Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020: Second Stage (Resumed)

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

As there are no Solidarity-PBP Deputies present, we will move on to the Regional Group.

I am sharing time with Deputy Peter Fitzpatrick. No one could say anything other than that this Bill is welcome, but there are some concerns I wish to raise in order that we might ensure the success of its implementation for all concerned. The Bill provides for free GP care for under 13s on a phased basis. I would like to add a note of caution on its introduction date, phasing in and the balance of availability of services. The issue of availability of GP services is one of grave concern, particularly in Wexford. Evidence-based research from Trinity College shows that an increase of 28% in GP visits occurred with the introduction of free GP care for those under six years of age.

When he was spokesperson in opposition, the Minister's response was:

This is a crisis. Doctors have been treated with contempt since Fine Gael came into power. It is about time there was meaningful engagement with GPs.

I am not trying to throw those words in his face, I say that because the situation has not changed. I appreciate that was then and this is now but that is why I remind him.

Take someone who moves from one part of the country to another, as many people in Wexford have done. Many of my constituents tell my office that they cannot get a GP to take them on. It is not the fault of the patient or the GP but it is something we must deal with urgently. People in Wexford are travelling back to Dublin weekly to get their prescription. The average number of patients per GP practice in Wexford is 1,118 while the national average is 861 so Wexford is over 30% above the national average for most practices.

A most concerning aspect for those unable to get on the books of a practice is that no one is collecting the data. We do not know the numbers. All the data is needed for any legislation. This is something that could be a question in the next census. GP practices are under huge strain and struggle to give the current patient list the care and attention required. They have no choice but to close lists to maintain cover and take on no new patients. Their staff are under great pressure to deal with patients requiring medical care, having to tell patients they cannot have an appointment within two weeks, which would have been thought outrageous once upon a time. GP practice staff would be enjoying their jobs were it not for the constant firefighting telling sick people they cannot have a timely appointment. The lack of new GPs to replace them means doctors are unable to retire from their practices, there is a serious shortage of locums if a doctor cannot attend his or her own practice. The State should consider a pool of locums under the HSE to assist in this, similar to the model used by the NHS in the UK.

If Covid has taught us anything, it is that this is a necessity. I encourage the Minister to get this under way as soon as possible. We cannot deliver legislation that looks like window dressing. Something that looks like that to me is the doctor-only GP card for those over 70 years who are not entitled to the full medical card. They are unable to access public health nurse services. Those over 70 years are a vulnerable category. If, say, they only require dressings changed once a week, it is much better that it be done by competent public health nurses than require a GP. It should be expanded because eligibility should be based on need not age.

In 2018, the Irish Patients Association said that 1,310 new GPs would be required to keep pace with the expected rise in consultations from the implementation of legislation for those under six years. I have tried to find what stage we are at with implementing that or furthering our GP services, including how many have qualified or are in training. Based on the phased implementation of this for those under 12 years a considerable increase in GPs is needed, rather than continuing with the overwhelmed services which cannot continue. In healthcare patients should receive the care they need. Doctors' primary focus is to deliver timely, high quality care as much as possible for healthy outcomes.

I wish to emphasise the cuts to disability services which has already been raised. Some €20 million was cut from the disability budget a year after we adopted the Convention on the Rights of Persons with Disabilities. I visited the Cumas centre in New Ross. Cumas means ability and capability. Though a disability service, it never uses that word. I was in awe of how it conducted its services during Covid. It never missed one hour of support for its residents. Its service is about providing supports to enable the ability of its residents and clients and that gives them choices in what life has to offer them. I was saddened about the 1% efficiency cut through the HSE that will come into operation in January. Previously, the Minister said that could not happen. I plead with him not to cut funding for these people who do unbelievable work on all our behalf. I ask that he not cut funding which will inhibit their success.

Home care services have also been raised today. Wexford is not on the community intervention team, CIT, services and badly needs to be placed on this. It is virtually everywhere else in the country except Wexford and we need it, particularly because our GPs are overwhelmed. The community intervention team provides services, enhancing overall primary care, providing access to nursing and home care supports from 8 a.m. to 9 p.m. seven days a week, but the service does not operate in Wexford so its GPs cannot refer people to it. Once again, home care hours cannot be provided unless someone dies. I am ashamed to say that in this day and age. How can we establish eligibility criteria that is not based on need when others cannot be provided the service unless someone dies? I understand the Minister is new in the job but he addressed these issues down through the years in opposition. I ask that he continue to do so now.

Finally, I commend all the front-line workers in Wexford, including those outside of the public health system, public health nurses, home care workers and everybody who provided services throughout the Covid crisis and who continue to do so. I hope the Minister will fight to ensure the promised increase in their salaries is honoured when the time comes.

I welcome the opportunity to take part in today's debate. Access to healthcare should not be based on ability to pay but on medical needs and requirements. Undoubtedly there is a two-tier health system in Ireland. I welcome the Government's commitment to Sláintecare and look forward to seeing it implemented during this Dáil.

The Bill's proposals include the framework for the further phased expansion of GP care without charges for all children ages 12 years and under on a three-phased basis, and an increase to gross income limits for medical card applicants for those over 70 years. Phase 1 will bring children aged eight years and under into a free care system.

Phase 2 will bring those aged ten and under into the system and phase 3 will bring those aged 12 and under into the system. While I fully support this move, I do not understand why it is to be done on a phased basis. This is not fair on parents or on their children who urgently need medical help. In my opinion this should be introduced straight away across the board. Why do we need to phase it? This is only adding fear and worry to those parents and children who are affected. We all know that, during the Covid-19 lockdown, many people stayed away from hospitals and doctors surgeries because of the fear of the virus. Now we have another reason for those parents and children not to attend their GP. It is estimated that more than 300,000 children will ultimately benefit from this change. We must give them the benefit now and not introduce this on a phased basis.

In my constituency office in Dundalk we see situations almost daily where parents cannot avail of medical treatment simply because they cannot afford the cost of a doctor’s visit or medicine. In 2020 we cannot let a situation continue where parents of children are unable to access medical treatment. I welcome the changes that the Government are proposing today but I do not agree with the timing or phasing of these changes. We need to implement these changes straight away and not leave parents of sick children unable to access medical care because of financial reasons or fears. Families are struggling and need help. Prevention is the best cure. The Minister has the opportunity here to do something right. I ask him, please, to put all of the children into one phase.

I support the measure to increase the threshold for medical cards, which it is stated will benefit 56,000 people. All people over 70 years of age should be automatically entitled to a medical card. The Bill before us today proposes that those aged 70 years and single will be entitled to a medical card should their income not exceed €550. This limit is currently €500. Couples aged 70 years or over whose weekly income is below €1,050 will be entitled to a medical card. This limit is currently €900 per week. As already stated, all those 70 years or over should be automatically entitled to a medical card. These people have worked a lifetime, in many cases for 50 years, and have contributed to this country in many different ways, both financially and in other ways. I remember hearing once that a country should be judged on how it treats its elderly. If we are to start putting barriers in place for access to healthcare for the elderly members of our society, then we will have much to answer for. People at this age have enough challenges in life without worrying about access to medical care. In many cases they are among some of the most vulnerable in society who, after having given a lifetime of work and commitment to the State, deserve better. If the recent events in nursing homes during the Covid-19 crisis have taught us anything, it is that we must protect those who need our help, most especially our elderly.

On the issue of medical cards, there are many situations where a card is cancelled and the person has to make a new application. Many people, particularly those aged 70 years or over, sometimes forget to renew a card, and when the card is cancelled, this causes great stress and anxiety. We need to look at ways of making the renewal of medical cards, especially for those aged 70 and over, more user-friendly and less stressful.

A further point on medical cards for the over-70s is income limits. For example, a single person over 70 years of age has an income threshold of €550 per week while a couple aged 70 years or over has a threshold of €1,050 per week. This is not fair as a single person, who is more than likely a widow or widower, faces the same utility, gas, electric, coal and house insurance bills as couples, yet he or she has an income threshold half that for couples over 70. This person does not have to pay half the bills. This is simply wrong and unfair to the single person, who as I have already stated, is likely to be either a widow or widower. Having a situation of medical cards for all those aged 70 or over would eliminate this unfairness.

It is wrong in this day and age for those over 70 to be assessed for medical cards. They should be automatically entitled to one. They have worked long and hard to be entitled at the very least to medical and healthcare in their retirement. I strongly urge the Government to reconsider its position on this and encourage it to look to introducing universal healthcare to all children and to those aged 70 years and over at the very least. While I welcome the changes being made today, they do not go far enough. Healthcare in this country must not depend on one’s financial well-being. Every citizen must be entitled to healthcare regardless of their income. We must not discriminate against any section of society and must protect it when it comes to healthcare. In spite of everything that has happened over the past four months with Covid-19, we now have a great opportunity to invest in our healthcare system and to make it available universally to all citizens. I have a habit of saying that a person's health is a person's wealth, which I strongly believe in.

The Minister now has an opportunity to look after families, children and the elderly people who have made Ireland a great country. I wish him the best in his new position, and if he works half as hard as he did when he was spokesperson for Fianna Fáil, he will do a good job.

I come from Dundalk. We have a fantastic hospital there which is a minor injuries unit, MIU. Back in 2010 it was downgraded, which should never have happened. A great number of people travel daily from the Cooley Peninsula, Omeath and Lordship and pass the Louth County Hospital but cannot use its facilities. They have to go to Our Lady of Lourdes Hospital in Drogheda, which is another fantastic hospital but which is completely overstretched. I invite the Minister to come to Dundalk to visit our Louth County Hospital and the MIU and see the front-line staff we have there. Our health system needs to be upgraded and looked after and I promise the Minister that when he comes, he will see the services we have and will see the potential we have for going further. I wish Minister the best of luck and look forward to working with him as closely as I can.

I thank the Deputy and that is an invitation there now for the Minister. We move on to the next group of Deputies, the Rural Independent Group of Deputies Mattie McGrath, Michael Healy-Rae, O’Donoghue, and Danny Healy-Rae. I call Deputy O’Donoghue now to speak up there in the high dome.

I thank the Cathaoirleach. We are discussing children up to the age of 13 having access to GP and surgical services free of charge. I welcome this. I am sure it is greatly needed, but are we ready for it? I will share a number of conversations with the House.

I have a lady in my constituency who has two children who have a complex need and have received cancellations for blood tests in the hospital with no explanations given. The children are on strong medication that requires regular blood tests, and they have not been tested since January.

In another case, children who need immediate physiotherapy have been told that the senior physiotherapist, who I am reliably told is the best in Ireland, is working in the Covid-19 swabbing centre in Limerick since March. We have at our fingertips many competent and qualified people who could do this swabbing testing, yet children who need physiotherapy are suffering and one of the best physiotherapists in Ireland is tied up doing swab testing. Who oversees the staff allocations in the centres?

I have also been told that some physiotherapists were so concerned about their patients, particularly children, that they got in contact with them by Zoom with parental control. The HSE then told them to cancel the Zoom calls because they were in breach of the GDPR. These are children in desperate situations and, with parental control, the physiotherapists wanted to help, but common sense did not prevail here and they were told that they had to cease making the Zoom calls.

Children’s surgeries are way behind. Taking the example of where there were once six operations a day, there are now only three. I understand the restrictions around Covid-19 but this is not the reason. It is, it seems, because there are no operating theatres open.

A parent was looking for a senior management nurse in a well-known hospital. When she was found, she said that she was trying to find an office in the hospital for the consultant to meet the parents. Where is the management? What is going on? Does anyone care about the children and their needs? Another constituent's child is awaiting surgery and it was left for so long that it became a serious operation. This could have been dealt with at an earlier stage and it would have stopped this serious operation from happening.

We have qualified staff in our hospitals and front-line workers around the country who are being put into Covid centres to do testing. We also have a list of competent people in the medical profession who came back from abroad looking for work and are being told that no work is available. We could simply remove the people from Covid screening who are needed badly by these children and hire the competent people to do the Covid testing in the interim. This is common sense. Children and parents are suffering because we are not using a common sense approach. I ask the Minister to intervene and help these children and people. I welcome Deputy Donnelly as a Minister because I know he is a good, hard-working person and I believe he will listen to everybody who needs help. These people need his help. I also ask him to look at the management of some hospitals. Many hospitals are run well but in a minority there is a problem in management. I need the Minister's help to sort this out.

I want to address medical cards and the change in legislation about the amount of money allowable. That should be changed as soon as possible because the delay in getting that through is stopping people from qualifying for medical cards currently. I thank the people who work in the medical card processing unit most sincerely. There are many times when urgent cases need to have medical cards processed quickly and I want the Minister, if he has a chance today, to thank those people who work in the medical card processing unit. I believe they give us all a great service. We try to work together on behalf of our constituents.

Since it would be remiss of me not to do so today, and I said it in the first hour that Deputy Donnelly was Minister for Health, I raise the case of Ronan Foley from Dungeel in Killorglin. He has a 90° curve in his spine. I acknowledge that the Minister is working diligently on his case but I want him to keep working diligently and to stand up here some day and be able to say that he is glad that he is the Minister who ensured that Ronan's operation is performed as soon as is humanly possible. I hate singling out a case on the record of the Dáil like this but I am doing so with the family's full permission because all they want is to get that operation done. I know the Minister is entirely committed to doing that. I am not fighting with him but thanking him.

Another terribly important issue is the question of why in the name of God we should have people who are in pain waiting to have hip and knee operations or cataracts removed. At the same time, I and others can organise trips to the North and get the State to pay for those operations. It is wrong. We should not have to do that. I am ashamed that that service has to be organised by politicians. I would like Deputy Donnelly to be the Minister who stands up here one day and says that people will no longer have to go to the North to get a cataract removed or to get a hip operation carried out in the North because they are in such pain here. I would like for that to happen in the Minister's term. Will he work to make sure that happens?

If we can pay to have it done in the North under the cross-border directive, why can we not get it here? We have excellent operating theatres and surgeons and the capability to do it here. Why can we not organise it? It does not make sense that on a Sunday morning, I can have a team of surgeons that will go into hospital in Belfast and operate on cataracts for as many as 20 people, while if one were to ask for that to be done here, we would be told that it cannot be done. Why can it not? It is like having a digger for hire. It can work as well on a Sunday as on a Monday or a Saturday. It will work as well at 12 o'clock at night as at 12 o'clock in the day. I know there are safety concerns about an operating theatre in a hospital, but things can work safely at odd hours too. If there is a backlog of people waiting, it is like having a crowd waiting for sandwiches, where one would then have a crowd making the sandwiches, not just one person. It is the same thing when it comes to health. We have a crowd of people looking for healthcare and for hip and knee operations. They are in pain and they are waiting.

I want to be able to stand here and say "Fair dues to Stephen Donnelly, he was the man who came into health, worked with other people, and made sure that we provided the service that we should provide." Enough money is being put into health. Nobody can argue with the amount of money. The staff, managers, people working in catering, nurses and everyone else is excellent. I have told the Minister before, though he has not been doing it, not to praise the people working in our healthcare service but to pay them. Pay the nurses the money owed to them. A payment agreement was in place that has not been honoured. I ask the Minister please to honour it and pay them. The people working in catering sections have not got an increase in 13 years. That is a long time and the cost of living has gone up a lot. I ask the Minister to pay those people. Do not praise them, pay them. That will be Deputy Donnelly's motto as the Minister for Health. We have much work to do with health and many things to get on with. We need to make sure that people who need medical cards urgently get them. When people are over 70, whatever about the little bit of money that they might or might not have, for God's sake give them a medical card because they deserve it. We should treat them with respect for the work that they have done while living here all their lives.

Ar an gcéad dul síos ba mhaith liom mo chomhghairdeas a ghabháil leis na hAirí, an Teachta Donnelly agus leis an Aire Stáit, an Teachta Butler. I wish them well and offer to work with them on behalf of our group because, my goodness, there is some work to be done in the HSE. I praise the staff who have always worked hard, especially with Covid. This will have a significant impact on our health service. It was bad enough as it was. The impact on people waiting for cervical smear tests, breast checks, bowel screening or whatever it is is substantial since those have all been put back. Procedures for children requiring orthodontic treatment and children with eye problems have been postponed. Deputy Michael Collins and the Healy-Raes brought busloads of people to Belfast to stop people from going blind with just a simple operation. Our medics go out with NGOs and do it in the deserts, in tents and makeshift hospitals in third world countries, yet we cannot do it at home despite that almost €18 billion or €19 billion goes into the health service every year.

I do not know that I welcome the extension to the ages for the medical card because it is a charade. GPs are under enormous pressure. People cannot get a GP. My own daughter got a sting on her hand the other night and there was significant swelling the day after. She tried to get a GP but the GP could not see her, so she was sent to the emergency department. Covid is one thing but we have to treat our people. I have issues with Covid. Everything is about Covid, forgetting about everything else. People get sick. A number of people will die because of neglect, not having appointments and not having checks. It is sad. I relayed some of the cases to the previous Minister relating to people with private health insurance and such. The Ministers have a hard job, including with regard to mental health and older people, but we need fundamental, radical reforms in the HSE and the Department of Health.

The Northern Ireland Assembly people recognise the Sabbath more than we do down here. It is anathema to them to work on the Sabbath and yet they can do fleets of operations on a Sunday. It does not make sense that our medical theatres are closed here, south of the Border, for weekends, bank holidays and the whole shebang. During the height of Covid-19 we saw that Enfer Labs in Kildare did not get a test sent into them from 12 o'clock on the Friday of a bank holiday weekend in June to Tuesday morning. They just stopped. Every Christmas, without fail, we see a disaster in January because holidays are taken, places close, people go off and the whole system is shut down. There are front-line nurses and doctors, and attendants and management, who run the hospitals during those times, but the vast majority of people take their holidays. It should be run like a business.

All of this carry-on with extending the free medical cards to the under-12s is useless because one cannot get a GP or get in. Then there is the poor woman in her madness inside paying €60, if she can get in, but if the GP surgery is overrun, then those people are pushed out of the way. We need to have a fundamental re-examination of this. I believe that every patient should pay something towards a medical card and a prescription. We brought them in some years ago and now there are charges on so many items, it is too much and too high. There needs to be some kind of re-evaluation in that regard. The GPs are under enormous pressure and they can only do so much.

I brought the previous Minister for Health down, and I invite the current Minister for Health down, to Cloonmanagh in the vale of honey, some day perhaps during the holidays, to visit the Mary Street Medical Centre to see the wonderful scanning equipment they have. They could do ultrasound scans. The then Minister, Deputy Harris, came down. That centre applied for a contract to do this because a person can be waiting six or seven months in the hospital. The Mary Street Medical Centre could do the scan there and connect it on to the University Hospital Limerick. The scans could be read by professionals and it would take those people away from accident and emergency departments. It is simple. After I raised this issue in the Dáil day in and day out, and after numerous high-level meetings, including with the Minister, we got a 14-day contract, which is probably the shortest contract ever issued by the HSE. It was then pulled after eight days because there was no funding. Such stopgap measures can provide expertise through the private practices and could be used to help the situation. That has to be done.

Will the Minister please indicate when we are going to stop the Covid-19 spending? I received a reply to a parliamentary question last week and the spending is just mind-boggling and frightening. Money is being thrown at this, that and the other. This will all have to be paid back. I ask the Minister for Health to put on the brakes and have accountability there.

I am glad to get the opportunity to talk on this important topic. As I have said before, if we are to be relevant at all, we must seek to do our best for vulnerable people, young and old. I will start with the old. Home help hours have been left very short of funding in Kerry. It seems to be a battle to get half an hour or an extra quarter of an hour for older people. I am aware of one 83 year old women whose home help application was shot down recently. She had been asked if she can get out of bed by herself and the poor woman was honest when she said she could but that there were a lot of other things she could not do. Her application for home help was shot down. Home carers have been totally forgotten about. I know of one man who has been minding his sister for the past 17 or 18 years. It is 24-7 care, for which he gets €219. He is rightfully complaining that he cannot stir or go anywhere. He is doing a massive job in minding his sister. No other person could or would do it. This man does not even know if he is putting up stamps for the contributory pension. He just does not know.

I turn now to the issue of nursing homes, which I have raised before. I am very concerned that family members still cannot go into nursing homes without savage restrictions. They can barely get as far as the door or must talk through the window. This is not satisfactory. I am aware of one case where an elderly man of 90 went to see his wife in the district hospital. He had to talk to his wife in through the window. This is not good enough. There must be some way it could be done better. These older people will only confide their needs with family members. This must be addressed. We have seen what happened in the case up the country of the poor man who was neglected and died with maggots in him. The fair deal scheme has to change in the way it is brought forward. The family farm cannot be assessed; yes, the residential house but not the family farm.

I cite the case of Ronan Foley who is still in pain, and all the other people in pain who are waiting for cancer treatment or who have bowel problems or need hip replacements. We still have to take people up to Belfast for cataract procedures. One woman was told recently that she would be waiting four years to get her cataracts removed in Cork. This is not good enough.

I must say to the Minister, Deputy Donnelly, that I believe he is going to lose the battle with Covid-19, given what he has done in opening up travel. Should the Minister jeopardise children's chances of going back to school in September, he will pay a very high price. It does not make sense to me that people are allowed out on foreign travel to green list countries. What about the people they will meet there who have come from other places that have a strong showing of the virus? If they meet up, then people can bring back the virus here. Consider the poor man who wants to have a pint in his local village. He will never stir because it is said he is going to be the cause of increasing the virus and would cause us to lose control of it. I believe the Government has lost control with what it has done. I hope I am wrong. I believe the Government has lost considering what it has done to allow this foreign travel. The Government is beholden to the airlines and the likes of Michael O'Leary. We appreciate them in other ways but not for putting pressure on to open up the foreign travel when we are not cleared here.

I put it to the Minister for Health that people have been waiting here for months for their procedures and it looks as though they will be waiting longer. The Minister must do something about that. The previous speaker said that operations could be done on Sundays as well as on weekdays. The Minister must remember that people get sick on Fridays and on Saturdays and then they must wait until Monday for consultants to come in. That day is gone. The Minister, Deputy Donnelly, must see that it is gone. People cannot organise when they will be sick. It is not fair to do this to them. Many of them are lying there in pain while such and such a consultant will not be in until Monday morning or maybe Monday evening. It is not good enough. The Minister must deal with that. They can do it in the North of Ireland and we can see them doing it on Sunday mornings and Sunday evenings. They are working around the clock and making use of the gear they have to ensure people are seen. The Minister will have to ensure this happens down here in the Twenty-six Counties.

The Minister would have had a hard job ahead of him even without what has happened internationally with the pandemic, which has caused a catastrophe in our health services and across the world. This is mainly because of decades of not mismanagement but an ideological move away from public healthcare and removing money and resources from it while moving towards the private health sector.

Today we are looking at a Bill that deals with two aspects of budget 2020 proposals as agreed. These are that the Government is to extend free GP care to children under the age of eight and to provide free dental care to children under the age of six. This was to be brought in by September 2020. Is that free dental care for children under the age of six included or when will it be brought in?

The budget also proposed to increase the medical card weekly income limit for a single person over 70 by €50 to €550 and by €150 for a couple to €1,050 from July 2020. The prescription charge for medical card holders was to be reduced by 50 cent, bringing the charge to €1.50 per item for those under the age of 70 and to €1 per item for people over the age of 70. This was to be introduced by this month. I have had several people on to me who found this change was not brought in by their pharmacies and they were charged at the current rate. The pharmacists in these cases claimed they were not instructed to make the change. When will this happen?

The budget proposed the monthly threshold for the drugs payment scheme would be reduced from €124 to €114 to be brought in by September 2020. Will it still be brought in then? The number of home care hours in 2020 is to increase by 1 million. We were all critical of that figure when it was announced, including the Minister, because it only brings the hours back to where they were before they were cut. How many hours will be provided to meet that increase?

The HSE will review and extend arrangements for the provision of the discretionary medical card to those with a terminal illness. Where is that at now? That is a big issue and we have had to deal with several cases of people who were turned down for a medical card when they were terminally ill. What extended arrangements are being put in place for the provision of discretionary medical cards?

The budget proposed that, to reduce patient waiting times, funding for the National Treatment Purchase Fund, NTPF, would be increased by €25 million to €100 million. In principle I do not agree with the NTPF because we are transferring public money to private hospitals when we should be bolstering our public hospitals to deal with these cases. I understand people will use the NTPF because they have been waiting for so long for treatment. It makes a joke, however, of trying to implement Sláintecare. It is the same with the cross-Border health directive.

Many of us, including the Minister, were on the Sláintecare committee. Much time and energy went into that and its proposals were put out three years ago. Deputy Shortall raised the point that free universal GP access was to be brought in by 2025. That is only in two years' time and we are only at this point. A criticism of the previous Government's implementation of Sláintecare was that it was doing so in parts. I raised with the Business Committee before Covid restrictions came in that we should have a review of the Sláintecare programme because matters have moved on so much. We should get the Trinity College Dublin experts in to explain why such and such has not happened and how do we move it on. It does not have to be a six-month or eight-month review, just a short one.

GPs will be asked to take on 300,000 extra children which is quite a big cohort. I accept they will not be all walking through the door on the same day but it is a big ask. We cannot get definite figures of how many GPs are operating in the country. There are different figures from the Medical Council of Ireland and the Irish College of General Practitioners. A comprehensive register of GPs has to be set up. The previous Minister found it difficult to get the GPs contract in place. That will be crucial. GPs should be salaried to take the private aspect out of their work and push them into primary care centres. Some 2,498 GPs signed up as family doctors, up seven since the start of 2019, a minuscule increase. There are not enough GPs on the ground.

At the Sláintecare committee several years ago, we were told 666 GPs were due to reach retirement age and 27% of GPs were over 60. We have not seen a targeted campaign to get more people into GP training. That is urgent. We should be promoting GP services, informing doctors that they will get a reasonable salary. I have put in many parliamentary questions on this over the years on finding out GP numbers in training and the increases are not dramatic. Many who come out of training go abroad which is another issue. Can we think outside the box in this regard? As we are in such a crisis, can we say to students that the State will pay for their training but on the condition that they stay in the country for at least ten years after graduation to pay the State back? Can we point out to them that they will get valuable experience with experts, work in a primary care units and so forth?

I had many contacts from people saying they were breathing a sigh of relief that they could get their hair cut, yet people cannot access vital health services to save lives. I know this is difficult. During Covid, I was amazed at how health service workers working together were able to move mountains. They were able to set up a hospital to deal with a surge which did not happen, thankfully. Those are the people who can tell the Minister and HSE management what needs to be done. The "Prime Time" programme last night highlighted the need for hospitals. We need to prepare for a possible second surge of Covid. We need to be able to expand Covid services again if needed. How, in the meantime, can we utilise our hospitals properly for day-to-day services and surgeries? If we do not do it and get a second Covid wave, it will be another six months that people will not have the services they need. That is not something we want to contemplate.

I welcome the Minister and the Minister of State to their roles and wish them all the best. The Minister has probably the most difficult job and Department in the Government. He knew that before he took the job, however. It is his own fault whatever happens.

In all seriousness, it is a job that could have huge potential and give huge rewards. It can definitely have huge rewards for the citizens which is most important. If it is tackled in the right way, it can be hugely significant. I hope that is what the Minister intends to do. Unfortunately, past Governments have shown they did not intend to do that, focusing instead on budgets and money. If that is the way the Minister sets out his stall on it now, unfortunately we will lose.

I welcome the Bill and its criteria will be welcomed by every Member. I do not believe anybody will oppose it. I do not believe it has gone far enough, however.

That is hardly surprising to the Minister, but it is the case. As Deputy Joan Collins mentioned, what the Covid crisis has shown is that we can achieve things so long as we stop talking about and strangling ourselves with budgets straight away. The budget for the health service is not enough. It must be increased. There is a great deal of rubbish talked about doing more for less and so on. That is a load of crap. The bottom line is that more funding needs to be invested. It will cost more for 15 or 20 years initially until we have dealt with the waiting lists and other problems, but it will then start to save money and grow cheaper as time goes on. That timeframe is outside of what any politician will spend here or as a Minister. Perhaps that is why nothing ever happens and there is no change. That is a problem, but recent months have shown that the issue can be dealt with and changed.

We cannot permit a recurrence of the problems of the past. For example, beds were closed in the 1980s and early 2000s. That pattern cannot continue. If it does, there will still be a crisis in ten years' time and those of us who are still in the Dáil then will be discussing the same issues. We must consider this issue.

Deputy Joan Collins touched on an issue that I believe can be sorted easily, that being, ensuring that cancer patients get medical cards as a right. The Health Act 1970 sets out that medical cards are awarded based on income, not medical need. My office in Killybegs is regularly attended by cancer patients who are over the income limit and consequently cannot get medical cards. Unfortunately, they must go through the process of income assessment and so on before their medical conditions are considered. That is the problem, and it dates back to the 1970 Act. No Government has been willing to address the Act. To do so would be to open up the criteria for making cards available. However, it must be addressed. Will the Minister ensure that it is? It would make a significant difference in many people's lives. I talk to cancer patients whose diagnoses have not been accepted as conferring an entitlement to a medical card. It is wrong that people still have to go through that. They have the stress of having cancer and, on top of that, the stress of not knowing whether they will be able to access medical services.

I will pay tribute to the Oireachtas Library and Research Service. The Bills Digest it has prepared for this legislation is useful and has put words to many of my thoughts on the health service. It references what the World Health Organization, WHO, says about our health services: Ireland uses income, age and health status to determine eligibility for publicly financed health services; this unusually complex approach has led to notable gaps in coverage and inequalities in access to essential health services; Ireland is the only country in western Europe that does not offer universal access to primary care; and it also has a large market for private health insurance, which mainly benefits richer people. This sets out in a nutshell the problem with our health services.

If we base access to services on people's incomes, it will cause problems. If we base it on private medical insurance, which is essentially for wealthier people, they will get access over and above what others get. How often do we as Deputies hear about someone who has been waiting for a CAT scan or something along those lines being told that there is a two-year HSE waiting list but that he or she could get it the next week if he or she paid for it? That is the reality. If a procedure can be paid for and done next week, then it can be done next week for a medical card patient as well.

These are the issues that the Minister must address. I hope he will do so. Unfortunately, history is not on his side. Perhaps we will see changes - I hope we do. If we do, I will support them. However, I will wait to see whether it happens.

Before I call on the Minister to respond, Deputy Dillon has a brief contribution to make.

I will take this opportunity to wish the Minister every success in his new portfolio, which will be critical in the period ahead.

The legislation under debate is one of the public health measures that will make a real difference to countless families. I welcome this Bill, as it benefits both older and younger people by increasing access to free GP care. It removes what can be a significant barrier to people visiting their GPs, namely, cost. I cannot imagine the distress caused to parents who are unsure about bringing their children to the local doctor due to financial constraints.

The Mayo constituency has approximately 40 GP surgeries serving all parts of the county. They provide an invaluable service to the public and, of most importance, that service is widely trusted by the public.

I note the concerns of the Irish Medical Organisation about the additional pressure that will be placed on GPs as a result of increased access to free GP care. Has the Minister or his Department considered developing and making available to the public greater information resources about the correct services to be used when feeling unwell? I make this point because I am familiar with efforts by the NHS in the UK to increase public awareness of what services to attend if people are feeling unwell. The HSE's website has set up a health A to Z link to the website of the NHS, but I feel that the use of posters and infographics similar to those used by the NHS should be further developed and strengthened. In particular, information on what services are appropriate to attend as a result of specific symptoms should be more prominently available to the public. This would provide useful guidance on whether self-care or attending a pharmacist would be more suitable than visiting a GP or emergency department. I must be frank and say that many of my conversations with front-line healthcare workers relate to patients with minor ailments presenting in acute settings. Sometimes, the opposite happens with more serious ailments. Will the Minister ask the HSE to consider a public information campaign to help alleviate the number of people presenting to inappropriate healthcare settings?

We will turn to the Minister to respond. I understand that he is proposing to share time with the Minister of State, Deputy Butler, and Deputy O'Connor. Deputy O'Connor will go first.

This Bill expands eligibility for GP care without charge on a phased basis and increases the gross medical card income limits for persons over 70 years of age, which I welcome. I will take the opportunity to congratulate the Minister on his appointment to the Cabinet. It is an extraordinarily difficult time for anyone working in the healthcare sector and I am sure he will excel in his portfolio. We are counting on him.

The Bill is a welcome step towards fairer and more affordable care over the Government's lifetime. It is essential that we continue putting provisions in place to ensure that there is care in the community and that it is at the heart of our health services. Making the vast majority of healthcare services available in the home or close to home rather than in our hospitals is the right step forward. Having care in the community would be a major benefit to people in my constituency of Cork East. During the Covid-19 pandemic when we want to put as little pressure on our hospitals as possible, any step towards providing primary healthcare services makes more sense than ever. I hope that this is the first step on a path to developing community healthcare networks to support the expansion of services based on the need and size of local populations. Increasing the eligibility criteria under the Bill will be helpful in delivering that.

Places like Youghal are in vital need of primary healthcare centres. It is not right that a town with a population of more than 8,000 and many more living in its catchment area - there was a population increase there of nearly 9% between 2011 and 2016, which was far above the national average of 3.8% - still does not have access to primary healthcare services.

Short-term emergency measures will be important until such time as the Government can put in place strategies to address the shortfalls in places such as my home town of Youghal. An issue that came up repeatedly during the general election campaign was the lack of access to healthcare services for many new residents living in east Cork. There is enormous pressure on the Government to try address that crisis. I look forward to working with the Minister on the matter.

In recent times there has been a great deal of fear among people accessing their local health services in health centres and hospitals because of the pandemic. It is an understandable fear. It is important that we put in place alternative arrangements for such individuals, for example, telemedicine, by means of which they will be able to have access to medical professionals. We need to look to provide additional services that complement our healthcare services. The World Health Organization defines telemedicine as the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and the prevention of disease and injuries, research and evaluation and for the continued education of healthcare providers, all in the interest of advancing the health of individuals for their communities. There is huge potential for the application of this across our healthcare service. It would go a long way to ensuring that citizens of this country have access to the medical services they need. In terms of the pandemic, it will dramatically increase the accessibility and safety of care and reduce the use of individual protection equipment and allow doctors under quarantine to continue to work if in a position to do so by expanding the available the human resources to our health services. It could also be used as a training tool to ensure that our medical students continue to have access to medical education during the pandemic. Looking to the future, there are advantages in terms of reduced travel costs for the patient and an increase in accessibility for individuals with mobility difficulties and the potential for the globalisation of medicine with patients being able to obtain expert opinions at great distance quickly via virtual means, which is encouraging.

Across east Cork there is a huge level of research and development ongoing and there is currently much talent and potential. Telemedicine assists in the sharing of this expertise and ensures that it gets to people that are most in need of it. There are some obstacles in regard to telemedicine in the future, such as data privacy and confidentiality, but it would be unwise of this House to not explore such complementary forms of medical provision, especially considering the Covid pandemic in which we currently find ourselves. Affordability is a vital issue when it comes to healthcare provision. I recognise the good work that is being done by way of this Bill.

As already stated, we need to look at areas such as east Cork, which I represent, where there are problems areas for people in accessing healthcare services, as well as the issue of affordability. I wish the Minister all the best and I look forward to working with him.

This is my first time speaking since my appointment as Minister of State with responsibility for mental health and older people. I thank the Taoiseach for the opportunity afforded to me. I congratulate the Minister on his appointment. He and I have worked closely over the past two and a half years and we are continuing that relationship. We are well aware of the many challenges facing us.

As Minister of State with responsibility for mental health and older people, I take this opportunity to warmly welcome the Bill, which provides a very welcome measure for older people in our society. Expanding eligibility for medical cards to this cohort is an important initiative in ensuring better health and active ageing for our older persons. It is my key priority to support older persons to live independently in their homes and communities for as long as possible. This can be made possible only by putting in place real and effective policies that enable older people to access high-quality care close to home, where feasible, to help prevent unnecessary admission to hospital. The correct wraparound supports are essential to enable older people to live at home safely and securely among their families and communities. This will be a key focus for me. This measure, which provides for a welcome increase in the gross income limits for medical card eligibility for persons aged 70 or older, is a key enabler in that regard. It will increase the number of people that can access a wide range of services in the community at no or very low cost.

I support the Minister's sincere acknowledgement of the sacrifices made by older persons in our society in response to Covid-19. Earlier today, on behalf of the Minister, I attended the funeral of Dr. Syed Waqqar Ali who lost his life due to Covid-19 while working at the Mater Hospital. He provided selfless emergency care in the accident and emergency department. Unfortunately, he succumbed to Covid and spent 92 days in ICU but, sadly, he lost his battle two days ago. To his wife, his three sons, his two daughters and his extended family I offer my sincerest condolences. This puts into sharp focus the seriousness of Covid-19. Anybody who is any doubt about that need only look to the absolute grief, hurt and upset it has caused to Dr. Syed Waqqar Ali's family. The Minister and I salute him for the work he did. He saved so many lives.

Accessing mental health supports will be key to enabling older persons to look after their mental health. Thus, public mental health services will now be more affordable and accessible for a greater proportion of older people as they become eligible for a medical card. As Minister of State with responsibility for mental health and older people, I will work hard to support older persons and ensure better health and active ageing for older people.

GPs are at the heart of health service delivery in the community and are the gateway to accessing necessary health services. I am, therefore, pleased that the second measure provided for in this Bill is the further phased expansion of free GP care to children of primary school age. I acknowledge the impact of Covid-19 on the mental health of schoolgoing children. I note a recent survey carried out by St. Patrick's mental health services found that 70% of parents are concerned about the impact of Covid-19 on children's mental health. Expanding access to free GP care for children of primary school age will, therefore, be important as GPs will play a pivotal role in terms of identifying mental health issues at an early age and signposting children and their parents to access the most appropriate mental health services in their communities first and foremost. As we all know, early intervention is key.

I thank all of the Deputies for their contributions, many of which were thoughtful and detailed in terms of the specific legislation before us and the two measures it contains. There has been a wider constructive debate around healthcare as well. It is a conversation we need to keep going. I have taken pages of notes. We will find more opportunities for continuing that conversation, including the scheduled statement and question-and-answer session in the House tomorrow on Covid-19. I acknowledge that a lot of work, thought and effort went into Deputies' contributions. I also acknowledge the spirit of solidarity and constructive debate on health. We all disagree with each other on any number of issues. It is part of our job to debate and push and challenge each other's ideas. In healthcare, there has been a lot of solidarity this year with the onset of Covid. I acknowledge that while Deputies will, of course, undoubtedly be holding me to account and pushing me, the Minister of State and the Government hard on various issues, as is right and proper, there is a genuine sense across the House that we are all bought into a single vision, which is Sláintecare, and we are all bought into the fact that we fight and act together on Covid on behalf of the country.

It might be of use to the Deputies who contributed and to the wider House to point out the three main points of focus that the Ministers of State, Deputies Butler and Feighan, the Department and I are considering. The first is Covid-19 and doing everything we can to protect the country, not only from a health perspective but from a social, mental health and economic perspective. Inevitably, we will get some things wrong and some things right, but there has been a great sense of solidarity. I was talking to a senior figure in the WHO last week and he was highly complimentary of Ireland's response to Covid, notwithstanding that it has not all been perfect. He said that when international experts look around the world, one area where they have said Ireland stands out, and one of the reasons they believe the prevalence rate here is so low, is that the political co-operation has been very impressive and has made it possible for things to happen that in other countries have not happened. They see political parties and politicians in other countries getting into destructive and self-serving debate. The man I was talking to said that one aspect that has marked Ireland out is that while there is, of course, political debate and political challenge, there is a great sense that we are in this together and are trying to find solutions together. I have heard that during this debate and I thank my fellow Deputies for that.

The two measures we are bringing forward will benefit the young and people who are older than 70 years old. They will ensure that, irrespective of ability to pay, all children of primary school age will be able to access a GP service without charge when required. This will enable childhood illness to be identified and managed early, which will have a positive impact on children's futures. It is not everything. It is not that all services will be free for everybody; that takes time, money, resources and capacity. Nevertheless, the measures in the Bill will make GP care free for 300,000 additional children. That is something we should be proud of as an Oireachtas because the Minister for Finance and the Minister for Public Expenditure and Reform will be asking Members of this House for the money to do that. It is a profoundly important step forward.

The increase in medical card limits will support older people to manage their health needs and will build on the benefit already provided by the GP visit card, which every person over the age of 70 automatically qualifies for. This will ensure they can access a wide range of healthcare services at no cost or low cost to help them achieve healthy ageing. I have gone through the figures with the Department. While the SWITCH model and other models have different estimates as to how many people over the age of 70 this will help, of those who do not have the medical card, it is a lot, while everyone over the age of 70 will already have qualified for the GP visit card. The increase in the threshold is only 10%, or from €500 to €550 for a single person, but the percentage of people over the age of 70 who currently do not have a medical card and will now get one is well in excess of that. It will be of great benefit, therefore, to many people. Most Deputies will have been contacted by people over the age of 70 who are waiting for this to happen, so I am very glad to bring it forward.

If the first big task we have is Covid, the second is the resumption of services, winter planning and ensuring we have a comprehensive plan in place that goes beyond anything that has been seen before because the Covid world means we must succeed as the winter approaches.

The third part is Sláintecare. The Bill is the first item of health legislation we have brought before the Oireachtas and it is not accidental that it concerns Sláintecare. It is a core building block of Sláintecare and I hope the House sees it as a serious statement of intent to progress universal healthcare, which is the core mission of the programme for Government and probably of most of us in the House. We will deliver it through Sláintecare and the very good work that is being done in that regard.

I thank Deputies again for their contributions and for their stated support for the Bill.

That concludes-----

A Cheann Comhairle, I wished to speak. We were notified that we would be able to speak.

No. If the Deputy might resume his seat, I will explain. This item of business was ordered to be taken over a three-hour period. I am not responsible for co-ordinating the speakers. There are Whips in all the various groups whose job it is to co-ordinate that, to provide lists of speakers and to ensure that Deputies are here on time. When I came to the Chamber, members of the Rural Independent Group were completing their contributions. The Independent Group made a contribution, as did Deputy Dillon, after which the Minister began the process of wrapping up. Once the Minister has begun to wrap up, nobody else can speak. They are the simple rules of the House, which are available to every Deputy, old or new, through the Whips.

I apologise to Deputy Gould. I am always anxious to allow Deputies to contribute but the rules apply to me, to him and to everyone in equal measure.

Obviously, I got the wrong information because I was told I would be able to speak. I wish to raise the case of a constituent who has cancer and who, because of the Bill, will not qualify for a medical card-----

We are moving on to Committee Stage and if the Deputy wishes to contribute to that, he will be more than welcome to do so.

Question put and agreed to.