Deputy Ó Caoláin is in possession. Unfortunately, as he has not arrived, we have to move on to the Technical Group. Deputies Richard Boyd Barrett, Thomas Pringle, Seamus Healy and Catherine Murphy are sharing time.
White Paper on Universal Health Insurance: Statements (Resumed)
I welcome the opportunity to speak on this issue. Having looked at this White Paper, I believe it is not a White Paper at all. It is, in fact, a Green Paper simply dressed up. While the policy statement that, in future, access to health services will be based on medical need alone is obviously welcome, there is little or no detail to allow for a forensic examination of the actual proposal. Therefore, we are at a huge disadvantage.
This appears to introduce what is effectively an additional tax on the public, a tax on top of the local property tax and the water tax, so we will now have a third health tax. There is even a difficulty in regard to that because the Minister, Deputy Reilly, suggests it will be in the region of €900 to €1,000 per person, while the Minister, Deputy Howlin, says it will be in the region of €1,600 per person.
The Minister, Deputy Howlin, never said that.
These are huge impositions on top of families and individuals who are already hugely hard pressed by the cutbacks and the reductions to services introduced by the Government.
It is suggested in the paper that medical card holders will be subsidised. This brings us to the whole question of medical cards. We have to wonder which individuals will have medical cards at the end of the current process of chaos and policy change in the medical card area. The fact is the Government has changed the policy in regard to medical card eligibility and there is absolute chaos in this area currently.
I come across very difficult cases every day, as I am sure every other Member of this House does, where medical cards have been withdrawn or refused which would have been granted in the past. I will give some examples. I came across a gentleman lately who lost his medical card because he was 8 cent over the limit. I came across a single person on an invalidity pension who had a small occupational pension of €10.25 per week and lost his medical card despite his total income being €213 per week. I came across a very ill young person who is wheelchair bound, has regular epileptic seizures and is suffering from cerebral palsy, but that person's medical card was withdrawn. I come across numerous individuals almost daily who have had medical cards all their lives but whose cards have been refused and withdrawn in the last 12 to 18 months.
There is no doubt that discretionary medical cards are no longer being granted on medical grounds and that the Minister and the HSE have changed policy in this regard. There is great difficulty for individuals who have chronic and serious medical conditions who always had medical cards but whose cards have been withdrawn or are being refused due to the question of new applicants.
There is no change in policy.
The other point that appears to be clear from the document is that there will be no extra funding provided for the health service. This brings me to another situation which arises every day throughout the hospital services, namely, the very difficult and chaotic situation in regard to patients on trolleys in hospital emergency departments. I refer specifically to the atrocious and unacceptable position at South Tipperary General Hospital which I have described previously as having Third World conditions. On Tuesday of this week, there were 29 patients on trolleys and on chairs in the emergency department and in the corridor of the emergency department, in the corridors of the hospital and in the main public thoroughfare of the hospital. The patients have no privacy and inadequate or non-existent bathroom and toilet facilities. That situation, which is totally unacceptable, has pertained for quite some time. In fact, in 2011, when this Government came to power, there were 750 patients on trolleys in the hospital and in 2013, there were 3,100 on trolleys, so the figure quadrupled in that period.
This simply cannot continue. We have a situation where the hospital has lost €11 million of its budget since 2008 as well as losing more than 100 staff. The staff are working above and beyond the call of duty every hour of every day, and they simply cannot cope and are struggling to provide a safe service. I call on the Minister to approve immediately the application which he and the HSE have received from the hospital management and the HSE south east management for the opening of an additional 12 bed step-down unit at Our Lady's Hospital, Cashel, to alleviate the difficulties that are seen daily at South Tipperary General Hospital. It is simply unacceptable in this day and age. I urge the Minister, as I urged the Taoiseach during the week, to intervene immediately in this situation and to solve that problem.
Universal health insurance is another con. It is another regressive tax to be imposed on people who are already struggling and already burdened with a massive tax burden, whether it is the universal social charge, all sorts of indirect stealth taxes and charges, bin charges, the planned water charges, VAT on everything people buy or parking charges. On top of all that, the Minister is going to land them with another flat regressive tax to pay for something they have already paid for through their taxes.
The Minister will be asking them to pay all of this money for a health service that is crumbling. It is extraordinary. This is a health service that has been butchered by the Government and by the Fianna Fáil Government before it, where we have €3 billion taken out of the health service and 10,000 staff gone, including thousands of nurses, where consultants in Dublin's leading hospitals say the hospitals are unsafe, where there is an ongoing crisis in accident and emergency and where we have enormous waiting lists for operations and huge numbers - hundreds of thousands - waiting for consultant appointments. To add insult to this injury and this shambles of a health service, the Minister is proposing to pile on top of that a new health tax. It is scandalous.
It is like so much we get from this Government. It is the pie-in-the-sky, so-called reform which in reality is just another austerity attack on ordinary people, particularly low and middle-income people, to the benefit of the usual gang of corporate, for-profit cronies. That is what this is really about. It is about using the atmosphere of economic crisis to privatise the health service and hand it over lock, stock and barrel to the private health insurance companies and the vultures who are moving in on private health care. This is possibly best symbolised by the recent takeover of the Beacon Hospital by one of the country's richest men, Denis O'Brien. One knows that something is going on when these people start moving into health because it is an opportunity to make yet another buck on the back of the misery suffered by ordinary citizens.
When one talks about universal health insurance, the first two words sound lovely and, of course, everybody is in favour of them. Universal health and a single-tier system are what everybody wants but when one adds on the critical word "insurance", one gives the game away because what one is really talking about is the private, for-profit sector moving in on health to make a profit. We know from the US and the Netherlands, home to the so-called Dutch model, that when one moves towards universal health insurance, vast amounts of money are sucked out of the pockets of people and front-line services into the pockets of overpaid executives and overpaid consultants and go towards the costs of billing, advertising and all the paraphernalia that goes with private, for-profit, market competition. The US spends almost twice as much per capita on health than any other country in the world but about 40% of what is spent goes on administration, executive salaries, advertising and billing. That is where it will go.
The question the Minister must answer is how much profit these companies will make. Why should they be making profits at all? How can the Minister possibly justify anybody profiting out of our health service when we all know that front-line services are crumbling? Could he explain how this is logical, justified and fair when everybody knows that what we need are nurses, ambulances, new equipment, primary care centres and drugs that are affordable for people. We need the actual service that keeps people alive and healthy. That is where we need to put the money into but as with Irish Water and waste services that were privatised, the Minister wants to put the money into the pockets of private companies who will make a very significant margin.
Once that profit motive is introduced, the idea that the system is single tier will disappear into the mist. While there may be a basic basket of services that the Minister will force people to pay handsomely for against a background where the money going into front-line services is totally inadequate, those people with money will pay for premium insurance cover and get extra services because they can afford to pay for them. That is what happens anywhere the private, for-profit sector operates. The alternative to this is a national health service model where everybody has the right to health care from the cradle to the grave, there is no private, for-profit interest involved, and the entire system is paid for through central taxation. One then does not need vast administration and vast amounts of advertising. Money is not sucked out for profits and executive salaries. The money is paid for through the taxation system administered by Revenue. Is that not more logical, more efficient and fairer?
I welcome the opportunity to contribute to the statements today on universal health insurance which have come about from the publication of the White Paper by the Department of Health in the past week or so and the discussion on universal health insurance. The one thing about the White Paper is that there is very little information that allows ordinary people across the country to figure out what universal health insurance will mean for them. There is very little information about what it will cost to allow the citizen to see how they can budget for it. There is very little information about what will be included in and excluded from the so-called basket of care. This is one of the key points that will be very significant in respect of universal health insurance coming into effect in the first place.
The Minister has made much of how universal health insurance will be the panacea for our health services. The first worrying thing in the White Paper is the fact that the Government has stated that it will be achieved without increasing expenditure on health. That is not possible. There is no doubt that the health services are in crisis and we need to find a way to fund them and provide equal and fair access for all our citizens. However, we cannot do that without providing extra funding for the health service. Even if the health service became more efficient and dealt with waiting lists and the treatments that are required for patients who need them, it would cost more money. If we ended waiting lists, it would cost. We would get better outcomes and it might work out cheaper for the State in ten or 15 years' time when less serious illness has accumulated because of the lack of waiting time to get treatment, but there is no doubt that it will cost more money. The contention that it can be done more cheaply is the biggest falsehood in respect of universal health insurance because it cannot be done. What will happen under universal health insurance is that the money will be directed away from the health service and towards the profits of private companies and people who want to make money on the back of citizens who require health care.
The Minister intends to establish hospital trusts which will be paid for services by the health insurers. Effectively, we are going to hand over control to the health insurers so we will have the VHI and if we are lucky, we might have two other providers who will dominate the market and control what they pay for the services to the hospital trusts who will try to deal with the patients on their books through the funding they get from private health insurance companies. The State will even take a back seat and be dictated to in terms of what it must contribute. We are handing over total control of our health services and this is seen as being a progressive step and something that will be good for our citizens. I think it is an absolute disaster, it should be scrapped and it should never have got to the stage of being the subject of a White Paper because it will not deal with any of the issues. I would like to think that the Minister believes that it will resolve the issues and difficulties within the health service but there is no way this will happen. If the Government gets back into office and is able to roll out this service, we will be sorry five or ten years down line that we ever did it and will try to roll back from it again.
The Minister talks about how the provision of universal health insurance will not cost the Exchequer any money. Let us look at the case of Letterkenny General Hospital, which is probably one of the most efficient hospitals in the country. Something like 93% of patients dealt with at the hospital are non-elective so it is run very efficiently and effectively, yet the hospital began the year with a deficit of €6.5 million. If universal health insurance comes into effect and there is no extra Exchequer funding and no extra cost to the citizens of the State, how will Letterkenny General Hospital be able to survive and provide the treatment it currently provides with a deficit?
The only way that can be done is by restricting access for people who require health care and treatment.
Then we come to the basket of services that will supposedly be available under the standard insurance package. We simply do not know what is going to be in that basket. Another worrying aspect of universal health insurance is that the Minister has already provided for a basket of top-ups. What we will quickly see is movement from the standard basket into the basket of top-ups because this has happened elsewhere. It has happened in the Dutch model of health insurance where services such as physiotherapy have been moved to a top-up payment. Is that what we are going to see here? I would like to hear from the Minister whether MRI scans and such like will be in the standard basket or the top-up basket. Those are the kinds of things that will move very quickly once universal health insurance is implemented. That is the real risk with this system.
The Government has said that universal health insurance will be gradually rolled out, with full implementation by 2019 at the latest, which is four and a half years from now. That sounds good, but the Dutch model, which no one except the Minister is holding up as a model to aim for, took 20 years to implement. The Dutch worked at it for decades but the Minister has said he will do it in four and a half years. When the Dutch model was introduced first in 2006, there were 18 insurance providers for a market of 20 million people, but today there are only five.
The market is 17 million.
Sorry, 17 million people. Still, there were 18 insurance companies in the market in 2005 and today there are five. We have 4.6 million people with three or four insurance companies. How will consolidation not take place? How will consumers benefit from this universal health insurance model? Even if I believed this was the way to go, on pure market terms, we cannot provide for competition or fairness for consumers in a market of our size with so few providers, given that in a market five times the size of ours, the number of providers has fallen by 80% since the implementation of this model. This model cannot work. I hope it never sees the light of day. I hope it stays as White Paper and goes no further.
That is the most likely scenario.
If one is to get good outcomes, it is important to have a good process, but we have skipped one of the fundamental processes here, that is, the Green Paper. The Green Paper should have asked what we want and how we will pay for and deliver it. There was a widespread expectation that when this Government took office, there would be very significant changes to the vehicle that delivers most of our health care, the HSE. From now on, people will measure what will be done on the basis of what has happened with the HSE. In essence, the HSE is underpinned by a 19th century health board system with a layer on top. This Government put another layer on top of that instead of radically reforming it. I accept that the current Minister inherited the system but it is in need of radical reform and the Minister said so before taking office. It has not been radically reformed and there is no sign of that happening.
People are asking what vehicle will deliver the health service. I do not believe we have had an NHS moment but we need one. We must look at this in a very broad way, from primary care right up to the most technically advanced units in our hospitals. I want to see a system where medicine is free at the point of delivery and where people are seen on the basis of being a patient rather than a consumer. I believe that we do have to pay for health care but we are already paying quite a sizeable amount of taxation. People are asking me what PRSI is actually for. There used to be a health levy alongside PRSI but they were amalgamated. We are still paying PRSI which now includes a health levy. Then the question is, what is the universal social charge for? What do we get for that? Now we will have universal health insurance too. There is also the new term, "basket" but no one knows what it is in it, which is part of the flaw in this model.
In essence, for many people, this is just another way of extracting taxation and they are not quite sure what they will get for it. Some Ministers have suggested sums of €1,000 or €1,600 which may well be way wide of the mark, but we do not know for sure. It is interesting that this Government is always hugely concerned about uncertainty in the context of the financial markets, for example, but in the context of individual household incomes, people also need certainty. Such certainty is essential, especially given the recently published survey by the Irish League of Credit Unions on levels of disposable income in Irish households. We need to know what will be in the basket. We also need to know whether it will be a tapered or cut-off model, as with the third level grant system. We need to know what services will be provided.
What is going to happen in the meantime? As colleagues have said today and as I have said to the Minister during Topical Issues debates, we are seeing sick people at the moment struggling to get medical cards while also seeing the roll out of medical cards for children under six, which may or may not work. Ideally, I would like to see children under six being able to go to their GP for free. However, I spoke to the Minister previously about a man who is on dialysis who does not have a medical card, although he is making an argument for one. I know of a child who is just over six and who is being PEG-fed. Crumlin Hospital would not discharge her until she had a medical card because she would not get services from the public health nurse without one. Recently, I spoke to a man who had his leg amputated. A public health nurse and occupational therapist arrived at his house and the very first question they asked was whether he had a medical card. Once they discovered he did not have a card, a line was drawn under his case and they said "cheerio", because they could not deal with him. That is the reality for people at the moment.
I am not sure what is going to be delivered from this and I have no confidence in the HSE. I put that on my election leaflet in 2007 which was not appreciated at the time as I was not re-elected. However, I still do not have confidence that the HSE is the vehicle to deliver this. The HSE needs radical reform if we are going to have a vehicle to deliver a decent health care system. That system must be underpinned by a decent primary care system in order that we can keep people well and out of the more expensive hospital system. Unless we get that right and have the right vehicle for delivery, people will resent paying for it. They will feel there is waste in the system and that they are paying for that waste. They had an expectation that the waste would be addressed before they were asked to pay more. I do not believe there is a person in this country who does not want to have confidence in our health system but what is being talked about at the moment is seen by many people as an additional tax rather than something that will pay for a predetermined system that they buy into. I do not believe people will have confidence in this. There are so many mixed messages coming out of this that I do not see how the Minister will build confidence and bring people with him on it. People do not know exactly what they are going to get.
Fáiltím roimh an deis labhartha ar an ábhar seo agus cur isteach ar an díospóireacht.
I welcome the opportunity to speak during these statements on the White Paper on universal health insurance. The previous speaker made a good point about having confidence in our ability to reform the health services. We will achieve nothing if we do not have that confidence. If we do not believe it can be done, to quote the Minister for Finance, we may all pack up our tents and go home.
We must have confidence and there is good reason for having it. I have sat in this Chamber for three years and have heard people decry the health system and predict its collapse. Over recent years, €3 billion has been taken out of the health service which now has 10,000 fewer staff. Many Deputies said the system would not work, but in fact there has been an 8% increase in the number of procedures carried out in hospitals in the past 12 months. People can therefore have confidence in the health system. Collectively, we have a responsibility to share that confidence. People should make the distinction between management and policy because this is a policy shift.
If someone falls down in Bantry General Hospital this evening, it is not the Minister's responsibility, nor is it his job to manage that hospital. His job is to bring about a policy to reform health care. The Minister has a responsibility, and rightly so, to taxpayers who are funding the health service to the tune of almost €14 billion. We must examine what we do and how we do it. Throwing more money at a problem is the political solution to everything, but who will pay for it? Will it be taken from the education or justice budget? We must have radical reform, so I commend the Minister on this initiative and I look forward to seeing it working. I also look forward to being part of that solution, rather than highlighting the problem.
I think everyone in the House accepts that the current system is not working as it should. We inherited a dysfunctional health system, but the question is what we will do about it. It is easy for people to complain about micro issues and say the system is not working. They all know about a lady on a trolley or an ambulance that arrived late. However, we must become part of the solution by supporting the Minister, the Department of Health and the HSE in bringing about the type of changes that are envisaged in the universal health insurance plan.
When there is a change of Government, people wonder if there really will be change or will it just be the same old same old. One of the most striking aspects of health policy since this Government came into office is how it views small hospitals. The day after I was elected, there was a big protest in Clonakilty to keep the local hospital open. At the time there was major unease in many communities about the future of local hospitals. The public rightly have an attachment to small hospitals. The Government sees such hospitals as a solution rather than a problem. It has decided that the only way to take people out of the chronic queues in major centres is by moving patients out to smaller hospitals, with money following the patient. The viability of local hospitals is not built on sentiment or community pride but on practical, procedure-based work. The future of the health care system is to move as many patients as possible from large centres to smaller ones. Hospital trusts have been established to do that. Consultants are no longer appointed to a single big hospital, be it in Galway or Cork. In my own constituency, hospitals in Bantry and Mallow are part of the hospital trusts. A consultant will spend one or two days per week in smaller hospitals to carry out procedures. This significant development is clearly paying dividends and showing great promise for the future.
As it currently exists, private health insurance is a major issue which is spiralling out of control, and the costs cannot be contained. Fewer people are availing of it, it is top heavy with those who are likely to use it, while those unlikely to use it are not paying into it. No Government policy can secure the future of private health insurance. The fundamental basis of any insurance policy is that one has a large broad base of subscribers, which is no less the case to ensure the survival of private health insurance. That cannot be done in the current climate, however, because it is optional. Fewer people are opting into it, so it just does not work. It is going to collapse on its knees, which is what has brought about the idea of making universal health insurance compulsory.
One of the keys to the success of, and building confidence in, UHI is the elimination of waiting lists. The only benefit for people with private health insurance, if they can afford to pay for it, is that they can gain access to health care more quickly. I commend the Department, the HSE and the Minister on the successes to date in eliminating waiting lists. There have been some substantial reductions involving people waiting on trolleys and waiting lists generally. There is a long way to go to get to where we want to be, but I am confident it will happen as a result of the measures being taken, which include co-sharing theatres and discharging 24-7.
In many hospitals, if a patient comes in for a private procedure and is ready to leave on a Thursday, the next person is due in the following Monday. However, there is every chance that bed will be gone with an accident and emergency case over the weekend, so the consultant will not have a bed for his or her private patient. The Minister has eliminated a lot of those issues by tackling them head on. That is showing significant results, with a 95% reduction in the numbers waiting over eight months for procedures.
Universal health insurance is about fairness, equity and ensuring everyone has access to the health service irrespective of their means. Everyone will contribute also. It is nonsense to say that people who do not have health cover will not have to pay anything, because they are paying anyway through the taxation system. They will also have free general practitioner care as part of the wider health reform plan. People who are paying GP fees at the moment will not have to do so.
The objective and overriding goal of UHI is to reduce the overall cost of the health care system by 15%. That will be a significant reduction in what is a massive bill. The current contribution of €1.5 billion from private health insurance will be spread over the population on a fair and equitable basis.
No one in this House and no commentator outside it has a monopoly on the right thing to do for the future. There is an onus on us, however, to engage rather than just criticising and objecting. It is nauseating to see some of the people who presided over the health system for the past 14 years, and who walked off the stage leaving a crumbling health service for us, now criticising a genuine plan to fix it. I would back anyone who criticised us for not having a plan, but not vice versa. Of course, any plan can he held up to scrutiny and debate, but opposition for the sake of it does not do any favours for the future of our health system. I appeal to Members of the Opposition to engage in this UHI plan and support health service staff. Morale is important for the practitioners in our health care system.
Everyone agrees that health service practitioners, including hospital staff, are superb, as is the treatment they provide. They deserve our support, encouragement and confidence concerning this significant reform. We have already touched on the issue of ambulances. My own constituency has seen real reform of the ambulance service through the reconfiguration process. Ambulances have now moved from being on call, whereby one could wait up to 20 minutes to have an ambulance mobilised, to being on duty sooner.
We must address the issue of ambulances being delayed outside accident and emergency departments. This is especially so in a large county like Cork where two or three ambulances serving the west Cork area could be outside an accident and emergency unit at any one time. Irrespective of the nature of the call, ambulances must collect patients and take them to an accident and emergency unit. These issues are being addressed and will form part of the overall solution to providing better health care.
There are many good examples of health care. Unfortunately, I have had first-hand experience of the health care system in Spain due to a serious traffic accident some years ago. It was superb and there were some notable differences in the Spanish system. One difference that has always stood out in my mind was that in Spain, they had very few nurses on the ward. They were more top heavy with doctors. In addition, family members were expected to come in to help the patient wash and eat in the morning. In the case of elderly patients, it was a particular requirement that the family would be there to contribute. We are, therefore, examining many such health care models.
I look forward to the introduction of universal health insurance, which is one of the most inspiring, innovative and imaginative reforms that I have seen. I am proud to be part of a Government party that is driving that reform. I wish the Minister, his Department and the HSE every success with this proposal.
I am grateful for the opportunity to speak on the debate. I agree with a great deal of what Deputy Jim Daly has already said. My understanding of the proceedings is that they are intended to provide Members with an opportunity over a couple of days to give their opinions and thoughts at the outset of this process. Listening to the last half hour of speeches, it seemed the Deputies wanted to know nothing more about the issue or to see the plan ever get off the ground. A range of problems were raised, but the most basic questions were never asked as to what they were going to get out of this. They have never offered any solutions or alternatives. They are saying they do not like the health service as it stands or what the Minister is offering, but they cannot tell us what they would do differently. They talk about a new tax. I wish I had the luxury of using the same speech no matter what topic was under discussion in the Chamber. Whether it is business, health or education, we hear the same speech.
The Minister's plan is hugely ambitious and he is very motivated about it. It is something he has always wanted to see come to fruition. My concern is the perception of it. People do not have a strong belief in our health service although that is something the Minister is driving to change. We discussed ambulances services last night and there are issues in certain accident and emergency departments across the country. It is a question of trying to marry the Minister's expectation of where the health service can go with what is happening on the ground. There is a great task there and the Minister has set out a road map as to how it will be completed over the next number of years. It is not as if the plan will be implemented next Monday morning. People have an opportunity to partake in the process.
There is an issue among the public. I recently attended an active retirement group in my home town, Mountbellew, and I asked the 40 people in attendance if they believed they would see universal health insurance in the next five years. Only two people put up their hands to say they thought they would. That must be considered against the backdrop of the issue people have within private health insurance and what they see as the problems with the health service. This is a hugely ambitious programme and one I firmly believe can be realised as long as it is taken in an orderly, step-by-step process. To do that there has to be a starting point, which is what today's debate represents. I understand from what I have heard from the Minister and read in the newspapers that the public will be allowed to make submissions on this. That is hugely important. I encourage everybody in every age category to have a say as to what should be contained in a universal health insurance policy.
We can learn from what has happened in countries where this has already been rolled out. There is the Dutch model and other European approaches. We can take into account the concerns and issues which have been raised. A previous speaker said the Dutch model took 20 years to come to fruition. What we are trying to do is to take the good parts from that model and work on those parts which did not work. It should not take us 20 years to do it. We should learn from our colleagues in Europe how best to roll this out.
There are concerns about what will be covered by a universal health insurance policy. While I do not expect the Minister to be able to answer the question today or even within the next six months, it is important that we set out a road map as to how all this can be achieved. It is important also to set out a road map as to how the hospital network and primary care centres will fit in. There is an issue currently involving general practitioners and the contract for under sixes. The point that came across to me in my discussions with general practitioners is that they want to see investment in primary care centres. They can do a lot more work in that context, which would free up a lot of our hospital resources.
It would be remiss of me not to mention Portiuncula Hospital. The Minister will have expected me to say this. It is a hospital which has been underutilised. The Minister is a great believer in moving more services to smaller hospitals. Portiuncula Hospital has a very bright future under the system the Minister envisages, as does Roscommon County Hospital. They can take on a great many of the smaller procedures and free up University Hospital Galway to function as a centre of excellence.
I welcome very much what the Government is attempting to do. It has my full support. I will take part in the process. I urge the public to do the same. More than that, I urge the Opposition to explain, if it has a problem with what is proposed, what it would do differently. The Opposition should cost it differently if it can rather than simply tell us it does not like the health service now and does not like the plan. It is fair enough if that is what it really believes but there is an onus then to give the Irish people a third option, cost it and show how it will work. Otherwise, Members of the Opposition should join in the process and help us to deliver a better health service.
Deputy Jim Daly referred to the establishment of hospital trusts. I am amazed in regard to the specific trust concerning the Cavan-Monaghan hospital group that we are not linked with the Mater hospital. The Minister, Deputy Reilly, knows as a medical doctor and a politician that there is a huge affinity, working relationship and pattern of Cavan people accessing tertiary health services at the Mater hospital. Whenever I have an opportunity to visit a patient there, I am always struck by the number of Cavan people I meet who are accessing services. I do not know if the Minister approved the trusts or if that was done at HSE level but I presume they are set down in stone at this stage. Whoever devised them made a significant mistake in failing to allow Cavan General Hospital and Monaghan Hospital to continue that great tradition of work and accessing of services at the Mater hospital.
Regardless of what funding system is put in place in future, I am anxious that we ensure it is proofed at cross-Border level. The Minister will be aware of the huge potential we have to deliver services on an all-Ireland basis. Representing two Ulster counties, I am aware of the great potential we have at Cavan General Hospital and Monaghan Hospital to work with Enniskillen hospital. Sligo General Hospital also has that opportunity. The Sligo and Letterkenny hospitals can work with Altnagelvin as well. I hope that whatever funding system emerges, it ensures no obstacles are put in place to the collaboration that exists and the potential for greater co-operation on the island in the provision of services.
Not for the first time, the Government has presented the House with a debate which is wrongly titled. Today's business is stated to be on the White Paper on universal health insurance but we are actually making statements on a Green Paper. Let us look at the standard parliamentary definition of a White Paper:
White papers are documents produced by the Government setting out details of future policy on a particular subject. A White Paper will often be the basis for a Bill to be put before Parliament. The White Paper allows the Government an opportunity to gather feedback before it formally presents the policies as a Bill.
I contrast that with the standard parliamentary definition of a Green Paper:
Green Papers are consultation documents produced by the Government. Often when a government department is considering introducing a new law, it will put together a discussion document called a Green Paper. The aim of this document is to allow people both inside and outside Parliament to debate the subject and give the department feedback on its suggestions.
What the Minister has produced more closely resembles a Green Paper than a White Paper. It raises many more questions than it answers and, certainly, indicates that we are a long way from implementation. A Government Minister was quoted in the national media recently as saying:
He [that is the Minister, who should have been referred to properly] has been allowed to call it a White Paper. He needed that at least but the reality is how is it a White Paper. A White Paper is something you produce when you are ready to go into the Dáil with legislation.
Is it a named Minister?
Of course not. It is easy to quote anonymously. Dúirt bean liom go ndúirt bean léi.
It is not a named Minister and unfortunately he or she did not refer to Deputy Reilly by his proper ministerial title either. I do not like that.
For the Deputy's information, the definitions he referred to are from the English Parliament not the Dáil.
I did not say they were not. There are parliamentary procedures which are quite common to parliaments throughout the world.
It is common to the Commons.
The Minister's White Paper falls a long way short of the programme for Government commitment which stated that a White Paper on financing universal health insurance would be published early in the Government's first term. We were told it would review cost-effective pricing and funding mechanisms for care and set out the care to be covered under UHI. We are now in the fourth year of the Government's term, which is not early by any stretch of the imagination. Not only is the White Paper late, it lacks any concrete information as to how it will be financed and how much it will cost people if the policy is every implemented. The truth that the Minister and his White Paper miss is that universal health insurance does not equate to universal health care.
What the Minister is proposing here could end up being very expensive for the already hard-pressed middle income earners. All of us who are public representatives know very well that many additional burdens have been placed on the cohort of people who do not have any more to give to meet extra demands. The White Paper fails to provide clear and concise answers to a range of other big questions, such as what will happen to primary care if the Minister gets his way, and whether, by introducing free GP care, the Minister will effectively make every GP a public servant.
There is no doubt our health system needs further reform so all patients receive health care on clinical need, but there needs to be a real national debate on how best to achieve this. A national debate can contribute to arriving at the proper architecture. There is a need to assess whether the Dutch model, to which the Minister so often refers, is suitable for the Irish health system and whether in reality it will result in better health care. When the Minister was in opposition we constantly heard him refer to the attractions of the Dutch model. While the system has some positives it also has some major negatives, as outlined by two Mullingar general practitioners, Dr. Wilkinson and Dr. Brennan, in an article they wrote some time back for Forum, the journal of the Irish College of General Practitioners. They quote the Commonwealth Fund report which ranked the Netherlands second to the UK in its ability to provide same or next day appointments to patients. Although, as they point out, Ireland was not included in this comparison, anecdotal reports from the UK suggest that waiting times for appointments in general practice are shorter in Ireland than in Britain. Will longer GP waiting times be the price of Dr. Reilly's expensive system? Those of us who flick through the news channels when we come home late at night see reports on the British channels of the difficulties people there have in accessing not only hospital care but immediate and ready access to general practitioners. It is a real problem. There is also a problem in some parts of our country, but not the delays we hear about in other countries.
Of more concern is the fact the report rated Dutch patients as second most likely to be hospitalised due to a complication after discharge. As the doctors themselves state, this may be a side-effect of a Dutch health care system where hospitals are paid per patient treated and procedure performed. Dr. Wilkinson and Dr. Brennan quote one of the Dutch delegates to the European Society for Quality and Safety in Family Practice, Dr. Veld, who concedes the Dutch system has its downsides. He states the basic insurance package is expensive and the costs of premia have increased by 40% over a four-year period. Not only have the costs increased but the content of the packages has already been reduced with a range of treatments and medications, such as ulcer drugs, tranquillisers and anti-depressants, being withdrawn and discussions are taking place on how the packages may be reduced further. Dr. Veld sees a threat to risk equalisation as insurers may alter the conditions for supplementary packages for people with pre-existing conditions, making it harder for such patients to change from one insurer to another.
A medical system funded by insurance companies ensures a competitive market. This is acceptable when it comes to routine procedures such as cataract surgery or hip replacements. However, Dr. Veld highlights the ethical issue of hospitals competing financially in their ability to manage life-threatening conditions such as cancer care, which could compromise treatment as a result. As insurers try to source the cheapest generic drugs, many patients obtain pills with different brand names or boxes every three months. The Minister knows better than the rest of us in the House this can prove distressing for patients at times, particularly older people, and compliance is compromised as a result.
The Deputy would have us pay a premium price for the brand leader.
I am not suggesting that. I suggest that at times people are concerned about a change in the particular drug they take.
The 2010 Dutch Health Care Performance Report discusses the fact that insurance companies mainly compete to limit the cost of health care services, with quality of care being of limited influence. This is a worrying feature of an insurance company-dominated health service. These are not the only issues with the Dutch model but couple these problems with major questions about how the system would be financed and how much extra burden would fall on individual patients and one must ask oneself whether this is really the right model for us to follow.
This is the question Fianna Fáil asked approximately one year ago when Dr. Brian Turner, an economist in University College Cork, prepared an independent assessment for us on what universal health insurance would mean for our citizens. In his report, Dr. Turner concluded it is far from clear the introduction of universal health insurance, as envisaged by the Minister, Deputy Reilly, would be of benefit to the Irish health system.
He went further, and stated, "There is simply insufficient evidence from international systems to suggest a change in the funding mechanism would produce benefits sufficient to justify the disruption that such a change would cause, and indeed there is some evidence to suggest that such a move would lead to higher costs for the Irish public without significant improvements in health outcomes."
Like all of us, he supports the goals of creating a single-tier health system, removing financial barriers to accessing GP services and reducing waiting times for hospital treatment but, like Fianna Fáil, he fears that what the Minister proposes will not alone fail to achieve these objectives but that radically redesigning the funding mechanism would entail additional costs. This fear of massive additional costs would seem to be borne out by estimates from the Department of Public Expenditure and Reform that this new charge could cost up to €1,600 a year per person.
According to the White Paper we are discussing, every member of the population will purchase a universal health insurance policy from his or her preferred insurer and this policy will provide cover for a comprehensive package of health care services. The package or basket of services is not outlined in the White Paper. It will be the subject of consultation. Neither are their costs as these will not be provided this year. The White Paper states that over the coming 12 months the Department will undertake a major costing exercise to ensure a full and comprehensive analysis of the estimated costs involved is available. However, the Minister, Deputy Reilly, claims we cannot know the costs because we do not know the tax rates which will prevail in 2019. This is fairly clear to all of us.
What is not clear is Fianna Fáil's policy.
We are discussing the Minister's White Paper, and from some commentary it appears to be the Minister's White Paper rather than the Government's White Paper.
We have a vacuum on the other side of the House and it is not a Dyson.
That is not true. We are discussing the Minister's White Paper. Why, in his fourth year in office, could he not provide costings based on 2014 prices and tax rates? It is very clear from the contents of the White Paper the practicalities of universal health insurance have yet to be clearly established. It is clear the Government does not know the balance of funding for universal health insurance between tax revenue, co-payments and insurance premia.
What did Fianna Fáil do for 14 years in government?
There were serious difficulties in many areas-----
You made a complete hames of it.
The Deputy has only a minute and a half remaining.
There were many improvements.
Fianna Fáil had 14 years when it could have fixed it. Instead it wrecked the economy and the health service.
Many improvements were made and the Minister railed against some of them with regard to cancer reorganisation. I hear some of the Minister's party speak laudably about the cancer treatment services available throughout the country, and they are right to laud them, but many members of the Minister's party opposed the changes when they were made.
Forget about the 569 people who lay on trolleys on one day after 14 years in government.
The Minister is selective.
No I am not.
I could give him figures also.
You would not even count the number of people on outpatient waiting lists. Tens of thousands of people were waiting years.
Deputy Smith without interruption please.
People cannot get on the waiting list now because they cannot get an assessment done.
They can and we measure it.
The Minister should speak to the people waiting for an orthopaedic assessment in the north east.
Yes.
We table parliamentary questions but we do not receive answers. People are not even called for an assessment.
They are.
It is hard to get on a waiting list if one is not even called to be assessed.
Fianna Fáil did not even count them.
I will not take the figures the Minister selectively quoted. We can all select statistics from a particular day or month to suit the argument we are putting forward.
Let us talk about the relevant statistics. The previous Government did not even have waiting lists for outpatients.
The Minister quoted figures from January and February 2011 when there was a huge number of admissions to hospitals because people were afflicted with injuries due to the climate conditions and harsh weather. This could apply in any particular year and it can be cyclical.
Last week the Minister was in Cavan.
He saw the improvements that have been brought about at Cavan General Hospital on foot of the substantial investment that was made in new facilities at the hospital between 2000 and 2010. He will be aware that many of the additional services which have been provided at the hospital were not available ten or 12 years ago. That creates extra demand on the hospital. I am sure some of those involved at management level at the hospital had an opportunity to mention to the Minister last Friday that the accident and emergency unit needs new facilities. The number of people attending that unit has increased on foot of population growth in the area and the downgrading of services at Monaghan General Hospital. I hope the Minister will ensure the proposal to provide new-build facilities is advanced as quickly as possible through the HSE. The next time I table a parliamentary question to the Minister on this issue, which is of great importance to the people of Cavan and Monaghan, I hope he will be able to give me a more positive response than I have received up to now.
I would like to share time with Deputy Heydon.
Is that agreed? Agreed.
I welcome the opportunity to contribute to this important debate. Health services should always be a priority for any politician or public representative. This debate is well worth having.
I wondered about certain things as I listened to Deputy Smith's contribution. His party was in government for 14 years, at a time when unprecedented levels of money were available. I do not normally play politics, especially when we are discussing health services, but unfortunately I have to say it was very hard to listen to the Deputy's criticism of this Government. At a time when a very restricted budget is available, the Government is trying its damnedest to reform the health system in the best interests of patients. The previous Government did not avail of the opportunity it had over 14 years to reform the health service, to put the patient first and to deliver a service we can be proud of.
It is sad to have to say there is a two-tier health system in this country, but we all know that is the case. Under this form of health apartheid, those who can afford the high cost of private health insurance can access essential health services while those who do not have enough money have to remain on waiting lists for long periods of time. The progress that is being made on waiting lists, in spite of the budgetary restrictions we are facing, will not suffice in the absence of major reform of the health service. We need to put the patient first and treat him or her as the priority.
We need to make the best possible use of the resources in the health sector to deliver a high-quality and efficient service of which the people can be proud. Reform does not come easy. It involves change, as we all know. Change often leads to concern, doubt and uncertainty. I do not underestimate the challenge the Government is facing as it seeks to introduce universal health insurance. I believe all public representatives have a responsibility to be honest and open with the electorate. The health services should not be used as a political football, especially at this time.
The publication of the White Paper on Universal Health Insurance gives us a welcome opportunity to engage in a debate on this issue. Under the proposed health insurance model, the State will have to play an important role in protecting those who are most vulnerable. It is acknowledged in the White Paper that the State's role will involve paying for children, students and people on medical cards and their families and subsidising those on low incomes. All insurance companies will be required to offer a standard package of health insurance that will cover all key services, such as hospital care, GP care and maternity care.
The system of community rating that is to be introduced will ensure that no insurance company can discriminate on the basis of age, sex or health status. The State will also be responsible for regulating the system and ensuring safety and quality are maintained to the highest levels. It will also be responsible for funding services that will not be covered by universal health insurance, such as long-term care, mental health and disease prevention. Public hospitals will remain under public ownership. They will be given much more freedom to run themselves. That is to be welcomed.
I have mentioned some of the challenges that exist. A public debate on the primary care sector is taking place at the moment. The Government has given a commitment to deliver free GP care to those under the age of six. Its long-term intention is to deliver free GP care for all. I appreciate that there is a genuine intention to be proactive in terms of health. The best place to do that is on the front line in the communities. GP practices should have a role in educating and building health awareness within our populace so that we do not have to react to long-term illnesses like diabetes at a later stage. Substantial resources can be required to deal with complicated illnesses that develop at a later stage of life. GPs on the ground are voicing their concerns. As I have said, change and reform are always accompanied by uncertainty.
I ask the Government to reassure the public that a quality primary care service can and will be delivered through GP practices, which will require resources. Everybody knows there is capacity and flexibility in the system to introduce specialist nurses in areas like diabetes care. Rather than taking up the time of our GPs, we should train our nursing staff to deliver services in specific areas of expertise. The same thing applies to consultants. We should train our GPs to do minor elective surgeries so that such practices are taken out of our acute hospitals. I would have no issue with that. If we are to manage that process, we are going to need all stakeholders, including GPs and their staff and the public, to buy into it. I believe these reforms will work as long as they are managed and resourced well. We should all remain focused on them.
I would like to speak about acute hospitals. As the Minister knows, there was a great deal of concern in the south east when the new hospital boards were announced last year. We were told that Waterford Regional Hospital, as it has always been known, would be taken into the southern hospital group. I welcomed the reassurances we were given by the Department of Health and the HSE last year to the effect that Waterford Regional Hospital would become a university hospital. The appointment of people to academic posts will enhance the hospital's capacity to bring in trainees and enhance services in specialised areas like accident and emergency, orthopaedics and cancer care.
I have a particular concern with regard to cardiology. In 2008, the cardiology unit at Waterford Regional Hospital had just two days' cover. In 2014, the same unit has five days' cover. The entire region is still not covered at evenings and weekends, unfortunately. I ask the Minister to ensure the appointment of a cardiologist at the hospital will happen as quickly as possible. I understand that someone is to be appointed in September. Cardiology services need to be available at Waterford Regional Hospital 24 hours a day, seven days a year, to service the whole south-east region. This should be an essential component of equality of access to health care, particularly emergency services.
I am delighted to have an opportunity to speak on what is undoubtedly the most reforming health care measure to have been introduced since the foundation of the State. It will have an impact on the lives of every citizen in the State for generations to come. The main purpose of this proposal is to deal with a health system that is not fit for purpose and is incapable of meeting the challenges it will face in the future. Some 41% of people have medical cards at present. A further 45% of people have private health insurance, but this figure is decreasing due to the strains of the economic times we are enduring.
People pay for private health insurance to give themselves access to health services. They want to reduce the amount of time they spend on waiting lists and in queues. Universal health care is fundamentally about equal access for all. One's ability to pay for insurance or services should not determine how long it takes one to receive a colonoscopy, a mammogram or some other service. That has been the case in the past, unfortunately. We have to move away from that situation. The universal health insurance system is going to have work in the context of a reduced health care budget. If we have learned anything from the previous Government's handling of the health service, it should be that money does not solve all our problems. That country threw money at the health service when this country was awash with money, but it did not solve our problems.
The importance of introducing this new structure now is evident when one examines this country's demographics. Older people place the greatest strain on any health system because they need a greater amount of care than younger people. The proportion of the population of Ireland aged 65 and over is 11%, compared to an OECD average of 15%. This should translate into expenditure on health care that is lower than average.
However, Ireland's per capita spend in 2011, the latest date for which data are available from the OECD, was $3,700, compared with an OECD average of $3,300.