Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020: Committee and Remaining Stages

Question proposed: "That section 1 stand part of the Bill."

A question was asked earlier about the timelines for the implementation of the various measures but we have not got them. I refer to the different categories of those under the age of 12 and people over the age of 70, as referred to by Deputy Gould. When will the measures come into effect? We are passing the Bill today and, as the Minister noted, we have all been contacted by constituents who are watching what is happening. They want to know when this will happen, so the Minister might respond to that. Other Deputies may also wish to contribute on the same issue but the Minister might outline in his response the timeframes for the different elements of the Bill.

This is my first opportunity to wish the Minister and the Minister of State the very best in their new roles. I look forward to working with both of them in this very difficult but important area.

I welcome the opportunity to speak on this important issue of amendments that will provide for the expansion of GP care without charge on a phased basis to children of primary school age and that will seek to increase limits for medical card assessment for people aged 70 or over. These are important issues.

The medical card issue is very important, as it has been for the past number of years. There have been many difficulties arising from people not qualifying and just being over the limit. People who were very ill lost the chance of getting a medical card. In fairness, I must give credit to the medical card section of the Department, whose staff have been very helpful. Criteria are set and staff must work within them.

There is a massive problem at Bantry General Hospital and I hope the Minister takes that on board. An endoscopy unit was promised to the people but it has not been delivered. An anaesthetist position also needs to be filled. It is very important. There are 80,000 young people who will come under the scheme being discussed today who must be looked after. Bantry is rural but we need Bantry General Hospital to be able to deliver services. The staff have done their best but there is a need for an anaesthetist.

I apologise but we must do this in a particular way. The Deputy cannot have a Second Stage debate on what is now Committee Stage. We are considering section 1, which deals with nothing more than the Title of the Bill and the definition of what is going on. I have given the Deputy some latitude.

I appreciate that. I was in the same position as a previous Deputy. We got our wires crossed.

Go on briefly, please.

That people over 70 will have a better chance of getting a medical card is very important but we must also look at other areas where those over 70 are suffering quite a bit. For example, people in west Cork are seeking cataract procedures and we have taken over 50 bus trips to Belfast because our older people are suffering. They cannot get a cataract procedure in Cork or Kerry. Deputy Danny Healy-Rae and I have taken more than 1,500 people to Belfast to take advantage of the cross-border healthcare directive. Although such action is welcome, it should not have to happen. The people who served their people well have not been looked after well themselves.

At a later stage we can further discuss the fair deal scheme and the lack of community hospital beds. There are many matters on which I wish to work with both the Minister and the Minister of State.

Deputy Gould wishes to contribute. Does this relate to the definition of the Bill?

I wanted to make a point on the timeline and ask the Minister for clarity-----

We will get to that in a moment. It is nothing to do with the definition.

Sorry, a Cheann Comhairle. I would not mind but you allowed the Deputy before me to speak. This is the second time I have contributed in the Dáil when you have spoken to me about procedure but allowed somebody in afterwards. I do not mind following procedures but I expect the same for every Deputy. Go raibh maith agat.

You might calm yourself, Deputy. We try very hard to treat everybody with respect. I reminded Deputy Collins he was getting-----

You allowed him to speak.

You were continuing to speak before-----

I was sent to speak here by the people of Cork.

Everybody was sent here to speak for someone. You are not alone.

Is it that the people of Cork-----

Have a bit of sense.

Excuse me. All I am asking for is to be treated the same as anybody else. Twice I wished to speak and twice I have been interrupted. Another Deputy spoke and the Ceann Comhairle interrupted him but then allowed him to continue.

I can now guarantee the Deputy we will impose the letter of the law from here on in. Thank you.

Go raibh maith agat.

Question put and agreed to.
Question proposed: "That section 2 stand part of the Bill."

Does anybody wish to raise anything relevant to section 2?

Section 2 concerns the income limits for those over 70 who apply for the medical card. I will use this opportunity to respond to Deputy Cullinane and the other Deputies who have, understandably, asked questions about timing. It is a question many people are asking. I will answer a similar question on GP eligibility when we get to that section, seeing as we are strictly adhering to sections and what is in them.

This relates to people over 70. This criterion was in the last budget to be implemented this year, as were various other eligibility criteria that various Deputies have raised. The problem is that the eligibility criteria being implemented for this year were contingent on quite significant savings in the health budget. As everyone will appreciate, none of those savings has materialised because of Covid-19 and instead I was before the House two weeks ago asking for an additional €2 billion. I will be back before the House again asking for an additional amount of money.

The measure was to come, essentially, from within the existing budget but as I am sure everybody understands, that is not now possible. However, the Government, along with tonight's contributors, recognises this is something that will make a major difference to many people. With this in mind, I will seek a discussion within the Government to see if a way can be found. It is not budgeted for and would require additional funding. It will require agreement of the Government and, ultimately, it would require the agreement of this House.

I recognise that this is an important measure, which is why it was in the budget and why we are bringing this forward as the first Bill of this Dáil. I would like to be able to revert to the House as soon as possible with progress on that.

I thank the Minister for his clarification but I am very surprised and disappointed. We all accept we are in the midst of the Covid-19 pandemic but I spoke earlier in the debate about money being wasted. People in nursing homes are telling me they cannot deal with the amount of personal protective equipment that is being dumped at their doors. I received a response to a parliamentary question from the Minister last week indicating that millions of euro is being spent on this. It seems there is no shortage of money but there are no tenders or appropriation procedures. We know we are going through an emergency but I asked the Minister earlier to call a halt to the waste. He is now telling us the budget probably will not allow the measure we are discussing.

That is not what I said.

I thought the Minister said he would have to come before the House again. I appreciate he has already sought an extra €2 billion. I thought the Minister said he would have to return to the House to seek approval for the budget and that he would fight as part of the Government to find the money to deal with this cohort of people over 70. They have paid their service to the State, with many working for 50 years, paying stamps, PRSI, etc. We thought they got a bit of breathing space in the budget with the change in criteria. The Minister might correct me if I am wrong but I understood from his comments that he does not know if he can do this and it will depend on financial circumstances and his lobbying of the Government. I would be very disappointed if that is the case.

Please rein in some of the spending that goes on every day. The money being thrown at every institution in my county and around the country is mind-boggling. Is there any accountability? Is there any need for such excess, unless we get a massive second wave? I am not saying the need was not there in the initial panic. We supported that spending but it needs to be stopped. Stall the horses now and pull the reins. Stop the mindless spending. It is crazy and there is no accountability. The Minister might clarify if I understood him correctly.

Going back to the point made by the Minister regarding the timeline, I referenced Mr. Tony McCarthy earlier. He is a cancer sufferer and his wife is seriously ill. He is her carer. When they were assessed, they did not qualify for the medical card. All cancer patients should have medical cards. This new Bill would mean Tony and his wife would get a medical card. We spoke today about the difference it would make to them.

I understand that there are serious financial implications ahead for the Government. I want to support the Minister. Where we can, Sinn Féin will work with the Government, especially on health because it is so important, but Tony, his wife and all the other people need timelines as soon as possible. I will write to the Minister to ask if he will consider those cases on compassionate grounds if those timelines are not going to emerge soon enough. We want to support this Bill but we need its measures as soon as possible.

All Opposition parties supported the speedy passage of this legislation because there was an expectancy that its provisions would be implemented very quickly. When the Minister took to his feet to respond to the Second Stage contributions, and in one of his first replies on Committee Stage, he stated that this was the first step from his perspective in implementing Sláintecare and referred to himself and others being contacted by those over the age of 70 and others who want this matter resolved. There was a clear expectancy on the part of those people because when we were being contacted by them, we were telling them that the Bill was coming before the Dail and that we expected that matters would be resolved when it was passed. That does not seem to be the case, however. It is important that those people who were promised that this would be done - and the Minister said that this was a budgetary provision also - are given some certainty and timeframes. In light of the spirit in which the Opposition has approached this, in the context of Covid-19 and taking all Stages in one session, it is important that we get as much information as possible so that we are in a position to communicate with people as to when the legislation will come into effect. If I was asked when I leave this Chamber when this provision will come into effect and when someone will benefit from it, I would have to reply that I do not have the answer. It is incumbent on the Minister to give us that answer. If he cannot provide a definite timeframe, it would be important for him to at least give us an estimate in that regard.

I congratulate the Minister on being appointed to his post. I look forward to working with him in a constructive manner over his period in government. I want to refer to timelines also. It was mentioned that any extension of the criteria for eligibility for a medical card for children and older people is very welcome. However, we need a clear and definitive timeline as to when that expansion will be delivered. We are living in uncertain times. People need certainty now. Covid-19 has shown the failures of the health system. I take this opportunity to commend the front-line health workers for all the work they have done and the service they have given to this country.

We must remove any obstacles in healthcare that hinder people in the context of getting treatment when they need it and where they need it. I support the Bill but I do not believe it goes far enough. It is a start, as the Minister said, but I ask that a clear and definitive timeline for its implementation be given. Otherwise, it will not be worth the paper on which it is written.

Can the Minister offer clarification on the timeline?

I agree with the Deputies. We are looking to put this together as quickly as possible. What I wanted to clarify for the House is the factual position. This measure was contingent upon savings. Those savings have not materialised. As we all know, the opposite is the case and the healthcare system is looking for significantly more cash to deal with the Covid pandemic. For the information of the House, what I am saying is that we are strongly supportive of this measure. It is the reason it is the first legislative measure we have brought forward. We fully understand how important it is for people over the age of 70. I am simply making the point that there is a process that has to be gone through. There is additional money that has to be agreed. That is a decision for Government. I will get as detailed a timeline as possible for the Deputies as quickly as I can do so. I fully understand and agree with the questions they have asked. I, too, am endeavouring to have the same questions answered.

Question put and agreed to.
Section 3 agreed to.
Question proposed: "That section 4 stand part of the Bill."

This section deals with increasing the age from six to eight. I referred to it on Second Stage, and it is a response that I would like to hear from the Minister also. Notwithstanding the timeframes, I am concerned about the response he just gave. I understand that there is a process but I expected that process would have been well under way before he brought the Bill before the House because expectations have now been raised. The quicker that he can expedite that process and come back with timeframes the better because it is important but the issue in rolling all of this out, including the provisions for those children aged eight, ten, 13 and people over 70, is that we need to expand capacity in GP provision in this State. One of the challenges we face in convincing GPs that this should be rolled out is that they tell us there are not enough GPs. We can pass whatever Bills we want and say that any number of provisions should be implemented. I want universal GP access for everybody and I want it done over a five-year period, but I also recognise that to do that we need more GPs working directly for the HSE. Does the Minister envisage a challenge in these provisions being implemented given that we have already a dire shortage of GPs? In some parts of the country, people cannot access GP services. They have to travel some distance because the GPs nearest to them are overburdened and cannot take on the workload. When he was in opposition, the Minister was one of those who raised that issue many times. What was absent from his Second Stage response was the issue of GP capacity. What additional GP capacity, in addition to the funding that needs to come to provide for this, does the Minister envisage will be put in place to ensure that this section, the previous sections and the next sections of the Bill can be practically delivered by GPs throughout the State?

I welcome the fact that up to 300,000 children may benefit from this change but, again, I have a concern that we may be putting the cart before the horse in not addressing the other issues and trying to repair the other cracks in our health service. I am aware, for instance, that an agreement with the Irish Medical Organisation on contractual reform, which was concluded last year, was supposed to increase investment in general practice by approximately 40% or €210 million by 2023. I would like to know exactly how much of that expected increase has been delivered. Are we still on track to have a €210 million increase by 2023? Has the figure of €210 million been revised downwards and, if so, by how much? This is vitally important because if those increases do not materialise we will be expecting GPs to deliver a rapidly increasing level of service with a rapidly decreasing level of funding. We need to know where we stand on that issue.

In my constituency of Laois-Offaly we have seen the out-of-hours Midoc service in Birr, which is a town with a growing population, close down because there were not enough GPs to service it. I ask the Minister again if we putting the cart before the horse in that respect.

I would like to add my voice to what Deputy Cullinane has said regarding the lack of capacity in terms of GP services. While we welcome the changes that are being brought in regarding eligibility and extending the children's eligibility for medical cards, it is vital that we will be able to deliver upon that. We have a bad history in the context of offering primary care services. As a result of that, we have put added pressure on acute hospitals, which has been seen recently during the pandemic. Since 2008, a primary care centre has been promised for Dundalk. This centre would also offer disability services, mental health services, dietary advice and a swathe of other services.

I call on the Government to begin works like that as soon as possible. Again, this is the sort of necessary work with a definite health impact that we would like to see carried out as part of the July stimulus.

I welcome this section. I note that there are more than 15,000 children below the age of 12 in Cork city. We welcome this aspect of the Bill. However, in my own area the dental clinic on Harrington Square and the Cope Foundation in Montenotte were recently closed down. Those closures have had a direct impact on 16 primary schools. Parents must now bring their children further afield to get the care they need. We welcome this section, but when children's health is considered, the whole situation must be taken into account. I hope the Minister will take that on board.

I thank the Deputies for the questions. They are exactly the right questions. I made my position on this very clear in the past; general practice does not have enough capacity. The contract was signed more than 40 years ago and a new one is urgently needed. Some very good work was done to augment the existing contract, including moves towards the management of chronic disease in the community. That was done in consultation with the Irish Medical Organisation, IMO, and general practitioners. It was a very useful step in the right direction, but it does not take away from the fact that we need a GP contract that is fit for purpose as part of modern universal healthcare. That contract must significantly increase resources for general practice and must increase the role of general practitioners in the community in line with Sláintecare. Sláintecare essentially calls for all possible care to be provided within the community, in or near patients' homes.

I fully agree that we need more GPs. We do not have enough. I fully agree that more needs to be done to make the profession more attractive. That must include maternity cover, increases to the rural allowance and other measures, many of which have already been outlined in Sláintecare. The 2019 agreement sets out significant increases in practice implementation. My understanding is that it is on track, as is the increase in funding. We also need to work with the Irish College of General Practitioners, ICGP, to increase the number of available training places. We are engaging with that issue.

The debate now concerns the next three sections, which essentially concern the expansion of GP care to various age groups. We are meeting with the IMO to address exactly these questions. I do not want to prejudge the conversation but as Deputies know, my previously expressed opinion is that we do not have sufficient capacity. Simply expanding entitlement without expanding capacity does not work. There are no winners with that approach. As such, we are asking the House to pass this Bill so that we have the legislative framework which to date has not been in place. It is hoped it will be passed by this House this evening and by the Seanad tomorrow. Once the legislative framework is in place, we can immediately begin to discuss these capacity constraints with the IMO so they are tackled in a phased manner. That is why this has been structured in three phases. Immediately expanding free GP access from children under six to children under 12 would not be wise from a capacity perspective for the very reasons the Deputies have outlined. That is why we are taking a phased approach.

I fully agree with the sentiment expressed by the Deputies. We need to expand resourcing, training, GP numbers and the support available to GPs. We need to introduce a new GP contract at the same time so the reforms are joined up. We also need to be very aware of just how crucial the role of GPs will be this winter. We will need to tease out the additional demands on GP services with the IMO. GPs really stepped up when Covid-19 hit. They went to an awful lot of effort to keep people out of hospitals. Services like e-prescribing were introduced overnight. That was not possible before.

Regarding winter planning, I note that resuming services and getting through the winter with Covid-19 will require GPs to continue to step up and work as part of an integrated system. This is the joined-up view outlined by Sláintecare. We must keep patients out of hospitals. That will mean working with GPs to find different care referral pathways. That is the approach we will take.

I thank the Minister for his response. I do not doubt his sincerity for one second or the wisdom of what he has said about taking a phased approach to ensure we have the necessary capacity. However, people listening will be concerned when they hear phrases like "phasing in", "consultation" and "engagement". They will fear that this will take an awfully long time to happen. In his last remarks the Minister referred to the extraordinary job GPs have done in recent months at the front line of Covid-19. I have spoken to many of them. They have undergone sleepless nights, long shifts and huge stresses brought about by all the changes to the testing regime. GPs are under huge pressure. In light of the coming winter surge, the need to roll out flu vaccination, Covid-19 and all of the existing demands on GPs, are we seriously saying this will be done any time soon?

Deputy Donnelly is a new Minister, so some of this is the responsibility of the previous Government. A previous speaker asked if we were putting the cart before the horse. We want this done as quickly as possible. I pointed out the fact that the Minister made these points when he was in opposition. The Government is introducing this legislation, making promises and talking about delivery when we all know that the infrastructure simply is not there. GPs are overstretched and overworked and we do not have enough of them, but the Government is saying it will increase their workload but not their capacity. Generous words butter no parsnips for those GPs. This will not solve their problems. I wish the Minister well in his discussions with the IMO but I imagine those discussions will centre on the need for capacity and how the Minister will deliver it. The Minister tells us about plans, timeframes and ambitions. One can have all the vision in the world, but unless we put the actual capacity in place, this is not going to happen any time soon. That is the problem.

We will have more statements on health tomorrow, as the Minister knows. I may follow up on this issue in that session. I am concerned. We are being asked to pass this Bill in good faith. It has been brought forward because a promise was made, but it cannot just be a promise. This must mean something for the people who will be affected. I spoke about the 300,000 children and the tens of thousands of people over 70 who we hoped would be affected by this. We are now told that there is a new process to determine timeframes for delivery, but the Government has not added the necessary capacity to primary and GP care to make it happen. We are told that there will be a phased approach. I imagine people are saying to themselves that this is more fudge. They will not believe that this will happen any time soon, and it is hard to disagree with that. It is disappointing, given that this was the first Bill the Minister has brought forward. I do not blame the Minister because he has only been in the job for a couple of weeks. The responsibility must be put on the previous Government, which did not put the infrastructure in place before the Covid-19 pandemic to ensure that when we pass this Bill, we will have the capacity to deliver it.

Deputy Cullinane and I are in danger of vigorously agreeing with each other. I agree with him. He says that we propose to increase the workload without increasing capacity. We do not. I am saying the opposite of that. That is the reason for the phased approach. There are several steps to this.

We in this House need to create the legal framework for it, and that is what we are doing tonight. Once we do that, we can sit down with the Irish Medical Organisation, representing general practice, and say that this is the will of the Oireachtas and the Government and we are only going to do it in line with capacity, and we can ask the representatives how it can be done. We want to listen to general practice and my hope is that the GPs listening to this debate will be glad to hear that. I hope they are glad to hear words and phrases like "consultation", "phased approach" and "doing it in line with capacity". As the Deputy correctly says - we are really in agreement here - there is no point, particularly in a Covid world, in increasing workload without putting in place the capacity. We have to do this in a collaborative way, in engagement with general practice, and that is what we want to do.

The Deputy asked if we are putting the cart before the horse, to which I would say that maybe we are. Perhaps we could have had those conversations first and then come into the House and looked to get the legislation passed, or maybe we say, "Let us get the legislation through so that we can crack on with the implementation." I am not hung up on which way it is done. We have chosen to bring in the legislation as quickly as we can in this Dáil term to ensure there are no legislative impediments and that we have a framework to engage with general practice and to be able to say it will be done in three phases and let us talk about what GPs need and about the timing. We want to ensure that when we open up this extra demand, general practice can deal with it.

Question put and agreed to.
Sections 5 and 6 agreed to.
Question proposed: "That section 7 stand part of the Bill."

We know the Bill is not going to commence any time soon. We want to work with the Minister in delivering all of this. The point I was making earlier around putting more capacity into GP services is that even when we get to the point where we can implement these provisions, I am not convinced the capacity will be there. At a time when we are trying to deliver Sláintecare, increase GP access and convince people that this actually can be done - many people are sceptical that we can deliver universal healthcare given that we do not have the capacity in primary care and we do not have enough GPs, and they are concerned about whether the political will is there to do it - it is really regrettable that we are now talking about going off and engaging in consultation. The point I am making is not that we should engage but that the engagement should have been commenced already and we should have had that work done before the Bill was brought forward. That is the point about putting the cart before the horse, which others have raised. The Government is saying we will set the legislative stage, get the Bill passed and God knows when we will be actually able to deliver the provisions in it. If we are saying that delivery is contingent on having increased capacity, but that increased capacity is not in place quickly enough, then people will ask those in this House who passed this Bill when they are going to see the colour of our money. That is unfortunate.

This is the first Bill the Minister has introduced since his appointment. I said in my opening remarks that I wish him well. We want to work with him to get things done. One of the first things we have to do as a new Dáil and as health spokespersons, and which the Minister must do as the new Minister for Health, is to convince people that change in healthcare provision can happen, we are serious about it and that when we say we will deliver universal healthcare and better GP services, we will actually do it. Covid or no Covid, we must commit to that and get it done.

Question put and agreed to.
Title agreed to.
Bill reported without amendment, received for final consideration and passed.