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

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

I am thankful for the opportunity to speak on the Bill. While it is welcome, it is not what the Government committed itself to in the last general election, nor is it what it promised in the programme for Government. The programme for Government in 2011 stated: "Universal primary care will remove fees for GP care and will be introduced within the Government's term of office." That programme for Government was revised less than 12 months ago and the commitment was reiterated as follows: "We remain committed to the introduction of a universal GP service for the entire population as part of universal health insurance, in line with the programme for Government." However, we now find that this is not going to be the case and, in fact, that policy, if it is ever introduced, will apparently take a further three years to happen, and we are not even sure of that. What we do know is that it has been delayed for three years and, at the earliest, will be introduced by 2019.

In addition, the Bill is not in compliance with what thousands upon thousands of the over-70s demonstrated for during the term of the last Government outside these buildings. They were addressed by the current Taoiseach and the then leader of the Labour Party, Deputy Gilmore, who promised the over-70s that their medical cards, which were being withdrawn by the Fianna Fáil-Green Government, would be restored. They were told they would revert to a situation where they had full medical card cover for GP services, hospital services, primary care and medication services. What happened is that this Government not alone did not do that, but it significantly reduced the income limits for over-70s from €1,400 per week when it came into office to €900 per week now, which is a huge reduction. What is now clear is that the current Taoiseach, the former leader of the Labour Party and their members were simply playing politics with elderly people at that stage.

Part of the difficulty with introducing this type of legislation for particular groups is that other groups are left out and find themselves placed in a very difficult situation. One of the groups that comes to mind is the 65-69 year old age group. Such people come to my office on a daily basis, as I am sure they come to the offices of every Oireachtas Member. The vast majority of these people have retired and are in receipt of State pensions but they are not covered by this legislation. Many of them will have only a very small occupational pension as they may have worked for the local authority, the health board or the council, or for a company which had an occupational pension scheme. Some who have pensions of as little as €10 or €20 per week find themselves over the income guidelines for medical cards and are in a situation where they are not covered because the medical card limits are completely out of date, given the last review of these limits was in 2006. To give an indication of the figures, the income limit is €298 per week for a couple aged 66 years and over. If a couple of that age group has a small occupational pension of, say, €10 per week, they will be over the limit and will not be covered for the card. That is the kind of thing that happens when selective groupings are introduced in regard to primary care and GP services.

It is important also to revisit the whole area of medical card applications and the granting of medical cards. There is no doubt that even after all of the difficulties that arose in regard to medical cards being withdrawn, or reduced from full cards to GP cards, many people with serious and chronic illnesses are not able to get cards.

While the situation may have improved slightly, there has been no significant improvement. From the point of view of medical card applicants, centralisation has been a dismal failure. We should consider organising the application system and processing of cards on a local basis. It is currently taking ten days for applicants to be registered on the central system. If one sends in an application today and calls the centre within ten days, one will be told one's application has not been received and is not on the system.

Another issue is that there is absolutely no filtering of applications on a medical basis at the initial stages. People have very serious illnesses that are flagged on the application form or by an individual or public representative, but there is no filtering. I am dealing on an ongoing basis with someone who has a very serious illness. The person sent in an application and found it was not on the system for ten days. In the particular case, the person had a cancer diagnosis. There is no way of fast tracking such applications which is simply unacceptable. If those applications were processed on a local basis, the situation could be dealt with very quickly. The worry for applicants like that is significant. They are already worried about their medical condition and now they are also worried about whether they will receive a medical card, if it has been lost in the post or whatever. There needs to be some filtering of applicants by way of medical illness at the earliest stage of the applications process.

It is vitally important that there is a contact person for public representatives, in particular, in the PCRS to whom we could speak. In the current system, applications can be sent on an Oireachtas line, but there is no individual to whom a public representative or advocate can speak, explain a situation or speed up the process, thereby ensuring that the medical card office does not need to send letters to applicants who do not apply, something which happens on a regular basis. I ask that the entire applications process be examined. It is not working well and it would be much better if it operated on a local basis.

From time to time, I and many other Deputies have raised the matter of GPs charging for bloods. It is happening on a daily basis. Following many representations, a system was put in place whereby medical card holders who are charged for the taking of bloods can receive a refund by applying through the PCRS. While that is all very fine, as the Minister, who is a medical practitioner, knows, there is a doctor-patient relationship and the majority of patients are not happy to use that system because it interferes with the relationship. I hope that any arrangements or agreements made with GPs under this Bill would ensure that medical card holders will not have to pay upfront for the taking of bloods and will be entitled to the service. The Minister and his predecessor have said people are fully entitled to have their bloods taken free of charge. They have told GPs that, but it needs to be clear in any contract in the future that it will not be legal to charge for the taking of bloods. While the refund system is in place, many patients feel uncomfortable about using it and do not claim refunds.

The fair deal scheme has been very difficult over the past 12 months, with long delays of 16 weeks before and 11 weeks after Christmas. It is to be hoped that with the new injection of funds this will change and it will take four or five weeks to process and award fair deal scheme funding. There is widespread unease among the elderly population and their families about a recent report on "Prime Time", where it was indicated that one option for the future would be further cost increases for those availing of the scheme. The report referred to increasing the threshold for savings and the number of years of payback on family homes and assets. It also suggested that there may be a change in the scheme whereby an elderly person who receives 20% of his or her social welfare income would have his or her income reduced. There was a suggestion that there might be a charge for other community-based services for the elderly. All of that gives rise to considerable difficulty, worry and concern for elderly people and their families.

We need to urgently address rural GP practices across the country. It is now clear that it is becoming more difficult for them to continue when a GP retires. It was an issue recently in my constituency, Tipperary South. Some initiatives will need to be put in place to ensure that it is attractive for GPs to locate in rural areas, something which is not currently the case. Difficulties in filling vacancies in rural practices are becoming more common.

I refer to the urgent necessity for community intervention teams to be put in place. As the Minister knows, such teams mean that services can be provided for people in their own homes, thereby avoiding the necessity of costly admission to hospital services.

Their purpose is to provide services to people in their own homes, thus obviating the need for costly hospital services. The teams are in place in some areas and they represent an effective and cost-effective method of ensuring people can remain in their homes for as long as possible and ensuring they do not have to take up very costly beds in general hospitals.

While the legislation is welcome, it is certainly not what we were promised or what was committed to in the programme for Government. It is certainly not what the elderly were promised by the current Government, including the Taoiseach.

Before I start, I extend a very special welcome to Mr. Mark McQuillan, who is job shadowing me today as part of a programme of the Irish Association of Supported Employment. He is in the Visitors Gallery.

I thank Deputies for their contributions on the Bill. As Minister of State, Deputy Kathleen Lynch, said in her opening statement on the Bill, the Government is committed to introducing, on a phased basis, a universal GP service without fees for all children and senior citizens within the term of its office, as set out in the programme for Government and the future health strategy. It was decided to commence this by providing all children under six with access to a GP service without fees and this will be achieved at the same time as the universal service for everyone over 70.

It is fair to say very few Deputies questioned the principle of universal primary care but some questioned its phasing. Let me explain it once again. The original intention was to start with those on the long-term illness scheme. However, that scheme is not underpinned by primary legislation, dates from a circular from the 1970s and includes all sorts of unfair provisions. It includes some illnesses but not others. Diabetes, for example, is considered to be a long-term illness while motor neuron disease and asthma are not. There are serious defects in the scheme that will have to be addressed in due course. An expert group was appointed to list illnesses or diseases in order, that is, from those which should be counted first and be provided with coverage to those that would be covered later. The group found it would be unjust, unethical and impractical to create a hierarchy of diseases and a list of illnesses in order, stating one was more severe than the next. We chose the under-sixes and over-70s simply because they are the youngest and oldest in society and the ones who need to see their GP most often. It is, of course, not an end in itself. It is just the first two steps in the phased introduction of a universal service in Ireland for all children and senior citizens. This is being achieved in parallel with an extension in coverage for chronic disease, starting with asthma among children and diabetes among adults.

People ask what happens to the six or seven year old with a chronic disease or very high medical expenses. It is important to point out that 40% of people, or 1.7 million, have a medical card based on low income. The rules are not changing and nobody will have his or her medical card taken away. In addition, there is the discretionary medical card system, which provides discretionary medical cards or discretionary doctor visit cards to people who are over the income limit but who have high medical expenses or a high burden of disease. The number of people with full discretionary medial cards is now 82,000 and the number with the discretionary doctor visit card is over 100,000. That is a very significant increase on last year. We are doing these things in parallel.

The system is not perfect, however. Some people are big fans of means tests but I am not. We do not means test for education or for free travel for the elderly. The problem with the means test is that there is always somebody who is €5 or €10 above the threshold. If one increases the threshold by €5 or €10, there will be yet another person just above it. There is a similar problem with sickness tests. Nobody has been able to come up with a test that is perfectly fair to decide what level of sickness should qualify one for a benefit and what level should not. There are horrible circumstances where people are told to return time and again with more doctors' and consultants' letters to prove they are sick, and then they are told to come back when they are sicker. That is really not a nice system. Therefore, this Bill represents a significant policy departure in health care away from sickness tests and means tests towards universal health care and universality. I am very proud to be a member of a Government that is doing that.

With the passage of this Bill, 36,000 people above the age of 70 who currently have to pay to attend their GP will no longer have to worry about the cost. Medical evidence suggests there is a significantly greater incidence of multiple chronic conditions among people over 70. That is why they will benefit particularly from this measure. Some have pointed out that these tend to be the better-off pensioners. This is true but we should ask ourselves why these 36,000 pensioners are better off. Very simply, they are the ones who probably worked and paid income tax and PRSI all their lives and set aside a small amount of money to pay into an occupational pension. In return for that, however, we do not give them access to their GP but punish them for having worked for 40 years, paid their taxes and paid into an occupational pension fund. Now we are going to change that. That is actually a good step forward.

As announced two weeks ago, an agreement has been reached involving the Department of Health, the HSE and the IMO on the terms for the delivery of free GP care for all children under six. The service will commence during the summer and it will provide GP care without fees to just over 250,000 children. It will benefit not only the 250,000 children but also children under six who already have a medical card or a doctor visit card because they will benefit from the enhanced service. That enhanced service involves the management of asthma in the practice, with an annual asthma check to make sure the asthma is being treated well and that the patient knows how to use his or her inhaler and is on the right medicines. At the ages of two and five, there will be a wellness check, focusing particularly on conditions such as obesity to pick it up early and to try to deal with it. Also included will be issues such as parents smoking in the home. There will be an opportunity there and then to intervene to deal with that. It may help us to pick up some cases of neglect because if a child of that age is not going to the GP once a year, one wonders why. That children will be called to see their GP will be important.

The estimated full-year cost of the universal under-six service, including the wellness checks and arrangements for the management of asthma, will be approximately €67 million per year. The service is based on the choice-of-doctor principle and the next step is to issue the contract to GPs so they can decide whether they want to sign it. The contract will be issued in the next few weeks. The service should be ready to commence in early July. It will be preceded by a public information campaign. Provided GPs sign up online, it will be very simple because parents will be able to go online and register their child for the service. All they will need will be their child's name, date of birth and PPS number. It will be much easier than booking a flight.

Deputy Ó Caoláin asked about the cost of the service. It was originally estimated that it would cost €37 million in a full year but that was based on the existing type of service and existing fee rates. However, the fee rates are being increased because it is an enhanced service. This is a universal service. There will be no lesser service running in parallel for children from medical card families. There will be no means tests, no sickness tests, no paperwork, no payslips and no letters from doctors or consultants.

Having considered the outcome of the discussions with the IMO, I have determined that an annual capitation rate of €125 per patient under six shall apply, with enhanced capitation rates in respect of children covered by the asthma cycle of care. The new enhanced service will cost an additional €67 million in a full year, which is €30 million over and above that previously set aside.

A question was asked about the number of over-70s who will benefit. The correct figure is 36,000. The previously used figure of 10,000 was based on an estimate of population figures available at the time but we have confirmed the correct figure is 36,000.

Deputy Naughten asked about dependants of those over 70. The reference to "dependants" in the Bill is a continuation of the existing position whereby dependants of persons over 70 can get a GP visit card also. The criteria for a dependant, as applied by the HSE when assessing couples for a medical card or GP visit card, refer to the spouse, partner or children if they are under the age of 23 and dependent on the parent, if that parent is over 70. That is just to ensure dependants of people under 70 can still qualify for a doctor visit card under certain circumstances.

I thank Deputies for their contributions on the proposed legislation and I commend the Bill to the House.

Question put and agreed to.