Health (General Practitioner Service) Bill 2015: Second Stage (Resumed)

Question again proposed: "That the Bill be now read a Second Time."

Deputy Denis Naughten was in possession and has four minutes remaining.

The final point that I wish to make in respect of this legislation concerns an issue which is fundamental to universal health care, namely, capacity. The capacity is not in the system to provide free GP care for the population as a whole. When we were working on this initiative prior to the 2007 general election, one of the key fundamental elements to ensuring the FairCare universal health insurance worked was that capacity needed to be built up within the system before rolling out enhanced accessibility. If that was not done, demand would be built up for services which did not exist. It is all well and good to provide people with free access to GP care, but, as we know, there are huge delays and backlogs in getting occupational therapy, physiotherapy, and all of those other therapies. This is not only in respect of adults and older people but also in respect of children. Giving children or older people free access to a GP without putting the physiotherapy, occupational therapy and speech and language therapy capacity in place is a pointless exercise.

When we look to the United Kingdom, we see an appalling situation where primary care is creaking and bursting at the seams. A study was completed last year which showed that GPs in the United Kingdom are under considerable strain, with insufficient capacity to meet the current and expected needs of parents. The interesting and telling thing is that the number of patients waiting up to four weeks, one month, for a consultation will increase significantly if capacity is not provided in the system. If we do not resource primary care properly, we will see waiting lists for GPs in this country. It will force people to go down the SwiftCare and Beacon accident and emergency route. People will have to buy in specialist GP cover because the public system will be creaking. It is fundamentally important that we put the proper resources into primary care. This is not only in order that GPs will be able to deal with the capacity issues, it will also bring a far more significant return in reducing demand in accident and emergency departments and acute hospitals. There will also be a knock-on impact in delayed discharges and nursing home supports.

We need to treat people before they need to go to a hospital. We need to try to reduce the number of people who are getting sick by putting resources for preventive measures into communities. We need to ensure that when people get sick, they can access a GP or other primary care physician or specialist.

Only those who are really sick should attend hospital. When they do, they should be treated and discharged into the community as quickly as possible. The system of housing adaptation grants which have been slashed significantly in recent years should not block people from being discharged from hospital. In the past two years in my county the grant has been cut by 72%, which has had a direct impact on the number of delayed discharges. This is replicated across the country.

There needs to be fundamental change in the health system. We must front-load it and resource preventive care services. If we can do so, we will reduce demand in hospitals and overcrowding in accident and emergency units and have a much better service for everyone.

Deputy Paul J. Connaughton is sharing time with Deputies Peter Fitzpatrick and Joe O'Reilly.

I thank the Ceann Comhairle for giving me the opportunity to contribute to the debate on the Bill. From speaking with many people on the ground since the initiative's announcement, it seems to be a welcome step, albeit a small one but in the right direction for those aged under six years or over 70. The majority see it for what it is attempting to do, particularly as regards regular checks for diabetes and asthma. It is viewed as progressive and positive. It is to the eternal credit of the Minister and the Minister of State, Deputy Kathleen Lynch, that it seems to be getting over the line. The concerns expressed by some Opposition spokespersons were related to how it had taken too long to reach this point. We wish it had happened earlier, but this is a positive step in providing for universal health care. One need only put oneself in the mind of a young parent whose child has a sickness that he or she does not understand. One would hate to think he or she would fear going to a general practitioner, GP, because the cost was prohibitive. This initiative will help in that regard and I welcome it as a step forward.

I do not know whether some members of the Opposition will support the Bill, but their objections gave the impression that doctors' surgeries would be filled with healthy and wealthy kids and that those who needed this initiative would not benefit from it. That is scaremongering of the worst kind. Why anyone would bring to a doctor a child who did not need to be there is beyond me.

There is an issue in accident and emergency departments, in that some people who attend might not need to do so. While the Bill will not solve that problem, it will help in some way.

I wish to address a point raised by Deputy Denis Naughten. In this debate there has been little conversation about the decision in respect of those aged under six years or over 70. Deputies have instead discussed everything else about the health service. They went off topic and everyone got to vent for five or ten minutes; the Minister will excuse me, therefore, if I do a little of the same.

There is still an issue with medical cards. If I had my way, I would dismantle the whole system because it is not fit for purpose. The first question I would then be asked would be what I would do differently, but that is the problem - I do not have an answer. This is why the Minister is where he is and I am where I am. We only get to deal with the hardship cases. Like Deputy Denis Naughten, some people whose cases I have encountered have been tortured and put through the wringer when asking the State for a medical card or assistance for the first time. Some people treat a medical card as if it was another card for their wallets and something to which they are entitled, but others who really need it cannot get one. Worse still, they need it within a certain timeframe, for example, cancer sufferers, but they cannot access one for 12, 15 or 18 months. Efforts have been made to resolve this issue, but we have a long way to go.

I will cite one or two examples. A constituent of mine who is in his late 80s only has an income of €4,000 per annum from renting farm land. He has never applied for a pension and is proud of having saved the State so much money for 20 years, but he was continually refused a medical card because his income had not been assessed for social welfare purposes. There was no assessment because he was adamant that he would not apply for a pension for the remainder of his life. He was hospitalised a number of times last year and living in considerable fear of large hospital bills. He was unwilling to visit a doctor because of the costs involved and, as such, was probably not on the correct medication to reflect his changing circumstances. Thankfully, he was granted a medical card in the past month after 15 months of effort. This individual had saved the State money for a considerable period only to find that he could not apply to one arm of the State for necessary assistance because another arm knew nothing about him.

The Bill is a welcome first step on the long road towards universal health care. Instead of knocking what is a positive start, perhaps the Opposition might explain how it would do things better or what the next step should be. All I am hearing is Deputies going on about issues in the health system about which we all know and in respect of which we will need assistance. Some of the proposals from the Deputies opposite have not been costed. It is pie in the sky stuff. Now is the time to admit that the Government has made a positive first step and support the initiative. If Opposition Deputies can make it better, please do. If they have alternatives or opinions, let us hear them. All I am hearing is Deputies giving out for the sake of it.

I welcome the opportunity to contribute to the debate on this Bill. In the programme for Government we committed to introducing a universal GP service for everyone. In line with the statement of Government priorities 2014-16, we prioritised the over 70s in providing free access to GP care. The Government decided to commence the roll-out of universal GP care services for the entire population by providing for all children under six years of age and all persons aged 70 and over. In real terms, this means that more than 36,000 people aged 70 years and over who currently must pay to see their GP will no longer have to pay such fees which can range from €40 to €70 for a single visit. Many constituents from Dundalk, Drogheda, Ardee, Dunleer and Carlingford visited my constituency office to outline the fact that they were encountering severe financial hardship in paying for doctor visits, despite the fact that they had incomes in excess of the limits imposed for the granting of a GP card. The Bill will be a great relief for them and will, once and for all, take away the financial worry of the costs involved in visiting a GP.

I wish to highlight the many improvements that have taken place in the health service in my constituency in the past two years. In 2015 the Government has increased the budget for the health service for the first time since the financial crisis began. This has meant 198,000 home help hours in County Louth, representing an increase of 29% on the 2013 figure; two new primary care centres opening in Ardee and Carlingford, and 48% of the population, or just over 59,000 people, having full medical cards. More than 60 houses have benefited from the disability housing adaptation grants scheme at a cost of €723,000.

I am working closely with Louth County Hospital to raise awareness of the many excellent services available which will go a long way towards alleviating the overcrowding issue in Our Lady of Lourdes Hospital in Drogheda. They include general, surgical, gynaecological, dental and urological services. It should be noted that Louth County Hospital's minor injuries unit is open seven days per week and sees almost 30 patients daily, with an average turnaround time of less than one hour. The venesection service at Our Lady of Lourdes Hospital transferred to Louth County Hospital in September 2010, involving the transfer of 300 patients with haemochromatosis. The number of venesection procedures has increased from 25 to an average of 65 weekly, representing a 160% increase.

While much is being done to improve the health service, I acknowledge that we have a great deal of work still to do in order to provide the world-class health service the people deserve. The are more than 400,000 people in Ireland aged 70 years and over. Of these, more than 36,000 must pay to access GP services. There is medical evidence to support the idea that those aged over 70 years have a greatly increased chance of contracting multiple chronic conditions. Therefore, there is a significant benefit to society in providing them with free access to core primary care in the form of GP services. It is widely accepted that a well developed system of primary care offers significant benefits for the health care system generally, which is welcome.

Under the provisions of the Bill, people aged 70 years and over who currently have a medical or a GP card will continue to receive all medical card entitlements as normal.

When the first phases of free universal GP care are in place, namely, the provisions for the under sixes and the over 70s, we will have a situation where the most vulnerable in society will have access to care without facing a financial barrier. In effect, the Government is ensuring an additional 250,000 people will have unrestricted and free access to GP care. I strongly support the decision to roll out the next phase of free universal GP care to all over 70 years.

I welcome the opportunity to contribute to this important debate. Primary care has been a key area of reform for the Government since it came to office. The quality of health care in any country is measured by its responsiveness to changes in society and the changing needs of the population. A Central Statistics Office report on population and labour force projections from 2016 to 2046 predicts that the number of people aged 65 years and over will rise to almost 1.4 million by 2046. More significantly, it forecasts a marked rise in the numbers aged 80 years and over, with the figure jumping to 470,000 by 2046. We cannot ignore these figures which highlight the fact that a strong strategy is needed to ensure we will have a quality health system in place well in advance of 2046.

The legislation before us represents a strong step forward in that planning process. Some 36,000 people over the age of 70 years currently do not qualify for free GP care. That is out of kilter with best practice internationally and among our European partners that, in most instances, provide free access to primary care. Section 2 of the Bill provides for the removal of all persons aged over 70 years from the means-testing process for free GP care. This section underpins the premise of the legislation and builds on the first stage of the implementation of free GP care for all citizens. In addition, free care is being extended to all children aged six years and under.

The Minister has indicated that both initiatives will be brought forward by the summer. I welcome this move which will see approximately 800,000 people aged over 70 years and under six being able to visit a GP without facing a financial barrier. I congratulate the Minister on his success in finalising the negotiations on a new GP contract. The majority of GPs have bought into the system, which is a very welcome development. GPs are central to the delivery of health services, functioning as the point of access for most patients. GPs enjoy the confidence of their patients and it is vital that they be properly remunerated and motivated. It is meritorious in itself that the Minister has managed to secure industrial peace, for want of a better term, between his Department and the majority of GPs.

One of the key components of the programme for Government is the undertaking to implement a phased introduction of universal free GP care. I am pleased to see that real progress is finally being made in this area, which will have a positive and reassuring effect on many individuals and families. It is progressive to seek to create a society where health care is related to need rather than income. I am very proud to be a member of a party which is pursuing that objective in government.

As I said, section 2 of the Bill, which amends the Health Act 1970, will give everyone aged over 70 years an automatic entitlement to free GP care, removing the requirement to go through the sometimes lengthy process of means testing. A study carried out by the Irish LongituDinal Study on Ageing, TILDA, at Trinity College Dublin found that there was some evidence to suggest persons without a medical card or a GP visit card might face barriers when it came to accessing the flu vaccination. Any disincentive in this regard gives cause for concern and the Health Service Executive strongly recommends that those aged 65 years and older ensure they avail of the vaccine. Influenza can be fatal, especially for those with underlying medical conditions, which is common among many of the population aged over 70 years.

TILDA also identified a significant reduction in the numbers of people over 70 years of age with full access to primary and secondary care services at a time in their lives when their need for health care was increasing. Such services are especially important at the end of life. As people age, access to health care becomes all the more important but often more difficult to access because of means. If initial difficulties are not addressed, people may end up being hospitalised or needing nursing home care, with the associated expense. There will always be a cohort of the elderly population who require that level of care in any case, but early intervention by GPs may help to reduce the numbers.

The main barrier to accessing GP care is financial, particularly for the older generation. Many elderly people put off going to their GP and, as a result, their condition may worsen, resulting in a potentially greater cost of care. These are startling facts and make this legislation all the more vital. The key message of the Department of Health's primary care strategy, published in 2011, was that the overarching goal of Irish health policy was to provide a strong, effective health system that would focus on the delivery of services designed to keep people well and out of hospitals. This involves placing a greater focus on early intervention, health promotion and regular screening. Primary care centres play a huge role in this regard.

In Cavan-Monaghan there are between 48 and 57 GPs per 100,000 of population. This is, by no means, ideal, but it does compare favourably with the figures for neighbouring counties. Nevertheless, there is a need for constant improvement. GPS are at the coalface of the health service, working on the front line and, in so doing, earning the respect of the patients and communities they serve. They are usually the first port of call for those seeking to access health services. Removing financial barriers to access is extraordinarily progressive and will be of great benefit to hard-pressed parents of younger children, many of whom have a range of competing financial obligations, including mortgage payments, and to those aged over 70 years, most of whom are living on reduced incomes and must cope with a reduced cash flow.

According to a recent EU-funded study, strong and effective primary care is associated with better population health, lower rates of unnecessary hospitalisation and relatively lower socio-economic inequality. This finding was issued with the caveat that health expenditures were higher in countries with stronger primary care structures, which are, by their nature, costly. The bottom line is that investing in good health care services delivers long-term savings. In Cavan we have a very good network of primary care centres with state-of-the-art facilities, including those in Cavan town, Kingscourt and Bailieborough, as well as excellent services in towns such as Cootehill, Ballyjamesduff and Virginia. However, there is always scope to do more. I ask the Minister to ensure funding for primary care services remains a top priority for him and his Department as we budget for 2016. In particular, home help provision and back-up supports are vital for those who care for others in the home.

Section 3 of the Bill, which inserts a new section 58A(1) in the 1970 Act, puts in place a new legal arrangement which will ensure GPs provide a free-of-charge service for all persons aged 70 years and over and, where income criteria are met, their dependants. This means that in the case of a married couple, where one partner is under the age of 70 years and provided that their joint income does not exceed €1,400 per week - a perfectly reasonable figure and nobody could suggest there should be an increase in that threshold - both partners will access free GP care. There has been some criticism of the legislation to the effect that it will be of more benefit to those with higher means, with those with lower means losing out. Bearing in mind the threshold mentioned, that is hardly the case in this instance.

The service needs to be supported by restoration of the reduction in the respite care grant of €300 or whatever the figure was. There is a need for strong support through carer's allowance and ancillary benefits to ensure we have a good primary care system because if we have carers, we will have a good system.

I am glad to note that the allocation of discretionary medical cards increased by 56%, from 52,000 last year to 81,000 this year. That is positive. A mechanism must be put in place to give such cards to people with a chronic illness, illnesses that are extremely expensive to manage, and who find themselves in difficult circumstances. While probity and other proper processes must be maintained, the procedure must be made as simple and as accessible as possible.

We have achieved a lot in this legislation, on which we can only build. I congratulate the Minister, Deputy Leo Varadkar; the Minister of State, Deputy Kathleen Lynch, and the Government on making a very progressive start in this area of health service delivery.

I understand the next time slot is being shared by Deputies Pringle and Fitzmaurice.

That is correct. We have ten minutes each.

Our health system is in itself unhealthy. Based on a two-tiered system, it both perpetuates and exploits inequality by prioritising those who can afford health care over those who need it. Privatisation has destroyed our health care system and it is the antithesis to a community-based approach. The large number of people on medical cards, accounting for 43% of the population, and the falling number of people availing of private insurance are all signs of an unaffordable system due to these privatisation policies. Privatisation has exacerbated the crisis of waiting lists in the public system across the country and elderly people have literally been pushed aside to the margins, on trolleys in accident and emergency department corridors, living in emergency wards for months on end, unable to afford a place in a nursing home or with insufficient care packages or for some, none at all. That is the most shameful aspect of privatisation policies imposed by consecutive governments; it is a system that marginalises the most vulnerable. Elderly people have not only been dragged through numerous Government policy changes over the years but they are the most vulnerable to those changes in the health care system. Age Action Ireland states, "it is those with the least means, often needing the most intervention and care, who are the current losers". It is clear that we must move away from a privatisation model towards a universal one based on the need of services. The only way to achieve that is through the development of a primary care system with universal health care at its core.

Unfortunately, this Bill, although positive in its intention and for its recognition of carers, contains unrealistic expectations. First, it assumes that a primary care system already exists which could support the introduction of GP cards for those aged over 70. Second, it assumes a free GP card will be sufficient to meet the needs of people aged over 70. Research has consistently proven that primary care is the best system both in terms of equal access and cost effectiveness. Strong primary care is associated with better population health, lower rates of unnecessary hospitalisations and relatively lower socioeconomic inequality. Countries with strong primary care systems spend less on health care. However, Ireland is the only EU health system that does not offer universal coverage for primary care. Nearly 1 million people will be aged over 65 by 2031, which will be an increase of more than 86% or an extra 20,000 people per year. How can the Government expect our current system to facilitate such an annual increase in the demand of our health services? How can we expect GPs to alleviate this pressure on top of existing costs and demand?

GP care is central to the primary care model. In the words of the authors Freeman and Moran, GP care "represents a powerful means of alleviating the anxiety, discomfort, and incapacity that come from sickness and ill health". GPs could provide many outpatient procedures, tests and check­ups in primary care centres, moving patients away from hospitals and into our local communities but that could only be done with adequate investment. In a primary care setting GPs would essentially take a medical advocacy role co-ordinating patient care according to the needs of the individual.

While GPs are central to primary care, other health care professionals also need to be supported. Nurses, physiotherapists, occupational therapists, speech and language therapists and others all contribute to a community model of health provision. However, structural issues exists which are not recognised under this legislation. Less than 20% of GPs work with more than four other GP colleagues in the same practice, suggesting it is not the norm for GPs to work alongside other health professionals. This work culture will make it difficult to establish a fully integrated health care system.

While this Bill attempts to respond to an ageing population, it has avoided responding to the changing profile of the GP sector. The sector is also ageing as younger doctors are emigrating or moving away from GP practice. There is a growing preference for flexible hours and early retirement and an increase in the numbers holding vocational training.

There is now significant shortfall and geographical disparity in the supply of GPs and health inequality is becoming an increasing worry. We are witnessing, especially in Donegal, a declining proportion of GPs working in rural areas, a decline from 33% in the early 1990s to 22% in 2005, and in Donegal there are only 48 per 100,000 of the population compared to 64 nationally. Therefore, long-term planning and investment are vitally needed to ensure that our health service can sustain the pressure of an ageing population as well as meeting the needs of those through all stages of the lifecycle.

The Government needs to prioritise the roll-out of these proposed primary care networks and move away from damaging privatisation policies. Primary care has been talked about for over a decade now with very few results. The Government's report card on health care investment has shown there has been a failure in terms of progressing it and we still have not seen a primary care Act, a primary care fund or recruitment of additional doctors, nurses and other professionals in the primary care area. It was envisioned that 400 to 600 of primary care teams, two thirds of the full requirement, would be established by 2011, but only 247 have been established four years on and to date there are 85 primary care centres in operation. It was also envisaged there would be 90 primary care networks across the country, each with about four or five primary care teams, essentially acting as a one-stop shop providing a wide range of health services at a local level. The Minister recently announced that 17 integrated service areas are being replaced by nine community health care organisations and that existing resources will be reorganised into 90 primary care networks but we still do not know what is the status of the primary care networks. Many organisations representing elderly people have been critical of the pace of development of primary care health centres and health teams. Unfortunately, at this late stage, moving towards a community-based approach will take time as large-scale structural reforms need to take place.

According to the National Association of General Practitioners, we are so far away from achieving this model that it is too late for the current Government to make any changes in time for the next election and it will not be until the middle of the term of the next Government that we might see some changes being made. Instead of using the elderly population as political capital in time for the next election, why not use the funding, time and resources to invest in a primary care infrastructure to ensure that universal health care can become a reality for all?

The Bill is naive in assuming that GP cards given to all those aged over 70 means their needs will be met. It presumes that our current system is highly developed with enough GPs and a fully comprehensive health system to address the complex nature of elderly health needs. The principle makes sense but the Bill is misleading. People are often put off going to the doctor because of costs, and those who have a GP card tend to visit the GP on average on two more occasions per year, which means that overcrowding in emergency departments may ease.

However, a GP card will not grant those aged over 70 access to the wide range of community services available under a medical card. A GP card does not cover hospital visits, community health services, dental services, prescription medicine costs, hospital care, optical or aural services, social work services and community services. The IMO expressed concern that GP cards are seen as an alternative to medical cards, when the two are not comparable. What use would a GP card be to someone aged over 70 whose visit is paid but whose further needs will come at a cost?

If we were cynical we might assume that the PCRS will use the fact that the over 70s have GP cards as a way of reducing the number of medical cards given to people in that age group. I envisage that the more elderly people visit the doctor, the more treatment they will need and the more they will need access to other primary care services which they currently cannot afford or cannot access. Could this mean that the quality of GP care to patients across the population will decrease as a result of this cyclical pressure? Already our community-based services cannot meet demand from elderly people for supports to live in their own homes and communities. There has also been a lack of capital investment to replace or refurbish community nursing facilities.

It must be made clear that a GP card does not mean universal health care and it is not correct to say that universal health care means only a free visit to a doctor. The two should not be confused. Today there is still no right to health care in the Irish Constitution or through any statutory provision even though Ireland is a signatory to Article 12 of the International Covenant on Economic, Social and Cultural Rights, ICESCR, which recognises the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Universal access to health care on the basis of need must be recognised in our legislation as a right for all citizens before it is at risk of privatisation again. Recently the Minister for Health imposed a deadline for those under 34 years of age to acquire private health insurance and we have seen Government proposals to increase nursing home charges for elderly people using community-based services. We also saw the Minister for Health appear in advertisements for private health insurance companies, encouraging people to take out health insurance. How does this equate with the commitment to a universal health care system? These are worrying developments as they signify the possible privatisation of our entire health care system in the future. In the meantime, doctors and patients do not want to see another primary care strategy or a mini-primary care strategy. We all want to see a structured, reliably funded investment programme for GP practice so that our primary care system can be developed. Building primary care clinics does not equate to the development of integrated primary care services; nor does the number of team meetings happening indicate progress in this regard. Only the health of our patients will indicate this Government's progress.

I am grateful for the opportunity to speak on this Bill. I welcome the fact that young families with children under six and elderly people will see some bit of light. There are a lot of families who are struggling throughout the country. People with young children often try to be the doctor at home, rather than paying the €50 fee. If children have the flu or some such, their parents will often fall back on the old medicines that their fathers and mothers before them used because €50 is not easy to come by for many. In that context, this move is a step in the right direction. The argument will be made that the rich will be able to avail of it and that is true but if we can help people in middle-class Ireland who do not have medical cards, then that must be welcomed. That said, I know that when they go to the chemist, they will still have to put their hand in their pocket but every pound saved is good. In terms of the elderly, many of whom worked all their lives, I would go further and give them full medical cards. Many of them deserve it because they fought the good fight down through the years. The number of people over 70 is growing all of the time and we should do whatever we can for them.

As other Deputies have said, great rural doctors have done so much all over the country. One could throw a stone up at their window at night and they would come out to help with a sick child or relative. Such doctors are getting scarcer however and now when one calls a doctor out of hours there is often a problem. In many parts of Ireland - people are afraid to say it - doctors are covering for local GPs and it is very hard to understand a lot of them, with all due respect. Generally one is told to head for the hospital when, in a lot of cases, there is absolutely no need to do so. We could be treating more problems at home. That problem has to be addressed and we must start with its root cause, which is where doctors go after college. We are educating a lot of youngsters in college and we must introduce some enticement for them to stay in this country. People are spending seven years at college and a lot of funding is invested in their education. We must give them some incentive to work here rather than go off to the sun the minute they qualify. We must address that problem because statistics indicate that the numbers are dwindling in rural Ireland. There is no point in trying to hide from that fact. People are having to travel longer distances to find a doctor. It is not as appealing to be a doctor in rural Ireland if the numbers living in the area are diminishing. We must do a bit of soul searching in this regard and do whatever is necessary to keep youngsters at home. We have a very good education system and the doctors who qualify here are of a very high calibre and we should do something to make sure that they stay.

Currently I am dealing with a seven year old child who needs an operation which is not available in this country. Even if families are given a GP visit card, the sad reality is that there are children who have to go to other lands for operations and their families are fund-raising in order for this to happen. Every child is special to his or her mother and father. Every parent wants to see his or her child growing up and we should try to facilitate them in whatever way we can. Medicine is moving on constantly and more operations are being carried out in different fields but there are still things that we, as a nation, need to do to make sure that these youngsters are given a chance. I spoke to a family recently who are trying to raise funds for their child to go to America and it is sad that we cannot provide the necessary care in this country. The Minister for Health is relatively new in the job and given that he comes from the field of medicine, he probably understands it better than most. I urge him to think outside the box and do things that were never done before because that is the only way we will achieve things.

Another issue of major concern all over Ireland is the fair deal scheme. Farmers, whether male or female, who have land are finding that the fair deal keeps eating into their package of land the whole time, even after the initial three years. It keeps going at it. It is a different scenario in every other situation and I encourage the Minister to look at that. There is also a lot of confusion out there about insurance. I spoke to a person recently who is 54 and who has no health insurance cover. He heard about the new health insurance scheme that he was supposed to join but he did not know if he would have to pay a 50% fine if he did not go into the scheme on the first day. There is a lot of confusion about that. It would be no harm to prepare and distribute a booklet on the matter to help people to understand it. I have spoken to many people and discovered that they have not grasped what is involved, particularly those who do not watch a lot of television. A lot of people are asking a lot of questions about what the insurance policy will cover.

Long before I ever came into the Dáil there was talk of providing universal health insurance for everyone. We heard that it would be 2019 or 2020 before it could happen but now we seem to be going down a different road entirely involving everyone having private health insurance.

As with any other scenario, this is because the powers that be like to move people through the system fairly fast as a result of the money which can be realised via some of the private hospitals. I am concerned about this matter because I am aware of people with various complications who were admitted to private hospitals and who then had to be transferred to public ones which had the technology and facilities necessary to treat them. I hope the position in this regard will be reconsidered.

I welcome much of what the Government is doing. However, we should examine the possibility of extending free GP care to children over the age of six. I accept that things might be somewhat easier now but in the past year children who were genuinely entitled to medical cards were refused them. It does not matter whether one is three, six, nine or 12 years of age, if one needs treatment, then one must have it. There should not be a distinction between children who are five and a half years of age and those who are six and a half. In view of what is proposed, the parent of a child of five and a half can bring him or her to the doctor immediately if he or she is concerned. However, the parent of a child who is six and a half might think twice as a result of the financial cost involved. This is a major problem.

Anything that will assist people who are under pressure financially is welcome. Those whose children are going to qualify for free GP care, will bring them straight to the doctor and will not take risks because there will be no cost involved. In general, one must welcome any development of this nature.

The next speaking slot will be shared by Deputies O'Dowd, Catherine Byrne and Regina Doherty.

This is a very important debate. I welcome the developments taking place, particularly those relating to senior citizens and children under the age of six. As a result of what is proposed in the Bill, everybody who reaches the age of 70 will now be able to go to his or her doctor and will not be charged for the privilege.

I wish to comment on a number of cases with which I recently dealt in the course of my work as a Deputy. One such case involved a 95 year old man who previously had a medical card but who lost his entitlement to it. The trauma experienced by him and his family was both unbelievable and heartbreaking. Notwithstanding the fact that the individual in question has an income which is not small, he had a medical card for 25 years. It was absolutely unacceptable to his family that he, at 95 years of age, was informed he was going to lose the card. What happened had a significant and adverse impact on the man's health. He felt he was no longer needed or wanted. In particular, he was of the view that he was a burden to his family. The good news in this case is that earlier today I received a call from a member of his family to inform me that the card is to be restored until 2017. It was a major battle for the man's family to achieve this result. They were obliged to approach various doctors and consultants and expend enormous amounts of energy to have the card - to which the man, from his perspective, is entitled and which he had previously held for 25 years - restored. The amount of pressure exerted on the individual in question was unacceptable.

The Government should consider restoring medical cards to all of those who previously held them and who lost them when, from a financial perspective, times were very difficult. As matters improve, we should ensure that those who lost their cards will have them restored. In addition, cards should be restored without people having to do what the man to whom I refer was obliged to do. I must also refer to the case of a 77 year old man who came to my office recently and who was totally out of breath. That individual is on oxygen 18 hours a day and he lost his medical card, again for financial reasons. He clearly has a very difficult medical condition. The individual in question was successful in fighting to have his card restored but matters should never have reached that point.

The Minister, Deputy Varadkar, has done an excellent job since taking up his position. He is aware of the issues to which I refer and I ask him to address all of them either now or in the context of the forthcoming budget. If there is any leeway in the context of the public finances - it is clear that there is - and if we are intent on cutting taxes for people, which we should do, then we should cater for the needs of those who are oldest in our society and who need greater protection.

I wish to comment on issues raised by a number of previous speakers, particularly in the context of the fair deal scheme. There are many people in acute hospitals who are awaiting discharge. In that context, there are alternative care arrangements to which we should give consideration. In many instances, the community services that are in place are not as good as was previously the case. I am aware of increasing numbers of people who are seeking home help hours and home care packages and who cannot obtain them. I visited the home of an 80 year old woman and her 82 year old husband. He had just returned from a day centre at which he receives dementia care. The woman's problem is not that she cannot care for her husband - who, in addition to his dementia, has a serious medical condition and is doubly incontinent - because, by God, she is doing her very best in that regard. Rather, this very elderly lady's difficulty is that she was offered 18 minutes worth of home help per day. That is both appalling and unacceptable. I have raised this case with the HSE and I hope it will be dealt with properly. There are many people who are involved in caring in the community who could be given greater support. The provision of 18 minutes worth of home help per day to the lady in question is simply not good enough. I should point out that she is on the waiting list for further home care package support if and when money is made available.

Large numbers of people are being obliged to access the fair deal scheme. These individuals do not want that to be the case and they would not be involved with the scheme if the relevant services were available in the community. It is far better to make services available in the community than it is to place people in long-term care, particularly if adequate supports can be provided to the families involved. The Alzheimer's facility in Dundalk, County Louth, is appealing for more funds because its budget has been cut by 5%. The Alzheimer's Society of Ireland branch in Drogheda is also seeking more money because it is not receiving the financial support it needs. I appreciate that the Government has one further budget to introduce. Regardless of that, we must consider how we support community services, particularly those relating to dementia care. The problem of dementia is going to increase in the years to come. As I understand it, every year a further 20,000 citizens are going to reach the age of 65. The total number of those above that age is due to increase by over 200,000, or 40%, by 2021. We must plan for that. While it works in many cases, the fair deal scheme is not the answer in a large number of others. There are significant alternatives which must be utilised. If we review both the scheme and the position regarding home care packages and home help hours and invest more money in the provision of support services, it will make a huge difference.

I wish to address a particular issue relating to home care. The role of migrant carers has been acknowledged and a policy relating to such carers must be formulated and implemented. As a recent report indicates:

The racial and cultural differences of care providers and recipients of care must be respected within domestic and long-stay care settings. Older residents, their families and the public need to be assisted in adapting to changes in the ethnic and cultural mix of care staff taking place within care organisations.

It also states that "Increased resources and support structures for education, training, orientation and integration should be introduced for migrant carers and Irish staff to cope with multicultural care environments". I came across a very sad case recently whereby the person involved insisted that their care should be provided by a person of a particular ethnicity. The cost of that care increased by over €2,000 per month in order that the demands of that individual, who is paying for the care privately, might be met. Clearly we need to examine the possibility of increasing the level of resources available in respect of integrating care providers.

Appropriate structures must be put in place for the reporting of racial abuse and labour exploitation at organisational, regional and national level. Better information should be provided on migrant rights and entitlements, particularly in respect of employment and equality regulations.

I congratulate the Minister on his successes to date, but in coming budgets we have to help that cohort of people over the age of 70 years who have reared their families and paid their dues. They want to live at home and their families want to support them. We must provide more resources to support community care, including home care and home help packages. The current system is almost like a factory. When patients are discharged from acute hospitals, their only option is a long-term care institution if adequate support is not available. It is far cheaper to support people at home than to put them into long-term institutions which are not necessarily the best place for them.

It is nice to hear an Opposition Member apply common sense. I refer to the previous Opposition speaker who called a spade a spade and acknowledged that what we were doing was good for young couples and children. It is welcome when Opposition Members refrain from knocking a proposal for the sake of it. I welcome the Bill and commend the Minister for Health on delivering on his commitment to grant free GP care for everybody over the age of 70 years. This is part of the Government's policy of rolling out universal GP care for the entire population.

When my children were very young, I was continually running to the doctor if a child had a temperature or a runny nose because of the risk that it would lead to something more serious. That remains the reality for many young couples. A GP fee of €50 or €60 is a scandalous amount of money to treat a baby that may be only three or four months old. As parents of young children are often anxious and want to do the best for them, they are likely to make multiple trips to their GP. The new arrangements will also alleviate pressure on the children's hospitals because parents are presenting to emergency departments instead of going to their GPs in the first instance.

I have met a significant number of older people who have lost their medical cards and some of them are very angry about it. Most of them worked for their entire lives, but they are being excluded because of their earnings, in many cases from private pension arrangements. The Bill is a step in the right direction because it will give them the opportunity to access GP care. It will also help to reduce the pressure on emergency departments in adult hospitals. If elderly people have the opportunity to visit their GP in the first instance, there is an opportunity to deal with a serious illness at an early stage.

Other speakers referred to primary care services. A number of primary care centres have been established in my constituency, including in Ballyfermot and Inchicore. They have brought huge benefits to everybody, from young to old. I meet people on a daily basis who express the greatest of respect for the successful revitalisation of previously poor quality health centres, with their green walls and smell of disinfectant, which have been replaced by modern facilities where one can see a community nurse, a doctor or a mental health professional. That is a step in the right direction and demonstrates the Government's commitment to dealing with this issue. It has been a slow process and we are under no illusion that it was a struggle for everybody who has had to contend with cuts, but the fact that primary care centres are getting the seal of approval in communities is a hopeful sign that we are doing the right thing.

The Bill is the second step in the Government's phased introduction of universal free GP care, as proposed in the programme for Government in 2011 and restated in 2014. This is the first time that any Government has tried to introduce universal health cover. We have to take small steps because we are not in a financial position to make big leaps. Buckets of money were poured into the health service in the past. I do not know what holes that money filled, but it certainly did not go into local hospitals.

At this critical stage in providing GP care for children under the age of six years, I appeal to GPs to come on board. I acknowledge that they have reasons for their doubts, but care should never be put ahead of profits. I have spoken to a number of GPs who are very much in favour of these changes, but others have complained that they will not have the same level of earnings. We are moving in the right direction. Most doctors take their oath to look after sick people.

When this legislation is enacted, 36,000 people will no longer have to pay for GP visits. This will be an important change for senior citizens because it will remove the financial stress associated with visiting a doctor. Our relationship with GPs is a vital link with the health service and it is important that older people in the community who have health complaints do not struggle to cope alone. The GP is the first port of call for all of us and I believe many GPs will come on board to deliver the services needed.

I join the previous speaker in paying tribute to the progressive approach Deputy Michael Fitzmaurice has taken to this Bill. We are sure to be onto a good thing if the Opposition is calling for its provisions to be extended to a larger cohort. Usually all we hear from the Opposition benches is empty rhetoric in which the Government is accused of a power grab or making promises we never keep. We have been accused in the past of breaking promises on health policy, securing economic recovery or taking people off the dole queues. The reality is that we are either delivering or have delivered on every promise we made. This is borne out by the fact that Ireland is the fastest growing European economy. We have taken 400,000 people out of the USC net and reduced PRSI. The dole queues have been reduced from 15% to 10%.

One of the pillars of our health strategy was to introduce free GP care as a start in moving to universal health care, particularly for those aged under six years or over 70. I pay tribute to the Minister for Health and his negotiating team for managing to get the issue of care for children under six years over the line with GPs. I acknowledge the cuts with which GPs have had to contend due to the economic crisis. We will be taking larger strides towards recovery in the future, which I hope will allow us to invest more money in health services. The Bill implements our commitments in the programme for Government, as restated in the statement on the priorities for Government published in 2014.

Deputy Catherine Byrne has pointed out that 36,000 people over the age of 70 years are currently paying for GP visits, even after working and paying into the PRSI system for their entire lives. It is time we started to give something back to them as a cohort rather than based on their individual means. It should be a universal right that a person who reaches the age of 70 years has access to free GP care.

The basis behind this is not just to return services to people through the money, but to facilitate and progress the Healthy Ireland initiative started by the Government. This will provide diabetes treatment and asthma treatment for children under six, which will be taken on by GPs. It will also allow for Healthy Ireland initiatives to be taken for those over 70. This is very welcome.

Many people over 70 have been entitled to GP and medical cards in the past, but the application process has been cumbersome and worrying for them. That is going and now these people will automatically receive their cards. I welcome this and the fact that their spouses who are younger than them will also receive these cards. Access is key to preventative care, medicines and holistic treatments that will ensure we have a healthy Ireland. I look forward to the day I can stand in this Chamber to welcome the next Bill that will include those over six and under 70.

I commend this Bill to the House. The Government is one that keeps it promises and we look forward to doing that over the next 12 months.

It is easy to support this legislation. I like to think that people on this side of the House take a progressive and pragmatic approach to legislation. However, while I support the Bill, it does raise issues. A number of years ago when driving in by Dolphins Barn one Tuesday morning, I saw a nice big yellow sign which promised free GP care for all. I felt a little sick on seeing it because, as we all know, nothing is free. There is a cost for everything and somewhere down the line somebody must pay. It is important to try to market our policies correctly, but rather than try to be populist, we should be open about the consequences of such a policy.

I have a concern regarding the concept of universal benefits, be they third level fees, health care or something else. I could pick at this legislation and ask whether it is fair any billionaire over 70 would have free GP access while somebody younger in financial difficulty who is just over the qualifying limit cannot have that access. However, in the area of health, more than elsewhere, the argument can be made that by providing people with access, we will save money in the long term. I have listened to some of the figures trotted out suggesting that people who have to pay for GP visits are less likely to visit the doctor. Perhaps the corollary of that is that people who have free GP cards are more inclined to visit GPs and waste their time. I know from GP practices around the country that many of them are frequented by the same people all the time.

I am loath to comment here at times - due to the use of social media and the fact there are so many people with little to do except to put their comments on the Internet or on Twitter - without giving an introduction, a preamble and a conclusion. Nevertheless, I would have been a supporter of the basic charge for prescriptions, not as a means of raising revenue but as a means of ensuring respect for the service. In general, people do not appreciate what they get for free, be it unearned rewards they receive financial or otherwise. We should look at a basic charge for prescriptions, for example a €1 charge or one linked to the consumer price index.

This legislation has been welcomed by most bodies, but I understand it was not welcomed by the Society of St. Vincent de Paul. One can always pick out a weakness in policy and consider that money could be better spent. However, in principle it is a good idea to give people access to medical facilities, particularly in the context of prevention. I understand this measure will cost in the region of €18 million. This is a small amount in the general scheme of things and will provide for 36,000 people. Some 10% of those over 70 do not currently have free GP care. While this legislation does not deal with children under six and I have not seen any costs in regard to providing this access, I am not as comfortable with the idea of providing free GP care for those under six as I am with providing it for those over 70. Other speakers have referred to free GP access for children under six and currently approximately just over 40% of those under six have that access.

Recent research showed that during the economic downturn people were less likely to visit GPs and it has been suggested this may be due to GP fees. There is huge diversity in fees charged across the country. People in both the public and private sector have taken a hit in their wages. I note that at the public service reform and innovation conference today, the public sector declared an increase in productivity will not be part of any deal. I am not sure what hymn sheet the Minister for Health, Deputy Varadkar, is singing from currently, but he seems to be caught between two stools. He will suggest there must be increased productivity as a result of this legislation. We must all, politicians included, put our shoulders to the wheel.

I believe it would make life easier for people if they saw a reduction in the cost of services. Accountancy fees have been reduced, but legal fees have not. I do not believe there have been any radical reductions in medical fees. Much of the reason for the failure to reduce fees is the lack of competition and the existence of monopolies. Wherever we find monopolies and a lack of competition, it is hard to drive down fees. If people saw a reduction in energy fees or insurance costs, it would be easier for them to accept a reduction in their wages. However, if people's wages are reduced, but the cost of services remains the same or increases, it is difficult for them to accept lower wages. On increased fees, I notice the clampers in a hospital in the Minister's area are seeking to increase clamping fees from €80 to €120 or €130. However, I have often thought parking or speeding fines should be reduced, unless there is clear evidence they act as a deterrent and ensure better road safety and smoother traffic flow.

There is not much to be said about this legislation as it is straightforward. Many people raised constituency issues and examples. It is important to recount these as these accounts inform policy. We can talk about health services and funding, but we must be prepared to recount the stories of those we meet who have had bad experiences. Few of us talk here about good experiences. Human nature being what it is, we are not inclined to articulate those experiences. Deputy Durkan is a strong advocate of pushing issues that illustrate wrongs and we all work on the basis that everything else is working smoothly.

I wish to raise the issue of an educational course provided in Britain for people in the medical profession, consultants and doctors, who must relay information, particularly bad news, to clients. Time and again I have met people who have been dealt with in an insensitive manner. This is understandable where there may be a language difficulty or where the doctor or consultant is under pressure. However, each case is individual to the patient or his or her family. I would like to see the Minister bring forward some proposal in this regard. A number of years ago we had a patients' charter, but I do not know whether it had any provision for this. Perhaps we should look at what has been done in Britain and arrange a seminar. We should ensure that when information is being relayed to people, particularly on occasions when people are being informed of a terminal illness, they are given privacy and dealt with in a sensitive manner. This happens in most cases, but not in all. Insensitivity can leave a terrible and negative impression on service users, yet this is an issue that could be dealt with quite easily.

I am aware of a case in Waterford where an individual waiting to see a dermatologist has been on the waiting list since 2007. I have not got to the bottom of this issue yet. I have been told there is a shortage of dermatologists and that interviews are due to take place. Eight years is a long time for someone with a skin problem to be waiting.

Deputy Naughten referred to the issue of capacity. I do not know what impact this will have on capacity but GPs are under a lot of pressure. The Minister will have heard their stories at their conference last week. Hacketstown in Carlow is across the border from me. A GP there has given a lifetime of service and he is finishing up at the end of this week. He covers a rural area in Wicklow and Carlow. It may be very difficult to find a replacement for him and there may be pressure on his replacement to move to a more populated area with a primary care service with extensive facilities. I am a strong advocate of the primary care concept but this should not be at the expense of the rural-based doctor. People in rural communities like the doctor to be based locally. They do not want to be travelling 15 or 20 miles to a primary care centre. It is not possible to have a doctor in every parish but if a rural population can support the service then pressure should not be put on the doctor to go to the primary care centre. I refer to the monopoly situation where the GP has control over the medical lists and the new GP is unable to access it. I ask if the Minister plans to address that issue.

Much good work has been done in the health service but I note a situation which affects my constituency and also parts of south Dublin. I refer to the STEMI centre in St. Vincent's hospital which provides emergency care for cardiac arrest. It seems that it has been decided to close the unit with effect from this Friday. This leaves two units, one in St. James's Hospital and one in the Mater hospital but people from south Dublin or the east coast will have to go to those hospitals. I hoped to raise this matter as a Topical Issue on budget day last year but it was deferred. I have been trying to ascertain the situation from the HSE. The Minister may not be familiar with the situation but it would be catastrophic to close it. I am glad to hear it is not a funding issue-----

I am very familiar with it; it is about patient safety and quality.

It is very important that the reasons are outlined. The Minister is familiar with the community first responders in Wicklow who work day and night to ensure immediate medical access. They believe they will be putting their necks on the line if the ambulance has to travel on to St. James's Hospital or the Mater instead of to St. Vincent's Hospital. Patient safety may be a funding issue. I ask the Minister to allude to this matter in his concluding remarks. I will not be in the Chamber but I will watch him on the monitor.

I am sharing time with Deputy Eamonn Maloney. I welcome this Bill and I compliment the Minister and the Minister of State, Deputy Kathleen Lynch, for bringing this legislation to the House. The Bill provides for universal GP service to be available without fees to everyone aged 70 years and over. This Bill is only one step in the process of providing free GP care to all our citizens. About 36,000 senior citizens will benefit and 436,000 children will benefit as a result of the agreement with the IMO on free GP care for those under six. The next step is to see about introducing a free universal GP service for all children under the age of 18. This Bill continues the process by providing the oldest and the youngest with free GP care with the aim of providing that care to all children which is very desirable.

This Bill is the ideal template for dealing with the most vulnerable. Health and education are essential for all citizens. We have provided free education, which is essential. Nobody argues against the idea of universal free education and any talk about reducing free access to third level is opposed from all quarters. Health is equally essential for citizens. To be in a position to provide a universal free health service to the most vulnerable in our society and to expand it on a phased basis to all citizens, is an ideal to which we all aspire. I am delighted that we have taken the first important steps in its delivery. I look forward to the next steps being taken to provide the full level of GP services to all our citizens free of charge.

The current system of means testing for access to health care stigmatises the poor. It is very bureaucratic and is the subject of all sorts of difficulties and rows. In this House no issue gets more attention than the health issue. The provisions in the Bill will help to limit the bureaucracy while increasing the quality of the service.

The provision of primary care centres is essential for dealing with the level of difficulty experienced for decades in our hospitals. The accident and emergency service is cumbersome in its operation and it is used as the first port of call by many people. A free GP service will help to relieve pressure on accident and emergency departments. The primary care centres soon to be available in all constituencies will provide at local level services such as GP care, public health nurses, occupational therapists, physiotherapists and dietitians. People will be able to receive treatment in their own community and this is the way forward. This service will be in tandem with the provision of free GP care. I refer to four primary care centres being developed in my constituency. One centre is open and serving the public in the Navan Road area and serving Cabra west, which is well known to the Minister. Three other centres are planned for Summerhill, North Strand and Grangegorman.

This package of measures is the most fundamental change in the delivery of health services in many a long decade. It will deal with many of the issues that currently cause significant grief to citizens. There is the danger that GP fees will prevent people from attending a medical practitioner and leaving their medical problems to a later stage which may be very dangerous in the case of many illnesses. The sooner the treatment the more likely a successful outcome. Anyone suffering from an illness or condition will be able to attend a GP without undue delay.

This Bill is an important, logical and sensible step. I look forward to a move to universal health care in the same way as we have gradually moved to universal education for all our citizens.

In common with other speakers I welcome this initiative. I thank the Minister and his Department for progressing both of these initiatives as they apply to children under six years of age and adults over 70 years of age. No one is arguing on this side of the House that this is some sort of revolutionary change in the whole health system but it should be acknowledged that given the economic climate and the difficulties with the finances, it is an achievement that we can make any progress in the area of health.

It is also an acknowledgement by the Department that not every adult over the age of 70 years has the financial resources to go to see the GP when he or she wants to do so. Likewise, all of us who are practising politicians understand there are families with children under the age of six years who have the same difficulty. They may wish to take their child or children to the doctor, but that is not always possible if one does not have the money to do so. There are hard-pressed families who are in that position. The Bill acknowledges this, which is the progressive element of the Government's policies. It is an illustration of a society that is more caring in the health area, which is good.

Some very positive contributions have been made showing much common sense, but I am always amazed at the level of begrudgery from some Opposition Members towards any initiative, whether it relates to health, education or job creation. Certain speakers, some of whom may have been here for a long time - perhaps for too long, but that is another matter – appeared to be in a delusional state and to think nothing had happened in this country seven years ago and that people had money at the bottom of their garden. I heard people talk about various issues, including trolleys and waiting lists. Any politician with a morsel of sense would not come to the House to criticise the Government for what it was doing to improve the health system. They act as if nothing happened, as if young people volunteered to emigrate and others to stand in the queues for the live register. I am appalled at the naked begrudgery and lack of acknowledgement of what I consider to be a modest but important health initiative.

I am trying to avoid references to areas about which other speakers have spoken. However, I must acknowledge one initiative which bears repetition, given the incidence of asthma in the country. I commend the inclusion in the GP contract of an agreed cycle of care for children diagnosed with asthma and the annual review of children diagnosed with asthma. It is an extremely important measure. The Minister is better qualified than I - I am sure he will correct me if I am wrong - but to the best of my knowledge, the incidence of asthma is very high in particular among the working class or poorer people. There are a variety of reasons for this which we will not go into, but in my constituency I am aware of more than one family with two or three children with asthma. The asthma care programme is one measure which will be welcomed by families who find themselves in that predicament.

Like other speakers, I am delighted to have an opportunity to speak about this particularly welcome legislation. I compliment the Minister for Health, Deputy Leo Varadkar, and the Minister of State, Deputy Kathleen Lynch, on their efforts in moving on the health service as nothing remains as it is. In recent years it was very easy during the difficult times to be critical of everything that happened. It was very easy also to have the solution to everything and know what could be done, while knowing very little about the cost of how to do it. Even in those very difficult circumstances we should congratulate the Government and the Ministers responsible for seeing fit to proceed in this fashion at this time. Of course, it is not the solution to everything. Neither is it the conclusion of the matter. I accept that it is not the adoption of universal health care that was originally intended, but it is part of the way and a step in that direction. Those who have criticised the starting position have asked about children aged over six years. However, one could also ask about children aged under six. One could equally have the same degree of anxiety about serious illnesses in children aged less than six as those over six. We are, however, moving in the right direction. The same is true of people aged over 70 years. In the first instance, it is a question of providing reassurance. People who may feel a little vulnerable and isolated, who are not in the best of health, can at least have one service readily available to them, namely, the GP service. That is something good which will ultimately save money because it will cost less rather than more to address the health needs of those aged over 70 years. As attention can be paid to people at an earlier stage, earlier diagnoses can be made and action taken which might otherwise be too late. It is also in keeping with the 21st century that we move in that general direction.

In recent days I heard criticism from speakers on the other side of the House. They referred to the Dutch system, the French system and various other models of health care around the world. There are nearly as many models as there are economic theories. The same was evident in the context of the economy. Reference was made to the Icelandic system, the Swedish model and the Danish model. One would not find as many models at a fashion show. Even in difficult times of financial stress we can learn from what has happened before and work within the exigencies within which we are forced to work and, in fact, improve the quality of service all around, which is what is happening.

The general perception appears to be that the quality of the health service is not as good as it is elsewhere. That is not true. There may be a difficulty in getting into the system or appointments and there may be waiting lists, but, with one or two exceptions, everyone admits that once a person gets into the system, the quality of the service is good. While comparisons can be made, in this country we have the best in the business when it comes to dealing with any medical issue that arises. Unfortunately, we live in an era when criticism comes easy. It is very easy to criticise all those who make the odd mistake, or more than one, but we have the ability to provide the best services in the world, as we have proved many times.

An issue that has come to the fore in recent times is the logistics of delivering the service. I have always believed it is a management issue. The simpler the system is, the easier it is to manage and the better, more effective and efficient it is to operate. The Leas-Cheann Comhairle will be aware that if we were to arrange a waiting list system for constituents to visit us in our constituency offices, we would never get our day’s work done because the queue would get longer. A system must be found in the health service to eliminate waiting lists. I can never understand what happens. If there is a waiting list, it grows. There is something wrong if that happens. One can ask whether it is because we do not have enough personnel to deal with it or because the population is growing and the demand is greater or if it is a combination of the two. Whatever the reason, it is part of the equation and it should be possible to deal with the issue effectively. We heard about the UK model also. The NHS becomes overloaded, too, and also has waiting lists. Accident and emergency departments become overcrowded in the United Kingdom also. We are not unique, therefore, in that regard, but that is not to say we should not improve because we do need to improve in these areas.

I have spoken previously about primary care which is a hugely important part of the health service. From a previous incarnation I have experience of the operation of the health service, but I accept that it is not medical experience. The management of the system is important in terms of how to deliver a good quality of service to an increasing population. The population is nearly double what it was in the mid-1950s and there has been a considerable increase in demand on the health service. I presume there are fewer hospital beds because thousands of beds were available previously. Medical science and the method of conducting operations have changed.

It does not necessarily mean that fewer beds is a bad thing. It is a question of how we deliver the service to those who are there. I compliment the Minister’s recent initiative on nursing home services. I hope that will percolate through to all our hospitals that have been experiencing overcrowding in accident and emergency departments. Overcrowding and disorganisation in the accident and emergency department does not make for a good reputation of a hospital or for the confidence of the general public. This has happened before: in the middle of the boom there were between 3,000 and 6,000 people on waiting lists for between two and five years. It is no harm to monitor the situation from time to time and consider how to move on.

I believe in ensuring that adequate nursing home beds remain available at all times with the potential to accommodate an overflow in the event of a serious epidemic such as influenza. I do not understand why sometimes hospital wards are closed. That does not make for good, efficient or safe delivery of services. There should be an ongoing evaluation of the requirements and best practice in that area. The general public recognises that we must pay for a service but thinks that because we pay taxes a certain amount should be free. There is nothing free in any service. As time goes on the cost increases. We must become more efficient and effective in delivering the service.

I compliment the work done and the quality of the service given by all the practitioners in the health service. Reference has been made to the young doctors and practitioners who go overseas after qualifying. That is sad and should not happen. We need to deal with it, otherwise we will have a seriously depleted health service which will lack the enthusiasm, dedication and energy of that new generation of practitioners who should be coming on stream in the health service here. I also compliment GPs throughout the country. They can be cantankerous from time to time. We all can be, I suppose. Many GPs have built up a high quality of service over many years at great cost to themselves. It is not unusual for such people to start work at 8 a.m. and to be still in their surgeries at 8 p.m. or 10 p.m. They also do house calls. I welcome the provisions being made now and hope there is general support for them and that we will see the evolution of a modern health service as befits the 21st century.

I too am delighted to speak on this Bill. We hear about targeting resources rather than giving them to people over the age of 70 who can afford to pay. I remember the march on Leinster House, the anger and the anguish, when the last Government removed the medical cards for people over the age of 70, and the promises made from the back of a lorry outside the House by senior members of Fine Gael and others. If that was not playing politics with it I do not know what it was. Nonetheless they got what they wanted: they got into government. We have a relatively new Minister now and I wish him well. I am glad he is here today for the debate. There are many issues and he should know more about them than I do because he is a medical practitioner.

I never agreed that everybody should be entitled to GP visit cards or medical cards. Michael O’Leary has said this and there are others like him who are wealthy and do not need medical cards. I do not understand why our system is not efficient enough to deal with that. I do not accept it is too difficult and costly because with specialised information technology today we should be able to distinguish between people and not waste scarce resources on people who do not need them and have said they do not want them. The Government could ask them to give them up.

The free GP card is for those over the age of 70 but their dependants, spouses and partners under the age of 70 will continue to be means tested in order to have free access to their GPs. How is that fair? The spouse aged 69 or 68 and a half, might not be in the best of health while the person over the age of 70 might be in excellent health. That is farcical.

Section 2 amends section 58 of the Health Act 1970 to remove all individuals over 70 years of age from the scope of a means-tested service based on holding a medical card or GP visit card. Instead, all persons over 70 years of age will automatically qualify for a GP service and it will not be necessary to hold a means test for a medical or GP visit card. Since that famous march, the withdrawal of the cards and the recession, many sick people and their families, if they are lucky enough to have families, who have been waiting a long time for cards, have come to my clinic. They are cancer patients and people with other disabling conditions and the stress and trauma of dealing with forms and sending more and more information has been enough to make them sick. When one is seriously ill, young or old, one does not need other stresses. One needs to be able to receive treatment and try to maintain a stable condition mentally and physically, to the best of one’s ability. My office has been inundated with horrific stories. I am no different from any other public representative in this respect.

The pet child of the former Minister for Health, Deputy Reilly, was free GP care for children under the age of six. I have eight children and often in the cycle had three under the age of six. They were normally pretty healthy, thank God, and did not have serious illnesses. We were blessed in that respect. A five year old who has a serious diagnosis, a disability, or some staggering disease will not have the free care when he or she turns six. It is nonsense. New diagnoses and treatments have turned up and people have lobbied and had to go the National Health Service, NHS, in the United Kingdom, but those treatments are now being provided here, after a battle. The free care should be available to all or none, instead of discriminating on the basis of age.

I know we cannot have a panacea for everybody but we need to improve the health services. Good work is being done. I returned ten minutes ago from the Mater Private Hospital. Appointments are kept there without queues of people on trolleys. It is useful to see how a private institution can be run. I do not know about its profitability but it is run efficiently. I have been there several times. I left here at 2.30 p.m. and am back with my procedure completed. That is how the service should be run. I have spoken to the Minister about this. He set up a so-called dynamic team to deal with the trolley crisis but I believe the wrong people were on it. Consultants, GPs and unions were represented on it. Certainly they have to negotiate but not on the strategic committee. It should involve front-line managers. The Minister told me Grace Rothwell from South Tipperary General Hospital was on it. There could not be a better person on it. That is the sort of person the Minister needs, not the vested interests. I am surprised at the Minister for allowing that to happen. Front-line managers and workers are the only people who know how to clear the backlog.

Hospital rounds should be changed to much earlier in the mornings in order to free up beds.

A relative of a patient in Cork University Hospital contacted me last week because ten days after finishing his treatment he could not get home. There was no taxi service. If they used an ambulance to bring him home they would have a free bed. I could not understand the logic of waiting ten days to get home. I contacted the manager in south Tipperary but she said it was a matter for Cork University Hospital, and rightly so, but there should be joined-up thinking. A person should not be waiting for ten days to get transport home. That is totally farcical. I see that the Minister, Deputy Fitzgerald, looked at the Minister, Deputy Varadlar, as if to say "Is that fellow raving again?", but I am not. I can give the Minister the details but it should not be happening. I have the details on my e-mail database and the reply as well.

We have seen the situation concerning GPs in Tipperary. I attended a public meeting 18 months ago and we saw an excellent GP, Dr. Paddy Davern in Tipperary town, who is now in Doha or Saudi Arabia. His wife is a nurse and they have a young family. He was a very good doctor with some specialties and had a great practice but he could not make it viable. The Minister knows as well as I do that GPs are under siege. During the health crisis people were discharged quickly when Trolley Watch announced figures in our hospital in south Tipperary. That was the answer to get rid of those waiting lists, but people were being sent home too early. As a result, that night they were looking for Caredoc or were in the GP's surgery the next morning. The Minister is creating the backlog, pushing people back and forth, but they are not being serviced.

Some great treatments happened in South Tipperary General Hospital and I want to praise the management and staff there and in other hospitals too. Once a person gets into the system some excellent treatments are carried out with good recovery rates and compassionate care, which is what it is all about. However, we need to have some kind of sensible management. Front-line staff must be supported but we should get rid of about four layers of middle management. When the health boards were amalgamated we were told it would be like manna from heaven. The former Taoiseach, Bertie Ahern, said he was going to disband them and the former Minister for Health, Deputy Brian Cowen, may have said something similar. They have not been disbanded, however, and even if they were, nobody lost any positions. There were no job losses, so that is where the fat is.

I am tired of saying it. When matrons ran the hospitals there was no MRSA and various other bad conditions. We now have a plethora of mangers in charge of beds, wards, floors, hygiene and day therapy. They are going around with flip charts to conferences and having case meetings about things. It is a joke.

The Deputy is moving a little bit away from the business before us.

The service always kicks the problem back to the GPs, as is happening with medical cards for the over 70s. They are the people who should be looked after above all. We all hope to reach that age with the help of God, le cúnamh Dé. It is nice to have some reassurance but that is what is going on unless some Minister tackles it, and not when he comes back from his Christmas holidays and is exasperated by the problem of having so many people on trolleys. I wish him well any time he takes a holiday, but what happened on the last occasion? They closed down the official side of the system for almost two weeks. Anybody who is self-employed will know that one cannot close down a service for even 24 hours because the system must go on. No letters were sent out, no discharge letters or correspondence from doctors. They will do the same thing next Christmas and laugh at us all. It is disgusting, immoral and unhelpful.

We are losing rural GPs, as the Leas-Cheann Comhairle knows being from a rural area. There are a number of vacancies in south Tipperary and Tipperary generally. In one area we failed to get a rural GP because there was no rural GP practice allowance. It was well earned and negotiated by the general practitioners' union. It was there to support them in rural areas because they need different equipment and a different dispensary set-up as there are all kinds of disadvantages. We failed to get a GP there, however, and I have been told that there are 39 GPs in the queue awaiting approval for the rural GP practice allowance. We cannot approve one or two because of that.

We are lucky in Clogheen, which is a huge area with a wonderful small district hospital, St. Theresa's. Two GPs who gave wonderful service wanted to retire for the last three years but could not do so. Eventually, God was on our side because He delivered an angel to us called Dr. Melanie O'Reilly. She applied for and got the job, so the community is blessed. She had to invest in the surgery because it was old and much equipment was missing, but she has been denied the rural GP practice allowance. If she has to leave because she cannot afford to stay, our district hospital will be gone as well.

We have heard so much in this debate about step-down beds. They are vital to taking those discharged from acute hospitals and allowing them to recuperate with wonderful care. However, if Dr. O'Reilly is assigned to hospital cover and leaves the rural GP practice, our hospital is dúnta, finished. That will be another 22-bed hospital gone. It is a wonderful institution whose matron, Anne Halley, and her staff have given sterling service. I was to have had a meeting tomorrow morning with the senior management there because she is not getting the support she needs. The situation is archaic. I plead with the Minister from the bottom of my heart, in as calm and rational manner as I can, to deal with management. There are silly issues ongoing between senior managers about who is taking responsibility for community care and acute care. They have been fighting over this for two years. I have had meetings every couple of months and something was supposed to happen, yet the meetings are futile and a waste of time. Senior managers have arrived to talk to the matron and myself. They appear to listen attentively and promise this, that and the other, yet they do nothing. Someone needs to catch these people and knock heads together - I do not mean physically - and get them to take responsibility. We need to have management accountability and a support service for this hospital, which is a great institution with a wonderful young matron. She will be driven out of the job, however, if she does not get up-line support.

HIQA is due to revisit the hospital. Following HIQA's last inspection, recommendations were made but they have not been carried out because the management in South Tipperary General Hospital would not go out to do fire inspections, although duty bound to do so. I hate to have to say it, but the situation is disgraceful and frustrating. I discussed the matter with the Minister on an earlier occasion, but I am so frustrated that I am saying it on the record now. It is a wonderful institution with wonderful staff. My own mother died there and it is a wonderful hospital. Many people were born there in the past, but now it has been abandoned because it is out in the sticks. The HSE management in the south east would prefer if it was in the ocean off Ardmore. They do not want to know about it.

There is a negligence of care by senior management and I do not say that lightly. They have a duty of care and are being paid for that responsibility but they will not take it and support the matron of that institution. A meeting was to be held there tomorrow morning at 10 o'clock but it has been cancelled because it could not be arranged. That is what is going on. I sought the meeting three weeks ago, although I should not have to be involved in it at all. However, senior management are wilfully neglectful of their onerous responsibility. I will give the Minister all the details afterwards. Support structures are meant to be there for the matron, her assistant and staff. After one of our meetings, we thankfully got permission to recruit some extra staff to come up to a minimum safety level. Whatever way the interviews were organised, however, the three wonderful nurses had to be re-interviewed. I do not understand it but it is a joke. Why would our nurses and junior doctors not be on aeroplanes to other countries when they are getting that kind of treatment here?

If there was any kind of management in the south Tipperary hospital system we would not have half the queues, chaos, costs and expenses that exist. I salute rural GPs who are the engine room, main arteries and front line. They need to be supported, as do urban GPs. They are all self-employed people. My own GP practice in Clonmel has about five doctors and it is like a small industry with 20 staff. They are employers paying taxes and wages, yet they have sleepless nights. Apart from the duty of care, they are wonderful employers in villages and towns. One will not see anyone with placards about zero-hour contracts outside those surgeries. They need to be supported, not stripped of resources.

We should not have divisive issues like those that arose at the conferences held last weekend, with one conference accepting a proposal and the other not.

We do not need that. They need to be able to help the people. They do not need their surgeries full of under-sixes because it is free. Some people unfortunately will attend because they do not have to pay for it. I always supported the fact that there should be some charge for medical cardholders for GP visits and some charge for prescriptions. Unfortunately, the prescription card has gone too dear now. There are no free lunches and I accept that.

The GPs have to be supported. From the point of view of their own sanity, they cannot stick it. It is not financially viable. They have to pay the banks. Some of them have invested hugely in their own surgeries. Some are getting into the new primary care centres. They are willing to put their money where their mouth is. They have spent a lot on their training and are still upskilling. They have set up practices starting with one doctor, expanded and employed other doctors. Many in County Tipperary and other counties are group doctors now and they have nurses and all kinds of services. They are taking enormous pressure off the hospitals, doing bloods and everything else. The hospitals would be chaotic, submerged and not able to function only for the front-line GPs doing this. They need a bit of respect, support and, above all, the rural GPs need that allowance. I do not know what it is, €25,000 or whatever, but it is a damned lot of money when they have to raise it to buy beds and the equipment that is needed in a modern surgery. Sometimes GPs leave and take away some equipment with them because they are still working. It is their equipment and they are entitled to take it but it leaves a person with nothing.

We have a wonderful angel of a doctor, a gem to have, and that is hard to get because many rural practices cannot get anyone. We are blessed. She comes over the mountain from Lismore, which is a nice spin, and is dedicated and committed to working with and serving the people and providing a service seamlessly and with no fuss. She needs the support, as does St. Theresa's Hospital and the matron and staff. This is probably replicated in many other places. I know it is in Carrick-on-Suir and in St. Patrick's in Cashel. Wonderful matrons and staff under huge pressure are now being forced to collect money off patients. Mar fhocal scoir, I ask the Minister to please take seriously what I am saying and have it investigated and I will give him any details that he needs.

Debate adjourned.