Health (General Practitioner Service) Bill 2018 [Seanad]: Second and Subsequent Stages

I move: "That the Bill be now read a Second Time."

It is my great pleasure to introduce the Bill. I was pleased last December when the Government announced that eligibility for a GP service without fees was to be extended to everyone who receives a carer's allowance payment. Following further examination of the proposal, the Minister for Health confirmed in April that this measure should also be extended to people who receive carer’s benefit. The purpose of this Bill is to provide a general medical and surgical service free of charge to people who receive half-rate or full-rate carer's allowance or carer's benefit. The Bill will result in approximately 14,000 additional people being eligible for a GP visit card, thereby enabling them to access vital GP services without having to consider their ability to pay for this service.

We all agree that carers are the backbone of the caring profession in Ireland. Their selfless dedication to providing hours of unpaid care to their loved ones and families is a major contribution to the provision of care in every community. Each caring role is different. Becoming a carer is a life-changing experience. It can be sudden for some carers, while for others it happens gradually over time as the care needs of their loved ones increase. For some carers, the time spent caring is a period of weeks while for others it lasts a number of years. Despite these differences, all carers begin the journey for the same reason. They are motivated by their love for the person they are looking after and the need to ensure they are provided with the necessary care and support they require.

The contribution of carers to our society is measured as part of the census. According to the 2016 census, more than 195,000 people, or 4.1% of the population, provide unpaid assistance to others. This represented an increase of more than 8,000 people since the 2011 census. A total of 6.6 million hours of care is provided each week, with some of this care being provided on a 24-7 basis by family members or unpaid carers. As the census figures have shown, there is an ever-increasing need for care. This need, which is being met by unpaid carers, can be expected to increase as our population continues to grow and the proportion of people living longer continues to increase. The CSO projects that the population aged 65 and over will increase by 59% by 2031. The number of people living to the age of 85 or more is forecast to increase by 97% over the same timeframe.

While the number of persons living longer is something to be celebrated, we must acknowledge that it is likely to place further demands on family members and friends to undertake caring roles. Studies emanating from the Irish longitudinal study on ageing have shown that more women will be caring for dependent children and elderly parents while also playing a more active role in the workforce and that this generation will become more relevant as our population continues to age. The impact on the health and well-being of carers is likely to increase as more and more unpaid care is provided by family members and loved ones. Therefore, the provision of a free GP service is another important step by the Government to provide much needed supports to carers.

I would like to reflect on the development of the first national carers strategy, which was published by the previous Government in 2012. It recognised the significant contribution and commitment that family carers make and the concerns they face. The strategy sets the direction for future policies, services and supports provided to carers by Departments and agencies. When I reviewed the strategy recently, I noted that its vision statement reads:

Carers will be recognised and respected as key care partners. They will be supported to maintain their own health and well-being and to care with confidence. They will be empowered to participate as fully as possible in economic and social life.

I am sure Deputies will agree that the measure we are debating supports carers in maintaining their health and well-being and caring with confidence.

General practitioners, GPs, provide support and assistance to carers in managing and maintaining their health and well-being. We are all too aware of the various health impacts suffered by carers, including the physical strain on their bodies and the associated mental health impacts. General practitioners also play a vital role in assisting the carer to care. General practitioners are valuable resources who have excellent knowledge of the supports and services available to carers in a locality. This is why we want to extend access to GP care for carers. While many carers might in theory have access to GP care, that care may not always be accessible due to the financial barriers carers may face.

Carers often have to reduce their hours of work or even give up work entirely but, although this is often done unselfishly, it does place a financial burden on their shoulders. Removal of this barrier and the introduction of free GP care to an additional 14,000 carers will therefore prove to be a significant benefit. Some 14,000 carers will benefit from this legislation. Carers' financial worries or anxieties regarding their ability to pay for this service will be eliminated. Instead, they will have access to high-quality GP care centred on their needs, which will ensure their own health does not deteriorate, particularly as we know that their health tends to do so gradually as their hours of caring increase over time. The HSE has indicated that carers will be able to apply for a GP visit card from 1 September 2018. Applicants will be facilitated to make either a paper application or an online application.

This measure is just one of a series of measures introduced in recent times to aid carers. As Members are aware, there were successive €5 increases in social welfare payments for carers in budgets 2017 and 2018 and an extension from six to 12 weeks for the continuation of these payments after the death of a cared-for person or that person's entry into residential care. This has gone some way towards easing the financial burden on the shoulders of carers. Last December, additional investment of €10 million in respite care services was announced. This will enhance the provision of respite care to people with disabilities, enabling more carers to take a break from the daily caring routine. It will provide them with much-needed time to maintain their own health and well-being. These actions reflect the commitment in A Programme for a Partnership Government to have a stronger voice for carers. We have listened to carers and have taken positive actions to address their needs.

I will now outline in general terms the main provisions of the Bill. Section 1 provides the relevant definitions to the Health Act 1970 and the Health (General Practitioner Service) Act 2014.

Section 2 provides for an amendment to section 47 of the Health Act 1970 in order that the HSE's appeals process can be extended to encompass this service.

Section 3 provides for an amendment to section 47A of the Health Act 1970 in order that the HSE's current "ordinarily resident" framework is extended to cover the provision of a general practitioner medical and surgical service for persons in receipt of carer's benefit or carer's allowance.

Section 4 provides for a new section 58D in the Health Act 1970 to provide in law for this new service. Section 4 of the Bill contains the text of the new section 58D, which has five subsections. Subsection 58D(1) provides that the HSE shall make available without charge a general practitioner medical and surgical service for persons in receipt of carer's benefit or full or half-rate carer's allowance. Subsection 58D(2) requires that persons in receipt of the carer's benefit or full or half-rate carer's allowance, furnish any necessary documentation the HSE requires from applicants to establish if they are, or continue to be, eligible for this new service. Subsection 58D(3) enables the HSE to deem persons in receipt of carer's benefit or full or half-rate carer's allowance who do not furnish the necessary information required as not eligible for the service provided under section 58D. Subsection 58D(4) provides that the HSE, insofar as it is practicable, provides a choice of GP for the services provided under section 58D. Subsection 58D(5) provides that "Act of 2005" means the Social Welfare Consolidation Act 2005.

Section 5 provides for the Long Title and Short Title of the Act and relevant commencement provisions.

All of us will be touched by caring at some point in our lives, whether we take on a caring role or need care ourselves. For me, this Bill is about looking out for people who spend their time looking out for others. Caring for those in need provides a major contribution towards health and social care in Ireland. Our Government recognises the major contribution carers make to the welfare of others. We aim to strive for a society that respects, values and supports carers. The needs of carers are being considered across Government and I hope we will receive cross-party support on this important legislation. I am personally very pleased to introduce this legislation. I would like to take this opportunity to stress the importance of enacting it before the summer recess in order that this service can be in place for carers in September.

Deputy Stephen S. Donnelly

I am sharing time with Deputy Michael Moynihan and Deputy Brassil.

Fianna Fáil supports the extension of GP cards to all carers and will be supporting this Bill. The Bill proposes a modest extension of the GP card to an additional 14,000 carers and this will be very welcome to every single one of them. It is very much deserved. It is estimated that carers provide approximately 7 million care hours every week, saving the State approximately €10 billion in unpaid care every year.

We are all aware of the sacrifices families make while caring for their loved ones. This Bill goes some way towards recognising those sacrifices and supporting the individuals. We need to go further than this Bill, however. We need to address the 6,500 older people waiting on home care and home help at present. That represents an increase of 19% just since last December. In the west and north west, the issue is particularly bad, with targets missed by more than 100,000 care hours just in January, February and March of this year. We must increase home care supports if we are to meet the demand.

We need to ensure that all carers receive a GP card. Family Carers Ireland has pointed out that even with tonight's measure, there are still carers who can be identified by the State as carers who will not be covered. I have tabled an amendment to address this. We will talk about it on Committee Stage.

Those in receipt of the carer's support grant, formerly known as the respite care grant, and who are not in receipt of the other payments will not receive the GP card based on this Bill. The good news is that the money should be in place. It has already been set aside to allow the extension to those in receipt of the respite care grant or carer's support grant. As the Minister of State knows, the Minister, Deputy Harris, stated some time ago when he initially started talking about this that €11 million would be set aside. It turns out that when the Department calculated its numbers, significantly less than €11 million was required. I understand that approximately €2.5 million will be required on foot of this Bill for those in receipt of the carer's allowance and less than half a million euro will be required to cover those in receipt of carer's benefit. The information we have is that the provisions in this Bill will cost approximately €3 million. Critically, we were told that approximately €11 million had been set aside when the idea was initially floated. The obvious question is whether it was the initial intention, when the idea was floated, that those in receipt of the carer's support grant would already be covered. The Government will be required to run the numbers in the Departments of Health and Public Expenditure and Reform. I have taken a look at some preliminary figures. It seems extending the GP card to those on the carer's allowance, which we support, to those in receipt of the carer's benefit, which we support, and to those in receipt of the respite care grant or carer's support grant who are not already in receipt of one of the other two grants could be done and that the cost still would be significantly lower than €11 million. We will be supporting this Bill. It is a move in the right direction. It recognises the important work of carers. It will come as very welcome help for the 14,000 carers. I would like to talk to the Minister of State about extending coverage to the other group also.

Like my colleague, I welcome this Bill. There are three issues I want to raise. The Minister of State referred in his opening remarks to the additional investment of €10 million for respite care services. There is a chronic crisis in respite care. We were told about the extra money coming in. I have worked closely with families to try to get respite for carers, particularly those caring for people with intellectual disabilities.

I was informed yesterday morning by senior executives in the HSE that there is no money, even for the clients who have been deemed to be a priority by the service providers. It does not have any money for respite care or for the shared care scheme. That must be examined. Given all the fanfare with which it was announced last year it is simply not good enough. Families are in crisis as a result.

It is estimated that €10 billion is saved due to people working as carers for loved ones in their homes. A huge volume of work is done in that regard and we do not give enough credit to people for it. As regards the home care packages and home helps, a circular has been issued by the HSE to various people working in the home help services stating that no holiday cover will now be given. It is withdrawing all holiday cover during the summer months. In previous times when a home help was going on holidays the person could get a colleague to cover. I pay tribute to the significant work being done by home helps throughout the country. My family has had the benefit of home help services for many years and I cannot say how grateful we are as a family, in the first instance, and as a community for the benefit of that service. A directive has now been issued from the HSE and as a result there is no holiday cover available if somebody takes annual leave, as a person is entitled to. This is putting families and the people in receipt of home help in a crisis situation. It is deplorable and must be examined. If we are serious about dealing with people who need these services we must ensure the services are available. The enormous service the home helps and carers are giving the State is not being given the proper recognition it is due.

I will conclude on those three points regarding respite care, home helps and carers in general.

I welcome the introduction of GP cards for carers and people on carer's benefit. It is another step towards the overall goal, which Fianna Fáil supports, of free GP care for all. However, that will not be achieved without the negotiation of a new GP contract. I hope that this modest expansion of the service is being done with the agreement of the GPs and that there is capacity in the system to absorb it. Last April the Minister intimated that the negotiation for the new GP contract had started. There has been zero progress since that announcement. The negotiation of the contract must get off the ground and over the line before any further progress can be made on the advancement of primary care.

The issue I wish to highlight is home care packages and people hoping to receive those packages. Carers getting a medical card is a great advance but, currently, in CHO 7, CHO 3, CHO 4, CHO 5 and CHO 9 no home care packages have been given since last January. I have been in contact with people in CHO 7 due to the fact that I am friends with them. There is little point in a Deputy from any party putting in a request in CHO 7 for a home care package because it will not be given. What is even more ridiculous is that CHO 6 is alongside CHO 7 and in some cases the geographical areas are separated by a road, so one side of the street is CHO 7 and the other is CHO 6 and if one is on the other side of the street one will get a home care package. I am reliably informed that there are 12 families looking for palliative care home care packages in CHO 7 and they will not receive them. This information is accurate; I am not being sensationalist. It is a huge issue. Deputies send in repeated representations seeking home care packages but none has been given since last January. The Minister of State can check; that is a fact.

While I welcome this positive development, I ask that the GP contract be negotiated and that home care packages be allocated to the areas that currently have none. Finally, will additional staff be appointed to deal with the 14,000 applications that this measure will generate?

This Bill is welcome, but it does not go far enough. We have put forward an amendment, which I will discuss later. The Bill represents progress on the current situation so my party will support its final passage, hopefully this evening.

Carers in Irish society are unsung heroes. Spouses, siblings, children, extended family members and, in some cases, friends or neighbours all act in caring roles for those who are close to them and in need of around-the-clock care. They deserve our respect, compassion and support. They perform a most unselfish role, in many cases leaving their careers behind and putting their lives on hold. As a society we too often take carers for granted, particularly our Governments which are obliged to provide the required financial resources and fail to do so time after time, so we must collectively step up to the plate and ensure that the best supports we can provide are in place for both the cared-for person and the carer. To provide carers with free access to GP and surgical services, if required, by way of a GP card is certainly welcome. However, I do not believe this measure goes far enough.

We submitted an amendment to address the deficiency in the Bill. We believe carers should have been given access to the provisions delivered by a full medical card. That, at least, is their due. Our amendment, therefore, called for "drugs, medicines, and medical and surgical appliances" to be provided to carers along with general practitioner medical and surgical services. We were most disappointed that this amendment was ruled out of order both in the Seanad and in the Dáil. This was due to it putting a cost on the Exchequer. Of course it would, but it is a cost we should bear. I have submitted a parliamentary question to determine exactly what the additional cost would be but, unfortunately, this has not yet been answered. I do not believe it would be a huge cost. Perhaps the Minister of State might have the figure to hand. That said, the Minister for Health should have taken this amendment on board. Not to do so is mean-spirited on the part of the Government and I ask the Minister of State to reconsider this additional provision in the short term.

Sinn Féin supports a full transition to universal healthcare for all our citizens. We need an national health service that is free at the point of entry, delivers healthcare from the cradle to the grave, is provided on the basis of need, not means, and is funded by progressive taxation. The Fine Gael Party supported this concept in 2007. It was in its famous, now seen as infamous, five-point plan.

Fine Gael Ministers for Health have since come and gone, including the current Taoiseach, Deputy Varadkar, and Senator James Reilly. When Minister for Health, the Taoiseach scrapped these plans. The problem with Fine Gael’s plan was that it involved privatising our health system through insurance contributions. It was selling off our health practices to the highest for-profit bidder, leading to higher and higher prices for patients through premiums. This plan was flawed. Sláintecare has recommended a universal single-tier health and social care system where everyone has equitable access to services based on need and not ability to pay. This is the correct approach. My party supports this model of healthcare delivery and has advocated it during my more than two decades as a Member of this House.

What is the status of Sláintecare? There is a fear that civil servants are watering it down, picking out what they believe are the best bits and shelving other parts. We will not accept this. The cross-party committee will not accept it either and the people we represent certainly will not accept it. In planning for universal healthcare, we should be transitioning as many qualifying people as possible to full medical cards. There cannot and should not be any half or bit-part medical cards, no GP-only cards or any other watered down provisions. Had the Minister accepted our amendment, it would have been a serious start on our journey towards universal healthcare.

I again raise the in loco parentis clause, which I have been raising for the past few months. It remains as pressing now as when I first raised it in March. Twenty-four-hours-a-day, seven-days-a-week carers, primarily the parents of very sick children, remain seriously inhibited by the enforcement of this clause by the HSE. As stated by Lynn McDonald in a "Prime Time" documentary in March, these parents are virtual prisoners in their own homes. This continues to be the case and it is in no way acceptable.

In the Sinn Féin Private Members' motion on disabilities on 27 March last, taken by the Minister of State, Deputy Finian McGrath, we called for in loco parentis to be immediately abolished. The motion in question was supported unanimously but nothing has happened since. I raised the issue again the following day, 28 March, under promised legislation. The Minister of State, Deputy Jim Daly, said he and an official from the Department of Health would meet me to discuss the matter further. This meeting took place on 26 April. In the interim, I raised the issue at the Joint Committee on Justice and Equality with the Minister of State, Deputy Finian McGrath. I have since written again to the Minister of State, Deputy Jim Daly, on 21 June seeking an update only to receive the following most disappointing reply, not from the Minister of State but on his behalf. It states:

Dear Deputy O'Caolain

I wish to acknowledge receipt of your recent correspondence in relation to the above.

You will appreciate that while Minister Daly facilitated your meeting with [a named official from the Department of Health], the issue does not actually come under his remit.

I will, however, forward your letter to [the named Department of Health official] while cc'ing the Minister Harris' office.

The Minister of State, Deputy Finian McGrath, has responsibility for disability. The response to which I refer is simply not good enough, particularly for those suffering families that are seeking a resolution to this problem. There are, I have learned, different degrees of application of the clause in terms of enforcement across different CHO areas. We need to seriously examine this with a view to removing the clause entirely. That would be my view as to what should happen. I am, therefore, seeking a detailed reply from the Minister of State, Deputy Finian McGrath, as to what will be done to alleviate this most unnecessary further difficulty for parents who, as he knows, are already coping with enormous challenges. That is no exaggeration.

I am happy to record that Sinn Féin supports this Bill. However, we are disappointed that it has not been a more generous provision for those in receipt of carer's benefit and carer's allowance. This particular cohort of people are deserving of full medical cards with all that these would entail and I urge the Minister of State to give serious consideration to this proposal in the shortest timeframe possible.

On behalf of the Labour Party, I am delighted to have the opportunity to support this Bill. I thank Deputy Alan Kelly for allowing me to replace him in doing so. Most Deputies will know that I have been a strong champion of carers for the past 26 years. I have done a lot of work in this area and that will be recognised by people on the ground. The Labour Party wholeheartedly welcomes the extension of eligibility for a GP service without fees to persons in receipt of a carer's allowance payment, although we believe that they should be given full medical cards.

In the course of our study, we found that very often a carer ends up in poorer health and in a worse position than the person for whom he or she is caring. In 2002, when I was Chairman of the Joint Committee on Social and Family Affairs, I initiated a review of the aids and assistance available to carers across the country. I had seen the work being done by very elderly people in looking after other elderly people, people with disabilities and young children with varying degrees of infirmity. These people were deteriorating before me eyes and this motivated me to ensure that their lot would be improved and that we, as an Oireachtas, would take this matter seriously. The committee sought submissions, oral and written, and it received 103 from, among others, Care Alliance Ireland and the Carers Association. The committee chose to draft the report rather than employ consultants to do it because, when let loose, all consultants want is to do is collect their €40,000 fee and so on. With due respect to Deputy Donnelly, we should rid ourselves of consultancy involvement in Oireachtas work. I would dump them and thus save a lot of money.

The report to which I refer was handwritten by me in one month. It contained 15 recommendations, only seven of which were implemented. We are all aware of the many reports that are lying around gathering dust. The most seminal recommendation in the report was that carer's allowance at 50% of the personal rate should be paid to people in receipt of qualifying social welfare payments. We broke the taboo that people said could never be broken, namely, that no person could be in receipt of two social welfare payments at once. I am very proud of that achievement. I will not contest the next election, so this will serve as a memento of my time in this House. Everybody said it could not be done. The late Seamus Brennan was Minister at the time and I was agitating from the Opposition benches. I was always agitated and I did more jumping up and down than Deputy Paul Murphy does these days. The late Seamus Brennan told me that if he agreed to what I was proposing, it would open the floodgates. My response was that if the floodgates opened, so be it. This was, and remains, costly but it is only a small token of recognition in terms of the work carers do. They are the unsung heroes. They work night and day and we exploit and abuse them and take them for granted. We should be collectively ashamed.

If I had a bundle of additional money, this is the area to which I would direct it. I would abolish the means test for carer's allowance in order that people would no longer have to be constantly filling out forms. There are 200,000 recognised carers in Ireland but there are many people who did not register as carers on their census forms, which means that the number of carers is probably closer to 350,000. There are carers as young as 16 and 17 years of age who are not recognised and I am acutely aware of that. If we were to pay carers the minimum wage, it would cost us in excess of €5 billion.

We have got them on the cheap. Talking about exploitation, we are paragons of virtue as exploiters here. We have effectively abused them. We should significantly increase the carer's allowance in the budget whenever we get to the stage and abolish the carer's allowance. It is an objective I have championed since I was first elected to this House. Some people might say it is far too much but let us think what would happen. What would happen if the carers of Ireland downed tools? We already have crises with accident and emergency departments, inpatient services, community hospitals and nursing homes. If they downed tools it would make what we have now look like a picnic. The whole health system would just capsize and collapse overnight. Let us recognise what they do and have done. We all know we can do much more for them.

Some 14,000 people will benefit from this provision, which is great. It is like how the snail got from Mullingar to Dublin - by degrees. We will acknowledge and accept every little improvement. However, there is more to be done to use that awful slogan of a political party many years ago. I would say a small bit is done, but there is a bucket-load more to do. No Government of any hue has ever properly recognised the Trojan selfless work of these carers.

I know thousands of carers in my Longford-Westmeath constituency and the work they are doing. I know the work that people like Caroline Poole, Denise Nolan and Ann Quinn do. I have met them and spoken to them. I have always fought their cause and always will until I leave this place. Even when I am gone, I will remain a very strong advocate for their cause because it is just and right.

The HSE gives organisations such as the Carers Association in Longford and Westmeath peanuts to survive. They are dependent on voluntary donations. I am sure the Minister of State, Deputy Finian McGrath, will remember the Classic Showband. Every August Billy McCauley, a local musician who used to be with the old Classic Showband, has a big Carers Association fundraiser in the Greville Arms Hotel, kindly sponsored by Christy Maye and others. All the top bands across the country come and provide a great night's entertainment to raise money. These organisations should not be reduced to having such fundraisers. They should have a core grant to enable them to carry out their tremendous work in advocacy and providing various things to carers across the area, such as pendants for people living alone. They do a lot of work on the protection of vulnerable people in isolated areas.

I am preparing a Bill that I will introduce in September - I am giving Members adequate notice. If it is the last thing I ever do it will be important. It is the carers need assessment Bill. I will be seeking to put this on a statutory footing. There will be no more grace and favours for carers. They will be statutorily entitled to various matters. Let us get this straight. Let us stop doing the grace and favour that we hand out some small thing to them and think it is a great achievement. It is, but let us put it on a statutory footing. From my dealing with carers, I know they are very often under strain.

There were 15 recommendations of which seven got implemented. One of them was the payment of the respite care grant, which is now called the carer's support grant. The name is not important; it is the €1,700 that arrives that is the important thing. One has to be there in June; it specifies dates and all of that. That now goes to people who are not in receipt of carer's allowance. There is almost an investigation beyond investigations to try to prove things in respect of people. The point is that it is €1,700 for somebody looking after a person to be able to pay for two or three weeks' respite care. Let us just imagine the cost - we are paying €900 or €950 down in the midlands, it could be €1,200 or €1,500 here in Dublin for nursing home care for a person. Let us look at the balance of the equation and the amount we are saving by paying the carer's support grant for people who do not get carer's allowance. We are paying €228 or whatever it is for carer's allowance. I know it increased by €5, which is gratefully accepted, but more needs to be done. If we were to pay even the minimum wage, it would be the guts of €400 and we have them for just over €200. That is only over a 39-hour or 40-hour week. Those people are working 24 hours a day, seven days a week without respite.

This morning I spoke to one of them who is looking after his elderly mother and trying to do a bit of part-time farming while being full-time devoted to his mother. They are the heroes. If we ever do an honours list, we do not want lords, ladies, Bonos or anybody else. We should collect up the 250,000 or 300,000 carers of Ireland and give them all an honour and salute them. I know the Minister of State, Deputy Finian McGrath, would want that. Those are the people we should put on a pedestal. They do not look for anything or claim to be great. They are great without ever looking for anything and we should acknowledge that.

We support the Bill. We support providing carers with access to medical cards but it is peanuts compared with the extent of unpaid labour of the estimated 360,000 carers, as Deputy Penrose said. For that reason we support both the amendments that seek to widen access and seek to widen what carers would be entitled to. All of it pales into insignificance compared with the unpaid labour of care, of social reproduction, of those who primarily - two thirds - are women. The 360,000 carers represent 10% of the adult population and that figure is only going one way. It is expected to be 20% of the population by 2030 according to Family Carers Ireland.

Care Alliance Ireland produced an estimate of the unpaid labour of those carers based on paying them the living wage of close to €12 an hour. It estimated the total saving on behalf of the State is €10 billion a year. That is an incredible amount of free labour done by people caring for either elderly relatives or young relatives - children, grandchildren etc. As I mentioned it is feminised with two thirds of carers being women. That increases to over 70% in the 50-plus category. The other feature is that the age profile of carers is getting older with a 50% increase in the number of older carers since 2006.

The way carers are treated appallingly relates directly to cutbacks and the absence of investment over the past ten years or so in the context of an increasing need for carers. It also relates to a broader societal issue. The structure of capitalism is such that it relies on a huge amount of free labour taking place which is overwhelmingly done by women. The impact on carers' lives, financially, emotionally and health-wise is obviously immense. In Ireland 66% of carers have said they struggle to make ends meet. One third of carers still keep a job outside their role as a carer to maintain themselves financially despite the fact that the average hours worked by a carer in Ireland is 44.6 hours a week. They are doing a full-time job or more caring and then they need to work outside of that to simply survive for themselves and possibly for the person for whom they are caring. In many cases it is not 44.5 hours a week; in reality it is 24 hours a day, seven days a week.

The impact of that is immense.

Apart from the financial strain on people working for free, 50% report feeling emotionally, physically and mentally drained from the role and pressure of being a carer. Over half reported physical injury, usually to their back, and another half reported mental health problems due to the role and stresses related to it. In the context of a society that does not provide appropriate public care, people wonder about what will happen to the people they care for and love. They wonder if they die or get sick, who will look after the people they are caring for. As a result, 27% of carers have a stress level of seven or higher on the care-giver strain index.

We support the Bill. We will seek to strengthen the Bill by supporting both of the amendments on Committee Stage. There is a much bigger and more fundamental change needed here in how care is provided in our society and an end to the reliance on unpaid labour, generally of family members. We need increased supports for home helps as part of a national health service. We need more quality residential facilities. We need more home help provided as part of a properly funded public service. We need full financial support for those who have to be carers. They need to be paid a living wage. We need to make funding available for home adaptations. We need support for minority care givers; 12% of carers do not speak English, which affects their ability to access the services available to them or which are available in theory to them. We need support for Traveller caregivers and LGBTQ+ caregivers and so on. Fundamentally, we need an end to the direction of travel of our health service towards privatisation. We need the development of a proper national health service within which the role of carers is properly resourced, publicly provided wherever possible and, where not possible, that carers are appropriately remunerated for the jobs they do.

I am delighted to have a brief opportunity to speak on the Health (General Practitioner Service) Bill 2018. I thank the Oireachtas library and research service as usual for its fine analysis of the Bill and on its information on the key issues for carers.

It is a very short but important Bill. Throughout my career, I have tried to advocate as strongly as possible for carers and believe the tireless, unpaid work they do in large part still goes unnoticed and unappreciated by the State. Almost 20 years ago, when I was the social welfare spokesperson of the Labour Party, I published a paper entitled Caring for Our Carers, setting out a list of basic supports for carers which I believed at that time were very badly needed. Many of those supports still have not been delivered by successive Governments, including this one. One of the areas we covered at that time was the introduction of carer's benefit which was a very tiny step forward.

Census 2016 showed there were over 195,000 carers across the country, which was an increase of 4.5% on the 2011 census figures. Of these, as other speakers have said, just over 60% were women and almost 53% were in the 40 to 59 years age group. One of the most shocking figures in the analysis is that 3,800 children under 15 were providing care for a family member and almost 1,800 over 85s were also providing care, which was an increase of nearly 35% since census 2011. That brings home to us the situation that members of families often find themselves in. It is particularly poignant when elderly people and young children have to perform this crucial function.

As other speakers have said, the number of care hours per week was estimated, at full-time job levels averaging 38.7 hours per carer, at 6.6 million hours of care per week in total. Almost 43% of carers provided around two hours per day and almost 17,000 carers were providing full-time, 24-7 care. The figures available for June 2018 show there were 2,747 recipients of carer’s benefit and 77,384 recipients of carer’s allowance and that 83% of these recipients already have access to free GP care through access to a medical card or GP card. The Bill before us is expected to extend this care to a further 14,000 carers at a full-year cost of approximately €2.8 million. The Bill will provide for this extension by amending sections 47 and 47A of the Health Act 1970 and by inserting a new section 58D.

Ireland is the only health system in the EU that does not already offer GP care universally. Hopefully this shameful situation will end over the next number of years, either in this Administration or the next, as Sláintecare is implemented. It is regrettable, after the all-party approach of the committee, which included a number of Deputies all around the House under Deputy Shortall, the Government seems to be dragging its feet on the implementation of the programme. We may have made some improvements in that regard since the extension of GP care to under sixes but it is disappointing to see the Bill will not include those 29,869 carers in receipt of the carer’s support grant, which is the new name for the respite grant. Will the Minister of State explain why he did not ask for funding to extend it to those recipients given many of them are giving many hours of care per week to loved ones?

Carers experience a huge amount of stress and are more likely than the general population to become ill. According to the Department of Health, 27% of carers over 50 have reported high levels of stress and distress. The toll that caring takes on a person’s physical and mental health cannot be underestimated. Deputies know that very well because week in and week out we meet people who give an extensive part of their lives to caring for their loved ones, an older person or a child, or an adult of any age who has a serious disability or illness.

Section 4 of the Bill provides the insertion of section 58D, which I mentioned earlier, allowing for persons in receipt of either carer’s benefit or carer’s allowance to avail of a GP medical and surgical service. The Minister of State mentioned in his address to the Seanad on 5 July that section 4 included persons in receipt of half-rate carer’s allowance yet the informative Bills digest, which the library and research service prepared for us, tells us it is not explicit in the Bill. Perhaps it is something the Minister of State addressed in his opening statement. I was attending the Select Committee on Budgetary Oversight and did not get a chance to hear it. Will the Minister of State confirm in his reply whether persons in receipt of the half-rate carer’s allowance will also receive a GP visit card?

According to the library and research service’s excellent work, the half-rate carer’s allowance in Part 3, Chapter 8 of the Social Welfare Consolidation Act 2005 uses the term "a payment under section 186A" throughout and this Bill before us makes no reference to "a payment under section 186A". Is the Minister of State looking into this to ensure they will not be excluded?

Other important issues arise. What consultation did the Minister of State and Minister have with GPs? The EU average number of GPs per 100,000 people is around 91 yet Ireland has the far lower ratio of 64.4 GPs per 100,000 citizens. It is also reported that many of our trained GPs leave the country for opportunities outside of Ireland, mirroring trends of other health sector personnel, and it is estimated there will be around 26.2 million visits to GPs per year by 2031 due to demographic changes. Given this welcome Bill, do we need to offer new opportunities to citizens, particularly those from lower income backgrounds, to train as GPs and to give strong encouragement to work in Ireland?

Another issue that may arise with the Bill is related to data sharing and GDPR. Due to the nature of carer’s allowance and carer’s benefit, there will be monitoring of recipients' eligibility for those payments and therefore, by extension, eligibility for the GP card. The primary care reimbursement service administers this system and monitors eligibility but there may be data protection issues around sharing this information for the GP visit card. The Minister of State might come back on that.

National carers' week took place last month from 11 June to 17 June. I commend the work of all the advocacy groups such as Family Carers Ireland and others for highlighting the need for carers’ roles and contribution to the State to be recognised. The interesting points about carers, as Deputy Penrose and Deputy Murphy have said, is that virtually all of us will be cared for and all of us are, have been or will be carers. It is something every citizen understands. I echo the comments of my two colleagues. There is a deep-seated wish that carers are properly valued by the carer's allowance, the respite grant and all the other supports we can get them.

It can often be an isolating and tiring time and carers deserve to know that the national carers’ strategy 2012 will have resources put into it, so that their lives will be improved and they are supported. I hope the Minister has plans to update it in the current legislation. He may know that I am a member of the informal disability group of this Dáil and Seanad, as is Deputy Ó Caoláin, and a proposal has come forward from the committee for an additional programme of €211 million for supports for citizens with a disability, which would be helpful to carers as well. I hope the Minister will strongly advocate for this at the Cabinet table and demand that kind of money in budget 2019, and does not have to come into the House to tell us he only got €35 million or €45 million. It was a well-structured exercise to lay out the improvements we need in disability services and €211 million is a basic price tag across Government.

I welcome this Bill. I join with all our society in thanking carers for the work they are doing and I am delighted to be supporting the Bill. I hope that budget 2019 will bring some further improvements in supports and packages available to carers and I urge the Minister to put forward such requests to the Minister for Finance, Deputy Donohue, without delay.

There have been a lot of reports of over 70s contacting offices about the removal of medical cards, possibly on income grounds, and being given a GP card instead. A lot of people are upset about this and about what may be happening to the limits. It is not directly related to what we are talking about now but the Minister may examine the issue to see if there is a problem.

Many people might remember last December, watching in horror the RTÉ "Prime Time" programme, "Carers in Crisis". We saw thousands of people all over the country dedicating their entire lives to looking after loved ones who were unable to care for themselves. In many cases, carers themselves were in ill health. Becoming a carer for a loved one is a life-changing experience. Each day brings new demands, new highs and new lows. On average, carers care for their loved ones for almost the equivalent of a full 40-hour working week and almost 9% provide full-time, 24-hour unpaid care with no break at all.

While there are many positive and rewarding aspects to caring it can also place huge physical and emotional demands on carers, who try to balance their own well-being with the needs of those for whom they care. I welcome the proposal in this Bill to provide general medical and surgical services free of charge to people who are in receipt of either carer's allowance, at the full rate or the half rate, or carer's benefit. This Bill will result in approximately 14,000 additional people being eligible for a GP visit card.

In December last year, my colleagues in the Rural Independent Group and I brought forward a home care package motion in which we highlighted the wonderful work of our carers and the fact that they are hugely restricted and unable to receive any respite care for themselves. Our motion called for the Government and our Minister with responsibility for elderly people to increase home help hours so that an efficient service could be provided to older people and that our carers can be given the support they need. A total of €10 million for respite care services was announced in last year's budget and I welcome the announcement.

This Bill is a step in the right direction but more can be done for our carers. The home help service is not getting any better and in my constituency people looking for home help are being told to advertise to see if people are available. The home help people are telling me they are quite willing to put in extra hours but they are not being given the hours. It is a total con job of a system and the people in charge of this have to be made accountable in the Dáil for it. If there are people who are willing to do home help hours but are not being given them, the people who are refusing to give them are conning sick people and home help people.

Being a carer can have financial consequences and many carers have to reduce their working hours or give up work entirely. Carers can go five, six or seven months without any payment, which is nothing short of outrageous, and the first day it is proven by medical evidence that a loved one requires care, a social welfare payment should be made to the carer. We need to ask who cares for the carers. There is no doubt that many deserve acknowledgement, understanding and support. This Bill is a step towards getting the recognition they deserve and the support they need to maintain their own physical and mental health.

I welcome the approval of a GP card for our carers. It should be a full medical card on account of the great work they do. Many are family members who give up their jobs and their time to care for their parents or other relatives who would have no one else to care for them and they get little respite or time for themselves.

I agree with Deputy Collins. The home help service is 30 minutes and when family members in Kerry ask for a second home help they cannot get one. It takes two trained people to operate a hoist and some patients are very fat at that stage so it is a total no-no. Many families pay for home help out of their own pockets. There is no home help on Saturdays, Sundays or bank holidays, apart from in very rare cases. Sick and elderly people do not get better for the weekend or a bank holiday. They need the same attention and care for seven days as they get for five days.

When carers apply for funding to be a carer they have to wait for 12, 14 or 18 weeks. Live horse and you will get grass, and grass is very scarce at the present time. The wait is too long. Another thing that is happening is the removal of medical cards from elderly people. I do not know who authorised this but they are looking for all sorts of information from people as old as 85 or 86 who have had medical cards since they got to pension age. Will the Minister explain what is happening? Why is there such a shortage of funding and why are we taking medical cards away from these people? Nobody can understand it. Reviews are being done into people's circumstances and I know one man aged 89 who had a medical card but does not have it now. He has gone through the hoops to get it back but he has to pay for his drugs and whatever he needs to take on a weekly basis. It is very unfair on old people who have served the country well and brought it to where it is now.

I welcome this announcement by the Minister, even if it is several years overdue. I am disappointed he is not here this evening. Many of us on this side of the House have long recognised the importance of carers to Irish society and we have not sought to have their access to basic care hindered by a lack of focus and a lack of priority, as was the case with the Minister, Deputy Harris. I ask the Minister of State to tell him that.

I could say a lot more but I will hold my tongue. He had other political priorities occupying his time. So be it.

The proposal to extend free GP coverage to those in receipt of carer's allowance and carer's benefit is part of a phased expansion of coverage to different groups and that is something that can also be broadly welcomed. We note, however, that since the introduction of free GP cards for the under sixes there have been chronic problems with accessing GPs. The Government was warned about that but would not listen. That action was not targeted at those in most need. If it was targeted it could have been used to provide access to additional kinds of care requirements.

I said to the Minister’s predecessor as Minister for Health, Deputy Varadkar, at the time of the introduction of free GP cards for the under sixes, that it would escalate the pressure being experienced by GP surgeries across the country as they struggle to adapt to the implementation of the scheme.

The National Association of General Practitioners, NAGP, confirmed to me that at the time, the then Minister, Deputy Varadkar, did not even engage in the minimal courtesy of consulting its 1,450 members about the plan. That must be a lesson he passed on to the current incumbent as Minister, Deputy Harris. It has rubbed off on the Minister of State, Deputy Finian McGrath, as well because he is not too good at consulting either. It was a case of not consulting GPs, just ordering them to do the work. As has been said by many Deputies, carers up and down the country are boundless in their energy and in what they do and try to do for their loved ones. The way they have been treated and mistreated by being cut down to half an hour or even 25 minutes in some cases is ridiculous. We must recognise them. I recognise the carers in Tipperary, as well as their manager, Councillor Richie Molloy, for all the work they do.

Instead of 2,954 GPs, we need 4,264 to have any kind of a service. Statistics provided by the Central Statistics Office, CSO, for Tipperary found that carers provide a staggering 250,000 hours of care per week within the county. That is in Tipperary alone. These findings also record that 7,041 people stated they provided regular unpaid personal help to a friend or family member, as has been mentioned by Deputy Danny Healy-Rae and others, with a long-term illness, health problem or disability. Without the carers, there would be even more chaos than there is now. A woman in University Hospital Limerick contacted me today. She has a serious diabetes issue and has been on a trolley for 80 hours. What is going on? If we did not have the carers, the volunteers and the families, there would be utter chaos but the HSE cannot see that. It is all about offices and mandarins, rather than supporting people on the ground.

What is deeply alarming to me is that the CSO found there were 138 carers aged under 15 years in County Tipperary alone. I have asked the Taoiseach for reassurance that this will be investigated. They would not be allowed to work for Deputy Danny Healy-Rae because they would be underage but it is fine to let them care for people in their own homes. That is shocking and is an abuse of children. They should be out playing with other kids, going to matches and doing their schoolwork and not having the worry of trying to care for their loved ones. The explanatory memorandum accompanying this Bill estimates that this measure will have a full year cost of €2.8 million. Of that, €2.4 million is for those in receipt of carer’s allowance and €400,000 for those in receipt of carer’s benefit. We must have that.

Details provided in the Revised Estimates for public services showed that the Irish Human Rights and Equality Commission was allocated €6.5 million in 2017, with €3.5 million of that going toward salaries, wages and allowances. There it is, those are CSO figures and that is where the money is going all the time. There are managers and more managers and line managers, as well as renting office space but not looking after the people who, as Deputy Danny Healy-Rae said, built this country. They should be recognised in their final years. The Minister of State, Deputy Finian McGrath, had a lot of talk when he was sitting over here on this side of the House. He was going to do everything but he has done little to help, including people with disabilities.

What am I doing today if not delivering?

I join other Members in welcoming the Health (General Practitioner Service) Bill 2018. It is a small but important measure in recognising the exceptional work that carers do. Many Members have referred to the outstanding work done right around the country by people caring for their children, elderly parents, partners and other people. It is done in a manner that is first and foremost about love for the person for whom they are caring and we see so many people devoting, in many cases, their entire lives to this role. They take it on willingly but there must be a recognition that in doing so, family members taking on the caring role are not only doing an extraordinary job for the people for whom they are caring - their loved ones - but they are also doing an extraordinary job in the saving they help to make for the State.

If a person requires full-time care and attention and has to go into a nursing home or other kind of facility, the cost is extraordinarily high. That always has to be the yardstick by which investment in carers is measured. The truth is we do not do half enough to recognise the work carers do because it is exceptional and very generous of them. It is done with an open heart but it needs to be recognised properly and we need to go much further than this Bill.

There is a need to ensure that training is provided for people in full-time caring roles. It is a specialised job to care for somebody who is immobile, such as an elderly person or a person who needs much lifting and handling. Carers very often do themselves serious injury by trying to cope with a situation like that and we could be doing much more in providing training in patient handling for people who are caring. We could also do much more to make aids and appliances, things like hoists and housing adaptations, easier to access. Funding for those services, aids and appliances is limited and very often, people must go on long waiting lists to avail of them. I hope in the run up to the budget that the Minister of State will make a strong case for increasing the funding for aids and appliances. I refer to items like ramps, grab rails and so on, as well as the need for walk-in showers and downstairs bathroom facilities etc.

That applies to people in private housing. When it comes to people in social housing, the lists are much longer and it is much harder to access those aids and appliances. There is a need to look at this again. I, and I am sure many other Members, have come across cases where a person, generally an elderly person or a person with a disability, is prevented from coming home from hospital and being cared for at home simply because there is inadequate funding for those kinds of grant schemes. For want of a ramp, rails or downstairs bathroom facilities, people often have to stay in a hospital bed, which costs about €1,000 a night. If a small amount of money is provided to make the house more accessible, that person could come home and be cared for there. Joined-up thinking is needed between local authorities and the HSE. That is not going on at the moment and there is a real disconnect.

On the granting of carer's allowance, there has to be a relaxation in the application of the habitual residency rules. This is a major problem now, as Irish people are living longer and many people can expect to live into their 80s and 90s. That is fantastic but the reality is that not everybody can live into their 80s and 90s and be fully mobile, healthy and free from debilitating illnesses. On a fairly regular basis, we see cases where the son or daughter of a man or a woman has emigrated to the United States, the UK or wherever. That elderly parent is becoming less mobile and wants to stay in his or her own home but needs to have somebody looking after him or her. When the son or daughter comes home to look after the elderly parent, he or she is refused social welfare support because of the habitual residency rules. They are applied very tightly and very strictly and that needs to be looked at.

The other thing on which we need clarification is the point raised by Deputy Broughan. We need the Minister of State to clarify that this provision of GP visit cards will apply to people in receipt of the half-rate of carer's allowance. It is not clear from the legislation. It also will be important to ensure that adequate funding is provided for the Carers Association. It is an extremely difficult job caring full-time for a person who is infirm, elderly or with a disability. People need regular breaks, regular support and psychological and moral support. That often comes from the local Carers Association, which can meet with people that might organise sessions where carers can come together and share their concerns, as well as get advice and a break etc. That can only happen adequately if the Carers Association is funded properly. We need to make sure that we are caring for our carers.

Very often they are left to care in isolation without the kind of supports necessary to enable them to continue to do their important work.

While I welcome improved access for carers in terms of access to free GP services and the extension of that facility to under sixes that has taken place in recent years, and indeed the additional work that will come to GPs as a result of the repeal of the eighth amendment, I note that GPs are expected to do a lot of extra work. At the same time recruitment and retention of GPs is becoming increasingly difficult and for primary care staff generally, including public health nurses, therapists, speech and language therapists and so on. The provision of adequate health services at community level is now a huge challenge. The aim is full implementation of Sláintecare, which not only proposes a universal single-tier health service with much greater access to healthcare, but also a new model of care, where we would move away from the hospital-centric model of care we have at the moment towards the provision of more and more services in the community. This is particularly the case when it comes to the management of chronic illness, which accounts for 70% to 80% of healthcare activity. Conditions such as asthma, diabetes and COPD should be managed locally in the primary care setting. They can be managed much better there. We get better health outcomes and much better value for money if we provide services in the primary care setting rather than in the expensive acute hospital sector. That can only be done if we have capacity at primary care level.

Many GPs are opting to go abroad to work in systems that are functioning better than ours, where they are treated better and where there is certainty about the future of the service. The financial emergency measures in the public interest, FEMPI, cuts, which took place a number of years ago and which amounted to 38% of the income and practice supports of GPs, have never been reversed, unlike the cuts endured by every other public sector worker. Those cuts have been reversed, or at least those affected are on a path to reversal. That has not happened for GPs. The cuts they faced have not been reversed at all and we are paying a price for that in terms of the loss of GPs. Of course, it is also the case that GPs want to work within multidisciplinary teams and in premises provided by the State. Unless the Government addresses these issues and faces up to the crisis in general practice we are now facing, much of this talk will be academic. Carers or other people will not be able to get access to GP services. That is the real challenge ahead and it is a challenge the Government is currently ignoring.

The Health (General Practitioner Service) Bill 2018 seeks to extend GP visit cards to those in receipt of carer's allowance or carer's benefits. It is welcome. The announcement that this legislation was to be brought forward was accompanied by an additional €10 million funding for respite care. I welcome the focus on the issues that carers face. However, Ireland has the only EU health system which does not offer universal cover for GP care, which is disappointing. The Government has promised to improve support for carers and it has to honour that. The 2016 figures show that 45% of the population receives free or subsidised GP care via medical cards or GP visit cards. The proposal to extend free GP coverage to those in receipt of carer's allowance and carer's benefits is part of a phased expansion of coverage to different cohorts. While GP card eligibility was initially solely based on means, it has been extended to all children under six and all adults aged 70 or over. I welcome that.

This proposed legislation will grant the GP visit card to some 14,000 carers. This represents the 70% of those in receipt of carer's allowance or carer's benefits who do not already have free access to GP care. As of June 2018, some 77,384 people received carer's allowance and 2,747 received carer benefits. The vast majority - some 83% - of this combined population already have access to free GP care as they satisfied the existing qualifying criteria for medical cards or GP visit cards. Figures from the census of 2016 show that there are 195,263 carers in the country. This legislation will bring a new entitlement to free GP care to some 70% of carers. GP visit cards, while granting free access to GP care, differ from medical cards in that they do not provide access to medication, aids or appliances, or a whole range of pioneering social care services to which medical cards facilitate access. People with GP visit cards remain liable for all other charges, including public healthcare levies for non-medical card holders.

Evidence indicates that carers have poor mental and physical health outcomes, so extending free GP care to carers would be of particular value to them. The explanatory memorandum accompanying the Bill estimates that this measure will have a full-year cost of €2.8 million, comprising €2.4 million for those in receipt of carer's allowance and €400,000 for those in receipt of carer's benefit. The 2016 census recorded 195,263 carers providing 6,608,515 hours of care each week. That is an average of 38.7 hours of unpaid care per carer. This represents 4.1% of the population, which is the same proportion shown in the census of 2011. The majority - 60.5%, which is 118,151 carers - are women and over half of all carers - 52.7% - were aged between 40 and 59. The greatest proportion of carers was in the 50 to 54 age group, accounting for 28,700 carers, or 14.7%.

Many people come into my constituency office and ask what the carer's allowance is. The carer's allowance is a payment made by the Department of Employment Affairs and Social Protection to people on low income looking after a person needing full-time support because of age, disability or illness. If a carer is in receipt of certain social welfare payments and is providing full-time care and attention for another person he or she can retain his or her main social welfare payment and also receive a half-rate carer's allowance. I am also asked what a carer's benefit is. It is a short-term payment, for up to 24 months, for people who give up employment to care on a full-time basis for someone who requires full-time care and attention. Carers do not work for the money. They have a vocation. The big problem I have is that many people come into my constituency office looking for carers. These people go to a GP and are told that they are entitled to carer's allowance. When I look at the medical report the GP gives that person I know that it is not sufficient. We have to be honest with these people. A large amount of time and effort is put into the application form for carer's allowance. The Department always asks for more information. We find that TDs have to send the information. We can scan the information and look after it. The Department just goes back and forth with the carers. The amount of money carers have saved this country is unbelievable. It is not about the money for those people; it is a vocation.

I welcome this Bill. Providing a GP medical card is a step in the right direction. I emphasise the word "step". However, I believe we need a total re-examination of the way carers are treated. Every one of us across this floor has put in applications or helped people with their applications. The process is very cumbersome. It might take three or four months, and longer if it goes to an appeal - possibly six, seven or eight months. That is a long period to wait for an outcome. I have seen cases, especially in rural parts of Ireland, where a potential carer might have a piece of land and the adjudication might be that the person spends time on the land so he or she could not care for the person. We must realise that morning, noon and night, these people are being cared for. The carers might go out and do a bit of work outside for half an hour or an hour, but they come in again. A person then makes the decision at the stroke of a biro to disallow the application. That is one thing we need to look at.

A problem can arise where a husband and wife are working and because of the love for his or her family, for a mother, father, son or daughter, one of them gives up work.

Then they must go through an assessment of means and all that craic. Does the State not realise that if they took the easy option for their loved ones they could go through the likes of the fair deal system, and a nursing home would cost the State more than €206 or €208 a week? Anybody who gives up work to look after their loved one should have these issues sorted out regardless of what their husband is earning, because they are causing terrible problems. Someone might give up a job and then they might be refused carer's allowance. They may have kids going to school. That puts a ferocious financial strain on them. Putting someone into a nursing home, as the Minister of State knows well, costs between €850 and €1,200 a week. The carers throughout this country are the greatest servants of this country, with the hours they put in, their patience and what they do for their loved ones.

Carers can also be neighbours that come in and help people. I know that the Minister of State does not have the money to do everything. However, in the upcoming budget, I ask him to do whatever he can to assist the carers and make their lives easier. I ask him to be mindful of those people, sons, daughters, brothers and sisters, who have given up work and all their time to make sure that they look after their loved ones, rather than see them go somewhere they might not want to go. In fairness, I know that he is looking at the fair deal system, which I appreciate. It is badly needed. I thought it was to be before Government yesterday, but I do not think it was. It needs to be brought forward as quickly as possible. I ask the Minister of State to change that situation. Every one of us in the House sees people being turned down. They are doing the work; they are helping their loved ones morning, noon and night, and they are doing this State a massive service.

I am very glad to have the opportunity to speak on this important matter. When it comes to carers and acknowledging the work that they do, we should be willing to provide whatever facilities or help we can give them, whether it is medical cards or any kind of assistance. It would be wrong to speak on this important motion without acknowledging the work that is being done by our general practitioners throughout the country. In the county that I represent our local GPs play a vital role. As we are talking about the subject, I am very worried about the future of our GPs. In rural areas, many of them find it hard to keep their businesses going, even though they are so pivotal and important. From a monetary point of view, it is getting more difficult to run a business, which is what being a local GP is. It is getting more and more difficult with overheads, insurance and everything becoming so expensive. They are finding it very hard. I worked diligently to ensure that in places like Waterville and Sneem we had GPs to replace excellent people that had given a lifetime of dedication, which was important. I do not want to see any place with a GP service in the county that I represent lose that service.

Coming back to the carers, a colleague behind the Minister's back said correctly that being a carer is not a job, but a vocation. It is giving a service and saving the State an absolute fortune. If at all possible, the best place that our elderly people can be, whether they are our family, friends, relatives or neighbours, is at home, receiving the care that they require. In situations where people cannot stay at home, I also want to acknowledge the work that is done by our community hospitals and private nursing homes. Again, private nursing homes find it very difficult. They operate to the highest of standards, but the Health Information and Quality Authority, HIQA, is a moveable feast. It raises the bar this high today and raises it that high the next day. It has certain rules today and a completely different set of rules some other time. We all accept and respect that we have to have standards, but HIQA is a runaway monster. It makes it up as it goes along. Complying with that can be extremely difficult.

We have seen this in the public service. We have built community hospitals to the highest of standards and there has been a delay in opening them. HIQA has refused to allow them to open, even though they have been built to its standards. The authority comes along, moves the goalposts and says that it wants the hospital management to do things differently, in a new building which would have been compliant months or a year or two beforehand. HIQA says that it is not compliant now. We actually have to change new hospitals and new buildings to comply with new HIQA regulations.

Coming back to the private nursing homes and the difficulties they have in running their business, I wish to acknowledge the excellent service they give and the excellent role that they play in our communities. This includes the employment they create and the care they give to elderly, vulnerable and sick people, keeping them as near as they can to being at home. Of course, I rightly acknowledge our carers and I hope to ensure that we help these people in every and any way we can in the very important work they do.

First, I thank all the Deputies for their contributions. I also thank them for their positive ideas and constructive comments. This is an important Bill and it is a step in the right direction. Equally, I acknowledge that we have a lot to do for carers, and I intend to do a lot more for carers. I wish to address some of the points raised by Deputies. Deputy Stephen Donnelly talked about extending the scheme and I am open to that. Extending home supports and issues like that are something we should look at in the future. The figure of €2.8 million or €3 million was mentioned. From my research, the figure that we would realistically be looking at is approximately €6 million. That is the ballpark figure. We acknowledge the step we have taken, but we have to put in more supports. I take that valid point. That is something we should look at in the budgetary process, and it is something I will drive forward.

Deputy Michael Moynihan raised important issues regarding respite and carer's holiday cover. That is an issue I have heard about as well. I am determined to work with the Department of Health and the HSE on this issue.

Deputy John Brassil raised the issue of GP contracts, which is an important part of this debate. We have to move on in those negotiations. The Deputy also raised the issue of home care packages, particularly focusing on community healthcare organisation, CHO 7, where there seems to be a problem with palliative care. Again, I will work with my colleagues in the Department of Health and the HSE, as well as the Minister for Health on that particular area. I will also address gaps in any other areas as well.

Deputy Caoimhghín Ó Caoláin was supportive of the Bill. He rightly said that it was a step but that we need to make more progress. I take that criticism, and I welcome his support for carers in society at large. I also take his point on the amendment. I know it was ruled out of order, but that is a live debate and something we have to drive for the future. I strongly believe in what the Deputy said about the principle of full transition to a national health service. We either believe in Sláintecare or we do not, and that is something I will push for within government.

A point was raised on those acting in loco parentis. Since our meeting at the Joint Committee on Justice and Equality I have put that question to my Department. I have my own views on that. We have to review it but I will come back to the Deputy with a more detailed answer, because the last response he received was in April or May. I put it the issue to my Department after the committee meeting. Like the Deputy, many parents and family members have come to me about problems arising from the in loco parentis debate.

Deputy Willie Penrose was supportive of the Bill. He is not here now. He has been pushing for the interests of carers in this House for many years.

He has been a champion of carers. I commend his work and I wish him well in retirement. Of course, I accept the valid criticism that we need to do more, but I emphasise this is a step in the right direction for starters. He also mentioned he will introduce a carer's need assessment Bill and I look forward to that in September.

Deputy Paul Murphy supported the Bill but, like many speakers, he felt it should be broadened. He also paid tribute to the home helps and pointed out housing issues with regard to residential centres. I remind colleagues that I announced €14 million last week for housing adaptation grants, a €2 million increase on last year's figure. Despite 83 press releases, it was not mentioned in any newspaper or media organisation. Good news does not travel.

Deputy Broughan mentioned the carer's half rate. I can confirm the GP-visit card will be there. He also mentioned those aged over 70. I welcome the support of Deputy Michael Collins. As he said, we have to do more for carers and home help. He strongly emphasised that when we are dealing with health services there should be accountability for the amount of money being spent. I accept that and it is something I focus on every day as Minister of State with responsibility for disabilities. Deputy Danny Healy-Rae spoke about home help, the physical issue of hoists and medical cards, and we need to develop on these.

It is a pity Deputy Mattie McGrath is not in the Chamber because I want to remind him my job is to deal with disability and carers as Minister of State and I am here. I try to push the agenda very strongly.

Deputy Róisín Shortall raised a number of important points and I welcome her comments. I did state the Bill is a small measure and a step in the right direction. I recognise the point she made on training. I accept that we need training for carers. On that issue, I was in Sligo recently where I met a group of young social care students who will come into the system next year. That is the type of training we need more of. We have a lot of people in the sector who are not trained and of course I take the point. The issue of aids and appliances has come up and I mentioned the housing adaptation grants. With regard to the habitual residency rule and social welfare supports, it is something we should absolutely look at and it is something I strongly believe in. Deputy Shortall also mentioned the carer's half rate and I confirmed they will get the free GP-visit card. Deputy Shortall acknowledged the work being done by Family Carers Ireland. I know many people in that association and we absolutely have to fund them. She also dealt with the issue of GPs, which is a very important issue.

To go back to the point made by Deputy Ó Caoláin and others: Sláintecare is a new model of care. There is a new emphasis on more services in the community, but we also have to face the reality that we have to have that capacity at primary care level. We have an issue there and I accept that point.

I welcome the support of Deputy Peter Fitzpatrick. He spoke about the bureaucracy of the application forms and the fact that Deputies spend a lot of time on them. It is something about which we need to remind people in the services.

Deputy Michael Fitzmaurice spoke about the rural issue and farmers who are carers. It is an important aspect of the debate. Another part of debate about which I feel very strongly, and on which he made a valid point, is those who give up their jobs to care. We have to be mindful of the people who give up work. There should be a long-term plan and we will work on it. Today is only part of the plan. I do not want to get carried away here. I accept the points on it but we need to look at a long-term care plan. Deputy Fitzmaurice validly made the point about giving somebody a couple of hundred euro a week to stay at home and look after a person with a disability or a senior citizen rather than that person going into a nursing home or residential centre. He spoke about €1,000 but I believe the cost of some is €1,200, €1,400 or €1,500.

The final point was raised by Deputy Michael Healy Rae who strongly supports the carers, which I acknowledge. I know from meeting the Deputy in Kerry he is very involved in disability issues. He rightly raised the GP issue. We have to have the GPs with us on these issues and we have to be conscious of this. The Deputy also mentioned the issue of nursing homes and regulation. These are issues on which I have regular discussions with the officials in the Department of Health. The Bill is a step for the 14,000 carers. It states we appreciate the work being done and this is why we are granting the free GP service.

Other things are also happening, which are often not recognised. The carer's grant was restored to €1,700 per family and 101,000 families got it. The other issue was the medical card extension for children in receipt of the domiciliary care allowance. An extra 11,000 children received that medical card over the past year. Three weeks ago at the Central Remedial Clinic I announced €16 million for ability programs for 2,600 young people with physical and intellectual disabilities. As I mentioned, we also had the €10 million in 2018 for the respite care homes. Many of these houses are now being opened. Another issue people should keep an eye on, because many people are not aware of it, is the annual home care credit increased by €100 to €1,200.

There are supports. Do we need to do more? Absolutely. Am I listening to the suggestion put forward by colleagues? Absolutely, but I ask everybody one favour. When it comes to the crunch over the next few weeks in the debate on the Estimates, and we have already had our first meeting, I will put residential services, carers and people with disabilities at the top of my list with regard to public spending. Other people will argue that we need more tax cuts and will argue for other issues. I need the support of all Members of the House, regardless of party or being an Independent. If everybody rallies around the carers we can get more in the budget for them because I totally value the magnificent work they do.

Question put and agreed to.

I am required to put the following question in accordance with an order of the Dáil of 10 July, that in respect of sections 1 to 5, inclusive, each section is hereby agreed to in committee, the Title is hereby agreed to in committee and the Bill is accordingly reported to the House without amendment. Fourth Stage is hereby complete-----

On a point of order, I want to speak on Committee Stage. It sounds like the Acting Chairman is skipping Committee Stage.

There was an order of the House yesterday.

So there is to be no talk on Committee Stage.

There is no Committee Stage.

Even though amendments were tabled.

Yes, that was agreed yesterday.

The amendments were ruled out of order.

Fourth Stage is hereby completed and the Bill is hereby passed. Is that agreed?

There is no other way to talk on the Bill.

I want to make a final contribution.

We will make an exception for the Minister of State.

I thank Deputy Ó Caoláin.

Only with the agreement of the House.

Perhaps we can-----

We can make an exception with the agreement of the House for the Minister of State.

I ask that we include Deputy Donnelly in this.

Is Deputy Donnelly sure?

I thank Deputies for their valuable contributions to the debate, and I really mean that. I very much welcome that we were able to bring the legislation through all Stages in the Dáil today. I express my gratitude to the House for allowing it to go through so quickly so we can move to have this important service available to carers as quickly as possible, on 1 September.

One of the many challenges for the health and social care system is to do everything possible to support the most vulnerable in society. This includes supporting carers to ensure they are able to undertake the vital role of caring for their family or loved ones. I thank colleagues for their support. I have listened to the constructive proposals they have put forward and I will include some of them in my negotiations in the programme for Government because we need to do more for carers. This is a step in the right direction, but it is a positive step and it is something we should acknowledge.

Bill reported without amendment, received for final consideration and passed.

A message will be sent to the Seanad acquainting it accordingly.