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Dáil Éireann debate -
Thursday, 17 Apr 2014

Vol. 838 No. 3

White Paper on Universal Health Insurance: Statements (Resumed)

One of the key tenets of a just society must be equal and fair access to health services. One's ability to pay for services should not in any way determine the speed and level of access, which is the situation we currently have. People who can afford private health insurance may get access to a colonoscopy or mammogram or another procedure more quickly. The basis of universal health care is that those who can pay for health insurance will do so, while those who cannot will still get the same level of access.

Free general practitioner care for children has been discussed extensively in recent times. That is not an end in itself but is an important step on the road to universal health care. What we are facing is a series of steps that will ultimately lead to universal health care in 2019. Other measures that will be required along the way include the dissolution of the HSE and the establishment of the health care commissioning agency, the health care pricing office, the patient safety agency and provider trusts. There will also be a strengthening of the roles of the Health Insurance Authority, HIA, and the Health Information and Quality Authority, HIQA, and ultimately, by 2019, there will be universal health insurance.

Constituents have asked me what the impact will be on the different groups of people. They can be broken down into three groups. Holders of medical cards will see the waiting lists reduce sharply, allowing them timely access to key services. People who currently have no medical card and no private health insurance will have their premium heavily subsidised. Access to free GP care for those people and their children mean that they will probably be the biggest winners from the change.

Many people currently have private health insurance and they ask me if they will have to continue to pay for it but get less access to services. The key element in universal health care is the continuing reduction in waiting lists. It will be critical to ensure that this system works comprehensively. We must ensure that the existing benefits will continue for people who have private health insurance and continue to pay for it. Reducing the waiting lists is absolutely vital. In addition, there will be a reduced number of people on trolleys in emergency departments and reduced waiting times for outpatients, neither of which is covered by private health insurance at present. People with private health insurance will also get free GP care. People often put off visiting the doctor because it will cost them €55 to €60 per visit. The health problems often become manifest later as more serious illnesses which, if they had been dealt with in time, might have been more easily remedied. Free GP care, early access and early intervention will solve many issues that might later manifest themselves otherwise.

With regard to the reduction in waiting lists, the special delivery unit has achieved great progress. Some hospitals have installed new computer systems which has led to patients spending approximately 30% less time in hospital, thus freeing up beds and space for those who need them. There has been a reduction of 99% in the inpatient waiting list over eight months and a reduction of 95% in the outpatient waiting list over 12 months. This has taken place at a time when there is a 10% reduction in staff, a significant reduction in the budget and an 8% increase in the overall population.

Naas General Hospital in County Kildare is my local hospital. In 2011, the number of people on trolleys in that hospital was 4,409. In 2013, the figure had dropped to 1,842, a reduction of 58%. When one looks at the links between that hospital and St. Vincent's Hospital in Athy, which cares for older people, one can see the real benefits that filter down throughout the community when one tackles these waiting lists. That is key to improving our health service.

Reference has been made to our aging demographic. At present, Ireland is below the Organisation for Economic Co-operation and Development, OECD, average for population aged 65 years and over. Ireland's is 11% while the OECD average is 15%. Ireland's spending on health care is relatively high given our relatively young population. That is the reason the Government has been cutting costs in the health sector over the last few years. We now must prepare for an older population in the future. Previous Governments have shown that throwing money at this issue does not resolve it. We must make our health service more fit for purpose, more efficient and better value for money while continually improving the services that are delivered. The increased demand in the future will require major increases in taxation or significant cuts in services if we do not address the issue now. If we do not proceed with universal health care now, when do we do so? Continuing with the status quo is not sustainable.

Under universal health insurance there will be a basket of general services. One's supplementary payment above that would pay for more luxurious accommodation or perhaps a private room but it will not impact on the level of service that is provided. That is absolutely key. The health care commissioning agency will be central in continuing to provide ambulance services and emergency departments. It will do that from general taxation and will pay directly for services that are not covered by universal health care.

Overall, universal health care is the way forward. There are huge challenges and pitfalls, but the challenges and pitfalls of doing nothing with our current health service as we face an aging demographic are far more frightening.

Deputy McLellan is sharing time with Deputy Colreavy.

Sinn Féin believes that health care is a right, not a privilege. It is an essential service that should be accessed on the basis of need, not income or private health insurance.

Consecutive Governments comprising Fianna Fáil, Fine Gael and the Labour Party have failed the Irish people in the delivery of health care. Our health services are in crisis and in need of serious, radical reform. The health service should be free at the point of delivery and funded by a progressive taxation policy. Simply put, that means people pay their taxes and those taxes are used to fund public services, including health care. Those who earn more pay more, but everyone has access to the same standard of health care service regardless of income, with nobody skipping queues with the wave of a cheque book or a private health care plan.

The Fine Gael-Labour Party coalition's concept of universal health insurance based on competing private health insurance companies is one that Sinn Féin has criticised as fundamentally flawed.

Even from the leaked extracts, the huge problems with such a system are apparent. Health care is too important to turn into an industry governed by profit margins and shares.

The Government's proposal amounts to the total privatisation of our health care system. This White Paper is the fundamentally flawed Fine Gael model based on competing private for-profit health insurance companies. The only people to benefit will be the private companies. The Minister has promised this White Paper for more than three years, and now we have a proposal that is not even costed. Clearly, this is a Minister who has been limping from crisis to crisis and has failed to live up even to his own standards.

The programme for Government reads: "This Government is the first in the history of the State that is committed to developing a universal, single-tier health service, which guarantees access to medical care based on need, not income." There are no arguments with that, but then the Minister goes on to state that "Insurance with a public or private insurer will be compulsory with insurance payments related to ability to pay." That is where we part ways. Why would a Government that is committed to universal health care introduce - indeed, make it compulsory - to use health insurance to access health care? It makes no sense, unless of course the Government wants to bolster the profit margins of ailing private insurance companies. The Minister attempts to calm the public's fears by saying that "Under UHI public hospitals will no longer be managed by the HSE. They will be independent, not-for-profit trusts, with managers accountable to their boards." After the debacle of Rehab and its links with Fine Gael, his honeyed words will do little to calm people's fears.

Compulsory health insurance will mean hard-pressed families having to pay out more money for basic services that were once seen as an essential service funded by our taxes. Domestic waste charges, home tax, water charges and the fire service are all paid for out of our pockets, yet we still pay the same amount of income tax for a diminishing menu of public services. Now the Minister want to add health care to that list. Immediate concerns for many families will centre around the type of services provided for under this health insurance model, whether families with greater needs have to pay a greater premium, and whether certain conditions and syndromes be included and others not. Clearly, Fine Gael fingerprints are all over this proposal. They will privatise health care, remove universal health care and replace it with insurance.

The Labour Party manifesto for the 2011 general election also commits itself to universal health insurance by saying that the cost of insurance premiums under a universal hospital care insurance system should not change from what they are at present. It, too, is committed to maximising the profits of health insurance companies. Any charade of the Labour Party being committed to universal health care is gone.

The big difference between our proposal and the Government's proposal is that Sinn Féin's is based on meeting the needs of the public while the Government's proposal is about meeting the needs of insurance companies. Sinn Féin's vision is of a new Irish health system, with care for all based on need alone. The current health care system is a two-tier system, where wealth can buy better care in the private health sector. It is a private sector subsidised by the Government at the expense of the public system. Even at the height of the boom, the health care system never received adequate funding to overcome the vicious cuts in the 1980s imposed by governments involving Fianna Fáil, Fine Gael and the Labour Party. The health care system will only be transformed if we have a clear vision of the kind of health care citizens deserve. Of equal importance is the need to agree on how this system is to be funded.

Doctors, nurses and health care workers do a great job in circumstances that are increasingly difficult. We need a system that has primary and preventative health care at its core. We need to refocus on primary and preventative health care, together with complementary measures to address the social determinants of ill health. Over time, this will produce health care savings to the Exchequer by reducing the necessity for higher cost acute care in many cases.

Sinn Féin is committed to a new universal public health system that provides care to all free at the point of delivery, on the basis of need alone, and funded from general fair and progressive taxation. We want an end to the two-tier system. We are committed to introducing comprehensive community-based primary health and social care services for all, free at the point of delivery, including general practitioner and dental services, and abolishing all prescription charges. Accountability and transparency is vital to restoring the public's confidence in public services.

Sinn Féin proposes to restore direct ministerial and departmental responsibility for health services which are funded by public money. Sinn Féin in government would establish a health funding commission to plan the transition to a new single-tier health care system. We fully understand the economic challenges this State faces, but front-line staff and patients should not suffer for the sins of others. We need to streamline the health service. We need fewer bureaucrats and more front-line health workers. Sinn Féin will carry out a review of managerial and administrative posts within the health service and the Department of Health, with a view towards eliminating those positions that are surplus to requirements and using the money saved to hire more front-line health professionals.

Public money funding private profit represents a big drain on resources. We want to see an end to public subsidies for private health care, invest all health funding in the public system immediately, end tax breaks for private hospitals, phase out public subsidisation and ultimately replace the private system within an agreed timetable.

Sinn Féin's goal is to create a united Ireland based on social justice, equality and democratic accountability, an Ireland where access to health care is based on need rather than on wealth, place of residence, gender or any other social status. Our vision is of a seamless all-Ireland health service based on universal public provision that provides full equality of access and that is free at the point of access. Access to quality health care should be a right, not a privilege to be granted or withheld by government or bureaucracy or health investment speculators.

At first glance, the Government's White Paper on universal health insurance appears to go some distance along the road towards this vision. The Minister for Health states: "I believe that to achieve a fair and just society, we must have a universal, single-tier health service with access based on need, not income." He goes further and states that: "Over the last three years the Government has initiated a series of reforms in the health sector which are improving the nation's health, developing services, making efficient use of resources and forming the building blocks for the future system of universal health insurance." A Cheann Comhairle, if you ask me or any person in Sligo and Leitrim, or any of the hard-working front-line staff engaged in trying to deliver acute and non-acute health care services, we would wonder what nation the Minister has in mind when he sets out his reality and his vision. Let us look for a moment at the reforms in health care on the ground.

Our excellent breast cancer service was removed from Sligo General Hospital by the previous Fianna Fáil and Progressive Democrats Government and never reinstated, despite solemn promises to do so by this Government during the 2011 election campaign. Mammography equipment was recently spirited out of the hospital under the cover of darkness, with no public announcement. When this was rumbled and made public by a local Sinn Féin councillor, the HSE said it was going to be replaced by a newer machine, but only when a mammographer was recruited. We have been waiting three years for the recruitment of this mammographer for Sligo General Hospital.

I have no expectation that it will happen any time soon.

It was recently rumbled, but again not announced, that the HSE's hospital group for the west and north west is considering the very future of maternity services in Sligo Regional Hospital. Had I had to go to Galway or Letterkenny, one of my children would have been born on the side of the road. The HSE's response was that it was not helpful that what was a discussion document was leaked. Contemplating the future of maternity services in Sligo Regional Hospital should not even be considered.

Just last week it was rumbled, but again not publicly announced, that vulnerable people attending the day service at Our Lady's Hospital, Manorhamilton, were informed it was to be reduced from five days per week to three, and that a once-weekly session in Kiltyclogher was being terminated altogether. It is probably fair to speculate, in the absence of any information from HSE west, that other locations are targeted for similar reductions. It is rumoured that the proposal for Our Lady's Hospital and Kiltyclogher is being put on hold but people are naturally fearful that this is only to prevent public discontent in the run-in to the elections, and that the cuts will be implemented after 23 May.

Should staff in our hospitals and community facilities, home helps working with people lucky enough to have retained their services, very ill people who keep having their admission as inpatients to one of the national centres deferred, and ill people who have had their medical cards taken off them although their income was only marginally above the income guideline trust a Government that preaches reform but implements the most brutal cutbacks?

Actions speak louder than words. The actions of this Government in fundamentally undermining our already dysfunctional health system say more than this White Paper can. Government vision does not extend to the next generation; it does not even extend to the next election. Government vision on health care services extends only as far as the end of the financial year. This White Paper will not change that. What it might do - perhaps this is the real intent - is set up the public health care services for privatisation by a Government that abdicates, rather than delegates, responsibility for the delivery of those services.

Our health service is never out of the news and there is a crisis of access for many. People regularly mention in my clinic waiting times for life-changing procedures that are unacceptably long. Our two-tiered system has numerous inefficiencies that prevent resources from getting to the people who need care most. Our current system is inherently unfair and those with health insurance get faster access based on their ability to pay rather than their medical need. This is unjust.

There has been much debate on the White Paper on universal health insurance since it was introduced two weeks ago. I welcome the real beginning of this conversation in the Chamber. However, the debate must be reasonable and based on fact. There is important reform proposed that has the capacity to reform our health service and ensure it will become more fair and equitable.

It is disappointing that, in this Chamber this week, Members are using their speaking time to link universal health insurance to the property tax, water charges and other unrelated issues. This is another naked tactic from the usual sources to appeal to an audience in advance of the local elections. There is enough time and space to debate the separate issues but what we should be discussing here is real reform of our health system.

As the White Paper states, universal health insurance will not be delivered until 2019. This involves a long process and one that needs to be carefully debated and planned, and ultimately delivered. The debate requires some element of long-term vision, which the previous Government lacked and is totally alien to the current Opposition. Reform of our health system is essential. The Government is determined to deliver it. I believe in universal access to health care and in a single-tier health system. The Government is the first to include a single-tier health system within its programme for Government, guaranteeing access to medical care based on need and not on income.

Our health system has been in a state of perennial crisis for years. However, it is not easy to fix 15 years of Fianna Fáil mismanagement of it. It is even more difficult to fix considering we were shackled to the EU-IMF bailout programme for the first two and a half years of our term in government. However, we are looking beyond the next poll and election. We are seeking to deliver a working health care system that is open to all.

Universal health insurance has been the Labour Party's policy since 2002. It is the most efficient and effective route towards tackling the two-tier health care system that has been a defining feature of Irish health systems for decades. The Labour Party, in government, has been fighting for free health care as it is one of the party's core values. We feel very strongly that there should be no barrier to gaining access to health care. We believe that can be achieved in the State; it is not beyond us.

Those most in need should and will have the full cost of their insurance subvented by the State. The cost for others should and will be based on ability to pay. The core of the Government's health reform programme is to put the needs of the patient at the centre of the health system. The initial step of this programme is to bring improved health and well-being, fair access to hospital care and free access to general practitioners by 2016.

I welcome this week's agreement by the Cabinet on the rolling out of free general practitioner care for the under-sixes. The implementation of free general practitioner care for the under-sixes will pave the way for the next strand of patients who will benefit from the health reform programme. It is essential that this first stage proceed with the full support of general practitioners and that it run effectively and efficiently from the outset. I urge general practitioners to respond positively to the invitation to talks on implementation. This phase represents the first in the provision of universal general practitioner access for the entire population, removing the barrier of fees at the point of use.

This is an opportunity for general practitioners to help those people who have yet to feel the effects of recovery and who are still struggling daily. The White Paper we are discussing today is an important part of the preparatory work for universal health insurance. This will be the basis for the following consultation.

Universal health care is the way forward and the Labour Party will be ensuring it happens. We strive to create a better, more accessible and reliable health care system for the people, which they certainly deserve.

Our system of health care is frequently described as a two-tier system in which ability to pay, rather than medical need, is a deciding factor. Such arrangements do not reflect our better side as Irish people and as human beings. We are instinctively caring and compassionate. Our institutions should reflect these instincts and values, and that should particularly be the case where vital matters such as illness and health care are concerned. It is imperative, therefore, that the existing arrangements be changed fundamentally. We need to introduce a new structure that expresses our better side, instincts as a people and sense of caring and a system that prioritises medical need and well-being, not the ability to pay. The latter should be the decisive variable.

What would or should such a new system look like? On what considerations should it be built? What values should it incorporate and what priorities should guide it? Deep down, we all believe its driving force should be the care of people and not the financial clout or considerations of consultants and doctors.

Were we to articulate a vision for a new system, one that we know deep down expresses our values and best instincts, I believe the following statement would do us justice and would articulate, reflect and capture the deeply held convictions and feelings of Irish people about health care structures. I will read a brief quotation about the National Health Service in Britain:

Since its launch in 1948, the NHS has grown to become the world’s largest publicly funded health service. It is also one of the most efficient, most egalitarian and most comprehensive.

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth, a principle that remains at its core [to this day]. With the exception of some charges, such as prescriptions ... the NHS remains free at the point of use for anyone who is resident in the UK. That is currently more than 63.2m people. It covers everything from antenatal screening and routine treatments for long-term conditions [right across the spectrum] to transplants, emergency treatment, and end-of-life care.

The fundamental changes that our Ministers wish to bring about in our system would, I believe, rest on a similar set of values and objectives to those that underpin the NHS. Take, for example, the first proposed phase, that is, free health care for all children up to six years of age. This measure, which the Minister, Deputy Reilly, and Minister of State, Deputy White, wish to bring in, will come very close to mirroring the values and practices of the NHS. That is why it is such an exciting prospect, but it is only the start of the mission to transform utterly the way we experience health care in Ireland, that is, by a process centred on people's needs, not on their wallets.

I believe the vast majority of Irish people support this ambition of Government. I believe they yearn for fundamental change of the sort planned by this Government, not least because it reflects the deeply held instincts, views and values of the Irish people. However, there is opposition to the Ministers' noble ambitions. A tiny minority of Irish men and women have set their face against this scheme and have set out to resist it. They have set out to stop the Ministers doing their job and doing what they were elected to do by the people. The opposition of doctors and consultants is already in full flow. They are opposed to the kind of delivery of medical care to children under six, as proposed by the Minister of State, Deputy White.

We remember the noble plan of the mother and child scheme in the 1950s and the opposition of church and some political forces and doctors in order to scupper it. This is the mother and child scheme Mark II. This time, however, it is the democratic will of the Irish people that will triumph, not the prejudices and interests of a tiny minority. Doctors and consultants should not cloak their opposition in any veneer to hide the main driving force of their opposition, which is money and their wallets. They should be ashamed of themselves, ganging up on the children of Ireland. Where is their Hippocratic oath now?

I want to finish with a quotation from an Irish journalist, Jerome Reilly, who recently wrote a good assessment of the system that is being proposed in an article headlined "Disgraceful 'two-nations' system must be dismantled". The article states:

A single-tier system will deliver proactive, integrated care at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. And it will provide equal access to healthcare based on need rather than the ability to pay.

How can this be achieved?

The basic principles underlying UHI is a multi-payer system where all citizens can buy insurance from competing insurance companies.

All those on a medical card will have their insurance paid. Those on low and middle incomes will be subsidised by the State. Most of the money will come from general taxation. Public hospitals will remain in State ownership.

Yes it is aspirational, yes it is loftily ambitious. It took the Dutch some 19 years to bring in fully their version of universal healthcare.

Dr Reilly, despite facing intolerable opposition ... has given himself a tight deadline with the full introduction planned for 2019.

But it is worth aiming high. Universal Health Insurance is about fairness, equality and justice. It is astonishing that critics of the system can't grasp that essential truth.

I had to check my calendar there to see whether we were, in fact, on 1 April. I was wondering were we listening to some April fool's joke, having been subjected to the previous contributions from Labour Deputies who seem to be inhabiting some planet very different to the rest of us. It is an insult that people would put up the model of the National Health Service in Britain, which is indeed the best model of public health care and is based on a taxation system where those who have the ability to pay pay through their taxation and those who need the service get it free at the point of access. The idea that the Government's proposal on universal health insurance has any relationship to that is quite simply farcical. Either the two Deputies who spoke before have no comprehension of that and do not understand what has been in front of us, or else they are engaged in a deliberate deceit. Either way, thankfully, the population at large are on to them and their ilk.

The reality is that this proposal is a substantial elimination of any notion of a public health service and it comes on top of the systematic undermining of that system which has taken place already. I do not blame Fine Gael Deputies for that. We know Fine Gael stands for privatisation and so on, and more power to them, but the other clowns going along with it is an entirely different matter, I have to say. There is no secret about-----

Sorry, Deputy. You cannot refer to Members as clowns, please.

Okay. I could think of something but-----

It is unparliamentary, as they say.

Sorry, Deputy. You are in the House of Parliament and you have to obey the rules like everybody else.

I do, a Cheann Comhairle. I did not mean any disrespect to any circus performers or others by the remark.

The Dutch model which is being promoted by the Government in this system has already been found wanting. It is one which has actually resulted not in a single-tier system but a three-tier system, with welfare recipients and those who cannot afford to pay becoming defaulters.

In essence, what is being proposed here is people being frog-marched into a system of private health insurance. The whole ethos is wrong. Only this morning the health committee was discussing the top-up payments to a number of medical staff in our hospitals, which are thankfully now ceasing. When we put down questions on that, the answers we got were that the hospitals put forward a business plan to justify those excess payments. Why would a hospital even have a business plan? Clearly, the whole ethos is about commodifying health rather than dealing with it in an appropriate manner. I do not believe that is acceptable.

In Ireland, families, at great pain to themselves, already pay thousands of euro in private health insurance.

We know that. Why do they do it? It is not because they are snobs who do not want to share a room with someone if they get sick. It is because they do not have confidence in the public health system and are paying as a way of getting their foot in the door. That is simply not acceptable but it shows that people would support a system where higher PRSI contributions were being paid in return for a properly funded public health system. This is not what the Government has on the cards with this proposal. In essence, what is at play here is making people pay at every level.

We need to go back and look at the British model because it has not been matched anywhere else in the world. Under this system, access is free at the point of care. About 60% of all institutional long-term care, pharmaceuticals, vision care and so on are all dealt with by the NHS. We need more investment in the precautionary levels of general practitioner services rather than just throwing people into the hospital system later on. However, a Dutch model and a compulsory insurance model with a population that is already failing to make ends meet because of years of austerity is not the way forward. It has been demonstrably shown that once one implements and gives over a service to the private sector, charges will inevitably rise. This is why Dutch families have found themselves done out of the market and in a far worse situation. This is a million years from the NHS or any idea of a proper publicly funded health system.

As part of this discussion, we need to look at where we are today and what has happened with our health system to date. We have a system that has been cut to the bone and a very demoralised workforce. The main problem for people is that it is very hard to get through the door. Once one is through that door, the staff look after one and one receives exemplary care. It is the wrong system.

I was also astounded listening to some of the contributions from our Labour Party Deputies about where universal health insurance will bring us and about how it will give us a single tier system based on the NHS because I also think we need to look at this system. The NHS was brought into being in the United Kingdom during one of the most traumatic economic periods in the country's period. Under this system, everyone has access at point of entry. This is what we should be moving towards. Instead, the Minister and the Government are bringing in a system based on insurance and competition. Competition will drive down costs at the expense of quality of care.

There are other options that can be looked. The Adelaide Hospital Society reported in 2008 that one of the ways would be to bring in universal medical cards, which would probably cost about €217 million. I note that in a previous life, Labour Party Members lauded the fact that the over 70s automatically got a medical card. Now that children under six are to get free GP care, more people over 70 are coming in to my office whose medical cards are being cut because they have just over €500 in income as an individual. The reality is that this €500 income limit does not take into account tax, the universal social charge, PRSI or house insurance. These people have been told to reapply under the general medical card scheme, which denies them access to it and causes huge distress to elderly people in the community. In a previous life, the Labour Party expounded on the role of the over 70s medical card and stated that it should be universally used throughout the system. People's health and the economy benefit in the longer term because people are not using the service as much and are able to access it when it is necessary.

The system we are bringing in will benefit private insurance companies at the cost of both care in our hospitals and GP services. It annoyed me when I heard a Deputy talk about self-interest on the part of GPs in respect of medical cards for children under six. This is not the case. Based on my information, including information from my GP, whom I have known for nearly 40 years, GPs are very concerned that they will be overwhelmed by the potential extra resources they will need to put in to deal with this. Before anything is done and before the Minister brings in these changes, they must be resourced properly, but they are not resourced properly. A so-called gagging order has been introduced where doctors cannot come out and say they have problems with free care for children under six. One cannot say it is because they are interested in what is going into their pockets, which is quite a nasty thing to say about people who are very concerned about the health and well-being of their patients.

Private health insurance is about queue jumping and getting into the system as quickly as possible. This should not be the case. We should be directing all our ideas into setting up a health care system that has access based on progressive taxation to allow everyone to have access to a health service based on need and not on ability to pay.

The Government will get no argument from me that the existing health service is undoubtedly unfair and penalises those on low incomes. However, jumping into a new system of short waiting lists where everyone is treated the same at no extra cost is a utopian proposal at a time of cruel blanket cuts. I have a feeling that there are huge doubts on both sides of the House about whether this plan will ever become a reality. We are discussing a system of health care which will not come into existence, if at all, until about 2019 and probably under a different Administration. More incredibly, the Government insists that it can construct this world class system on the foundation of our current health system, which is a completely unstable shambles. In the region of 54,000 adults and children are on public waiting lists for surgery while another 300,000 are in the queue to see a specialist. Thousands more are being added every week. Unacceptable standards of hygiene are consistently putting people's lives at risk. Our public system is under intolerable pressure as increasing numbers of people find private health insurance beyond their means. The proposal cannot succeed without a functioning health service to work with.

I have no doubt that people who are struggling to keep up their private health insurance payments will mutiny at the details of this White Paper, which will force on them additional costs for such supplementary benefits as a private hospital room. These are extras that are already included in their existing private health insurance package. A recent Red C opinion poll suggested that nine out of ten people who currently pay for cover do not want to queue for treatment. There is no mention in the White Paper of dealing with waiting lists and delays.

The issue of cost remains foremost in everyone's minds. The Government's proposed vision has been compared to the Dutch model. It must be acknowledged that this system increased overall per capita ratio costs by approximately 46% since it was introduced in 2005. A central element of the Dutch model was significant investment in general practice before they even put the model in place. This created a high-functioning primary care sector. We cannot even get agreement with GPs on care for children under six.

If we cannot get our primary care system functioning adequately, what is the point in putting forward all of the these proposals which are unrealistic? We are unable to deal with the consultants at present and I gave an example in the House some time ago in that regard. A woman went to a consultant to get a letter for an insurance company. The insurance company then asked for a second letter so that as well as paying €180 to see the consultant in the first place, she had to pay €300 for the letters. We cannot deal with the consultants or the general practitioners so how we are going to deal with a health system that is free for all at the point of entry?

Figures from the Health Insurance Authority show that the average premium paid per person in 2012 was €1,048, which has decreased since. Even if payment is subsidised to a certain extent, paying for universal health insurance will surely be beyond the capacity of many people. We cannot get the current health system right in terms of the basics of dealing with general practitioners, emergency departments, beds and the consultants who rule the roost and tell the Department what they will accept as pay and what they will do. At present we have consultants who are still insisting on working in public hospitals only when they see fit to do so, while also working in private hospitals. This would not be tolerated in other countries - doctors are either working in public hospitals or in private hospitals. Until we deal with such simple issues, which are simple in the sense that the Department of Health has power over consultants and doctors and their working conditions, then this proposal will fall and will not succeed.

The publication of the White Paper on universal health insurance represents the cornerstone of a move towards full implementation of the system. This move towards an all-inclusive model is reflective of the commitments made under the programme for Government that health care should be provided across the board to everyone, regardless of illness or income. I firmly believe that it is right that we do not treat public and private patients differently. The universal health insurance model moves us towards a more all-inclusive system that puts patient before purse. It is a shame, despite all of the resources made available to the health system between 1997 and 2007, that this kind of change was never enacted. It is to the credit of the current Minister for Health and the Minister of State, Deputy Alex White, that - irrespective of how one evaluates the working out of this - this is the first genuine attempt to remove the inherent discrimination that currently exists in the health system. That is to be applauded.

This White Paper gives an assurance that the universal health insurance sector will become completely transparent under the new model. It will place a requirement on all insurers to unconditionally accept and provide an individual with a health insurance policy, regardless of age, health status or other factors which could be deemed high risk. That is critical and is the central plank of the proposed policy.

The demographic profile of our country has changed drastically in recent years, with an increase of 21% in the number of people aged 65 and over. According to CSO projections, this trend is set to continue, with an increase of 50% by 2026. That is why we need change now, to deal with that. The existing health system is an unfair, two-tier system and is in urgent need of replacement. According to the White Paper, the relationship between age and health care costs is central. Pharmaceutical costs incurred by 70 year olds are seven times greater than those incurred by 20 year olds and the cost of private health insurance is, on average, ten times greater for 70 year olds. One of the major barriers faced by older people when deciding to take out private health insurance is that some private insurers place a five to ten year waiting period on customers who are 65 or older before they can access the enhanced benefits for a medical condition which is either new or was evident at the time of purchasing the policy. The private health insurance market has become increasingly segmented with insurers offering tailored packages to younger people that are designed to be unattractive to older people. The new universal health insurance model will stop this practice and give everyone the luxury of choice, immediate cover and the right to be accepted by their chosen insurer. More importantly, it will give everyone the right to be charged the same premium for the same policy, regardless of age or risk profile and that is critical.

I know some are concerned that this new model will put a greater strain on hospital waiting times. Indeed, the current system has been doing that but it must be put on the record that the Minister has made a great deal of progress in tackling this. I am very proud to put on the record of the House the fact that in my own county of Cavan, hospital waiting times were reduced by 19% from the beginning to the end of 2013. Great credit is due to the management and staff of the Cavan Monaghan Hospital Group for that achievement. I was happy to hear the Minister say yesterday that he will shortly bring forward a strategy to bring waiting times in Ireland in line with European norms and that this will take place in advance of the introduction of universal health insurance. The removal of long waiting times is a central plank because the entire principle of the new policy is equity, fairness and equality of access.

The White Paper makes reference to the types of service that will be included under the umbrella of the new universal health insurance system. This health basket will be a standard package model and will cover a comprehensive suite of core health services. The paper makes a commitment that the services to be included will be safe, effective and of high quality. It will include, importantly, core primary care services as well as those provided by acute hospitals and our mental health services, which is central and should be the case. In recognition of the fact that the process of establishing this basket under the eventual one-tier system will be a complex one, the Government is committed to engaging in a comprehensive public consultation process and establishing a commission to present the costings of each option to the Government. We will have costings and an effective analysis which is what public debate should be about.

I am happy that the Minister of State, Deputy White, has invited general practitioners to dialogue. I encourage both the Minister of State and the Minister himself to continue with that dialogue and to take on board the concerns of general practitioners, particularly about bureaucracy and the need for back up to deliver free medical care to children under six. I urge the Government to interact with general practitioners and to review their contract in light of their concerns because they are important front-line providers.

Under universal health insurance, there will no longer be any distinction between public and private patients. Neither insurers nor providers will be allowed to sell faster access to services in the standard universal health insurance package. That day will be gone and that is the attraction of health insurance at the moment. Last night the Minister made the point that hospital services are free and yet more than 50% of people in Ireland take out private medical insurance on an annual basis. The rationale for doing so is to get faster access to the same services which would otherwise be free of charge. This means that those who cannot afford private insurance have to wait, often indefinitely.

This is what universal health insurance will eliminate. It is what the Minister is working to achieve all the time. The current situation is simply unfair.

I am happy to see that there is a system of support in place to ensure that health cover will remain affordable for everyone. It is vital that those who are in a difficult position in relation to paying will not have a problem. It is especially important for those from lower socio-economic backgrounds or on lower income as they will have their costs fully paid by the State. The Minister has made a commitment that people on low incomes who currently qualify for medical cards will not lose their core benefits. It is a concern people have but it will not happen. Regardless of whether a person pays all, some or none of the costs of universal health insurance, he or she will be able to access a standard package of health services on a fair and equitable basis to meet his or her health needs.

Under the current system, high general practitioner fees are deterring people from seeking initial treatment which might prevent serious illness from occurring. There is empirical evidence of this phenomenon, which is critical. It is therefore important to include free access to general practice care. It is an essential part of the Government's plan, in which context the under-six provision represents a very real start. Free general practice care will mean there is a greater level of prevention and early diagnosis. It is a hugely important initiative in respect of which I hope the Minister of State, Deputy Alex White, succeeds in his negotiations. The State inclusion of free general practitioner care represents further financial assistance to those who may not be able to afford health insurance. It is expected to have a positive impact, in particular on young families with children. It is in line with the Government's goal of reducing waiting times to ensure that everyone receives adequate care in a timely manner. It is a huge thing.

I am greatly in favour of the primary care dimension of the proposals and the delivery of services at local level. It is central to the Dutch model and in line with our substantial record of delivery of primary care centres. I have opened a number of them in my own constituency recently across a number of towns. I am delighted by the openings, of which we must have more.

We must look at the rigidity of roles in the system. There are jobs being done by nurses currently that could be done by care attendants. Functions are being carried out by doctors which could be done by nurses. We need to remove rigidities and deal with orthodontic treatment, which is far too inaccessible and costly.

The fundamental principle that everyone regardless of personal circumstances or income has equal access to health care, however we implement it and whatever adjustments we must make to get there, is the core guiding vision that should keep us going. It is an admirable concept and a disgrace to our country that we are only turning to it now. It is to the eternal credit of the Government that it is the first Administration to face the inequality in our health system head on. I welcome the White Paper.

The Government has embarked on a major reform programme for the health system, the aim of which is to deliver a single-tier health service supported by universal health insurance where access is based on need and not ability to pay. Under universal health insurance, everyone will have mandatory insurance. There will be a choice of insurers, including the State-owned VHI. Insurers will be obliged to accept customers regardless of age or health status and will compete for business on the basis of price and service. The insurer will have contracts with providers in the public and private sectors to provide services to their customers. The State will subsidise or pay for the health insurance policy premiums of those who qualify on income grounds.

The current health system is unaffordable, unfair and unsustainable. The Minister for Health is committed to developing and implementing the most cost-effective system of universal health insurance possible. It will be fully compliant with Government expenditure targets. Initiatives to improve population health include effective community-based models of care, efficient money-follows-the-patient approaches and standardised value-for-money contract arrangements with general practitioners, consultants and other health care providers. These measures will be introduced over the next few years and will provide demonstrable evidence of lower cost and enhanced productivity and efficiency in the public and private health care systems.

The Minister is committed to ensuring that a comprehensive analysis of estimated costs is undertaken before the implementation of reforms takes place. Calculating the cost of universal health insurance is a complex matter which will require expert analytical support and time to undertake. The cost will be dependent on a number of decisions on the future of the model, including the package of services UHI will cover, and the scope and design of the financial support system. Other factors include a number of crucial and inter-dependent variables such as demand for the health care, service-delivery models, payments systems and regulatory and administrative costs. The Department of Health will progress work in 2014 with a view to its completion in early 2015.

There are a number of important stepping stones which must be put in place to pave the way for universal health insurance. Primary care services must be strengthened to deliver universal care with the removal of cost as a barrier to patient access. As part of the 2014 budget, the Government announced that it would commence the roll-out of a universal general practitioner service by providing all children aged six and under with access to GP services without fees. The work of the special delivery unit to tackle waiting times is another stepping stone as is the reorganisation of public hospitals into more efficient and accountable hospital groups delivering improved outcomes for patients. Another stepping stone was the introduction in January 2013 of a new statutory system of risk equalisation for the private health insurance market along with ongoing efforts to further develop risk equalisation to support community rating while promoting a sustainable market based on fair and open competition. A money-follows-the-patient policy was delivered in February 2013 and the phased implementation of the money-follows-the-patient funding system in acute hospitals was commenced in January 2014. National health care standards have been developed and there is ongoing work to support legislation.

The Government is committed to introducing universal health insurance so that everyone has health cover from an insurer of choice and access to high quality care on the basis of medical need rather than ability to pay. The Minister has signalled his intention to carry out by early 2016 all necessary ground work for the introduction of universal health care. He will proceed to have the new system implemented by 2019.

The White Paper is utterly unconvincing. It is a White Paper in name only and perhaps by virtue of the fact that it is printed on white paper. That is all that makes it a White Paper. A White Paper is supposed to be preceded by a Green Paper which sets out the broad thrust of an approach to a particular issue. A White Paper is intended to fill in the detail of the approach at a later stage and following discussion. This White Paper contains no detail of any kind. It is in effect a Green Paper. It sets out the very early stages of a notion which has not been thought out at all. It is clear from many of the contributions from the Government benches that not only have people not read the document, but they cannot answer questions on any of the detail involved in the proposal.

This is an attempt to paper over the cracks of an entirely leaderless health service, which is what we have. Nobody knows where it is headed. One must recall that on the day the White Paper was launched, an Assistant Secretary General in the Minister's Department admitted that it posed as many questions as it answered. That says it all. One must ask what expertise was used to draw up the document.

Immediately after the previous general election, a commitment was made to establish an implementation group. There was a long delay and it was a year after the election before it was established. The group brought together a number of international and national experts to examine this issue. One of the difficulties is that prior to the implementation group setting about doing its work and examining the detail of what is required for a new model in this country, it was specifically precluded from considering any other type of model, such as a social insurance models or an NHS-type model. It was constricted from the very start and could only examine multi-payer private insurance models. This was a very clear direction given to it by the Minister for Health. This was not an objective exercise to look at what system is best for Ireland. It was an attempt to shoehorn a particular ideological position of the Minister into a draft policy. We did not have a fully objective examination of the system or objective recommendations on what the country needed. Another question I must ask about the implementation group is what input it had to this document. It is very difficult to see that any of its thinking was brought to bear in any serious way. I must also ask, given there is no health economist in the Department of Health, whether any health economist had a role in drawing up this document.

It is interesting to note that before the document was published, the word from the Cabinet, and the Departments of Finance and Public Expenditure and Reform in particular, was this was not a sustainable model. This was quite clear. There was a rush to get out to the media to make this point. This could never work because it is far too expensive, would mean a huge loss of entitlement for medical card holders and a huge increase in the cost of private health insurance across the board, with an average figure of €1,600 used. These were very serious concerns which the two economic Departments had on this proposal. In a matter of a couple of weeks, these serious concerns were buried and suddenly disappeared. We then had the narrative that approval was given to the Minister, Deputy Reilly, to go ahead with this so-called plan on condition it would not cost the State any more than it does at present. There is no way to give this undertaking. Who knows what the circumstances will be in 2019. Who knows who will be in government. Stating it will not be allowed unless it costs the same as it does now just buys time.

If it costs more, what happens? If the State will not pick up the tab, individuals will have to do so and health cover will cost the ordinary individual an awful lot more. If it turns out to be completely unsustainable, which it most likely will, what if this is discovered in two or three years time when the Minister has already dismantled what we have as a public health service? Where do we go then? The system will be in disarray. There is no coherent plan whatsoever from the Government on the handling of this issue. Many questions remain unanswered.

When will we actually have a White Paper on universal health insurance? When will all of the detail be filled out? When will we hear about what the Minister and the Government have planned for our future health service? Does anyone on the Government benches, even after reading this document, actually know what the future shape of the health service will be? What do we know of the future shape of the health service that we did not know before the publication of this document? This does not fill in any of the blanks.

Of course we would all love a more equitable health system, but just because the Minister states universal health insurance will deliver a more equitable health system does not mean it actually will. This depends on a great many factors, most of which have not been addressed. A number of key questions arise. How basic will the basic package of health insurance be? The experience with the Dutch model suggests the basic package will become increasingly basic, so people who now have a certain level of health cover pay more and have fewer entitlements. There is no doubt this will happen. What is the future of the services and entitlements enjoyed by people with a medical card? How exactly will the Government prevent insurance companies from denying these entitlements, particularly with regard to free medication? What insurance company will pay for a public health nurse to visit an elderly person to dress a leg ulcer? What insurance company will pay for family support workers to go to vulnerable families to assist them in surviving and keeping children within the family and prevent them from being taken into care? What insurance company will pay for other types of family support and home care supports? This is the big danger. We have a certain level of public health cover at present. It may not be ideal, but the big concern is this basic level of health cover will be diminished even further under this very scatty and ill thought out plan.

Who will pay the wages of the 100,000 public sector health care staff in the system? This has not been addressed. Who will be their employer if the HSE is abolished next week? Who will set the terms and conditions of employment of these workers, particularly when some part of the work may be funded by the Exchequer and other parts may be funded by an insurance company? One cannot just decide arbitrarily that 100,000 public sector workers will work for another entity yet unknown. None of this detail has been worked out. How will preventative medicine be incentivised in a system where people can switch insurers? If health insurance is to become compulsory, what will the effective marginal rate of tax be for people who choose not to have health insurance at present? How is it at all beneficial for our health system to have our public hospitals compete against each other? Surely this will result in a race to the bottom.

All the issues regarding the efficiencies we should be trying to achieve can be worked towards in the existing system, but it is a nonsense and a market view of the world to speak in terms of public hospitals competing with each other. Who will pay for the myriad of regulatory bodies envisaged in the White Paper? Has anyone actually done a count of the new agencies which will be created? We are told the HSE will be abolished next year, but it will be replaced by umpteen agencies and many different bodies with their own boards of directors, well-paid chief executives and all the rest that goes with it. In recent times we have seen what happened with Irish Water. Who is to say there will not be a repeat of this with all these agencies?

The White Paper states the future model of universal health insurance involves a sea-change in the role of the State. Do people realise this? There will be a sea-change in the role of the State. The White Paper states that, in essence, this change will see the Stage shift from direct financing and delivery of health services, which is what it does at present, to regulation and oversight of a competitive system of purchasers and providers. Our health system, for all its faults at present, will transform into a competitive system of purchasers and providers and the State's role will be reduced to a regulatory one. Is this what we want for our health service? A total of €12.5 billion of taxpayers' money is spent on the health service.

What is the sense of rerouting that vast amount of public money through insurance companies that will have to cream off their profits?

The Taoiseach has said that everyone will win, but the opposite is actually much more likely to happen. The medical card system will be scrapped, in effect, which means that the poorest people will risk losing the current entitlements that are available to them from the State. People who currently have private health insurance risk losing the kind of access for which they pay their insurance premiums. A great deal of nonsense has been spoken about tackling waiting lists. We know that progress has been made in reducing the amount of time that has to be spent on waiting lists by those who have been waiting for the longest periods of time. However, the amount of time being spent on the waiting lists by those in the mid-range is increasing. The waiting lists are still long; it is just the outliers that are being addressed. The people in the middle, who choose not to have health insurance because they cannot afford it, will not be able to afford it under this system either but will have no choice in the matter.

The health insurance companies and other price setters in the health system will be the only winners. Under these proposals, we will have a State-sponsored profit system for insurance companies. If there is anything concrete in these proposals, it is that they will turn a largely not-for-profit health system into a largely for-profit health system. I have to ask whether this is what we want. Do people realise that this is the direction we are going in? At the heart of these reforms is the belief that competition can solve the problems in our health service. There is very little evidence to support this contention. With competition comes profit margins, which act as an added cost to our health services. It is as simple as that. People are becoming increasingly sceptical that universal health insurance is actually the most desirable model for our health service.

I would like to remind the House of what the Minister has said about the legislation that will be necessary for these changes. According to this document, "the legislation represents a critical interim step on the path to UHI as it will legally create a purchaser/provider split, thereby preparing healthcare providers to operate as independent entities in the future market-based health system". Do people in this House and the public realise that we are heading towards a "future market-based health system"? Is that what we want? Is a market-based system what health care should be about? I do not want to see that and I think the vast majority of Irish people do not want to see it.

It is about time people on the Government benches woke up and realised that this is the direction of travel. This is where the Cabinet wants to take us. According to the document, "Under the new system, the Department of Health will have a central governance and policy development role in relation to the health service", and that is all. In the future, the principal purchasers of health care will be insurance companies. That will apply at primary and community level as well as at hospital level. I believe this is a disaster for our health service. It is not the way to deliver a single tier universal health care system. There are much better models that suit the Irish situation. We should start looking at them. If we go down this route, it will result in a completely dismantled and disjointed health service that will certainly not meet the needs of the people.

It is definite that the debate and the consultation on this issue will continue over the next few months. I hope we get an opportunity to engage in a clear debate, as opposed to merely making statements, on what is being proposed.

Any policy change can be undermined by the fear of the unknown and the perception of what it might mean for the individual. Trust will always be a huge issue in any political system. There are people who disagree with or have concerns about the changes that were made to the Dutch system. Concerns have been raised about the German system. I remind those who are promoting the Swedish model of care as the one this country should be aiming for that huge concerns were raised when Sweden was introducing major reforms and changes. Sinn Féin seems to support the NHS model as the ideal system for this country, but anyone with the most basic reading skills will understand that huge concerns have been raised about the way some reforms have been carried out under the NHS system. No one seems to be talking about the model used in Denmark, which underwent a huge amount of reorganisation in recent years. It was all done by consensus. It seems to be the reform that created the fewest difficulties for the citizens of the country in question.

There has been a great deal of talk about the Dutch model during this debate. It has been mentioned that a decade after it was first implemented, the Dutch system now costs twice as much as the old system did. Given that our health expenditure has more than doubled over the same period of time, it is funny that no one is queueing outside Hawkins House to seek to replicate the system we have been using for the last decade. It is even stranger when one considers that Fianna Fáil, which is pointing out the flaws in the Dutch model, was responsible for doubling our expenditure on our own system.

There are huge issues we need to discuss and of which we need to be aware . The cost of the VHI in this country could easily increase by 40% or 50% over the next five or six years because of the way it is structured at the moment. High demand older patients are holding on to their private health insurance by their fingernails, whereas low demand younger patients let go of their health insurance a long time ago. That sort of instability in our private health system could sink the VHI and many of the other insurance companies operating in this country. That might not bother Sinn Féin, as the tone of its Deputies' contributions to this debate suggests it probably wants to get rid of private health insurance in this country by abolishing it completely. That is a policy decision for that party to make for itself.

The public debate on this initiative should not yet focus on the basket of services that will be available. We should not focus on the cost of universal health insurance. While these issues are important, it is far too early to be discussing them as if they were the main issues we should be discussing now. It has been pointed out that it will be necessary to follow a number of stepping stones as we pave the way for the introduction of universal health insurance. If we can manage the public perception of how these stepping stones are being followed, that will help to reduce the level of concern about what we are doing. Therefore, the focus should remain on the stepping stones that relate to the reforms that are being carried out at present.

The special delivery unit has reduced the waiting times of patients in accident and emergency departments and the waiting times of those waiting for outpatient appointments. Deputy Shortall said that the figures are skewed because these reductions relate solely to those who have been waiting for a long time. She suggested that people in the mid-range, as she called it, are waiting longer. The current approach is working. It has reduced waiting times. People used to have wait up to four years to see ear, nose and throat and orthopaedic consultants. I ask the Minister to go a bit further. There are many problems with the way the system works in this country. I do not think it matters whether we introduce the multi-payer model or any other model that has been proposed.

There is a sense of secrecy about all the systems that operate in this country. In addition to driving reforms, the Minister must aim to improve transparency and provide more information. If we are to talk about a patient-centred health service, we must ensure everything is centred on patients. It should be possible for a patients to look up hospital websites to see how long they will have to wait to see consultants. As a doctor, I cannot find out from a hospital how long a patient will have to wait to see a hospital consultant. It sounds fairly rudimentary. It sounds like the simplest thing in the world to do, but we cannot do it.

I am told that this information is being collected by someone. Therefore, it should be in the public domain. A patient who would like to go to see a certain doctor should be able to look up his details on a website and find out that the waiting time is six months, for example. If we cannot provide such information to patients, we should not expect patients to trust us to do the right thing.

This issue of trust is equally relevant in the context of how we are reorganising the service into hospital groups. It is imperative that these groups are patient-focused. I have sent patient referral letters to hospitals within the so-called hospital group in which Wexford is included only to receive a reply indicating that my patient is outside that particular group's catchment area. I have sent referral letters to a hospital that is not in my hospital group and received the same reply, that the patient is outside its catchment area. What is really confusing, however, is that I have a letter from the Minister for Health himself saying there is no such thing as catchment areas. Who has come up with this notion of a catchment area, which I am told does not exist? This is a system problem. I should be able to refer patients to whichever hospital I like and whichever consultant I choose on the basis that he or she will provide the best and safest service. That decision should be made by me, not by somebody else unilaterally dictating who my patients can and cannot see.

An issue of concern in respect of many hospitals is that the collation and measurement of data is very poor. Notwithstanding the substantial investment in information technology in recent years, the quality of the data we are receiving remains very poor. We need to take steps to address that problem before we can hope to get anywhere.

There is a need for the system itself to change in order for any programme of reform to work. Moreover, the drive for that change must come from within the system itself. We must have real and effective co-operation between hospitals. If the hospital groups are to work, consultants must be able to move between hospitals. It was always the policy in the past that consultants would serve outlying hospitals. In practice, however, that practice has been very piecemeal and is not working well.

We cannot have a properly functioning system of universal health insurance until the principle of money following the patient is fully embedded and operational. We must be able to measure the level of activity within the system such that we know exactly where every euro is being spent, what it is being spent on and how it is working within the system. The money follows the patient concept must be working absolutely right before we even consider which system of universal health insurance we will operate. I have a proposal in this regard which the Minister might comment on. My suggestion is that universal health insurance be implemented in the first instance only for children aged 16 and under. Paediatric services in this country have a very low input from the private sector, with many of the services in the Dublin area being delivered by stand-alone hospitals. If we begin in this area, we can show people what universal health insurance is all about and instil confidence that it can work. The debate in this House and elsewhere in recent days has highlighted how it is possible to manipulate and twist certain proposals in such a way as to present the conclusion that nothing can lie ahead other than disaster. Once people understand how the system works, however, they are more likely to get on board. They will see that what works across most OECD countries also can work here. Indeed, most of the countries which are considered to have a superior health service operate some type of universal health insurance model. It can and will work for this country.

An absolutely vital component in the success of any universal health insurance model is that we have a properly functioning patient safety authority. Patients must have confidence that they are protected within the system. The Minister is focusing on administrative reform at this time. I accept that this is only his opening gambit and that he supports a fully functioning and powerful patient safety authority. We cannot move down the road to universal health insurance until that particular element is in place. Again, it is a question of ensuring patients have confidence in what we are doing. There will be confidence and increased trust if people know there is a completely independent organisation protecting them. There have been too many crises in the health service in the past decade. Patients, including infants, have lost their lives because of delayed investigations and so on. There have been poor standards of hygiene in hospitals for a long time. All of these problems were happening at a time when the State was doubling the amount of money spent on health. All of the crises we have seen, including Leas Cross, illegal nursing home charges and so on, only became apparent years later. We need a properly functioning patient safety authority to keep such issues in check and ensure patients have confidence in what we are doing.

An important component of a successful delivery of universal health insurance and the delivery of health services in general is the issue of a new GP contract. A great deal has been said in this regard but it is important to note that, for the past decade, it is doctors themselves who have been seeking a new contract. The current impasse must be resolved and we must put the additional resources that are required into primary care. Investment in information technology is required, for instance, before we can even measure - let alone address - such things as the number of children who are obese or have diabetes. It is easy to do all these things with the right system and with a little effort and investment.

That investment must include the provision of resources such as practice nurses, who are the mainstay of the service. In fact, they have prevented the collapse of general practice services in recent years. We are no longer attracting young doctors towards general practice, as can be seen in the number of unfilled places on GP training schemes this year. We are already 40 to 50 places behind in terms of replacing the huge number of GPs who are due to retire in the next four or five years. The reason the system has not collapsed is the increased diversity in how the work is being carried out, with group practices being formed and practice nurses, secretaries and practice managers taking up some of the duties carried out formerly by doctors themselves. That has alleviated the pressure up to this point. However, the latest round of FEMPI cuts has put general practice under unbearable pressure because it has impacted on such issues as the rural practice allowance, provision of practice nurses and so on. We must take a proactive approach to ensure the crisis does not get any worse.

The ongoing review of medical card provision is the number one issue being raised in my constituency office. There is a serious concern about how patients are being treated, an issue I have raised in writing with the Minister. Elderly people in their 70s and 80s are being asked to provide all types of additional information. For most of the elderly people I know, their lives have not changed dramatically in the past two years and are highly unlikely to do so unless they win the national lottery or have a very good day at the races. The idea that we must put medical card recipients through the wringer is wrong and has to change. Again, it is a question of enhancing patient trust and building confidence that we know what we are about.

I am genuinely of the view that universal health insurance will work very well for patients. However, it requires the types of reform I have outlined to be implemented. It requires the special delivery unit to operate in an open and transparent way. Patients must be able to follow through on their outpatient appointments, obtain a reference number and know exactly where they are on the list. The hospital groups must work effectively. Doctors seeking to refer patients must not be given the run-around, which is patently wrong. I have no problem with a hospital indicating that a patient will be waiting four years for a referral, but it should not be able to decide that particular patients cannot be referred at all.

The money follows the patient concept must be the number one priority for the Department and the Health Service Executive, with every single euro accounted for and recorded. That was the downfall of the former Minister for Health and Children, Mary Harney, in that she could not account for so many of the millions of euro that were spent under her watch. That legacy is coming home to roost in terms of what we are seeing at the Committee of Public Accounts. That committee should not devolve into a witch hunt, concerned only with chasing one or two well known personalities.

There is a need to change our approach. I hope we will get matters right in that regard. I look forward to even more public debate on this issue during the coming period.

Next we have Deputy Maureen O'Sullivan. I understand the Deputy is sharing time with Deputy Higgins.

Ba mhaith liom aitheantas a thabhairt do na buntáistí atá ag baint le cúrsaí sláinte. In order to discover what people think of our health services, I chatted with some friends who work in the service and asked them to highlight its particularly positive aspects. The first aspect to which they all referred - I completely agree with them in this regard - is the national cancer screening service. There is an excellent quality of care available to people who develop cancer. The second aspect to which they referred was equality of access in the context of the ambulance service. In other countries, particularly the United States, when an ambulance arrives at the scene of an accident, for example, the crew will first obtain the details in respect of a person's health insurance before taking him or her to hospital. That does not happen here. The third aspect they highlighted relates to the fact that the majority of staff in the health service are excellent and that they, particularly those taken on in recent years, are very highly educated. With the increased use of technology and improvements in IT, a great deal more research is being shared across the Continent.

We also discussed the disadvantages and negative aspects relating to the health service. Obviously, the first negative aspect which my friends identified was the moratorium on recruitment. If the health service is to work properly, this must moratorium be lifted. We are paying out more to employ staff from agencies than would be the case if they were recruited directly into the health service. The employment of agency staff has led to the development of a kind of stop-gap service and a lack of continuity of care in respect of patients. The second negative aspect my friends and I identified was the position with regard to step-down beds. We must increase the number of the latter and improve the facilities in which they are located.

Can we have silence for Deputy Maureen O'Sullivan?

The third negative aspect we identified is that which relates to community health care, particularly as it relates to those who have just given birth. The type of care provided in this regard could be a great deal better. Another negative aspect we discussed was that which relates to accident and emergency services. Originally, the latter were meant to be for trauma patients. The clue is in the title "accident and emergency services". However, accident and emergency departments are increasingly treating people with minor ailments. As a result of the increase in substance misuse and abuse, these facilities are also being frequented by those with addiction problems. There is a need to re-evaluate the entire accident and emergency system in order that a better service might be provided.

Let us take on board all of what I have said and view it in the context of what is planned in the context of universal health insurance, UHI. The Government has stated that it is determined that total spending by the State on health care in Ireland under the proposed single-tier UHI system, will not exceed total spending under the two-tier system it is replacing. We are aware that anything from €12 billion up to €15 billion is currently spent on health. One would think that with this amount of funding available, the quality of care and service available to everyone would be excellent and that it would be based on need rather than an ability to pay. However, that is not the case. It is certainly not clear that which is proposed will help us achieve that to which I refer.

The White Paper states that everyone will purchase a universal health policy with a standard basket of health coverage. This will cover hospital and primary care, while social and long-term care will continue to be funded by the State. There will be a multi-payer model, with competing private health insurers and the State-owned VHI. I find it very difficult to understand how this will work and be cost-effective within the current budget. That budget is not working effectively and we all know the gaps which exist and which will not be addressed by what is proposed. The Government's approach to this matter is similar to that taken in respect of water. In that instance, a new body was established and the entitlements and pensions of its employees were decided upon first. Irish Water is nothing other than a new layer of bureaucracy and it seems the new national insurance fund will be something similar.

We have been informed that a number of key elements are yet to be clarified. I presume the issues raised in this debate will be taken on board and clarified. We have also been informed that a commission has been appointed to prepare the detailed options for consideration by Government in respect of the scope and composition of the health basket. It has been further stated, however, that the consultation process in this regard will not delay progress in respect of the introduction of UHI. I do not know how it is possible to reconcile the two. We continually refer to what is needed while the Minister states that the new system will proceed.

There are some extras which are included in health insurance policies at present and which can be purchased. The fear is that the costs in this regard will increase.

When I read the White Paper, I tried to find mention of the word "prevention". I may have missed it but I did not identify any commitment to provide significant funding in respect of preventative measures. As we all know, such measures save lives in the long term. If keeping people healthy is a core principle, why is there not a better commitment to prevention? The relevant reports, studies, statistics and anecdotal evidence all confirm that prevention is better than cure. We know that we can prevent the development of certain cancers, certain forms of heart disease and strokes. Promoting healthy eating and exercise will do a great deal to reduce the impact of the illnesses - diabetes, asthma, etc. - associated with obesity in children and adults. Substance abuse currently costs the State €3 billion in the context of health care provision and dealing with crime. However, there are no significant prevention programmes to deal with substance abuse. I would have liked the Minister to have come forward with a White Paper or a Green Paper - I do not care about the colour of its cover - which really focused on the preventative measures that are necessary within the health system.

The purpose of the Government's approach to UHI is to promote the key role of primary care. I want to focus on the latter in the context of mental health. The National Coalition on Mental Health Reform is concerned that the proposed standard basket does not include talking therapies that are accessible through GPs. This is a serious drawback. Failure to cover the provision of counselling in primary care settings under UHI will mean that the majority of people seeking help in respect of mental health issues will not have the same access to such counselling as they will to medication. There are enough instances of there being a pill for every ill in this country. We must move away from that philosophy. Recent initiatives relating to primary care counselling gave rise to more than 5,000 referrals. The latter provide a very positive example of how early intervention can lead to the prevention of more serious mental health issues. That to which I refer is cost effective. There is a need to promote positive mental health initiatives because, again, these are cost effective.

There is a vagueness about the White Paper, particularly in the context of the costs involved and what will be included in the basket of care. What is proposed is based on the Dutch model and I do not think the Government has taken account of the fact that the market in the Netherlands is very different from that which obtains here.

I addressed the CityWide conference on substance last week. We are aware that substance abuse - regardless of whether it relates to alcohol or licit or illicit drugs - is a serious problem. This issue does not relate just to Dublin's inner city, its impact is felt right across the country. Cumulative cuts of 38% have been made to the funding available for substance misuse projects. They will not be able to continue their work if their funding is cut further. There does not appear to be any sense of urgency on the part of the Department to deal with this matter.

We are all in agreement in respect of the need for equal care, timely access, quality health care and cost-effective delivery. There is, however, a glaring lack of detail in the White Paper with regard to how these are to be achieved. There is no guarantee that UHI will provide the answer.

The Government's universal health insurance policy is designed to lead to further wholesale privatisation in the Irish health service, particularly in the area of hospital care. If anyone doubts this, all he or she need do is return to the source of this policy. I refer, in this regard, to the FairCare document which was published by Fine Gael five or six years ago. That document is brutally clear on what Fine Gael envisages in the context of universal health insurance. It states that "At the moment, Ireland has two administrative systems for health – one public (the HSE) and one private (the insurance companies) ... Over time, these two systems will become one, run by the insurance companies." There we have it. The policy of this Government is to hand the health service - particularly that part of it which relates to hospital care but also other elements relating to other forms of treatment - to private health insurance companies, which exist solely to make private profits. The maximisation of private profits is the key responsibility of the chief executive offices and the boards of these companies. It is their job to make profits for those major shareholders who invest in health care one day and in spuds, coffee or petrol the next. The nature of the investment does not matter to the shareholders in question.

It is simply a matter of where the profit comes from.

What we will have, therefore, is a system where private business will be dictating to doctors and nurses the level of treatment to be given to patients and the type of medicines to be given to patients, because, of course, those decisions will have a major impact on the cost of the care that they will be given. Since private insurance companies exist to maximise profits they will attempt to minimise the level of care that will be given to patients in hospitals, to our elderly and our sick. That is the grim reality of what is being legislated for.

The emergence of so-called hospital trusts is simply another step in the direction of privatisation. Let us consider the rampant move towards the privatisation of the National Health Service in Britain. Similar measures have been introduced there in recent decades. The National Health Service in Britain was an outstanding conquest made by the British working class and the British labour movement after the Second World War. It came about as a result of the specific weight in society and the outlook of the labour movement and it achieved a universal system of health care. It was a major concession wrung from capitalism in Britain for the benefit of ordinary working people. However, for decades now, in the hands of Tory governments on the one hand and right-wing Labour Party governments on the other, that system has been dismantled.

Professor Allyson Pollock is a wonderful defender and champion of public health care in Britain. She is based in Scotland. She has carried out coruscating analysis of what the policy of hospital trusts and the move towards control by private insurance companies is doing within the British health service. In The Guardian newspaper on 14 January this year she sums up as follows:

Since the Health and Social Care Act removed the duty on the secretary of state to provide universal care, it is every hospital for itself, competing against each other in a market place; there is no planning, only forecasting for income and sales. But A&E is expensive and, like geriatric care and children's services, the price the government pays may not meet the costs. Hospitals would rather concentrate on niche markets like cancer, cardiac and elective care, especially if they can raise some private income at the same time. Markets don't like risk or uncertainty.

Is it not perfectly clear what is happening in the British National Health Service? That is precisely what this Government is legislating for; hospitals are being forced to become businesses.

The health service in this State has of course been historically under-funded, for decades, by comparison with similarly resourced countries within Europe. In the crisis within Irish capitalism and to a certain extent within international capitalism in the 1980s the health service here was ripped asunder. Thousands of beds were taken out of our hospitals and never replaced. Is it any wonder, therefore, that we have queues at our accident and emergency departments and waiting lists? To make matters worse, thousands of health care workers have been taken out of that system by this Government. Yet the Government expects that the health service can work. To add insult to the injury of the victims of austerity and the bailout of bankers and bondholders by this and the previous Government, the proposal provides for a new health tax that will be up to €1,600 per year for those who currently depend on their general taxation to pay for their health care.

The solution is to fund our health services by progressive taxation on wealth, corporations, etc., those who are not paying at present. The management of the hospital and health care system should be publicly funded, publicly owned and controlled democratically. We should bring the front-line workers, including doctors, nurses, auxiliary carers and cleaners, who have a crucial role in hospitals, to the heart of the management of the hospitals and health care services generally. In that way we will have a system and a health service that cares for sick and elderly people only on the basis that they are human beings in need of care rather than commodities, that is to say, the subject of profit-making by private millionaire- and billionaire-owned insurance companies and so on.

Anois, An Teachta Catherine Byrne and an Teachta John O'Mahony are sharing 15 minutes.

Before Deputy Maureen O'Sullivan leaves the Chamber I wish to agree with what she said earlier about the misuse of accident and emergency departments and how that must be examined. We must ensure that when people come to accident and emergency departments, they come for all the right reasons. If we are to have universal health insurance we must consider what happens in accident and emergency departments. The key to having a proper health service is having a link with primary care and ensuring that primary care units throughout the country are staffed properly. Special needs services will form part of primary care services and they must be in place as well.

Like many people, I have knocked on doors in recent weeks. I congratulate the Cabinet for signing off yesterday on the free GP card for children under six years of age. In recent weeks while campaigning for local elections I have been asked on numerous occasions by many people about the under-six free GP care card and when it will be introduced. I have been reluctant to say it would come in but I am pleased after yesterday's news that there is finally some light at the end of the tunnel. I appeal to the Irish Medical Organisation and doctors and GPs in general to come back in and sit at the table with the Minister and the Department and put a final seal on this for parents. I had young children myself in the past although they are grown up now. I remember the many times when I had to go to the GP with them. The cost of that alone was crippling, even then.

I am pleased to take this opportunity to discuss the Government White Paper on universal health insurance published on 2 April. I welcome the public consultation process that will take place to allow people to make submissions up to 28 May. It is important that people are given the opportunity to make submissions after they digest the contents of the White Paper.

Universal health insurance is a key commitment in the programme for Government. I recall while running in the last election how important the issue was for people at the doors. They were keen to have a health service that would treat everyone equally. It is being introduced to bring about a fundamental change in the structure of our health service and represents a brave and bold move towards reforming our health service to make it more friendly and equal for everyone. Sometimes I think this should have been introduced a long time ago and that we should not have been waiting for so many years to bring it in. As many of us know, for far too long there has been a two-tier service in this country. This has meant that people who can afford it can jump the queue and have greater access to anything in the health service. This is mot fair and it is why the Minister for Health, Deputy Reilly, is introducing this new scheme of universal health insurance in order that everyone has the same access to the best level of care. This is what we should be about and what the Government should be about. It should be about giving people the opportunity to access the care they need.

As other speakers have noted, at the centre of the proposal is the money-follows-the-patient principle. I fundamentally disagree with some of the speakers who have said that hospitals should be given great blocks of money and then allowed to do what they with them. If we ran our homes in that way half of us would never be able to put food on the table. The money should follow the patient because it means people must do the work that they are asked to do. This is why the Minister is introducing this system.

There has been much debate about universal health insurance and who will pay. At present, approximately 41% of the population hold a medical card and therefore have free GP visit cards and free hospital care.

Free GP care for children aged under six years will, please God, be introduced. Everyone else must pay for a GP visit, sometimes up to as much as €60, or €75 per night for a hospital stay, up to €750 over a 12-month period in a public health hospital. Currently, 45% of the population has private health insurance to ensure faster access, but why should everyone not have the same access? This is what universal health insurance, UHI, is about.

In recent years, waiting lists have sky rocketed, with many people waiting up to two years for treatment. Some have waited even longer. However, the Department of Health, the HSE and the special delivery unit have been working hard during the past three years to reduce waiting lists. Figures prove this is happening. A major overhaul of the system is still necessary in particular areas, one or two of which I have already mentioned.

In light of our aging population, it is important that we have properly resourced primary care centres so that people need not attend hospitals every time. We need to take on the challenges presented by the health service and make tough decisions, which is what the Minister is doing. It is important to keep the end goal in sight, that is, a better and fairer health service for all regardless of whether someone has money.

I will welcome UHI being debated by the health committee, of which I am a member. It is important that the matter be debated by the committee so that all parties have an opportunity to discuss the Bill at length before decisions are made. I thank the Minister for being present at the resumption of the debate this morning. I also thank the Minister of State, Deputy White, for his attendance. What we will be introducing is complex, but if we give people the right information and support, I do not doubt that everyone will enjoy the same coverage, which is what people deserve as citizens of this country. That is what I want as a citizen and as a public representative.

I am glad to contribute on this debate. For many years, there has been a saying in Ireland - if something is not broken, there is no need to fix it. It does not apply in the case of our health service. The irony is that the service was broken during the country's wealthiest time, albeit one based on a false economy generated by the 2000-08 construction bubble, when the Fianna Fáil-led Government of the day decided to reform the health service. Fianna Fáil Members are conspicuous in their absence this afternoon. The then Government abolished the regional health authorities and created the HSE, which was meant to be the solution to all of the health service's ills. In reality, the HSE introduced layers of bureaucracy, became a monster and soaked up the funding thrown at the health service, which became more dysfunctional as time passed. There was no problem with overruns or missed targets because there was plenty of money to throw at problems, but the service's dysfunctional nature and real problems were not addressed. This is the background of the task given to the current Government. A major problem must be fixed at a time of financial constraints.

During the Celtic tiger, we developed to the ultimate degree our two-tier health service. If one had private health insurance, one was able to jump the queue. If not, one needed to grin and bear being at the back of the queue. The challenge facing the Minister and the Ministers of State, Deputies White and Kathleen Lynch, is to fix that broken system using available resources, which has led to this White Paper.

In the past three years, approximately 500,000 extra medical cards have been issued. I agree with Deputy Twomey that the increase has presented its own problems. The reviews being undertaken in respect of elderly people and so on must be handled in a more sensitive way than is currently the case.

Progress has been made in the reduction in the number of people on trolleys and waiting lists. This has been achieved when €3 billion less is being spent on the health service, highlighting the wanton waste and inefficiencies of the past.

I welcome the White Paper's publication and agree on the need for a radical overhaul of a health service that is two-tiered, inequitable and top heavy and in which there is insufficient emphasis on front-line services. Having read the White Paper, I note that it contains a vision of an end result with which few would disagree. It will result in a fairer, more efficient and more accessible single-tier system for everyone. However, many building blocks must be put in place between now and then. Clarity in the information supplied to the public and stakeholders is necessary at the earliest stage if everyone is to buy into what will be a better system. I welcome that consultation will take place with the stakeholders.

I also note that primary health care is to be a central component of UHI, with an expanded role for primary care centres, GPs and the services they provide. I attended a meeting of GPs in my constituency of Mayo a couple of weeks ago. It was hostile and I have supplied details to the Minister. We were told in no uncertain terms that, despite primary care being a policy priority, funding had been reduced. It was pointed out that, although 98% of patients' initial contacts were with GPs, only 2% of the health budget was spent on primary care. It was outlined clearly that GP services in rural areas were being affected by the removal of the rural allowance and distance coding. GPs claimed that this would result in more referrals to accident and emergency departments, costing the health service even more. They highlighted some procedures for which they were paid €4, but that cost €400 in accident and emergency departments. There is much food for thought in this. I hope that the relevant heads are knocked together on this. GPs will play an important part in UHI. There is no point in their being kept waiting outside the discussions.

I look forward to the implementation of UHI and its building blocks. On the way to the winning line, it is important that we not trip up by failing to consult. I am glad to see that consultation is a part of the process. The other building blocks should be structured in such a way that allows people to buy into and feel a part of them and achieves the creation of a single-tier health service by 2019 for everyone's benefit.

I thank the Minister for attending the debate. I acknowledge the contributions to date of my parliamentary peers on both sides of the House.

The objective here is to mend a system and create a new stage or platform for caring for the people of Ireland, of all ages and genders and regardless of background, wealth or lack of it. Even the title of the concept in the programme for Government, universal health insurance, is interesting. Let us parse that title. We like the concept of universality; it has an aura of equality about it. "Health", which is the middle of the label, is important. "Insurance" is good. It reduces risk and helps to protect against the calamitous unseen or unexpected. The quick, kerb-side reaction to the definition is that we should opt for it.

The framing of concepts is now displacing the substance of a concept or idea. That is dangerous. We must use our second line of thinking, as Daniel Kahneman calls it in his great book, Thinking, Fast and Slow, which will become a classic if it is not already. He cites an example involving postgraduates of the Harvard Medical School, men and women who by definition will be quite bright. One does not get through Harvard Medical School if one is dull or slow-witted. One might not be perfect, but one is at least bright intellectually. The experiment, conducted in the realm of presentation of ideas and concepts, asked the control group of postgraduate doctors to consider a medical management situation for a certain illness. The medical course of management of the disease was presented to the control group, which was divided into two, as having a 90% survival rate within two months. Alternatively, the same group was told that the medical management course had a 10% mortality rate within two months. In arriving at the decision of what medical management course to opt for, the information is the same in substance but the framing is different. We must be careful with this White Paper. I am not picking holes or looking for problems, but simply stating that we must look into the corners of what is involved.

The contributions of Deputy Higgins and Deputy Shortall are worthy of consideration. Insurance is an interesting industry. Underwriters charge premia, which they receive up-front. It is immediate cash to cover risks and events that are back-loaded over time. Only experience shows what will be required. In the meantime the reservoir of cash which they receive is a reservoir for investment. As Deputy Higgins said, it can go into pork bellies, cornflakes, oil, engineering, shares or whatever. That is the reserve which is put aside to cover the costs of the delivery of medical services to babies, teenagers, mothers, fathers, single people and grandparents as they get sick. It is therefore important to examine the physics of what one is addressing. If one measures the physics of a situation, wha t is involved in concrete realities, one can get a better idea of what are the costing requirements. Who is likely to get sick and when, and with what disorder or diseases?

As Deputy Shortall correctly said, we are now moving conceptually from a direct system of responsibility for delivering what is ultimately a vocational service involving doctors, nurses, auxiliaries and so forth. It is vocational. The people involved are not in it for profiteering; they will not move careers, as others do in secular occupations in the competitive marketplace and in the secular production and delivery of goods and services. It is essentially about looking after people's physical health and well-being, psychologically, psychiatrically and so forth.

Let us examine what is happening in this country in the realm of the vocational delivery of medical services. The up-to-date situation was outlined on the radio a few days ago. Young GPs are leaving this country in waves because the work conditions are impossibly demanding and the reasonable remuneration has failed. The same is true for nurses and trainee nurses. According to the interview on the radio, and it was not a sensational conversation, more than half of the trainee nurses are taking on second jobs to meet the bills and the cost of living until they qualify. After they qualify they are getting out of this country, because the atmosphere is shocking. The patient lists must be attended to and they do so to the best of their ability, but they are exhausted. One girl who was interviewed had worked for ten weeks without a day off. She has a patient list and said she regrets it. She knows the people they are looking after in the hospital are sons, daughters, mothers, fathers, sisters or brothers and their condition requires that the people providing the service be alert to little nuanced changes in their well-being. If one is exhausted, one cannot do that, even if one tries. One is bleary-eyed. That is wrong.

Another practical aspect to the concept of free GP care for children under six, and it surprises me that nobody has mentioned it, is that when a young family presents to the GP with a child under six, there are usually other children in tow. They might be under or over six. I am aware from the GPs I know that it becomes a family consultation, not a consultation for a child under six years of age. It can take up to an hour, because the mother has a complaint and the doctors, being mainly decent human beings, will deal with it. In the marine environment there is a flag of convenience for shipping goods back and forth; now there is the child of convenience for the family to come to the GP for their medical. That is not fair on the GPs, although I have not heard anybody talk about it. Has the Minister?

I have heard many things.

The doctors are telling him that. It is worth listening to them. Most of them are in the job for vocational motivations. There are some who might think of lifestyle and so forth, but that is human nature and there are people who are tempted by other things rather than the essence or meaningfulness of their work. However, most doctors have that vocational motivation.

I agree with the Deputy.

These things are important.

I would be wary of the insurance industry having that purchasing power over the medical services. They are vocational medical services. Insurers are not the people who should do that. It is difficult to arrange but, generally, people are prepared to pay directly for the people who provide their health services. If the Government wishes to introduce the concept of universality, we already have universal taxation. People understand that. The rules are the same for everybody, or at least they should be. However, we now discover that corporations appear to have a preferential universe - to remove the "al" from the word universal - whereby they can hover over nations like hovercraft and not be connected for the purpose of contributing fiscally to the countries over which they hover.

That is not right either.

The idea should be to get to a system whereby we have looked at the thing and understood it in its physical, concrete realities. The best people are always those in the front line. It is like sports. If we want to build an Olympic pool, we should not ask engineers, quantity surveyors, accountants and so on who will number crunch. They have not swum competitively. We should ask somebody who has travelled around the world to compete at international events, be they European or world championships or the Olympics. They will tell us what is needed in order to provide the stage for what we intend to do, and then we can refer back to the people who can cost it. That is what should be done here.

The concepts are framed in a way that there is a lurch to go there, rather than asking where we are at the moment, what are the demographics, what are the age cohorts and other profiles. Ireland has its own profiling. We have more red-headed people per capita than anywhere else in the world. That is a reality. We have a disposition to multiple sclerosis that is higher than other parts of the world. We have a disposition towards lots of things. The Government should get a feel for those by people who are in the front line and then it can work out physically that so many hours of attendance will be needed to be devoted to that over the years. Only then can it be given to the accountants and the guys with the ritzy headed notepaper. They will be able to send the fee notes, as we found out from the guys who set up NAMA. The professional firms invoiced at will once they got in there. Some of the advices and the measurements they gave us were absolutely pathetic, such as the estimates for loan losses in the portfolios that travelled to NAMA. Just because there is a ring about the name and the notepaper is five star vellum does not make it intelligent. We can get silly people giving orders to inexperienced people to crunch numbers, and they produce a glossy spiral bound and everybody thinks it is great, but it is not. People with back of the envelope calculations were able to say that the NAMA loan loss estimates were absolutely nuts. People with experience in the front line of doing restructuring and recoveries of loan portfolios were able to get it right to within 5% on a figure of €100 billion.

This is very important. No face is lost ever in doing the right thing. When the correct concrete measurement and physical analysis is done, the Minister may feel that this is not the way to go. Deputy Higgins pointed out that Allyson Pollock, who has a lot of experience, has examined the UK situation, where they are trying to unravel and pick at the National Health Service, which was being divided into hospital trusts and insurance-led stuff and so on. It begins to loosen the nuts and bolts at the joints and that is not a good idea. We will need trained vocational, dedicated, motivated men and women as doctors, nurses and auxiliaries. At the moment we have not got it as they are getting out of here. I have nieces and nephews who are qualified in medicine and some of them are at consultancy level, and it is a bad place atmospherically in many hospitals. We must be aware of that reality as well at the GP surgeries. We cannot have a GP, who is already under pressure on an income front and on a time basis, having a whole heap of family coming in. If elderly people have medical cards, they do not bring a bundle of others. They are on their own and they get one consultation. It may be awkward and it may be a geriatric complication, but if a young mother comes in with a child under six she may have three other children in tow, and we must remember that she may need more than general practice consultation and a lead in to gynaecological consultation.

I am just saying that we need to pull in the reins, do a check and make sure that there are not just egos at large here, saying that we said we would do universal health insurance, but that is not what it is. It is the delivery of a health service that has been properly assessed, properly forecast for the next five, ten and 15 years in terms of headcounts and realities, the equipment needed to do that and the spaces to deliver it. Then we should do the costing. If the physics are right, the financials follow. Money follows the patient.

I am glad to have an opportunity to speak on this very important subject. I must confess that I do not possess any expertise on any subject, least of all this particular subject. However, I have spent nigh on 20 years as a member of a very large health board. I heard all the arguments before, and you heard them as well, a Cheann Chomhairle. Every Member of this House has heard the expert opinion on all sides, each deemed to be the ultimate in expertise, each having found out eventually to be wrong, and that is the sad part about it. The situation in which we found ourselves was how to deliver a comprehensive, effective, modern, reliable and safe health service in a situation where we have 10% fewer staff and 10% less money. I have not heard anybody from that side of the House suggest how that was going to be done. In actual fact, every single contribution, with the exception of Deputy Mathews, did not suggest the spending of more money, which is unusual coming from the Opposition side of the House, but is not unique.

The challenge is how to deliver the services. I would be very concerned that we are reaching a situation whereby we are rummaging around looking for the right answer, and we have to find it whether we like it or not. I remember many years ago when were compared to Calderdale in Greater Manchester, which has a population similar to this country and where it was deemed that a single health structure was the ideal way to deliver the services. I did not believe that at the time because there is no comparison between the length and breadth of this jurisdiction and an area that somebody can walk across in a couple of hours. Therefore, the two areas are not comparable at all.

We need to have a system that is accessible. We need to have a system that does not have people on waiting lists interminably. I disagree entirely with Deputy Shortall. There have been huge improvements in waiting times for particular services. In the past people were waiting for up to four years for a hip replacement, and nobody seemed to understand that the patient was suffering extreme pain during the course of that waiting period. Very few people realise this, except the patient. I remember dealing a few years ago with a patient who was waiting for a hip replacement. I am sure it was a great consolation to the unfortunate patient to be told "You are on a list, we will eventually get to you." However, when something else comes in of an emergency nature in the meantime, that list is lengthened considerably and the wait goes on.

In the old days of the health board system, the three key areas were the delivery of the general medical services, the delivery of the mental health services and the delivery of community care. There were programme managers who were responsible, whether we liked it or not, to the public representatives who were elected by the public. We had access to that. The health board system was set up in 1970, and critics at the time said that the old county health board system was better. We inherited that system from the previous administrators in this State. Maybe there were good aspects to it and maybe there were not.

During that period, I saw some things in various hospitals throughout the country, including mental hospitals, that were embarrassing, to say the least. If anybody suggests to me that system was better, he should realise it was not.

What happened next was that we tried to adjust, change and modernise. A great deal of work was done on this. The problem was that every time we did such work, it was presumed we could do better than before by changing the system. The challenge now is essentially a management one. It is a question of determining how we manage the system we have to deliver the required services to the population, with its various demographic characteristics, efficiently, effectively, reliably and safely. It is a management challenge. Everybody has his own view but the fact of the matter is that somebody must deliver the change.

When the HSE was established I remember asking Professor Brendan Drumm whether he believed the HSE concept, that of a single structure to develop the health services nationally, was the ideal one. I remember his reply well: "I don't know". He does now, as does everybody else. He had to wait and see. Professor Drumm genuinely did not know the outcome. I was totally opposed to the proposal at the time because I felt it could not work based on the little bit of knowledge I had. I had no expertise at all but believed it simply would not work.

When the good people who are now absent from this Chamber decided to change the system, they introduced the HSE to replace the health boards. Previously the number of health boards had increased from eight to nine, and then to 11, and then reduced to eight, each time incurring administration costs. Eventually, it was decided to have a single structure. We then heard how difficult that would be to achieve. The number of staff increased by approximately 60,000 over a couple of years during the boom, when the Celtic tiger was roaming the land looking for prey.

What really happened was that the HSE began to show creaks in its structure straightaway. Delivery could not be possible under that kind of structure. There are managers within the health service who are criticised regularly - they are in our respective areas - but who are well capable of running the system. They know how it needs to work. They know how to proceed and could do so effectively, efficiently and cost-effectively, which is important at present. Generally, they comprise people from the old system who taught those in the new system. They need some kind of support and for somebody to tell them they can do what is desired and what the structure will be.

The proposal to dissolve the HSE is the correct one. The HSE was not accountable and it was independent. It was roaming around itself and it was a satellite of the Department of Health. Any new system would be better than that. I would like to see a system involving restructuring of the old health boards but with fewer boards and a single board of administration accountable to this House.

I remember sitting on the other side of the House only to have been told daily that the Minister could not answer question I asked. I was told he had no responsibility to the House. We believed this system would be cost-effective and that it would result in the better running of the health services. Had we gone mad? Did we lose our reason? It could not be done. If there is no accountability, it is not possible.

We have now amassed the knowledge required to try to deliver the service desired. We need a modern hospital structure. Community care is very important. Deputy Maureen O'Sullivan made a very interesting intervention on prevention. Deputy Peter Mathews referred to statistics that should be available, and I agree with him. Some of us have pursued this for many years with regard to autism and various health conditions that appear to be more prevalent in Ireland than in other jurisdictions. Modern health research is now such that it should be possible to come up with some kinds of answers in order to plan ahead with knowledge of the costs that might arise.

The main point concerning the delivery of health services is that they are demand driven. One cannot postpone maternity services, for example. They must be made available within a certain cycle, and they are; it is as simple as that. National maternity hospitals are all under pressure because we have an increasing population. Those who referred to 2035, which is regarded as the black spot in terms of our ageing population based on the view that we will all be elderly at the same time, should note we are better placed than most other European countries in terms of the age profile of our population.

With regard to insurance, is it better to have a single organisation through which the health services can be delivered? Is it better to have a two-tier system involving private insurance or a public system? If there is duplication, there are obviously higher costs. There are those who have private health insurance, including me and most Members in this House, and we have had it for years. During my time in public life, I have tried to ensure people in the public health sector got services in the way they should when required, and that they were not put on a waiting list interminably.

I do not regard it as particularly wrong to have universal health insurance at present. It is a way of providing for the kind of demand everybody knows about. To a certain extent, it is an increasing demand, but it is varying. There is a necessity to recognise that if we are to provide a health service to a large number of people, we must have a safety net that will facilitate co-ordination.

Deputy Róisín Shortall made some remarks about two systems competing. For me, the jury is out on the concept of competition as a means of delivering services. It is debatable. One can gain and lose from competition because, as we all know, it works in both directions. It certainly worked in the banking sector, but not to the benefit of the country or its economy or people.

I acknowledge primary care is very important. However, I am not so certain it is the most cost-effective or efficient type of care. The jury is still out on that. The reason I say this is based on the care requirements of patients heavily dependent on nursing care for 24 hours per day, as opposed to elderly persons who can be cared for in the home. What is the best way to deliver the service of the highest quality to 100 patients who are 100% dependent on those around them? I have no doubt but that the best and most cost-effective and safe way from the patients' point of view is to have them housed in a central area, be it sheltered accommodation or otherwise, where they can be cared for. The medical services need to be readily available to such patients. How else can it happen?

The thrust for many years has been towards closing down the public nursing homes. Several public nursing homes throughout the country have been affected. The finger is pointed at such nursing homes regularly on the grounds that they cost more than the private nursing homes. They cost more only because they deal with the heaviest nursing requirements in the system; it is as simple as that. In the course of any evaluation of the system, I encourage those concerned to take that into account. If the heavily dependent 100 patients were dispersed throughout the country and had to be attended to by doctors, nurses and consultants daily, I would hate to think of the cost. All of us in public life know well the costs that are incurred if one must travel regularly. There are travel costs involved that seriously skew the system.

I cannot understand why some elements of the Opposition can see nothing positive about anything, ever. It gets tiresome after a while that they can think of nothing. They can criticise but not one of them came forward with a single positive or constructive view as to how the system could be improved, with the exception of the poor unfortunate man over there. With all those years and all the experience those on the other side of the House have of running the health services down, surely they could have come up with some little modicum of help, support and vision for the Government at this time.

I am glad the Minister of State, Deputy White, is in the House. He and the Minister, Deputy Reilly, have been given a very difficult job to do. I do not think the public outside this House fully understand that, or that they understand that to deliver the kind of service that is required, given the expectations of the people at present, requires a Herculean effort on the part of those charged with the delivery of the service to be able to do it all.

To continue on from Deputy Durkan, we know what the Opposition believes in and we saw it in action during the 14 years that Fianna Fáil tried to deliver. In my own county of Monaghan, they tried their best to close Monaghan General Hospital, including Deputy Micheál Martin, as Minister for Health and Children. They very nearly succeeded except that they were rejected in the previous general election. In addition, they wanted to close Cavan, Navan, Dundalk and Drogheda hospitals, and they had this pie-in-the-sky notion that they would build a super-hospital somewhere north of Dublin to replace all those hospitals. Thankfully, the new Minister for Health, Deputy James Reilly, is protecting the smaller hospitals and investing money in them. We are investing €9.5 million in Monaghan General Hospital to upgrade it and put in a primary care unit on the site. Just last week, we opened a primary care centre in Cavan town and we are also opening a cystic fibrosis unit in Cavan General Hospital, where we have also upgraded the medical assessment unit. These are positive changes that are taking place under this Government and helping small rural communities. In terms of the hospital groups, small towns now see a future for health care in their towns. It is being upgraded rather than downgraded, as was the case under Fianna Fáil.

This took us some time. The people who founded our State believed in republican ideals, in universality and in equal access to health care and education for all. It took us 40 or 50 years to get our act together before we gave people access to secondary education in the 1960s. Our public health care system does not work. The reason people buy private health insurance is that they have no faith in the public health care system. Fianna Fáil is reactionary, as always, and wants to retain the current system whereby poorer people have to wait longer for access to services. That is the Fianna Fáil model we know - let the poor wait while we who can pay get in through the front door as quickly as we want. What we are trying to do, as a Government, is live up to the republican ideals of the founders of this State by providing universal health care for all based upon need rather than ability to pay. I commend the Government and the Minister on trying to move this agenda forward.

What will be covered has been dealt with at length by Members in the House. Everyone will be entitled to a suite of services and to a choice of providers, and they will have free general practitioner access. This is all beneficial. I hear many people scaremongering about cost and asking how the middle classes will cope with paying the taxes to introduce this system. I point out that many people who have private health insurance at the moment are also paying for the public system through general taxation. In future, what we hope to introduce is a system which is efficient but, at the same time, more equitable and allows people who do not have the ability at the moment to access private health care to be given the exact same access as those who can. That is to be commended.

Many on the Opposition benches suggested this is about profit. It is not. The hospital groups are not-for-profit organisations. Their modus operandi is not to make profits but to deliver services. The private health care providers want to make a profit but they will only deliver a profit to their shareholders if they provide a service which the public want. Given that people will have a choice, if a provider is not providing a suite of services the public wants, they can go to another provider. If the hospital is not providing a service the public wants, the public will have an option to go to another private insurer and go to another hospital.

I see this as a real opportunity for small towns and small hospitals that were faced with closure under Fianna Fáil policies. It gives us an opportunity to provide specialist services in the hospitals of the country that people will access and use. I saw no hope for Monaghan or Cavan under Fianna Fáil and I saw no hope for our smaller hospitals. All I could see was closure and more centralisation closer to Dublin. Under this system, we have the hope that we can develop our services again. We have been able to retain our hospital and keep it open, and we now have a commitment from Government to provide extra money to develop it. With universal health insurance, if our hospital group and the people on the boards of the hospitals can define services which the local community really needs, I believe the local community will use those services and the hospitals will have a future.

This model is to be commended and is long overdue. If introduced between now and 2019, it will be a positive step in ensuring the ideals of the people who formed our country and State are finally realised.

I welcome the opportunity to speak on this very important White Paper. If we were to ask at the beginning of this debate or even at the publication of the White Paper what universal health insurance means to the citizen outside, we would be hard pressed to get consistency of answer. That is why it is important that we hold a national conversation on the future of our health service, what it should be about, the basket of services, values and so on.

The Taoiseach referred to everyone winning. Deputy Shortall in her remarks spoke about the poorest running the risk of losing everything. Of course they do not. As Deputy Durkan said, it suits a particular slant to come in and criticise. However, if we are to reflect on where we stand, our private health insurance costs are spiralling upwards all the time, the demand in health is increasing and we are spending €13.2 billion in our health system. We are living longer, we are getting obese more quickly, and associated illnesses are having a profound impact on the people who require to use the services.

I listened to Deputy Twomey speak about the private health system requiring stability and equilibrium, and he is right. The public conversation must be about that. Perhaps the Minister of State, Deputy White, and the Minister, Deputy Reilly, could consider extending the public consultation beyond 28 May. I do not believe that has resonated with people in terms of their ability to play a role in that consultation, so I just ask whether that could be considered.

The basket of services and the costs involved are important, and that is what will focus the minds of people at the end of the day. However, if we are to really look at what we are trying to achieve, then let us look at the building blocks we have put in place, the reform in terms of the abolition of the HSE, the creation of hospital groups, the creation of the special delivery unit and money following the patient. Some of the Members who came in yesterday and today to criticise did not take account of the fact of the 34% reduction in the number of people on trolleys that has occurred under this Government, the 99% reduction in the number of people who wait longer than eight months for an inpatient procedure and the 95% reduction in the number of people waiting longer than a year for outpatient appointments.

These have never been done before. This has happened at a time when, as the Minister keeps telling us, there has been a 20% reduction in funding, 10% fewer staff and an 8% increase in the population.

Everything we do must be about the patients, who must be at the core. This is why I very much welcome the creation of a patient safety authority where we can protect the patient. If we look at what has happened in certain instances in our health system, we can see that the patient has been the secondary part of the process, which should not be the case. The commitment to public consultation, public awareness and the role of the Oireachtas Committee on Health and Children is an important component.

At our committee meeting this morning I am happy to say the committee took the decision to participate, as per the request by the Department of Health and the Government for the committee to play a role in the conversation surrounding universal health insurance. The words "basket" and "values" are now in our lexicon but it is important that the committee plays a role in that. I applaud the Ceann Comhairle because in his role as Chair of this House he has made the relevancy of committees central to what we do as a Parliament. An Oireachtas health committee has the fundamental task of participating and playing a role in determining the value in the basket in terms of universal health insurance. I very much welcome the fact that the committee made that decision this morning. We accept that the introduction of universal health insurance is the most fundamental and radical reform of our health system that has ever taken place. It would, therefore, be remiss of the committee if it did not play a participative role in that. I understand the difficulties that certain members of the committee had in this morning's meeting and I know that members in Fianna Fáil and Sinn Féin are opposed to this. However, if the committee did not play a role, it would have been the wrong decision. The Minister and Government have asked the committee to look at the development of a values framework. If one looks at the development of such a framework, one can see that it is about holding hearings on the shared values of Irish society to facilitate a national conversation. I hope that in doing that, we will assist the Government in guiding the development of a model that has at its core equality of treatment.

In setting a fee, it is important that we do not go beyond where we are at the moment where the individual fee is €920 per person in private health insurance. In doing that, it is important we allow the debate to be about what is affordable and what is in the basket and that we be as inclusive as we can. In respect of the decision to allocate money based on a money follows the patient basis, I would have a small concern that if we are setting this model, we do not necessarily drive hospitals to compete against each other but make it about seeing and treating patients. We are all in favour of that. In the renewal of the health system, we have an obligation to be completely honest. We must look at the recruitment moratorium and ask ourselves about how we allow new graduates, be they nurses, physiotherapists, doctors, occupational therapists or radiographers, to take part in our health system.

During the week, I met a young married woman and health professional who told me about her frustration at being unable to get job sharing or flexitime allowing her to have a career and to be at home with her children as well. In the new health system we are trying to develop, we must be conscious of professional development, get the mix right and create a health system that empowers those working in it as well as those who need to use it. If we cannot bring staff with us, we have lost some of the battle. I am concerned that the moratorium in the health system is one-size-fits-all. We have had the nurse graduate programme and changes to parts of it to allow for this in the area of mental health but there is a fundamental need to look at the recruitment moratorium and to be able to renew the staff and staff levels.

Deputies Durkan and Twomey spoke about primary care. It is important that we acknowledge that since it came to power, this Government has developed at least one primary care centre per month. The number is up to 35 with plans to complete a further 20 by 2015. This is important.

The McCraith report on non-consultant hospital doctors has been published today. I welcome the report. I have not read it in full as I had to come in here to speak. We need to look again at the appointment of non-consultant hospital doctors who are a fundamental bulwark in our health system. Mr. McCraith is right in saying that the appointment of a consultant should be considered as a key step in a medical career rather than an end point. Equally, he is right in saying that we need to look at the onerous out-of-hours commitment and rotas of smaller hospitals. We need to ensure that our health system has doctors who are qualified and who are not under pressure. In a meeting of the Oireachtas Committee on Health and Children, the Minister heard from non-consultant hospital doctors. I pay tribute to Dr. Mark Murphy from the Irish Medical Organisation, IMO, for the campaign he led and the Minister for acknowledging that there as an issue. We should not allow young men and women to work around the clock - in some cases for 36 or 48 hours without a break - to go home exhausted and to almost have catastrophic injuries on the way home.

My next point concerns free GP care for those under the age of six. I welcome the fact that the Minister has engaged with the IMO and the fact that the IMO acknowledged today that it is considering attending talks with him. It is important that there is dialogue and that this dialogue is meaningful because any of us who attended public or private meetings in our constituencies will recognise that doctors across the country have fundamental concerns. The best way to address them is by meeting the Minister. It is important that this invitation is taken up. I will not delay the House by going through the definitions that have been placed in the public domain because the Minister is well aware of them but it is important that this dialogue is meaningful and real and that it takes on board some of their concerns.

My final point concerns medical cards. As of 1 March 2014, there are 1.8 million medical cards in our system and 124,000 GP visit cards. This provides around 43% of the population with access to free GP care. This is commendable but there is an issue in terms of probity that is causing concern and about which many of us have spoken in the past. It is causing particular concern among people who are ill, have disabilities, are over the age of 70 or have cancer or a serious long-term illness. These people have had their medical cards taken away or have been given the letter when their circumstances have not changed and their applications have been subject to inordinate delays. The Minister was involved in rewriting the relevant letter and form but let us make sure we do not allow people to fall through the cracks. We need to be considerate in how we approach the issue of probity and I hope that the Minister would reflect upon this along with the staff in the primary care reimbursement service. People who are sick and undergoing treatment, be they patients with a multiplicity of illnesses or those with transplants, who require lifetime medical treatment should not have to face the pressure and stress of worrying about their medical cards. I understand and acknowledge that the movement towards a universal primary care application system away from the regions has presented difficulties.

It is important to ensure that while we are investing in primary care we do not allow a situation to develop whereby people cannot avail of treatment in the context of medical card probity.

We have started on a journey towards universal health insurance. Questions need to be answered and a national conversation is possible. I hope that the Oireachtas Committee on Health and Children will play a role in that. The creation of the expert commission which will report back on the standard basket of care and the costs involved will be pivotal. Having said all of that, theory and practice are not the same thing. We must make this as easy as to follow as possible. We must be as informative with people as we can be and we must involve a multiplicity of people in this task.

We have put in place a lot of building blocks, both in terms of legislation and organisation, to enable us to put universal health insurance in place by 2019. People have spoken about the Dutch and German models but we must look at what we spend on health in that 70% of our taxation goes on health, which is way more than in many other countries. This is a new departure and it is a welcome one. It is one that we must embrace because what we have at the moment is a two-tier system which is based upon inequality. I look forward to a single-tier system based on medical need rather than ability to pay. We have a long journey ahead and must carry people with us. I look forward to that journey and to the Oireachtas Committee on Health and Children, which I chair, playing a role in that.

The current health system is both unaffordable and unfair and it is, therefore, unsustainable. The current system can be and is being improved but there are limits to what reform of a fundamentally flawed system can accomplish. If we want to realise the health service we want, radical reform is the only option. This Government made a commitment to the kind of radical reform that we need to tackle one of the most profound inequalities in Irish society. We committed to introducing a system of universal health insurance so that everyone has health cover from his or her choice of insurer and has access to high quality care on the basis of medical need rather than ability to pay. The publication earlier this month of the White Paper on universal health insurance underpins the Government's determination to deliver on that commitment. We were clear from the start that achieving this goal would require at least two terms of office. The job of this Government is to put in place the building blocks so that a fair and cost-effective system of universal health insurance can be delivered by 2019.

The delivery of a single tier health system, supported by universal health insurance, is a central pillar of the Government's overall health reform programme. Our aim is to ensure more efficient and effective delivery of services so that we can move away from a hospital-centric model to one that provides the most appropriate care in the most appropriate setting. The introduction of universal health insurance is the most radical reform of the Irish health system since the foundation of the State. It requires both time and careful planning to implement. It is this Government's goal to put in place the essential groundwork to underpin universal health insurance in this term of office so that universal health insurance can be implemented by 2019.

The White Paper identifies and outlines progress to date on the key structural, regulatory, financial and information-related building blocks that will pave the way for the introduction of universal health insurance. Yesterday, the Government approved the legislation to enable each of the 420,000 children in Ireland aged under six to access a GP service without facing the barrier of fees. This legislation will bring Ireland into line with health systems in Europe that ensure that all children can access a family doctor when they need to do so. The Government has provided new, additional funding of €37 million to meet the cost of this measure. This represents the first step in introducing a universal GP service for the entire population. Ultimately, under universal health insurance, every member of the population will have a universal entitlement to the core primary care services provided by GPs.

A number of Deputies have referred to the fact that I have been in touch with the representative bodies for GPs, engaged in correspondence with them and have invited them to meet me in connection with the draft GP contract, published last January, which the HSE put out for public consultation. I would encourage the GP representative bodies, in particular the IMO, to take up the offer of real engagement, consultation and negotiation that I have extended to them. The only way we can proceed with this reform - or any reform of public policy - is through dialogue. That is absolutely essential in this case, as much as in any other area of public policy. I must emphasise, in response to what Deputies have said, that it is the intention of the Government, and my intention in particular, to have a very real and meaningful engagement with the representative bodies for GPs. To anyone who thinks that it will be anything less than full and comprehensive, I must say that is not the case and is not my intention. I must also emphasise that the negotiation and consultation process that I have offered can extend to each and every one of the concerns that have been raised by GPs and their representative bodies in recent weeks. I exclude none of the issues from that process that Deputies, in the course of this debate, have referred to and are aware of from their own contacts with general practitioners.

The universal health insurance White Paper sets out the details of the methodology for determining the future health basket. This includes both the services that will be funded under universal health insurance, as well as the ongoing management and review of the future basket. The paper includes consideration of the options for financing UHI and deals with the key regulatory and cost control frameworks governing the universal health insurance system. The basket of services, in particular, is a matter that has been referred to by many Deputies in the course of this debate, including Deputy Buttimer most recently. I welcome the decision of the Oireachtas Joint Committee on Health and Children to host a consultation process on this. While it is entirely a matter for the committee, the decision follows on foot of an invitation to do so issued by the Minister and the Department of Health. The committee, as has been the case in the past, can make a real contribution to the development of universal health insurance. The committee has been invited to make recommendations on the values framework that will underpin decisions on the future health basket and to consider the options proposed by the expert commission.

All of these questions, including those on the basket of services and which particular services should be funded through universal health insurance, directly by the State or through individuals' own resources, are of fundamental importance to every citizen of this country. The answers to these questions are not simple but are complex, multi-faceted and involve various technical, economic and ethical considerations. These are deeply value-laden decisions and it is therefore important that the values underpinning the health basket reflect the values of broader society. Good practice in other jurisdictions in these decision-making processes involves a critical blend of both technical appraisal and comprehensive consultation with all relevant stakeholders, including patients, patient advocacy groups and others with an interest in these issues, as well as the citizens of the country. An expert commission will be tasked with developing detailed costed proposals on the composition of the future health basket, including those that will form part of the universal health insurance package of care. As part of its work, the commission will consult with both the public and with system stakeholders. Responsibility for the final decision on the services to be provided under UHI will of course rest with Government.

Universal health insurance represents a substantial shift in how we finance and organise the Irish health system. The White Paper sets out a comprehensive cost control framework to ensure affordability and to contain costs, which is a very real concern. These controls range from price monitoring of insurers and setting maximum prices for health care providers, to more aggressive measures such as capping insurer overheads and profit margins. Ultimately, the cost of universal health insurance in Ireland will depend on a number of key decisions, including the basket of services to be covered and the scope and design of the financial support system. These issues remain to be addressed and resolved. Work is already under way to further develop and refine proposals on cost control mechanisms, the financial subsidy system and, critically, costed recommendations for the basket of services to be provided.

Delivering a single-tier health system, supported by universal health insurance, is central to achieving our policy vision for the health system, a vision that is far-reaching and ambitious. We want everyone to have an opportunity to contribute to the development of our universal health insurance policy and help us to ensure that the major changes are put in place in the best possible way for the benefit of everyone. So I urge individuals, local groups, national organisations and other bodies to participate actively in the consultation processes and make their views known on the future funding and delivery of our health services.

Whether we ask who will be funding the health service in five or ten years' time, the answer is that it will be the Irish people. The real question is how they will fund it. Will it be through the universal health insurance system we advocate and seek to put in place? If so, how should it be configured and what services should be included? All questions that are required to be addressed can be addressed in the course of the debate.

I ask Deputies opposite, particularly those who have opposed this set of proposals at the outset, to agree with the following proposition at least. What we have in the White Paper is a serious contribution to the debate we must have on the future funding and organisation of our health services. It is at least worth an airing and a fair wind. It is our first opportunity to tease out and scrutinise the issues associated with the vexed question of funding of health services. Which services should be funded and how? This is the first time we have given ourselves that level of opportunity via the publication of such a comprehensive statement and set of data. These are not simple issues and their resolution will not be easy.

I heard Deputy Joe Higgins recall earlier the great achievement of the British Labour Party after the war in putting in place the great NHS system. One must ask whether any electorate can now be persuaded to fund an NHS system purely through taxation. I do not say that advocating the NHS model is illegitimate, but let Deputy Higgins and others get involved in the debate on the basis of the proposal we have put in place. Let parties opposite come forward with their alternatives. It is for the Opposition to oppose, with which principle I do not quibble. I do not expect the parties opposite to support uncritically what the Government proposes any more than we would if we were over there. However, in this area of public policy more than any other, we should have a concerted debate and discussion and share views and insights into how we want our health service to function in future.

It is a health service for the people of Ireland that we want to put in place. I do not exclude politics or even ideology from the debate, but I ask that we have a frank and open discussion based on evidence. The White Paper on universal health insurance is the best possible grounding for that debate. I commend it to the House and thank Deputies for their contributions. I look forward to continuing the debate with them.

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