €2 it would be €96 million and at €5 million it would be €240 million. We all realise where this will end up if the amendment tabled by Sinn Féin and supported by the Labour Party and Fine Gael is not accepted.

I support the amendment. I am sorry to see the Bill passing through the Dáil in any event. There are other ways the Minister could have saved the €24 million expected to come from this scheme. I refer to a drugs scheme in the past whereby if doctors issued prescriptions of cheaper drugs, they would be obliged to have their premises billed in respect of money paid back to the Department. Does this scheme still operate? Other measures could have been considered and savings could have been obtained from other schemes.

It is wrong to charge the most vulnerable people in society, those under extreme pressure already whose social welfare payments have already been cut. Such people are barely able to survive at present and now find they must pay an extra 50 cent per prescription up to €10.

The Minister must provide an exemption for people in nursing homes. We cannot allow a situation whereby such people, who are already paying 80% of their pensions and trying get by while their families try to support them, to prevail. The Minister must allow for exemptions. Who will administer the charge if they are unable to get medicine themselves? Many people in nursing homes are unable to do this themselves. I call on the Minister to make an exemption for people in public and private nursing homes. They should not have to pay this charge. It will not be easy for such people. In cases where medication is sourced for them, how are such people supposed to deal with the funding? This is wrong and I call on the Minister to do something about it.

The Minister refers to the limit of €10 per family. If a child is over 21 years and handicapped, he or she will not be included and will not be subject to an exemption. A given family could pay double, up to €20 per week. This matter should be carefully examined. The medical card charge is an attack on the most vulnerable and the weakest in society.

I support the Sinn Féin amendment on the basis that the charge will be forced through the Dáil. I refer to a valid point made by Deputy Jan O'Sullivan. The Deputy was correct to claim that last week people were concerned about stag hunting and were prepared to bring down the Government over the matter. Where are the members of Fianna Fáil, the Republican party, and the Green Party, which is supposed to defend the rights of the weakest in society, tonight? The Fianna Fáil backbenchers have already walked through the tunnel. They will do so again shortly to support this outrageous legislation. There has not been one word from one of them. They are all in favour of the measure. Last week they were concerned about dog breeding and stags but not at all concerned about the underprivileged in this country. Shame on Fianna Fáil, the Green Party and shame on anyone who could allow this to take place. If they believe animals are more important than people, I realise now why the people have turned on this Government.

I am not in a position to accept the amendment. The powers in the legislation will allow the Minister to set the charge at zero if he or she wishes to do so. The powers do not necessarily mean the charge will go up; it can come down, go up or be set at zero. The legislation indicates the issues to be taken into account, in particular the consumer price index, information on expenditure, the number of items prescribed, the medical needs and financial burden on persons who avail of the service and the necessity to control health expenditure. We will keep this matter under review.

I accept this measure is new and has not happened before. Deputy Reilly made some valid points about the patient populations in Northern Ireland and here. However, why is it 83% of items are prescribed in their generic form in the UK as against 18% under our GMS scheme? What is the reason for this? This is not to do with people who are sicker. The fact is our prescribing of branded products is extraordinarily high by any standards and, unfortunately, we must legislate to deal with that through reference pricing and generic substitution.

I refer to the wider issues. If someone moves and buys another prescription elsewhere, I am advised the computer system will be able to deal with this. With regard to medical card applications, among the reasons for the difficulties which arose this year were the industrial relations difficulties which operated throughout the public service. As Deputies are aware, many staff in the HSE, elsewhere in the public service and Civil Service, in Departments and other public sector organisations were engaged in industrial relations activities for a considerable time. Thankfully, that has now been suspended. This led to delays in the administration of medical cards and the centralisation of medical card applications, which is now proceeding to free up staff to carry out other duties. We cannot have it every way. We wish to reduce the burden of administration and bureaucracy but at the same time maintain all the various offices dealing with medical card applications. This is not the case with other social benefits and the approach operates successfully on a centralised basis in the case of welfare payments.

I believe the charge is modest. I accept a DPS patient pays €120 per month. Many patients in nursing homes are DPS patients who pay €120 per month, which does not pose a difficulty or challenge for the operators of nursing homes or pharmacies. Pharmacists are used to charging such people. I accept they have never before had to charge medical card patients but medical card patients may also receive items not covered under the medical card and would be accustomed to paying for these in a pharmacy environment.

Earlier, I stated that in an ideal world this would not be necessary. However, we must examine every possible option to control costs, which are rising here rapidly, in respect of the number of items being prescribed and the volume and cost of medication. Everything we are doing, including measures to address the off-patent price, the retail margin and the wholesale margin is to reduce the rate at which the costs are increasing. This year we will spend more money than last year because of the higher volume of items prescribed and dispensed, the ageing of the population and all the other factors of which we are aware and which affect the demand-led schemes, including medical cards.

I am unsure whether we have ever had as many medical cards in the population as at present. Some 1.55 million people are covered. In addition, we have the doctor only card, which has been allocated to more than 100,000. This amounts to 1.65 million people who have free access to their general practitioner either through the doctor only card or through the medical card. I refer to those who have a medical card and an LTI, long-term illness, card. For the purposes of certain listed drugs, such people would use the LTI card. Some 16 conditions are covered under the LTI card. I realise Deputy Reilly has tabled an amendment with regard to extending this which we will have a chance to discuss later.

Recent weeks have been troubling with regard to the matters to be addressed and some of the harsh measures presented. There have been occasional funny moments which have helped to keep our sanity in the midst of all of this. However, the Minister has cracked one of the funniest of all jokes that I have heard here for some time. I refer her suggestion to set the charge at zero and keep it under continuing review. If this were part of the Minister's intent, she would support the amendment. The logic is that the Minister would follow through by voting for the amendment. We seek to restrict the charge to what is proposed or less, including zero. This is a live option and one which I prefer. I would prefer if the legislation were never introduced but it is here now and we must deal with it. There can be hardly anyone in this Chamber who believes the Minister has any intention of reducing this figure any time soon and that any consideration will be given to such a proposition. The only thoughts in the heads of those who will have an impact on this charge in the future will relate to increases and how much more revenue can be generated out of the pockets of the most unfortunate in our society. Nobody is buying that.

The Minister referred to generic prescriptions and the comparison between figures for Northern Ireland, the neighbouring island and this State. That has nothing to do with what is proposed in the legislation. It is not the fault of medical cardholders that GPs are not prescribing more specific generic alternatives. This is something the Minister has to address and each of us, as health spokespersons, has indicated our support for every measure to curtail this outrageous expenditure. We note with alarm the Minister's suggestion that some generic alternatives have become more expensive than branded products. All of that must be wrestled with but it is not the fault of the medical cardholder and it has no place in this debate. That is part of what the Minister must do and I am addressing something she should not do, which is to take 50 cent out of the pockets of the poorest and most deserving in society for each prescription item they receive up to a €10 limit per month under the legislation.

There can be no question that this is a severe measure and the great fear of Deputies, and this Deputy in proposing the amendment, is that the figure will increase in the future. The Minister again used the word "modest". Deputy O'Sullivan said I had used the word but I was only referring to what the Minister and other Ministers have said. It is not a word I would employ and I do not see the measure in modest terms at all. However, in reply to contributions on this opening amendment, the Minister has used the word once again. Let us try to hold it at that. Surely if it is her view that this is modest and if it is, as she claimed, a live option to examine a zero charge in the future and that this will be kept under review, she should make sure that will be the case by accepting the amendment and using the word "lesser" as appropriate in two places in the opening section. Let us live up to that and let us hope that at some point in the future she will announce the reduction of this charge to zero. I will welcome that whenever it will present.

The McCarthy report presented a wide menu of options, which would have provided more savings than the Government decided on. Mr. Colm McCarthy did not say the Government had to introduce all the measures he suggested under different headings in each Department. The Minister will have done a great deal to reduce the cost of drugs when she introduces generic substitution and reference pricing. She does not have to be too zealous in embracing everything Mr. McCarthy suggested should be done in her Department. Other Ministers have managed to avoid making cuts proposed by him. The Minister will say the Department has behaved responsibly but it has been over zealous in responding to the report. It would have made more sense for her to review the impact of reference pricing and generic substitution to see if she had managed to achieve savings after a set period without having to hit those who will be affected by this legislation.

I question the Minister's assertion that by imposing a charge, behaviour will change and people will seek fewer drugs from their doctor, thereby saving money. Other countries have found that has not happened when adopting similar measures and that is one of the reasons Wales and Northern Ireland, for example, are going back on the measures they introduced.

The self-care movement in Britain is much more about people's motivation and need for drugs rather than behavioural change and that might be a more useful road to go down. The health supplements in many newspapers give a great deal of coverage to lifestyle, exercise, diet and so on and point out that addressing these issues can change people's dependence on drugs. I am conscious I am straying into an area in which Deputy Reilly is more expert but the State is more likely to reduce people's dependence on the use of drugs by getting through to them about how they think about themselves, how they behave and live, their lifestyle choices and so on rather than by imposing a blunt instrument such as a charge of 50 cent every time they fill a prescription. A better result might have been achieved and it might not have been as difficult for those on low incomes to have considered the changes reference pricing and generic substitution could bring rather than trying to do everything that Mr. Colm McCarthy proposed in one go while in the process inflicting financial hardship on them.

With regard to Deputy Ó Caoláin's comments, I did not say I would reduce the charge to zero but the Minister has the capacity to do so. In other words, an amendment is not needed to reduce it to zero, as that is provided for in the legislation. I do not want to mislead anybody and I did not suggest the charge will suddenly be zero in a few months. However, we need to establish how the provision performs over a period of 12 to 18 months.

I very much share the views put forward by Deputy O'Sullivan regarding lifestyle and so on. It challenges us all to lead healthier lives and to take exercise. Professor Drumm made a presentation earlier to the Cabinet sub-committee on health and I must ask him to make it available to the Oireachtas Joint Committee on Health and Children. He referred to Dr. Thomas Allinson, who is better known for his bakery than for practising medicine. He was a GP in the UK who was struck off in 1893 for recommending that smoking was bad because, apparently, at the time smoking was regarded as good for one's lungs. He recommended that people should exercise three hours a day, eat fruit and vegetables at least once a day, cut down on salt, not work too hard, avoid tea and coffee before bed and be teetotal. He asked people to stop smoking and he was brought before the medical council. He was struck off and then he opened a bakery. He wrote letters to the British newspapers advocating his recommendations. It is amazing how much has changed in the intervening years but, as we move forward, all these issues have to be reviewed.

The reason generic products are more expensive is the pharmaceutical industry, on foot of a request of mine earlier this year, reduced the cost of off-patent drugs by 39% and that reduced their price to below that of many generic drugs. We were unable to get that agreement from the generic manufacturers but their contract is up for renewal in September and we expect to get substantial savings. In any event we will have the legislation for reference pricing and generic substitution later this year, under which the State will set the price it will pay. If individuals want the branded product, they will pay the difference and pharmacists will have the capacity to substitute.

I am a strong fan of drug reviews. We currently have a pilot project in operation with a number of pharmacies and patients. I am not sure how many pharmacies are involved but it is being conducted during the months of June, July and August. We will have the data in the autumn. It will examine the medication across the approximately 100 patients who are part of the review. We are working with the community pharmacy sector on it. The intention is to use pharmacies and the skills of the pharmacists, as professionals in the health care sector, to a greater extent. As I mentioned previously, we had a good meeting recently with Dr. Barry White who is leading for the HSE on quality clinical care. He has a number of leading clinicians developing care pathways and I believe pharmacy has an important role to play in that.

I am conscious of the fact that we do not have additional money. We have effectively taken €1 billion out of the public health services and reduced the staff over the last four years by 4,000 but the number of procedures and treatments has greatly increased. That is a fact. We are trying to drive value and get more for less. The HSE's procurement is now probably the best that is operating in the public sector in terms of the value it has been able to drive. That is one of the big advantages of having a single entity — one has more muscle when procuring goods and services. That muscle is delivering more for less, be it in terms of legal or other services. We must continue to do that because next year will be a challenging year as well.

Deputy Reilly mentioned the Minister for Finance. The Minister for Finance is always involved with regulations that involve money, across all Departments. He is responsible for the public finances, so raising money or reducing one's charges must involve the authority of the Minister for Finance as well as the line Minister, in this case the Minister for Health and Children.

We knew the Minister was not seriously considering bringing this down to zero anytime soon and, sadly, we will not hold our breath with regard to her or her successors once this is passed.

The Deputy might be a successor himself. He should not be pessimistic.

Once it is passed, the temptation will be to keep it in place and to build on what has been achieved for the public coffers.

It merits repeating that it is often the case with regard to the most unpalatable proposals for the health sector that the Government is very happy to have the Minister carry the can individually. She is the line Minister and carries that responsibility at Cabinet but nobody here is in any doubt that this measure has the approval of the two parties in Government. Each has refused to participate in this debate. Not a single seat on the Government benches has been occupied throughout Second and Committee Stages to this point, except for during the vote at the end of Second Stage. It is absolutely disgraceful. People should note that nobody from either Fianna Fáil or the Green Party is present either to observe or to contribute to the debate on what is very important and most objectionable legislation. They have cleared off out of sight but, I hope, not out of mind for the many people who will be adversely affected when this legislation is forced through by their numerical strength in this Chamber. I will press the amendment.

Amendment put.
The Committee divided: Tá, 67; Níl, 75.

  • Allen, Bernard.
  • Bannon, James.
  • Barrett, Seán.
  • Behan, Joe.
  • Breen, Pat.
  • Broughan, Thomas P.
  • Bruton, Richard.
  • Burke, Ulick.
  • Byrne, Catherine.
  • Carey, Joe.
  • Clune, Deirdre.
  • Connaughton, Paul.
  • Coonan, Noel J.
  • Costello, Joe.
  • Coveney, Simon.
  • Crawford, Seymour.
  • Creed, Michael.
  • D’Arcy, Michael.
  • Deenihan, Jimmy.
  • English, Damien.
  • Feighan, Frank.
  • Ferris, Martin.
  • Flanagan, Charles.
  • Flanagan, Terence.
  • Gilmore, Eamon.
  • Hayes, Tom.
  • Higgins, Michael D.
  • Hogan, Phil.
  • 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.
  • Varadkar, Leo.
  • Wall, Jack.

Níl

  • Ahern, Bertie.
  • Ahern, Michael.
  • Ahern, Noel.
  • Andrews, Barry.
  • Andrews, Chris.
  • Aylward, Bobby.
  • Blaney, Niall.
  • Brady, Áine.
  • Brady, Cyprian.
  • Brady, Johnny.
  • Browne, John.
  • Byrne, Thomas.
  • Calleary, Dara.
  • Carey, Pat.
  • Collins, Niall.
  • Connick, Seán.
  • Coughlan, Mary.
  • 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.
  • McEllistrim, Thomas.
  • McGrath, Mattie.
  • McGrath, Michael.
  • McGuinness, John.
  • Mansergh, Martin.
  • Martin, Micheál.
  • 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.
Tellers: Tá, Deputies Aengus Ó Snodaigh and Joe Carey; Níl, Deputies John Cregan and John Curran.
Amendment declared lost.

Amendment No. 2 is the name of Deputy Ó Caoláin and has already been discussed with amendment No. 1.

I move amendment No. 2:

In page 3, line 32, after "other" to insert "lesser".

I am pressing the amendment.

Amendment put and declared lost.

Amendments Nos. 3, 4 and 5 are related and may be discussed together.

I move amendment No. 3:

In page 4, between lines 12 and 13, to insert the following:

"(a) a homeless person, or a person accommodated in emergency or transient accommodation by reason of his or her lack of an abode,”.

Section 1(4)(c) exempts certain people from the prescription charge. The Minister listed people such as children in care and those on methadone and she can make regulations to include other people in this section. Amendment No. 3 proposes that homeless people should be exempt and amendment No. 4 proposes including a person who is dependent on medication to such an extent that he or she would be at immediate risk of death or serious injury, including psychiatric injury, if he or she ceased to receive such medication.

It will be extremely difficult to collect the charge from homeless people. In many cases their lives are quite chaotic and they do not have money when they need medication. If they live in a hostel, they usually have an arrangement whereby the cost of the hostel is taken from their income in an organised way. It is unlikely many homeless people presenting at a pharmacy will pay the 50 cent charge. There will be great difficulty in collecting this. Homeless people come to see me, as they come to see other Deputies, on a regular basis. In some cases they do not receive social welfare payments because they do not have an address. They will not have the money to pay a prescription charge.

Also, many homeless people do not stay in the same place for any length of time. In some cases they must move around to where a bed is available. Sometimes they are put into bed and breakfast accommodation and in other cases they move from one area of the country to another. This will be very difficult to implement with regard to homeless people. I ask the Minister to consider the amendments. The Minister referred to the difficulty in identifying homeless people in the system but Dr. Reilly said there used to be a designation of no fixed abode for people with medical cards.

Amendment No. 4 is important because it concerns those at risk of death or serious injury, including psychiatric injury, if they do not receive medication. The Minister did not respond to this point during the debate on Second Stage. What is the pharmacist to do where they believe people are at risk if they do not receive medication and are not willing to pay 50 cent? What should the pharmacist do? I imagine pharmacists will be out of pocket because they will not deprive people of medication that is absolutely needed. It is not fair to pharmacists in circumstances where a person needs medication.

These amendments address real situations that will arise once the Bill is enacted. I want a proper answer from the Minister regarding those whose lives are at risk if they do not get their medication. Sometimes those people are not rational in how they behave if told they cannot receive medication without a 50 cent fee. There are real difficulties for the person trying to take the money from them and I ask the Minister to treat these amendments seriously and accept them.

I echo the comments on amendments Nos. 3 and 4 by Deputy Jan Daly. I mean Deputy Jan O'Sullivan.

I do not know who Jan Daly is but I will find out.

I hope she is not one of Deputy Reilly's patients or he will be in trouble.

Deputy Jan O'Sullivan is correct in her assertion about homeless people. Many have come through the psychiatric service and have serious psychological damage and psychological issues. They will not pay the 50 cent charge. Many are on psychiatric medication and will go off the medication and end up presenting a serious risk to themselves and others. They will end up in hospital, costing the State horrendous amounts of money. I remember this as a major issue in the greater Dublin area when I was on the health board and chairman of the psychiatric hospitals committee. When people moved from one service to another, they fell off the wagon, stopped taking their medication and did not present for further injectable medication called depot preparations. Many of these people are not prone to compliance because of the nature of their illness. When they feel well, they do not like the idea of attending for injections. They must be monitored. I see terrible trouble if we include those who have got better to the point where they can depend on medication and then create a block between them and their medication. This Bill is unwise but if the Minister is hell-bent on proceeding with the Bill, so be it.

It speaks volumes that not a single Member of the Fianna Fáil and Green Party coalition Government is in this Chamber for any part of the debate. They saunter in for the vote, yet they can get exercised and agitated about puppy farms and stags. The country is quite upset that when there are so many important issues, these are the matters we spend what little time we have discussing, notwithstanding that they are important in their own right. This is particularly true of puppy farms.

Psychiatric patients represent a major issue. I alluded earlier to the long-term illness card. Most people with medical cards have dispensed with their long-term illness book a long time ago. Those with medical cards and with illnesses covered by the long-term illness book will be seriously disadvantaged unless the Minister accepts these amendments. There is no harm in these amendments; they empower the Minister. I note the Minister has the power to exclude other groups by ministerial directive. If she made it clear these groups were excluded in the legislation, it would go some way to protecting the most vulnerable in society. Those I would like to see covered include those with a mental handicap or mental illness, even though this only applies to those under 16 in respect of the long-term illness card, phenylketonuria, cystic fibrosis, spina bifida hydrocephalus, diabetes mellitus, diabetes insipidus, haemophilia, cerebral palsy, epilepsy, multiple sclerosis, muscular dystrophy, Parkinsonism, conditions arising from thalidomide, acute leukaemia and high blood pressure. I also wish to include cancer care, asthma, congestive cardiac failure, chronic obstructive pulmonary disease, Crohn's disease, lupus and Huntington's disease. Many of these conditions are not even on the long-term illness scheme although they should be. The entire thrust of this measure is not simply about raising money. The Minister has been talking about trying to improve prescribing or at least to discourage the concept to which Deputy Jan O'Sullivan referred previously, which often is described as taking a pill for every ill, rather than looking to oneself and one's own lifestyle issues to address some of the problems one develops as a consequence of smoking, drinking too much, being overweight etc. If one wants to get away from this by including a prescription charge, that is one thing. However, to have a prescription charge apply to those who absolutely need their medication and, in its absence, whose chronic illnesses or condition will deteriorate, thereby necessitating hospitalisation, simply does not stack up or make sense.

Although I do not believe Members will get to it, I wish to give notice that I would table an amendment that also would cover people with disability who are adults. At present, as Deputy Ring and I pointed out previously, a family of two parents who have medical cards but who are getting on in years and who look after their intellectually disabled child, who may now be in his or her 40s, will face a maximum of €20 and not €10, per month. Consequently, they also should be included. In addition, I had hoped to include nursing home patients because notwithstanding the Minister's comment that there are many private patients in nursing homes, many such patients have medical cards and are on extremely limited incomes. They are the very people who are likely to have the full ten or 20 items on prescription but they are going to lose out. As already has been pointed out, they now have very little spare money as the fair deal scheme takes 80% of their income to pay for all their other needs, including clothing, therapies or any form of social activity and this measure will hurt such people and hit them hard.

Moreover, as Deputy Jan O'Sullivan mentioned earlier, this Bill raises an issue for pharmacists in respect of how they will manage to collect this money and how they would make decisions to deprive people of their medication, were they to fail to collect 50 cent from them. This simply does not stack up and somewhere along the line, they also will be obliged to bear the burden in this regard. In addition, this will not do anything for the pharmacist-patient relationship. Members have frequently discussed the massive issue pertaining to compliance. All doctors have visited people's houses in which one opens up the wardrobe, only for a load of stuff to fall out on top of one that has not been used. This is a huge issue, as is getting people to take their medication. People are not always as upfront with their doctors as they might be. Someone with high blood pressure might have been put on five different tablets because one is trying to chase after them but then one discovers the patient is either taking none of them or does so sporadically. Alternatively, people might swap and change their medication with their spouses and doctors come across all such scenarios. Compliance is a huge issue. It will not be achieved in the absence of a good relationship and the pharmacist must maintain that relationship with the patient.

As it is 6.55 p.m., I do not wish to take up any more time. I ask the Minister to indicate she is prepared to accept these sensible amendments that affect the very people who should be encouraged to keep taking their medication. They should not be penalised for being compliant with their chronic condition medication, which saves us money in the long run by keeping them out of hospital.

While appreciating the shortness of time, I support the three amendments tabled in the names of Deputies Jan O'Sullivan and Reilly. In the Bill, the Minister specifies two categories of people who will be exempt from prescription charges, namely, children in care and people in receipt of methadone on prescription. Obviously, I support those exemptions as I wish to see everyone exempt. However, why did the Minister make these choices and not others? It is not obvious from the legislation or any comment by the Minister. As I noted, I want to see all categories exempted and that is the critical argument.

I agree with Deputy Jan O'Sullivan's amendment to exempt homeless people and those in immediate risk of death or serious deterioration in their medical condition, were they not to receive their medication. Deputy Reilly's amendment lists approximately 24 medical conditions that he proposes to exempt and I also support this. It would go some way towards ameliorating the impact of this legislation. However, a far better approach, on which all Opposition Members are of one mind, even with their respective amendments, would be to not adopt the Bill at all. My final appeal to the Minister is that even at this late stage, she would accept that this Bill should not be passed.

Before concluding, I have one question for the Minister. This measure is supposed to save money and is about raising and saving money in the context of the overall health budget. How does the Minister justify the continuing practice by the HSE of entering into contractual arrangements with local developers for the provision of primary care facilities when significant idle space already is in situ in HSE-owned buildings, including local hospital sites? I have never seen, and am unaware of the existence of, a directive to the HSE from the Minister or the Department stating the primary care facilities must not or cannot be located in existing acute hospital premises or other hospital facilities. The Minister should clarify this matter.

I refer to the just-exposed instance in Carlow where, at a cost of €1,000 per day, that is, €365,000 per annum, the HSE has acquired access to a newly constructed building to provide primary care facilities even though there is idle space aplenty within the local hospital site that could accommodate such services. This story is replicated in many locations nationwide and this constitutes waste and is where real savings could be addressed. It entails better HSE management to ensure there is no waste of money and not to penalise the poorest, that is, the medical card holders across the State. I refer to senior citizens and those who, because of their income base, are entitled to a medical card. To penalise them now would be an absolute disgrace.

Co-payments are in operation from Australia to the United States and in many European countries. There is no evidence to suggest that when people make a co-payment, they do not take their essential medicines. I referred earlier to research from Holland in 1998. The reason I included children in care is that as the HSE pays for those children, there is no point in having a circular movement of the money in which one would be obliged to reimburse foster care parents or children in institutional care where medication is procured on their behalf.

For obvious reasons we want people to take their methadone. Those patients are a definable group. I have some sympathy with the homeless. Homeless people living in hostels or in institutional accommodation will not be obliged to pay the charge because their medication is procured by the institution on a generic medical card for the institution and the charge will not apply there. I would have wished to have excluded other homeless people but they are not identifiable. This has been confirmed by the HSE. I have the power under regulations to look at categories of people for exclusion, for example, women who have had symphysiotomies or thalidomide sufferers, because they are identifiable, or perhaps asylum seekers who only get €19 per week because of the direct provision. These are categories of people we can exclude. The vast majority of people with mental illness, psychiatric patients, do not have medical cards and do pay for their medication.

Senator Feeney made the point in the other House that we need to eat and drink to survive and there is no suggestion that because people have to pay for food, they do not buy it.

They eat the wrong kind of food.

It is wrong to assume, and there is no international evidence to suggest, that if people require essential medication that they are not going to get it because there is a small co-payment.

Will it always be small?

As it is now 7 o'clock and in accordance with an order of the Dáil today, I am required to put the following question:

"That sections 1 and 2 are hereby agreed to in Committee; the Title is hereby agreed to in Committee; the Bill is accordingly reported to the House; that the Fourth Stage is hereby completed and the Bill is hereby passed."

Question put.
The Dáil divided: Tá, 78; Níl, 67.

  • Ahern, Bertie.
  • Ahern, Dermot.
  • 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.
  • Cregan, John.
  • Cuffe, Ciarán.
  • Curran, John.
  • Dempsey, Noel.
  • Devins, Jimmy.
  • Dooley, Timmy.
  • 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.
  • McEllistrim, Thomas.
  • McGrath, Mattie.
  • McGrath, Michael.
  • McGuinness, John.
  • Mansergh, Martin.
  • Martin, Micheál.
  • 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.

Níl

  • 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.
  • Crawford, Seymour.
  • Creed, Michael.
  • D’Arcy, Michael.
  • Deasy, John.
  • Deenihan, Jimmy.
  • English, Damien.
  • Feighan, Frank.
  • Ferris, Martin.
  • Flanagan, Charles.
  • Flanagan, Terence.
  • Gilmore, Eamon.
  • Hayes, Tom.
  • Higgins, Michael D.
  • Hogan, Phil.
  • 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.
  • 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.
  • Varadkar, Leo.
  • Wall, Jack.
Tellers: Tá, Deputies John Cregan and John Curran; Níl, Deputies Emmet Stagg and Joe Carey.
Question declared carried.
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