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Seanad Éireann debate -
Tuesday, 29 May 2001

Vol. 166 No. 18

Health (Miscellaneous Provisions) (No. 2) Bill, 2000 [ Seanad Bill amended by the Dáil ] : Report and Final Stages.

This is a Seanad Bill which has been amended by the Dáil. In accordance with Standing Order 103, it is deemed to have passed its First, Second and Third Stages in the Seanad and is placed on the Order Paper for Report Stage. On the question "That the Bill be received for final consideration", the Minister may explain the purpose of the amendments made by the Dáil. This is looked upon as the report of the Dáil amendments to the Seanad. The only matters, therefore, which may be discussed are the amendments made by the Dáil. For Senators' convenience, I have arranged for copies of those amendments to be made available. As Senators are aware, they may speak only once on Report Stage. I welcome the Minister.

Question proposed: "That the Bill be received for final consideration."

I hope not to delay proceedings unduly as I am sure Senators have already contributed to the debate and are keen to make final comments on it. The majority of amendments made to the Bill by the other House are drafting amendments of a technical nature, some of which are consequential on the more significant amendments made. For reasons of clarity, I will go through the amendments made by the other House in the sequence as printed and circulated. However, to avoid taking up time unnecessarily, I will not dwell on technical amendments but will focus on the more significant ones. I will be happy, however, to provide more detail on any technical amendment should Senators require it.

Amendments Nos. 1 and 2 are technical amendments to the Long Title required in the context of significant amendments set out later. Amendment No. 3 was introduced in the other House to allow for the automatic extension of the medical card scheme to everyone over the age of 70. In the budget 2001 package, the Government announced its intention to extend eligibility for the medical card to all persons aged 70 and over, regardless of means, to come into effect on 1 July 2001.

The background to this measure rests in the Government's decision significantly to improve eligibility for older people in recent years across a range of areas, particularly those which are the responsibility of the Department of Social, Community and Family Affairs. This decision must be seen in the broader context of a key theme of the budget, which was to improve things for the elderly in society generally. These measures included the dramatic increase in the old age pension, the extension of many free schemes to people over 70 and the extension of medical card eligibility.

In An Action Programme for the Millennium, the Government identified the need to review medical card eligibility for older people and decided that the income guidelines for entitlement to medical cards for persons aged 70 years and over should be doubled. This improvement, which was introduced over a three year period, began on 1 March 1999 and the income guidelines for those aged 70 to 79 and 80 and over, which were already higher than the normal guidelines, increased by one third in 1999. The second stage of this process was implemented on 1 March 2000, followed by implementation of the third stage in March 2001.

The logical conclusion to the three year programme is the granting of medical cards regardless of means to everyone over the age of 70. The measure goes some way to bringing peace of mind to our older people and a sense of security about their health care. It also acknowledges the wonderful contribution older people have made in building up the country through the difficult times which led to the creation of the tiger economy. Our current prosperity affords us the opportunity to repay our older citizens.

We should also remember that most people over the age of 70 already have medical cards as a result of the three year programme initiated by the Government. Allowing for estimated increases in the elderly population since the 1996 census, it is estimated that approximately 30,000 people over 70 will receive medical cards as a result of the budget provision.

Agreement was reached with representatives of the Irish Medical Organisation last month on a number of outstanding industrial relations issues, through the HSEA. As a result the IMO has agreed to meet my Department, again through the HSEA, on the subject of the extension of eligibility to all persons aged 70 and over. I look forward to a positive outcome of these talks and the timely and efficient introduction of the scheme on its official start date, 1 July 2001. Discussions are also taking place with the Irish Pharmaceutical Union on the implications of the measure for pharmacists. The precise cost of the introduction of the medical card scheme will depend on the outcome of the discussions with the IMO and the IPU and I will revert to the House on that matter.

On the conclusion of negotiations with the IMO and the IPU, the Department will embark on a public information campaign over the next few weeks to promote fresh awareness of the budget initiative and to inform those eligible of how they can avail of it. This campaign will be carried out in conjunction with the health boards. Newspaper advertising features, press releases and an insertion on the departmental website are the means being considered to achieve maximum coverage. Furthermore, the relevant section in my Department will continue to give the fullest information available to any person making an inquiry on the subject now or in the future.

Amendments Nos. 4 and 5 are technical amendments dealing with typographical errors. The background to amendment No. 6 is that section 1(10), as passed by the Seanad, provides for the making of regulations in relation to community pharmacy contractor agreements, including that regulations may provide for the making of appeals to the Minister when an application for a community pharmacy contractor agreement has been refused by a health board. This reflects the current situation where unsuccessful applicants may appeal to the Minister for Health and Children. I indicated on Committee Stage in this House that I was not convinced that the Minister of the day should have this function and that I was examining the matter with a view to proposing an amendment in the Dáil. As the person ultimately responsible for the regulations, it is not ideal that the Minister for Health and Children should also be the decision maker in appeals by unsuccessful applicants for community pharmacy contractor agreements. The amendment made by the Dáil will, therefore, allow the establishment of an independent appeals body, thus ensuring the continuation of a transparent, equitable and accessible appeals system.

Amendments Nos. 7 and 8 are technical amendments of a drafting nature. Amendment No. 9 is also essentially a technical amendment. A definition of supervising pharmacist in this amendment reflects current practice and is directly in line with the provisions of the Pharmacy Act, 1962.

Amendments Nos. 10 and 11 were made following advice from the Attorney General's office that the recommended maximum limits for monetary penalties for summary offences are to be raised from £1,500 to 3,000, about £2,362, to allow for inflation since 1994 when the £1,500 limit was first established. This has allowed me to raise the maximum fine for the sale of tobacco products to persons under the age of 18 years to £2,000. That matter was the subject of considerable debate when the Bill was introduced in this House.

Amendment No. 12 deals with regulations made under the Nursing Homes Act, 1990, an Act which is amended by the Bill. As Senators will be aware, the report of the Ombudsman into the nursing home subvention scheme was published earlier this year. The report deals, inter alia, with the role of the Department of Health and Children in making regulations and overseeing the introduction of the subvention scheme.

Chapter 8 of the report draws some far-reaching conclusions as to how Government operates under the Constitution. The report goes on to make a number of suggestions as to how the position might be improved, including the development of a mechanism for monitoring secondary legislation by affirmative resolutions of the Oireachtas. This general question is one which must be addressed in the context of wide consultation and careful consideration of all the implications. However, in light of the Ombudsman's report, I introduced an amendment to the Bill in the Lower House to provide that regulations under the Nursing Homes Act, 1990, shall be laid in draft before both Houses of the Oireachtas and that the regulations shall not be made until a resolution approving of the draft has been passed by each House.

I indicated my agreement to amendment No. 13 during the Dáil debate on Committee Stage and it was agreed on Report Stage in the Dáil. It provides that the Minister for Health and Children will make a report each year to each House of the Oireachtas on the measures taken by health boards in the preceding year to address the problem of suicide. This amendment does not refer specifically to the number of suicides each year as this information is already available to the Oireachtas by way of the annual report of the Central Statistics Office which is laid before both Houses. However, I am advised that this fact would not preclude the Minister from referring to, or commenting on, the number of suicides in the course of his or her report. In this regard I am pleased to inform the House that the CSO's recently published statistics show that the number of deaths from suicide has fallen for the second year in a row. There were 413 registered suicides in 2000. This represented a decrease on the 1999 figure of 439 and a significant decrease on the 1998 figure of 504. However, while this is a welcome development, we must not become complacent. I intend to ensure that the good work now under way in the health boards' suicide prevention programmes continues and is further developed in the coming years.

Amendment No. 14 is a technical amendment which excludes the Tobacco (Health Promotion and Protection) Act, 1998, from the collective citation for the Health Acts, 1947 to 2001. The Tobacco (Health Promotion and Protection) Act, 1998, is included in the collective citation in subsection (3) of this section.

The technical amendment to which the Minister referred was necessary because the Government did not have the legal framework in place at the time. We are accepting this amendment now, which is consequent to the announcement in the budget granting medical cards to people over 70 years of age. Indeed, as the Minister stated, people over 70 well deserve such a measure which will be crucial for their continued good health. Fine Gael's policy is to extend the free medical card scheme to people over 65, in addition to children up to the age of 18 and those in continuing education. In extending the scheme to those over 70, the Minister has in mind a very small group.

There is no doubt that serious health issues are faced by people in the 65 to 69 age bracket. As of 1 January 2001, £162 is the medical card income guideline for a married couple aged between 66 and 69 but their old age contributory pension is £183, which is £21 above the medical card limit. While there is a favourable balance towards the elderly, the scheme should at least be extended to those over 65. It is rather miserly of the Minister to take 70 years as a cut-off point. He could have been more generous by amending the Health Acts to include all young people under 18 years of age and those in continuing education.

I have many times met women, particularly, who cannot afford to pay for spectacles or eye tests and so on because they prioritise the health of their young children and husbands and do not get an opportunity to look after their own health. Irish women are extremely badly off by comparison to other European women in terms of their state of health, particularly in the areas of cancer and heart disease. A contributory factor is that women unselfishly do not look after their health if they are above the eligibility threshold for a medical card because the cost of doing so is astronomical and they prioritise the health of their children and husbands above their own.

Granting medical cards to everyone aged over 70 years is a sop. The Minister had the money to implement the Fine Gael policy which was to reduce the age limit to 65 years and provide medical cards for all those aged under 18 years and those in continuing education in line with our European neighbours.

Ba mhaith liom fáilte a chur roimh an Aire go dtí an Teach. I welcome the return of the Bill to the House. It has consolidated elements of the various Health Acts to which the old adage, "Too many cooks spoil the broth", applied. I congratulate the Minister and his Department on addressing the problem. I welcome the amendments to the legislation, not least in regard to nursing home regulations. It was important that this area of heath care was identified as being in need of rectification and addressed by the Minister. We all read newspapers and were aware of the malpractices in some nursing homes and it was essential that they were addressed.

The Government will provide medical cards for everybody aged over 70 years. My colleague on the other side of the House, Senator Jackman, stated medical cards should be provided for all young people aged under 18 years. Was her party not a member of the Government which abolished medical cards for those under 18 years and linked their eligibility for such cards to the means of their parents? If their parents were entitled to a medical card, so were they. It is important that the people who were pathfinders and built Ireland into the great state it is are rewarded by the Government. The provision of medical cards for everyone aged over 70 years is one important step in that direction.

The regulation regarding suicide is crucial, given the incidence of suicide in recent years. I am a member of the Joint Committee on Health and Children, as are Senators Jackman and Fitzpatrick, and we have received submissions from groups whose members have been adversely affected by tobacco consumption during the years. We are considering submissions, reports and evidence from those who have been affected by tobacco products and those who supply them. The World Health Organisation regards smoking and tobacco-related illness as a global epidemic causing four million to die prematurely each year and estimates that ten million will die annually from smoking by 2030. These figures are a dreadful indictment of these deadly products, yet they are legal.

I welcome the increase in the fine from £1,500 to £2,000 and I congratulate the Minister and the Members of the other House, irrespective of the direction from which the proposal came, because £1,500 was minuscule. The fine should be an even greater amount. There will be no hiding place from this regulation for those who sell tobacco products to children and young people up to the age of 18. I ask the Minister to raise the age limit even further in the coming years because there is only one place for the people who sell cigarettes to children and young people, and that is behind bars or, at a minimum, they should be put out of business. I spoke on the Bill previously. I commend it to the House.

I welcome the Minister to the House. As he knows, there has been a considerable amount of excitement in my profession over the extension of eligibility for medical cards to those aged over 70. There is a good deal of merit in that because a considerable number of people are on small private pensions not much over the limits on which other old age pensioners get medical cards, and it will be a major gain to them. It was unfortunate, however, that the Minister did not discuss the matter with the medical profession before he went ahead with it but perhaps the man who runs the health service – he who lives in the Department of Finance – would not let him do that. It would have been a help if they had felt they were forewarned before they found it included in the Finance Bill.

The over 70s are major users of the medical service and, from what the Minister said, he does not appear to have made an agreement with family doctors on how this service will be supplied. It is a difficult issue because patients are much more demanding now and they expect a better service from their family doctor. The establishment and operation of a practice costs a great deal more and the remuneration for taking care of medical card patients is not that high. I hope the Minister can come to an amicable solution with them in the near future because there is a considerable number of people over 70 who are just over the eligibility level and it is much better to have them treated at primary care level rather than have them end up in accident and emergency departments. I have frequently seen people in, say, cardiac failure which they might have avoided if they had been regularly attending their doctor.

I hope this issue is amicably settled between the Minister and family doctors because primary care is an area which we have neglected in our discussions about the problems in the health service. What is happening in accident and emergency is very dramatic so it is much easier to forget what may be going on in primary care. I hope the Minister manages to come to an amicable conclusion of his discussions with the Irish Medical Organisation, the College of General Practitioners and so forth.

Any efforts the Minister makes in rationalising the position with pharmacies is most welcome. The possibility of deregulation must be the next item so that there is a wider number of pharmacies in society. It is an exclusive business currently, as the Minister is well aware. It is easy to say that once the price of drugs is decided in town, that is the price it shall be.

I am also interested in the position regarding the use of pharmaceutical products on the Internet. As the Minister knows, the Irish Medicines Board spoke about this matter recently and I hope its funding will always be sufficient to investigate these areas because they are important. I heard Dr. Gilvarry speak about the importation of Botox from sites on the Internet for the treatment of wrinkles and other cosmetic surgery. Some international sites sell Viagra, U486 and all sorts of antibiotics, but I do not know how we can regulate the importation of these drugs. If we cannot stop large quantities of heroin coming in, how are we going to stop small packets of pharmaceutical products? We must ensure the Irish Medicines Board has sufficient resources to continue to investigate these areas.

Some of the Internet sites do not even require a doctor's prescription, or only require the most rudimentary prescription. In many cases they will know little of the patient's history. It was reported some time ago that 86 sites in America were selling Viagra without prescriptions, without carrying out any investigation of the patient's condition or inquiring about other drugs which the patient may be taking. We need to be vigilant about this area.

The reduction in the suicide rate is excellent news and makes one feel that the work of people such as Deputy Neville and others has been worthwhile. We are constantly addressing the number of suicides among young people. However, there have been depressing articles about suicides among older people, particularly among men over 65 years of age. These articles have highlighted issues of loneliness, depression, feelings of isolation and failure which need to be addressed. This is primarily an issue for social services rather than a medical issue. I would not wish to see loneliness being "medicalised", but we should pay more attention to the issue.

I am delighted by the increase in the fine for selling tobacco to children. The last occasion on which I objected to a child being sold cigarettes in a shop in Donnybrook, the owner said, "But I know his mother." I said, "I don't care if you know the whole family. This is against the law." Why is the fine not given in euros? Everyone else is converting to euros.

I got this far.

Is it too late to change the fine to 2,000 which would be a little more than £1,500? That would cheer Senator Glynn as the Seanad would have increased the fine.

The fine is going up to £2,000 which more or less corresponds with the euro amount.

I welcome the Minister. There are some welcome provisions in the Bill, but other issues have been omitted. I welcome the extension of the medical card to senior citizens over 70 years of age. This is an effective recognition of their health status and the contribution pensioners have made to society.

I am concerned by some of the comments of the medical profession regarding this provision. As the Minister acknowledged, senior citizens built up this country. They made the sacrifices, paid their taxes and did their duty. As people get older, they need the services of a doctor more regularly. Therefore, it is a positive and constructive measure to assist their health needs by giving the medical card to those over 70 years, regardless of income. This is what the Minister is proposing. It may be that people over 70 years will use health services more regularly. In the light of this possibility, the Minister should reach an agreement with the medical profession regarding an increased capitation for those in this age bracket. This may resolve the difficulties. However, there is no doubt that those over 70 years should have a medical card.

Senator Jackman referred to the fact that some do not have a medical card. Health boards are pursuing an aggressive policy in terms of reviewing medical card eligibility. Fewer people have a medical card now than when the Government took office four years ago. This is wrong. There are those who do not have a medical card, despite the fact that they are on low income. Thousands of people in the north-east are losing their medical card because their income is above the limit. The Minister must address the fact that the income limit for medical cards is not keeping pace with inflation.

Senator Jackman also referred to the issue of young people and medical cards. Like me the Minister was a teacher and he will be aware that the incidence of asthma is very high among young people. Some 20% of children in the north-east are asthmatic. The Department of Health and Children estimates that extending medical cards to asthmatics would cost approximately £600 per person. The £42 drug limit does not meet their needs. Significant numbers of families on low incomes who have children with asthma are not entitled to medical cards. It is, therefore, unacceptable that the medical card scheme has not been extended to asthmatics. While it would cost money it is proper and fair to do so.

There are thousands of admissions to hospitals as a result of asthma attacks, yet many parents do not have the money to pay their doctor for advice on whether different inhalers or medication is required. As a result many people, including asthmatics, are suffering under the Minster's health policy because they are not being looked after. The Asthma Society of Ireland makes clear demands on all political parties. Asthmatics should be given medical cards.

Senator Glynn referred to the nursing homes regulations. The Minister rightly proposes they must be brought before the Houses of the Oireachtas before they are changed. We have repeatedly asked the Leader of the House to arranged a debate on the health services. Is the Minister prepared to participate in such a debate?

Each health board has a team of doctors and nurses who seek to enforce the numerous nursing home regulations but they have far too many other responsibilities. They do not have the capacity, time or the dedicated staff to deal with them. As a result they are inadequately enforced. By law the health boards are required to visit homes twice per annum. That is all they can do at present but it is not enough.

The Minister must establish an independent group of inspectors separate from the health boards who will enforce these regulations. What is happening in some of these homes is disgraceful and unacceptable. I have requested some of the inspectors' reports under the Freedom of Information Act. When I have received them all I hope to make them public. They make for shameful reading. Many nursing homes are doing an excellent job but the Minister must look at this issue urgently because the health boards do not have the capacity to deal with it. He must act to protect our senior citizens. While I welcome his move to ensure that regulations are brought before the Houses of the Oireachtas for debate more often, nothing is happening at present.

The Department is spending millions of pounds per annum on nursing homes subvention. In the Eastern Regional Health Authority approximately £25 million per annum of taxpayers' money is being allocated to subventions to nursing homes, yet the implementation of the regulations is not good enough. I hope the Minister will respond to this when the facts are before him. I am not happy that adequate attention is being paid to this area by him and this Administration. It badly needs to be investigated at the highest level.

I welcome the Minister to the House. I congratulate him on the excellent work he is doing in the Department of Health and Children, a difficult Department to run due to the constant demands and expectations of people.

I am in favour of people over 70 getting medical cards without their having to have a means test. One of the big problems regarding getting old is the fear of ill health. For various reasons, many elderly people tend to postpone trips to the doctor or the receipt of care if they have to pay the bill themselves. If for no other reason than to eliminate this problem, the medical card should be welcomed for people over 70.

I hope that this is only the beginning of free primary health care for everybody, not just the over 70s. This cannot be achieved overnight, but it should be the aim of the current and future Governments to bring it into effect. Some 90% of people who attend a GP do not need to go further – they do not require secondary or tertiary care. Ultimately, the extension of medical cards to everybody would be a worthwhile investment in the health of the people.

I agree with Senator O'Dowd in that I too would welcome a wide-ranging discussion on the health services, not with a view to picking faults but to looking at their future development. Having entered the third millennium, we are moving from the poor law system upon which the health services are based to a far more sophisticated and well-funded system, a system upon which there are many demands. I would also like a discussion on the setting up of a health inspectorate similar to the inspectorate of mental hospitals, but extended to all health facilities.

Hear, hear.

One may think this would establish a vast bureaucracy, but we will need an independent, stand-alone, ombudsman or health inspectorate, somebody between the patient and the providers of the services who would have a value-free stance on whatever problems arose.

I thank the Senators for their contributions to the debate. I particularly welcome the support on both sides of the House for the extension of the medical card to those over 70. Many desired that it should be extended further. It is important that the Oireachtas will be endorsing unanimously the decision to extend medical cards to people over 70. It is an important signal to society, demonstrating how we value older people. As Senator Fitzpatrick said, primary care is an essential feature of older people's lives and they should not be, in any way, inhibited from visiting a GP.

As Senator Henry pointed out, we have to conclude negotiations with the Irish Medical Organisation. The Government has made its decision in this regard. We could not consult in advance of the budgetary decision and one does not normally do so. We do not negotiate the rate of the old age pension or the extension of the free schemes under the social welfare code. There is secrecy attached to the preparation and eventual publication of a budget and the medical card extension was part of that. Nonetheless, once a decision is made, it gains certain momentum and I am satisfied we will be able to implement it on 1 July.

I am conscious of the role of general practice and the Government has sanctioned me to engage in the most fundamental review of general practice since the foundation of the State in collaboration with the Irish College for General Practitioners and the Irish Medical Organisation, each of which has outlined its vision of general practice in the future.

Six weeks ago, we concluded an agreement with the Irish Medical Organisation in respect of a number of items it had raised. One item concerned additional allowances for practice nurses with GPs, additional allowances for secretaries of GPs, once-off payments for the GPs who are treating asylum seekers and payments for GPs in respect of the discretionary medical card. The Irish Medical Organisation has been seeking additional payments for GPs because there are thousands of discretionary medical cards that were not accounted for in terms of payments to GPs because of the discretion the chief executive officers have in the respective health boards. The full impact of that agreement, signed six weeks ago, was in the order of £10 million. The Irish Medical Organisation would have engaged in discussions earlier, but one member, Dr. Michael Boland, was recently elected president of the World Organisation of Family Doctors. Many GPs were in South Africa celebrating his success, something of which the country is very proud.

He is a Corkman to boot.

Obviously, he is a Corkman to boot, from Skibereen. Negotiations are commencing this week on the finalisation of the issues. There was a lot of debate on the issue of means for people over 70. My view is that very few of the millionaire set would be utilising this particular facility.

Senators Jackman, O'Dowd and Fitzpatrick raised the issue of wider eligibility for medical cards. That is being examined in the context of the health strategy that is being prepared. A sub-group has been formed to consider eligibility for medical cards and the health services in general. There are a number of ways by which we can approach this. We can do so on an income threshold basis alone. In other words, we should increase the income threshold incrementally over time. However, that does not account for asthma sufferers or those with specific diseases or conditions. This must be examined because there are people with long-term chronic illnesses, many of whom represent small minorities. I have come across many such groups, often comprising no more than 100 people, but their condition requires ongoing regular contact with GPs and a need for medication. The existing scheme does not adequately facilitate people in that category.

Do we continue with the concept of age-specific eligibility? We have taken an important decision in this regard where people over 70 are concerned. There is much concern about children in that they are a target group in terms of medical needs and their parents' peace of mind. All these competing approaches to widening eligibility for the medical card must be balanced, and our strategy aims to do that. In terms of a broader widening across all age groups, the income threshold offers, on a financial equity basis, a preferred approach. However, we must look at some of the existing schemes regarding children, particularly babies, and improve them for all concerned.

We have estimated that if we brought in free GP cover for everyone, not including the cost of medication, it would cost about £600 million – that is an approximation – while the cost of providing medical card cover would be about £800 million. This must be considered in the context of the bed capacity review that we have completed and the number of beds we need, the huge capital infrastructural projects needed in the health service and the extra consultants identified in the manpower forum. The desire to fulfil the EU working directive criterion will involve bringing junior doctors' working time down to 48 hours within nine years. This will reduce the ratios between full-time consultants and junior doctors and, if we are really moving towards a consultant-provided service as opposed to a consultant-led service, have significant financial implications, not only in terms of the extra consultants required but in terms of extra backup staff, nurses, paramedics and so on.

There are no quick-fix, easy solutions to all this and we must look at the free medical card, GP for all issue in the broader context of prioritising what is possible, realistic or desirable within the next seven years. Some have argued that perhaps it is more desirable to get the matter of quality in the existing services correct before we expand access to a service which is not delivering to those currently endeavouring to avail of it.

With regard to penalties for selling tobacco to under age individuals, we cannot go beyond 3,000 because it is a District Court type offence. After much pressing with our legal advisers, we have gone up to £2,000, which is about £200 less than 3,000. I am advised that this is as far as we can go. A more comprehensive tobacco Bill has nearly completed its drafting stage. This will have a significant impact on people's behaviour and consumption of tobacco.

The recent all-island report on cancer makes for quite frightening reading in terms of the incidence of cancer, particularly in urban areas, where it is running at about 10% higher than in rural areas. Lifestyle factors seem to have a profound impact on cancer levels. Diet is a big issue, in terms of eating fruit and vegetables and so on, but cigarette smoking is the key issue. It is the one preventable measure which is within our power to take that would have a major impact on cancer statistics in the future. There are currently 2,000 deaths per year from lung cancer alone, which is almost entirely preventable. As everyone knows, we top the European league table for heart disease.

The House has been very supportive and when the Bill was first discussed there were some ringing declarations of support for whatever I wanted to do, in terms of being tough on tobacco and so on. I appreciate that support from all sides of the House. I may look for that kind of support throughout the summer, because I am looking at other issues to try to improve the situation. We have been too complacent on environmental and passive smoking. We can initiate certain new measures under existing laws, and I think we are going to have to do so. The all-island cancer report is a very significant wake-up call, if we needed one. We need to get our act together as a society for the future. Unfortunately all the lifestyle research surveys, such as SLAN, are showing us that the behaviour and lifestyle patterns of the younger generation are no better than their predecessors. In some instances they are becoming worse, in terms of alcohol consumption generally and cigarette smoking among young women.

I endorse what has been said about suicide and what Senator Henry said with regard to an increase in suicide among older people. The downward trend in the last two years may be an indication of the effective work of bodies such as the Suicide Research Foundation and the National Suicidology Association, which is headed by Deputy Dan Neville and others. The increased budgetary allocation for research into awareness and greater services within the health boards may also be paying dividends. It is too early to say, but we hope that is the case, and that we can continue to improve our services.

We are dramatically increasing funding for the improvement of psychiatric services, particularly in the area of child and adolescent psychiatry. At the end of this year we will have for the first time a consultant-led service in this area. This is particularly important. It was obviously a huge deficiency that we did not have this basic service in some health board areas.

I take Senator O'Dowd's point on nursing homes, although we also have to accept and acknowledge that whereas health boards are charged with the responsibility of inspecting private nursing homes, no one has responsibility for inspecting public sector nursing units under the care of health boards. We are going to give additional powers to the social services inspectorate to conduct inspections of all health board run nursing homes. We are looking at whether we should extend their remit to cover all nursing homes. This would involve significant resourcing of the social services inspectorate, which was initially focused on child care, which was also very badly needed as we have seen from recent reports that it has conducted on our behalf. Rome was not built in a day. We acknowledge that we need to improve our inspectorial regime with regard to the care of the elderly, an area in which ultimately the social services inspectorate will have an increasing role to play.

In reply to Senator O'Dowd, the reduction in medical cards for the general population is due to the economic boom and the fact that we have reduced unemployment so dramatically in the last three years. Three years ago some 200,000 to 300,000 people were unemployed. We are now down to an unemployment rate of almost 3%. This will clearly have a huge impact on eligibility for medical cards because people are now earning money instead of being on the dole. Nonetheless, as part of our strategic review we will look at increasing eligibility from the current level of some 31% to 32% to a higher percentage of the population.

Single parents on low incomes going back to work is a major issue.

Yes, I am aware that is a major issue that needs to be addressed.

Question put and agreed to.
Question, "That the Bill do now pass", put and agreed to.