Dáil Éireann debate -
Wednesday, 25 Feb 2015

Vol. 869 No. 2

Priority Questions

General Practitioner Services Provision

Billy Kelleher

Question:

1. Deputy Billy Kelleher asked the Minister for Health if he will provide an update on the introduction of free general practitioner care; when the scheme will commence for children under six years of age; when the Bill to provide free GP care to those over 70 years of age will be introduced; how he will address concerns that sick children who are older than six years will not see any benefit from this; if he will widen medical card eligibility to help these children; and if he will make a statement on the matter. [8305/15]

Deputy Billy Kelleher

I ask the Minister for Health for an update on the introduction of free general practitioner care. When does he expect the scheme to commence for children under six years? When will the Bill to provide for those over 70 years of age be introduced? How will he address the concerns that sick children who are older than six years will not see any benefit from this, and will he widen medical card eligibility to help these children?

Minister of State at the Department of Health

The Government is committed to introducing a universal GP service without fees on a phased basis. The first phase will be for all children under six years of age and all persons aged 70 and over to have access to GP care without fees. These arrangements will come into operation in quarter 2 of 2015, subject to the conclusion of contractual discussions. I expect the Bill to extend GP services without fees to all over-70s to be published in March. These measures represent a major step on the way to universal health care. The Government recognises that different age groups have different health care needs and abilities to access services and that children and older people have particular needs in this regard.

The medical card system is fundamentally based on means, and this position has obtained for more than 40 years. However, the Government recognises that the health service needs to be responsive to the circumstances of people with significant medical needs. In November 2014 the Minister for Health and I announced a series of measures to enhance the operation of the medical card scheme and make it more sensitive to people's needs, especially where serious illness is involved. Where deemed appropriate in particular circumstances, the HSE may exercise discretion and grant a medical card even though an applicant's means exceed the prescribed threshold. Where a person does not qualify for a medical card, he or she may be provided with a GP visit card, appropriate therapy or other community supports or drugs and appliances under the long-term illness scheme, where the qualification criteria are met.

The HSE has recently established a clinical advisory group for medical card eligibility. The group will provide oversight and guidance to the operation of a more compassionate medical card system and will focus initially on the development of a framework for assessment and measurement of the burden of illness in this context.

The Government is reforming the system of health service eligibility that it inherited and is seeking to make it fairer. For many years we have had universal eligibility for acute hospital services, but free access to the first and most effective point of contact with the health service - that is, GPs - has only been provided on a public basis to those on very low incomes. The provision of universal GP access through greater public investment in primary care services is a critical reform in resolving inequities and rebalancing our services towards earlier prevention. The introduction of universal GP access for the youngest and oldest members of our community is an important step in the phased implementation of these reforms.

Deputy Billy Kelleher

I thank the Minister of State for her reply. We could have this debate until we see the roll-out of universal free general practitioner care, but there is an interim period. As the Minister of State has limited resources and limited opportunity to introduce the various policies, she has to prioritise and make decisions in the context of what cohorts get the various resources. The Central Statistics Office publishes reports regularly, and one of these, which deals with life expectancy and health outcomes in the various socioeconomic groupings, has been commented on by the Irish Cancer Society and others. As late as this morning it was revealed that there is a widening gap between health outcomes in the various income groupings in Cork North-Central and parts of Cork South-Central. While we are talking about health outcomes in the context of the Department's reasoning for rolling out universal general practitioner care, the reality is that people from poor backgrounds with socioeconomic problems have poorer health outcomes. With regard to children under six years of age, how does one square that circle in terms of priority?

Deputy Kathleen Lynch

Inequality in general has an impact on health, and this is an issue for the entire Government, not just the Department of Health. I think the Deputy would agree with me on that. The system that is in place and which we hope to expand has ensured that the number of discretionary medical cards has increased enormously. There is a more compassionate way of looking at it. It is about the burden of illness. Even where people do not qualify through a means test, there is a recognition that illness brings an additional burden with it. We have increased the number of discretionary medical cards to over 70,000. The number of GP cards has increased to almost 85,500, and the figure for medical cards in general is over 1 million. A sizeable proportion of the population, therefore, are now covered by free access to a primary care medical card and, in many cases, GP access also. There is no shortage of people in need. We all understand that that is because of particular circumstances, but I am sure the Deputy understands that the general inequality in society is a much wider issue, which is the responsibility of more than just the Department of Health.

Deputy Billy Kelleher

We do accept, in terms of the provision of medical care, that there is always an element of universality in some decisions, but when the Minister of State is making a decision to rule out further additional universality, this has an impact in other areas. There is no point in saying otherwise.

We should be clear. There has been a change in how the Department is assessing discretionary medical cards. There has been a substantial increase in the number of discretionary medical cards awarded. The reason is that the policy the Minister of State was pursuing until the U-turn was wrong. It was wrong, unfair and inhumane that we were taking medical cards from the most vulnerable and the sickest in our society while at the same time outlining plans to give free GP care to others. I have no problem giving it to the others, but those who deserve it most should get it first, and then, as resources allow, the roll-out must happen. At least the Minister of State is now acknowledging that the issue of discretionary medical cards is a central one. The awarding of medical cards to vulnerable sick people is humane, compassionate and fair.

Deputy Kathleen Lynch

The argument that we should not provide free GP care to healthy children when there are others in need is sometimes a false one. As SUN, or Scaling Up Nutrition, tell us - one sees it in all the advertisements now, but we have been looking at it for years - proper nutrition and proper care are essential in the first thousand days of a child's life. If a child does not get the essential nutrition within that first thousand days, this has an impact on the rest of its life. The Deputy and I know that there are certain groups of people to whom that essential nutrition is not being delivered, sometimes because it is not clear what it is.

Until the day when we have universal free access to GPs and health care in this country, there will always be hard cases.

I am astonished that we are doing it at a time we have to be extraordinarily careful about how we spend money, but the Fianna Fáil-led Government did not do so at a time when it was awash with money.

Universal Health Insurance Provision

Caoimhghín Ó Caoláin

Question:

2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health his views on the report by the World Health Organization, WHO, that has raised concerns regarding the Government's plan to introduce universal health insurance, UHI, and mentions European examples where insurer competition has proved ineffective in improving efficiency and controlling costs, including the fact that no country has been identified in which costs went down on the introduction of such a model based on competing insurers; and if he will make a statement on the matter. [8164/15]

Deputy Caoimhghín Ó Caoláin

In light of the WHO report that has questioned the Government's plan to introduce UHI, I seek to establish the Minister's most up-to-date thinking and intentions regarding the Government's proposed UHI-based health care model.

Minister for Health

I am aware of the WHO report referred to by the Deputy. My Department provided information and observations on an early draft of that report. The report emphasises the need for reform of our health services and acknowledges that the Government is the first in the history of the State to commit to the principle of a universal, single tier health service which guarantees access to medical care based on need, not income. The first concrete manifestation of that will be seen this year by extending GP care without fees to the younger and older in our society. We remain committed to the goal of universal health care and to driving forward reforms in other areas such as extending GP care without fees to other groups, further widening discretion for medical card based on medical need as well as income, improving the management of chronic diseases, establishing activity-based funding, establishing hospital groups, and making health insurance more affordable. These initiatives are important reforms in their own right that will drive efficiencies and bring benefits in advance of moving to a system of universal health care. This Government's commitment to major reform is long overdue with the report noting that reform "was largely ignored in the pre-crisis period".

With regard to the potential cost of a competitive universal insurance system, my Department is working with the ESRI, the Health Insurance Authority and others on a major costing exercise. This exercise will examine the cost implications of a change to a multi-payer, universal health insurance model, as proposed in the White Paper on UHI. The analysis will include a review of evidence of the effects on health care spending of alternative systems of financing and changes in financing methods and entitlements. It will also estimate the cost of UHI for individuals, households, employers and the Exchequer. I expect to have the initial results from this exercise in April, following which I will revert to the Government with a roadmap on the next steps to UHI.

The work of the WHO and others points to the fact that there is no magic prescription for all countries when it comes to health service reform. At different points in their development, some health services may be charged with control of excessive costs while others - arguably including our own - will need to focus on responsive and equitable access.

Deputy Caoimhghín Ó Caoláin

I found the Minister's response interesting and I would have been quite comfortable delivering the opening part of it myself. I note there is just an evaluation and I take some encouragement from that because I am very much of the view, as the WHO has confirmed, that there is no evidence of any country in which a competitive insurance system has kept costs under control. While the Government, through the voice of the previous Minister for Health, anticipated that if every citizen was forced to have health insurance, providers would compete against each other, thereby driving down costs, the international evidence does not support that. As the WHO report clearly demonstrates: "The experience of insurer competition in Germany, the Netherlands and Switzerland suggests that such systems have not been effective in health care cost control." It further states: "It is questionable whether a competitive insurance system will help to improve efficiency and control costs." While the Minister is on hold pending the review, would he like to share any other insight into his current thinking and disposition towards the UHI model?

Deputy Leo Varadkar

I can only give a two-part answer to that. The first part is to advise the Deputy of the plan, which we are currently enacting. First, we will extend tax-funded GP care without fees to the oldest and youngest in society. Once that is done, hopefully, by the summer, we then wish to enter contract negotiations with the Irish Medical Organisation, IMO, on extending it to other groups, including other schoolchildren, chronic disease groups and so on. At the same time in parallel, we are trying to make health insurance more affordable for more people because it is good that people take out health insurance in the same way they take out other forms of insurance, whether it is life insurance, pension cover or travel insurance. It is open to debate whether a multi-payer system is the best way of keeping costs down. The best example of keeping costs down is our own system. We spend €1.5 billion less than we did seven years ago and more patients are seen. The public system is a good example of keeping costs down. I just wish we were able to do much more than we can at present.

Deputy Caoimhghín Ó Caoláin

We are of one mind again on that. It is not only the WHO that questions this. I refer to the commentary from the Department of Public Expenditure and Reform. The Society of Actuaries in Ireland has warned that insurers could need up to €2.4 billion in additional regulatory capital to operate UHI. I attended and participated in an IMO seminar towards the end of last year in Dublin city centre. Professor Trevor Duffy and his colleagues at the helm of the organisation stated: "The system as outlined will restrict choice and lead to rapid closures of smaller health facilities throughout the country." There is strong and real concern across the board regarding the UHI approach.

I am absolutely committed to universal health care and I refer again to the opening sentences of the Minister's reply. I indicated to the previous Minister of State at the Department of Health on the announcement of the introduction of free GP care for under sixes that I was prepared to support this, which is a different position from my Fianna Fáil colleague, as it was to be part of a programmed roll-out of universal access to free GP care. Will the Minister undertake to ensure there is not an inordinate time lapse between the introduction of the roll-out to the under sixes and over 70s and the roll-out to the rest of the population? That would only perpetuate inequality and a double standard within the system. We need a speedy move towards the universal roll-out of free GP care. Will the Minister please give a clarification?

Deputy Leo Varadkar

Universal health care is a group term that can mean many different things. It can be a fully tax-funded system like the British National Health Service, a system with a mix of co-payments, a system that involves compulsory health insurance using a social insurance model or a competitive compulsory private insurance model. There are many different ways to achieve universal health care. Looking across different jurisdictions and countries, one cannot say definitively that one model is best. I do not buy that. There are pluses and minuses to all models. There is the option of a mix of models and the right model has to fit the right country because countries are different culturally and we must bear that in mind.

The major delay in providing GP access without fees to the under sixes has been the time it has taken to come to an agreement with family doctors, but it was worth taking the time to do that. Once that agreement is concluded and assuming GPs take up the contract in sufficient numbers, and they do not have to, we will then immediately enter negotiations on extending such access to other cohorts. Initially it will be other schoolchildren and I am particularly keen to include adults with chronic diseases as well.

Hospital Services

John Halligan

Question:

3. Deputy John Halligan asked the Minister for Health further to Questions Nos. 246 and 249 of 18 December 2013, if he will provide a guarantee that 24-7 cardiac cover will be introduced at University Hospital Waterford, UHW in the lifetime of the Government; his views that this service has been promised since 2010; the infrastructure that is currently lacking at the hospital, which prohibits the introduction of a full-time service; the plans his Department has to increase the staffing complement of consultant interventional cardiologists from its current three to six to operate a 24-7 unit; if funds have been ring-fenced to provide for this additional staffing; his further views that there is a sufficient level of care being provided to cardiac patients between the hours of 5 p.m. on Friday and 9 a.m. on Monday in the hospital; his views that no deaths will occur as a direct result of the lack of experienced cardiac cover at the weekends; the outcome of the Health Service Executive examination into options for the location of the long-awaited catheterization laboratory within the hospital; and if he will make a statement on the matter. [8166/15]

Deputy John Halligan

Can the Minister finally guarantee that 24-7 cardiac cover will be introduced at University Hospital Waterford in the lifetime of the Government, as promised since 2010? What infrastructure is currently lacking at UHW that prohibits the introduction of a full-time service? What plans has the Department to increase the staffing complement of consultant interventional cardiologists from its current three to six, to operate a 24-7 unit?

Deputy Leo Varadkar

University Hospital Waterford's regional cardiology interventional suite opened in 2008 and serves a population of almost 500,000 people. In 2012, the suite was identified as the designated primary PCI centre for the region, under the national clinical programme for acute coronary syndrome. Its services cover Waterford, Kilkenny, south Tipperary and Wexford. The centre currently has one catheterisation laboratory, which operates five days a week and incorporates a dedicated six-bed cardiac day ward. Staff include three consultant interventional cardiologists based at Waterford and two visiting consultant cardiologists, from Wexford and south Tipperary, who work there one day a week.

Having 24-hour emergency PCI cover requires, as a minimum, two cath labs on site. As for any complex acute hospital service, a key criterion for deciding whether a 24-hour PCI service should be provided is whether there is a sufficient volume of appropriate activity to ensure safe provision of the service to patients. Without sufficient volume, the number of staff required to man a 24-7 roster will not be in a position to treat the number of patients needed to maintain their skills.

A review of PCI services in Dublin is due to be completed shortly. On the completion of that process, PCI capacity and requirements in areas outside Dublin, including in Waterford, will be examined. Any decision on further provision of PCI services in any region will be based on the best interest of patients and on evidence on the volume of clinical need, the quality and safety of the service that can be provided, the ability to staff it safely and the resources available.

Deputy John Halligan

I am not happy with the Minister's reply. This Government and former Minister committed to a 24-7 service. The cath lab is open from Monday to Friday until 5.30 p.m. and, despite the fact that Waterford is one of the busiest regional hospitals in the country, it closes at the weekend. Lives are being lost. I was recently in contact with the Minister's office concerning one of these lives. The person is Andrew Doherty, who was admitted to the cardiac unit in Waterford last October for ten days. During that time, he had two stents implanted and was transferred to the medical ward for surgery. He began to feel chest pains on Sunday afternoon, but no doctor was called or consultant informed about the change in his condition. As it was the weekend, the cath lab was closed. The family was told not to worry and that he was having a panic attack. Mr. Doherty passed away that night, and a junior doctor whom I contacted told his wife he did not know the man's history and could do practically nothing until the consultants returned on Monday morning. Why is the Minister talking about volume when this is about people's lives? Perhaps one life can be saved over a weekend. The Minister made a cast-iron guarantee to the people of Waterford. Some 15,000 people marched on the streets of Waterford two years ago. After the march, the then Minister for Health promised a 24-hour service. Now I am looking to hear a yes-or-no answer. Will the service be provided before the end of the current term? If not, there will be another 15,000 people on the streets of Waterford shortly.

Deputy Leo Varadkar

I do not know the details of the case to which the Deputy referred.

Deputy John Halligan

I sent the details to the Minister.

Deputy Leo Varadkar

I do not have access to patients' files and I doubt Deputy Halligan does either. I think it inappropriate to raise such cases in the Dáil unless the Deputy has full access and expert knowledge of the case. I do not know whether that is the case. I may be incorrect, but at any given time in University Hospital Waterford there will be a consultant physician on call, if not a consultant cardiologist. Why the person was not called in a particular case, I cannot say.

I can guarantee that one thing that costs lives is the setting up of any specialist service that is not adequately staffed and does not have an adequate throughput to ensure quality and to ensure that those providing the service are able to keep their skills up to date. We have already seen this with cancer services, which is why they had to be centralised. In order to be viable, a 24-7 PCI service must serve a population of 500,000 to 1,000,000 people and it must also have at least six interventional cardiologists to provide a 24-7 cover rota. The most obvious first step in the improvement of services in the south east and Waterford is that the hours of the existing cath lab be extended, perhaps from 8 a.m. to 8 p.m., covering Saturdays and Sundays. It is important to see whether the three cardiologists are able to cover the rota. We have had problems in other parts of the country where consultant cardiologists are unable to cover the rota. It is a much greater patient safety risk.

Deputy John Halligan

The cath lab is closed from 5.30 p.m. on Friday until Monday. The Government prepared a business plan in the 2015 Estimates which stated that University Hospital Waterford needed an additional three consultant interventional cardiologists to enable the lab to operate on a 24-7 basis. The hospital recently sought funding for these, and the total revenue cost, according to the Government, was €2.7 million. We are now being told that the cost benefit analysis must take place again. The Government has already done a business plan. The former Minister for Health put together a business plan and categorically told the people of Waterford that the 24-hour service would be guaranteed. I met him in the hospital. The Minister is now saying that it may be, that he is not too sure, and that it probably will not be.

Deputy Leo Varadkar

It is not standard practice for the Government to do business plans. Maybe it was done by the hospital group.

Deputy John Halligan

The Government supported it. The former Minister supported it. I am sorry for cutting across the Minister. This is a very serious issue.

Deputy Leo Varadkar

I will answer the question if I am not interrupted.

Deputy John Halligan

I apologise.

Deputy Leo Varadkar

I am not aware of the preparation of any business plan by the Government. Business plans for services are generally done by a hospital, a hospital group or the HSE. To ensure that lives are protected, it is important that any specialist service has adequate throughput, which means enough patients and in sufficient volume to ensure quality, critical mass and specialisation. It must also be adequately staffed. The first step in Waterford is to extend the hours of the existing cath lab, because any new cath lab will take time to build. There are currently three cardiologists. If six people can cover a 24-7 service, surely the existing three people can cover a 12-hour service seven days a week. As the Deputy should know, if he does not already, there is great difficulty in hiring cardiologists and being able to cover rotas in the way that people expect. If a rota is not covered, this results in a greater patient safety risk. An unsafe service is not a good thing. We want people to have a safe service, and it is better that people travel to obtain a safe service than have an unsafe service close by.

HSE Funding

Billy Kelleher

Question:

4. Deputy Billy Kelleher asked the Minister for Health if he will provide an update on the financial position of the Health Service Executive; his views on whether the executive has sufficient funding to deliver its 2015 service plan without recourse to a Supplementary Estimate; and if he will make a statement on the matter. [8306/15]

Deputy Billy Kelleher

I am requesting an update on the HSE's financial position and asking whether the Minister is confident that the HSE has sufficient funding to deliver its 2015 service plan without recourse to a Supplementary Estimate.

Deputy Leo Varadkar

The gross provision for the health Vote in 2015 is €12.677 billion, comprising €12.295 billion in current expenditure and €382 million in capital expenditure. Following restatement on a like-for-like basis consistent with the new Vote structure, the Exchequer funding provided in 2015 represents an increase of €564 million on the original 2014 provision. In addition to the Exchequer funding, increased non-Vote income of €130 million collected by the HSE will support expenditure in 2015. This contributes to a total increase of €694 million compared to the original 2014 Estimate. Savings of at least €130 million have also been identified, and this will be retained within the HSE to support services.

When adjusted for one-off issues, the January 2015 net Vote position is €16 million, or 1.3%, greater than the January 2014 position month-on-month. The 2015 net Estimate, compared on a like-for-like basis with the original 2014 net Estimate, is 4% higher, indicating that the January cash drawdown is not out of line with the available provision.

The Irish health services endured a seven-year period of significant retrenchment and funding constraint as a direct consequence of the financial crisis the Irish State had to address in the period 2008 to 2014. Improved 2015 budgetary parameters have allowed the HSE service plan to include a number of targeted enhancements to health and social care services, while providing generally for the delivery of existing levels of service. The 2015 HSE service plan represents a welcome turn of the tide in terms of the increased level of funding available.

In a welcome new development, any further savings that can be achieved over and above the target set in the national service plan will go back into the delivery of improved health and social care services.

It is not possible to address all of the issues and priorities in one year, and the operation of health services in 2015 will continue to demand very careful financial management. Nevertheless, we have made significant progress in putting the finances of the health system on a steadier and more sustainable path.

Deputy Billy Kelleher

The Minister said his first aim was to draw up a realistic budget in the context of last year's Estimates and on the basis of negotiations with his Cabinet colleagues, the Minister for Finance and the Minister for Public Expenditure and Reform. Already, however, on 24 February, it is clear we do not have a realistic budget. The Minister repeatedly tells us things will get worse before they get better, which is an obvious statement of fact. We have huge problems with overcrowding in emergency departments throughout the country and a consistent problem with delayed discharges. We can already see that the fair deal funding for this year is wholly inadequate. We knew that already because Mr. Tony O'Brien, director general of the Health Service Executive, told us so at a recent Oireachtas committee hearing. The Minister must give his colleague, the Minister of State, Deputy Kathleen Lynch, additional funding for that scheme. The money must be found somewhere.

Pretending we have a realistic budget will not do. It is entirely unrealistic to claim the services can be delivered on the basis of the funding the Minister has set out. We are already, at this early stage in the year, in a situation where the health services are beginning to dismantle before our eyes.

Deputy Leo Varadkar

We have a realistic budget in place. The Vote for 2015 represents the first increase in funding in seven years and a greater increase than was proposed by the Deputy's party in its alternative budget submission last November. The figures we have for January show spending is in line with projections. In other words, there is no evidence at this stage of any significant overspend. There are, of course, issues with delayed discharges. That figure is down since the start of the year but it remains a problem. We also have difficulties with waiting times and overcrowding in emergency departments. We need additional resources for the fair deal scheme, home care packages and home help provision.

As the Minister of State, Deputy Kathleen Lynch, and Mr. Tony O'Brien have outlined, there are three options for achieving these objectives. We could opt to reprioritise spending within the health Vote or we could bring forward a spending plan later in the year. The third option, pretending the problem will somehow go away in the summer, is not really an option. That is a total nonsense and fewer and fewer people believe it. When it comes to a decision on the three options, it is not one I can make on my own; it must be done in conjunction with the Cabinet committee on health and the Economic Management Council. All members of the Cabinet committee and the EMC are fully apprised of the situation and have been since November.

Deputy Billy Kelleher

The Minister's response does not give us much comfort. He says we have a realistic budget which is on course and on target. If that is so, then my concern is that the Minister is saying that having 550 people on trolleys in emergency departments on a daily basis and people waiting 12 and 14 weeks for a bed under the fair deal scheme is acceptable. Surely these numbers do not represent a budget that is on target? In truth, it is a wholly inadequate service and the idea that it might get a little better at some stage and we should proceed on a wing and a prayer is not good enough.

There must be a sustained attempt to address the fundamental problems in our health service, including emergency department overcrowding. We must tackle delayed discharges if we are to address that issue, as acknowledged by the Minister and by the former national director of acute hospitals, Dr. Tony O'Connell, who resigned at the start of the year. The latter warned of the threats to patient safety as a consequence of overcrowding. The trundling acceptance that there is a difficulty without actually dealing with it is the major problem. The time for lethargy is past and we must now have a redoubling of effort.

Deputy Leo Varadkar

At 8 a.m. this morning there were approximately 420 patients on trolleys across 28 acute hospitals. That number will fall dramatically during the day, as it always does, probably by half. Of course, it is still not acceptable that anybody should be on a trolley for more than nine hours. What was in Dr. Tony O'Connell's letter, which was not addressed to me but to others in the HSE, was nothing new. It is absolutely the case that older people who are in hospital longer than they have to be because they are waiting on a nursing home bed or home care package are at risk of falls, medication errors and infection. In addition, the fact they are not being discharged certainly does delay treatment for others, who are then put at risk. There is nothing new in what Mr. O'Connell pointed out in his letter. It is something that could be said about our health service for as long as I can remember, certainly going back to when I was a medical student.

We are taking action to alleviate the situation and that is why the number of delayed discharges has gone down and the number on trolleys is going down slightly week on week. It is one of the reasons the wait time for the fair deal scheme has gone down. I agree with the Deputy that it is necessary for us to press on with that, redouble our efforts and keep chipping away at the problem throughout the year. There are three options as to how we proceed, as I indicated, and a decision in that regard requires the approval of the EMC and the Cabinet committee on health.

Nursing Homes Support Scheme Review

Caoimhghín Ó Caoláin

Question:

5. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will provide details of the review of the funding of the fair deal scheme; if there are plans to charge older persons more for their care under the scheme; the percentage of assets and income planned to be taken; if a further proportion of the funding will come from the public purse; and if he will make a statement on the matter. [8165/15]

Deputy Caoimhghín Ó Caoláin

The recent remarks by the Minister of State, Deputy Kathleen Lynch, regarding the future funding of the fair deal scheme have caused considerable concern and, for some, fear. Will she confirm today that there will be no increase in the forfeit contribution requirement and the 7.5% per annum up to a three-year ceiling State take of the property value of the service recipient following his or her demise?

Deputy Kathleen Lynch

The nursing homes support scheme is a key component of our health service and a recurring theme of our discussion this morning. While older people prefer to remain at home if possible, there will always be a need for long-term nursing home care. The scheme's introduction in 2009 relieved families of potentially very onerous expense and ensured equity of treatment based upon means, regardless of the type of nursing home care provided. It involves a very significant financial commitment on the part of the State, with €948.8 million allocated to the scheme in 2015. This represents an increase of €10 million on the 2014 figures.

When the nursing homes support scheme commenced, a commitment was made that it would be reviewed after three years. This review is being carried out by my Department in collaboration with the Health Service Executive, with analysis and recommendations provided by Deloitte Consultants on specific issues which required specialised expertise. The review is considering the long-term sustainability of the scheme, including funding arrangements. No decisions have been taken and no plans put in place regarding changes to the way the scheme currently operates.

Between now and 2024 the population over 65 years is projected to increase by some 200,000. Based upon current trends, those requiring long-term care will increase by a third over the same period. On that projection, spending on the scheme at current prices would approach €1.3 billion per annum from its current level of just under €950 million.

The review of the nursing homes support scheme, as well as considering how the scheme has operated to date, is expected to identify some of the broader issues that will need to be considered and tested more fully into the future, including the future financing of the full range of supports for older people, how community and residential supports and services should be balanced, and whether new care approaches can contribute positively. A continuum of more efficient care might serve to reduce the number of people requiring nursing home care and limit the projected increase in the cost of the scheme.

There is much reference these days to the challenges that demographic trends represent. That we are facing these challenges should be welcomed, as it means we are achieving longer lives for more of our people. It is these older people and their families who will be the central priority in planning services and supports for the future.

Deputy Caoimhghín Ó Caoláin

The Minister of State's response is not a reply to the question I posed. In the course of her attendance at a recent meeting of the Joint Committee on Health and Children, she stated: "The idea that a person with means would pay in the range of €250 to €290 per week for a service that is costing anything up to €1,200 to provide is unsustainable." In a subsequent interview she stated that struggling families will not face extra costs or lose supports. In the confusion around all of this and the absence of certainty - there is no detail in the Minister of State's reply today - it is understandable that people are experiencing considerable concern and some fear as to what lies ahead.

It is incumbent on the Minister of State and her colleague, the Minister, to clarify the situation for those already in long-term residential care and the many who are currently seeking to access long-term residential care because they are no longer able to provide for themselves independently and do not have the necessary familial supports in order to live independently. When will the review conclude? When will it report? When will we have the certainty? Can the Minister of State say anything to the cohort of people whom I have referred to that will allay the real fears that I have described?

Deputy Kathleen Lynch

Everyone agrees that the current scheme is unsustainable. We do not have enough money. Delayed discharges are a major difficulty for the entire health service. However, this is not just a question of the fair deal scheme. As I have been saying for a considerable time, it is also a question of the community-based services that each and every one of us would prefer were we to need them. We would be able to stay in our own communities and homes. Mr. Tony O'Brien reiterated at the meeting what I had been saying for the past 12 months, that being, the fair deal scheme must become demand led. It is as simple as that. The scheme is perfectly constructed to be demand led. It has a tight access point and stringent eligibility criteria.

We will need more money. It is estimated that, were we to make the scheme demand led, it would cost approximately €1.3 billion, which is exactly what we pay in disability services every year.

We cannot pretend that this is not an issue. We have reduced the waiting time to 11 weeks, but even that time is still impacting on families. We must continue the work. For the past 12 months, I have worked with the Minister for Health on ensuring that we put in place a scheme that benefits those of us who might need it in future and that people do not delay too long in accessing the service. Unless families are extraordinarily well off, they cannot pay the type of money that is necessary to keep their loved ones in continuing care.

Deputy Caoimhghín Ó Caoláin

There can be no question but that our senior citizens not only require, but are deserving of our collective societal support in every and any way that we can provide it. The Minister of State made reference to Mr. O'Brien's contribution at the last Oireachtas health committee meeting. He also indicated in his reply that day that we were looking at the 11 weeks rolling out to up to 20 weeks by the end of this year. This is a very worrying situation.

It was also indicated that the Government would discuss the review in Cabinet at the beginning of next month. That is what I noted. That is March, which is only around the corner; March is this weekend. I asked the Minister of State in my supplementary question how quickly we expected this review to be presented and the clarity that we need issuing from it.

Deputy Kathleen Lynch

I am sorry.

Deputy Caoimhghín Ó Caoláin

In conclusion, it has to be responsive to the needs of people. It cannot operate on a capped basis, telling people to wait until January or September. That is not on and has to change.

We also need to take on board the requirement of increased numbers in terms of beds availability. Increasing the capacity of existing long-stay residential provision is required. Responding to the Health Information and Quality Authority, HIQA, reports in the way that we have without actually building in additional capacity is a real failing and poor use of public moneys in times of design teams and contractors.

Deputy Kathleen Lynch

I apologise for not answering the question on the review. As we speak, the review is on the desk of the Secretary General of the Department of Health. I have not seen it. I have heard snippets of what is in it, but that is about it, and it would be unfair to comment further at this stage.

Deputy Caoimhghín Ó Caoláin

The Minister of State could share the snippets.

Deputy Kathleen Lynch

I will not. I have not seen them, so I am not certain that they are correct. I will get the review shortly and it will go to the Cabinet. I am not certain that it will give us or recommend what is necessary. Rather, I believe it is an examination of how the scheme has operated and whether we need to change it. I do not believe that it will recommend, for instance, that the way of accessing should be different, but I am not certain. As soon as the process is complete, I intend to publish the review.

I agree with the Deputy in terms of beds capacity and availability. However, if we get the balance right between community services and beds, the need for the latter will not be as great as we imagine.