Health (Amendment) (No. 2) Bill 2010: Second Stage

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

I am pleased to have the opportunity to address the House on Second Stage of the Health (Amendment) (No. 2) Bill 2010. The Bill provides for charging modest fees in respect of prescribed items dispensed by community pharmacy contractors to persons who have medical cards. It provides for a charge of 50 cent per item prescribed by a registered medical practitioner, dentist or nurse and dispensed by a community pharmacy contractor. The maximum amount payable will be €10 per family per month. The charges are being introduced on foot of a budget decision last year to address the rising costs in the general medical services, GMS, scheme. The scheme also seeks to influence demand and prescribing patterns in the GMS in a modest way. We do not set out in the Bill to make the level of savings of the order of €200 million and more which we are already achieving with regard to the prices of drugs and the cost of distributing and dispensing drugs. Nor is it on the scale of the savings we expect to achieve in coming years by introducing reference pricing and generic drug substitution. However, every saving and every contribution counts. This charge should raise approximately €2 million per month. Every saving achieved by and for the HSE Vote will reduce, though not eliminate, the pressure on funding for front line services including hospitals, home help, home care packages, mental health and services for people with disabilities and their families. Given our current financial situation, it is important that we take every step possible to provide public services efficiently, to limit costs to the greatest extent possible and to involve users of resources in better understanding of the value of those resources and their appropriate use. We are doing this in a pragmatic way in the context of Ireland today, with regard to not only the national finances, but to our patterns of prescribing and use of drugs and the costs we face.

Almost 1.55 million people, or 35% of the population, have medical cards. Payments to pharmacies under the GMS scheme increased from €748 million in 2004 to €1,279 million in 2009, despite a reduction in the fees paid to pharmacists from July 2009 and ongoing reductions in the prices of off-patent medicines. The cost of the GMS scheme, including payments to pharmacists and general practitioners, in 2010 is projected to be more than €2 billion. The rate of increase, on average 12.5% during each of the past six years, in the cost of supplying drugs and medicines is not sustainable. The number of prescriptions issued under the GMS scheme has increased by 4 million between 2004 and 2009 to more than 16 million. The number of items dispensed during this period increased by more than 15 million to in excess of 50 million. The average number of items per script has also increased from 2.74 in 2004 to 3.11 in 2009.

I refer to the main provisions of the Bill. Section 1 provides for the amendment of section 59(1) of the Health Act 1970 which currently requires the HSE, Health Service Executive, to supply drugs, medicines and medical and surgical appliances to persons with full eligibility without charge. This is being amended by section 1(a) to provide that where prescription items are supplied by a community pharmacy contractor, they shall be subject to the charges as provided for in subsections (1A) and (1B)(a) subject to the exemptions provided for in subsection 1(C). Subsection (1A) provides that a person who is supplied by a community pharmacycontractor with a drug, medicine or medical or surgical appliance on the prescription of a registered medical practitioner, dentist or nurse who is entitled to prescribe shall be charged 50 cent per item. It also provides that any variation in this amount may be determined by regulations subject to conditions set out in the amended subsection 59(4) of the Act, which I will outline.

Subsection (1B) provides that the maximum amount payable by any person or his or her dependants in any month will be €10. In addition, provision is made for the HSE to refund, credit or otherwise relieve any amount paid in excess of the maximum aggregate amount. Any variation in the maximum aggregate amount is to be determined by regulations subject to certain conditions set out in the amended subsection 59(4) of the Act, which I will outline.

Subsection (1C) provides that two classes of persons will be exempt from the charges, namely, children who are in the care of the HSE under the Child Care Acts 1991 to 2007 and persons who are supplied with specific controlled drugs such as methadone. The section also provides for the making of regulations to exempt other classes of persons from charges, subject to certain conditions as set out in the amended subsection 59(4) of the Act, which I will outline. Prescription charges will not be payable by holders of long-term illness cards. In addition, charges will not apply to persons who are covered by the Health (Amendment) Act 1996, that is, persons who contracted hepatitis C through the use of certain blood products.

Subsection (1D) provides that, notwithstanding the contract between community pharmacists and the HSE, the amount paid to a community pharmacy contractor by the HSE will be reduced by an amount equal to the amounts collectable by that contractor in charges. The amount collected in charges will be retained by the community pharmacy contractor. Subsection (1E) provides for a definition of "community pharmacy contractor" and a definition of "dependant" for the purposes of section 59(1). Section (1E)(b) inserts a technical amendment relating to the existing section 59(2).

I refer to the conditions for making regulations. Paragraph (c) replaces the existing section 59(4) and provides in the new 59(4)(a)(i) and (4)(b) that, in deciding whether to make regulations to vary either the amount of the charge per item or the aggregate monthly amount, the Minister will have regard to such of the following as is considered appropriate: information on the consumer price index, information on expenditure and the number of items prescribed to medical card holders, the medical needs and financial burden on persons who avail of the services and the necessity to control health service expenditure.

Paragraph (c) also provides in the new sections 59(4)(a)(ii) and 59(4)(c) that, in deciding whether to make regulations specifying classes of persons to be exempt from the charges, the Minister will have regard to such of the following as considered appropriate: the particular medical condition, disability or medical needs of persons in that class, the number of the prescription items required in respect of those medical needs, information on expenditure and the number of items prescribed to medical card holders generally or in respect of the specific class, the necessity to control health services expenditure and whether the overall financial situation of the proposed class is worse than that of other persons who are charged for items supplied on prescription. Paragraph (c) also provides that the Minister may make regulations on refund, credit or other relief arrangements where he or she considers it necessary to do so. Paragraph (c) provides that any regulations made under section 59 shall be made with the consent of the Minister for Finance.

Section 2 provides for Short Title, construction and collective citation with the Health Acts and commencement. The Bill is part of a set of actions the Government has taken or is taking to address rising costs in the GMS. These actions include the introduction of off-patent price cuts, reductions in wholesale and retail mark-ups and the introduction of generic substitution and reference pricing.

Significant progress has been made in recent years to improve value for money in the area of pharmaceutical expenditure.

Off-patent price cuts have been implemented and wholesale and retail mark-ups have been reduced. As a result of off-patent drug price reductions in February, the cost of prescribed medicines measured by the Central Statistics Office as part of the consumer price index reduced by more than 12% in that month. Discussions are under way with manufacturers of generic medicines and lower prices for generics are expected to be introduced in September this year.

Despite these reforms, pharmaceutical expenditure continues to pose a challenge because of our aging population and increased use of medicines. Further changes are required to secure a sustainable system of pharmaceutical expenditure while, at the same time, ensuring patients can continue to access necessary and innovative medicines. On 17 June last, I published a report on the proposed model for the substitution of generic medicines and reference pricing. Generic substitution and reference pricing represent significant structural change to the system of pricing and reimbursement of medicines in Ireland. As more medicines come off patent, the introduction of generic substitution and reference pricing will ensure that taxpayers and patients will benefit from increased competition in the pharmaceutical market. Giving patients more choice and promoting price competition between suppliers will help reduce the overall drugs bill without compromising the efficacy or safety of the treatment patients receive.

Savings will be achieved by limiting reimbursement to the reference price, allowing patients to opt for less expensive versions of the prescribed medicine and promoting price competition between the manufacturers of interchangeable medicines. The level of savings will depend on a range of factors, including the number of medicines included in the reference price system, prescribing practices, and the behaviour of manufacturers of interchangeable medicines. The system will be introduced on a phased basis and, therefore, savings will be achieved on a phased basis. An expert group will provide guidance on which medicines can be safely substituted. Exemptions will be required in some instances for individual patients for clinical reasons, for example, if a patient has difficulties swallowing.

Under the legislation, the maximum monthly amount payable is €10 per family. Payment of the maximum amount will only arise where a family receives 20 items or more in a month. In 2008, just over 2% of medical card families had 20 or more items per month prescribed to them. More than 35% of families had no items prescribed to them. Almost 18% had one or two items prescribed. It is expected, therefore, that only a small minority of medical card families will have to pay the €10 per month maximum charge. Based on trends in previous years, it is expected the prescription charges will yield €24 million in a full year. I commend the Bill to the House and look forward to hearing the views of Senators.

I welcome the Minister to the House. Fine Gael opposes the legislation, as we believe the introduction of the prescription levy will mean that some of the poorest and most vulnerable families and patients who have serious illnesses may have to go without their medicines. The levy of 50 cent per medicine may not appear to be much but that will not be the case for many families, particularly those on low incomes. The vulnerable in our society have been asked to bear a significant burden of pain, despite not being responsible for the banking crisis or the economic recession the country is experiencing. From the point of view of social protection and caring for the most vulnerable, we will oppose the Bill.

In addition, we oppose the legislation on health grounds. Prescription charges were abolished in Northern Ireland in April this year. Since 2008 prescriptions have cost £3, prior to which the cost was £6.85. The Stormont health minister said on removing the prescription charge that, "The move marked an end to the tax on illness". Our Government is bringing in a tax on illness for the most vulnerable. The Northern Ireland health minister said at the time the cost of abolishing the prescription charge would be met within existing health budgets and would not affect any existing health services in Northern Ireland. He argued against such a charge on health grounds.

I am interested in the Minister's view on the deterrent effect of this cost on the most vulnerable and those with chronic illness. Significant international research shows any disincentive for people to take the medicines they need should be avoided. If there is a deterrent effect, people will end up needing more crisis care and inpatient or institutional care. If diabetics do not take their medicines or those who are on a range of treatments for chronic conditions such as schizophrenia, bipolar disorder or other psychological and medical conditions, the outcome will not be good for them and they could ultimately cost the health service more. Has the Minister examined the international evidence of the impact of a prescription levy?

I refer to the Welsh Assembly report on helping to improve health in Wales. This report found that there was no increase in the number of prescriptions dispensed following removal of the charge. Clearly, this indicates that imposing a levy is not necessarily an effective way to tackle waste. I agree with the Minister that waste, over prescribing and inefficiencies are significant issues and I accept she is examining other issues, such as those relating to generic products. It is not correct that the first step is to opt for a prescription charge on the most vulnerable and on medical card patients. For example, in England, the British Medical Association has long called for the abolition of the charge which it claims is "outdated, iniquitous and detrimental to the health of so many patients by acting as a barrier to their taking necessary medication". Why is the Minister going against the tide of international experience in this regard?

She probably has spoken to representatives of the Irish Medical Organisation about the Bill. They presented a plan to her last year, which they claimed would shave €300 million off the State's drugs bill. What progress has been made in this regard? They said money could be saved by regularly reviewing patients to ensure they did not stay on expensive drugs for longer than necessary, establishing a system under which the State would only pay for drugs if they were going to be of clear benefit to the patient — that seems obvious but apparently that does not always happen — tackling the relatively high cost of generic drugs and by ensuring more generic rather than costly branded drugs are prescribed.

Everybody has anecdotal evidence of drugs being much cheaper abroad than in Ireland. That continues to be an issue and this raises a question about the influence pharmaceutical companies exert as opposed to people who struggle to make ends meet and who have a medical card but who will now be subject to a prescription charge. It is easier to target them than the pharmaceutical companies. Will the Minister spell out in her reply what action is being taken to address these companies? Are they being held to account enough in the context of the challenges the country faces in reducing costs?

I have had discussions with the Minister about breast cancer screening. We have a superb system but the most vulnerable women still do not take up the screening even though it is free. Low incomes, preventative health care issues and social factors often keep people away from the care they need. International evidence, which we also discussed during the Minister's last visit to the House, highlights that higher incomes and better social circumstances lead to better health. The people affected by this levy are under pressure socially. This is a short-sighted decision, which may cost more in the longer term. This is particularly true with regard to health issues. We ought to do everything we can to ensure those who are most vulnerable to chronic illness and the illnesses that arise from habits such as smoking receive the help and medication they need. The Bill will act as a disincentive in that regard, which is the main point. Given the pressure on people these days, if an elderly person must spend 5% of his or her income on prescription charges, it will become another disincentive to use the medication prescribed for them. The direct adverse effects on health are a concern about the Bill. The Minister is well aware that if patients do not comply strictly with their medicine regime, they risk medical complications which could require further expensive hospital care. That cost might be greater than the money the charge will generate which, according to the Minister, is €24 million.

I have a number of other queries for the Minister, one of which always arises with regard to the HSE. What will be the administrative cost of managing the scheme? People will wish to know the answer. According to the briefing notes, people will be able to claim back over-payments. How will over-payments occur? What systems will pharmacies have in place? Will they require detailed administrative systems? Let us say a person needs a prescription at the beginning of the month and needs more medicines later in the month. They have paid the €10 maximum charge and pay again when they get more medicines. Will a costly administrative system have to be put in place to deal with the matter? What number of staff will be required?

Obviously, pharmacies will have to make their own arrangements, but in the case of the HSE, will extra staff have to be recruited to administer the scheme or are staff being relocated? What exactly will be involved in the administration of the scheme and does the Minister have any costings? One of the issues with the HSE, among many others, is that it has many administrative staff. The Fitzgerald report issued last year showed that there were issues and a lack of clarity surrounding people's job descriptions. Perhaps the Minister will outline what sections will deal with the scheme, the number of staff and the cost involved.

Has the Minister had discussions with the Irish Pharmacy Union? Pharmacists are opposed to the prescription levy for similar reasons to those I have outlined. They are also concerned about the administrative task of collecting the levy and the change in the relationship between them and their patients and in the contractual relationship with the HSE. What arrangements has the Minister made with the pharmacy sector? There are people who just do not have the money to pay this charge and obtain their medicines and they might pressurise pharmacists. There is probably no answer to how that matter can be dealt with, but it is a possibility.

There is the question of reference pricing and tackling the cost of generic drugs which the Minister said could probably save about ten times the costs she is saving with the Bill. The generic drug prescribing rate in Ireland is low in comparison with other EU member states which have generic drug prescribing rates in excess of 50%. By contrast, the rate of generic drug prescribing in Ireland fell from 22% in 2000 to 19% in 2007. Perhaps the Minister will confirm if she has the relevant figures for 2008 and 2009. I do not have them, but the rate was falling. That is very disappointing, given the efforts being made to increase the rate of generic drug prescribing. In that seven year period it actually reduced rather than increased. Following the actions the Minister has taken and the discussions she has had, did the position change in 2008 and 2009?

The agreements have kept the price of generic medicines in Ireland high. It is hard to believe but in some countries savings as high as 90% have been achieved on generic medications. It just shows what is possible and the amounts of money involved if progress could be made on the issue. Am I correct that legislation on reference pricing to permit generic drug substitution by pharmacists is due to be introduced next year?

Is there any possibility that legislation could be brought forward in 2010 to ensure savings are made? How will the Minister reduce the price of generic drugs? How much will be saved through reference pricing? What drugs will be excluded?

The international trends and advice on prescription charges have not been taken on board by the Government in introducing these prices for people who are struggling to cope in Ireland today. The Minister should be tougher on the pharmaceutical industry rather than taking this approach. This target is far too easy and I am very concerned about the health implications. If the Minister insists on persevering with this legislation which also gives her the power to increase the charge — therefore, this might just be the beginning — I urge her to consider other vulnerable groups for exclusion from its remit, particularly those with certain chronic long-term conditions that affect mental as well as physical health.

I welcome the Minister for Health and Children, Deputy Harney, and thank her for giving the House so much of her time. I am also delighted to welcome the Bill which is a very workable measure. It reminds me of what happened in my last term in the Seanad when the Minister promised reforming measures in the pharmaceutical sector. This is a start.

This is not a political point, but there is opposition to the Bill for the sake of it. The main aspect of the Bill, on which the Opposition has focused, is the 50 cent per item charge. I do not know what one could buy for 50 cent; I do not believe one could buy a bag of crisps with it, or that one could buy any food item for less than 50 cent. I have the height of respect for Senator Fitzgerald and agree with many of her comments. However, she has said that if one charges 50 cent per prescription item, it will somehow lead to people not taking or not being able to afford their medication, that subsequently their health will fall into disrepair and that they could die. If that is what she is worried about, does she advocate asking the Government to give free food to people to ensure they will live and be able to feed themselves? I do not believe she would do this. It is worth pointing that out.

This is a good Bill. It is the start of the Minister's reform of the pharmaceutical sector, which I welcome. She said 2% of families with medical cards had more than 20 items per month being prescribed to them, while 35% had no items, leaving 18% with one or two. That works out, roughly, at a family having to pay perhaps €2.50. Considering the savings of €24 million that will be made, it is a small charge that might cause some pain, but those who are most vulnerable will be exempt from it. I have always found the Minister to have a heart, and she relates almost every measure in terms of the way it might affect her family to determine how it will affect families. It is in her nature to know how people will be affected by measures she might introduce.

On the category of people the Minister has exempted from the charge, it is right to exempt children who are in the care of the State, particularly with the Health Service Executive. They will not be affected by this measure. I am very pleased the Minister has exempted patients on methadone because as we have discussed in this House previously, anybody who has gone through the scourge of drug addiction and is brave enough to come off drugs and use methadone should be supported, and the Minister is rightly supporting them. I smiled, however, when I read on the Irish Pharmaceutical Union website that it was rather critical of the Minister for not doing more and referred to its customers as vulnerable patients. A little over a year ago I was very critical of the IPU when it closed its doors on vulnerable people reliant on methadone and older people who could not have their prescriptions filled. That responsibility was put on the shoulders of the Minister and the HSE to deliver the service the private community pharmacies failed to deliver. Some pharmacists had grave misgivings about the conduct of some of their colleagues but if the cap fits, wear it. Now, when it suits them, they talk about vulnerable patients but they were still vulnerable when the IPU was waving the stick and closing its doors to them.

The Minister stated earlier that long-term illness cards will be exempt from the charge. She might indicate when replying to the debate the illnesses covered by the long-term illness card.

There is a cohort of patients, mainly palliative care patients, who have their medicines changed on a daily or weekly basis. The Minister might examine that because as we are all aware, palliative care of any age group — young, middle aged or elderly patients — rightly pulls at our heart strings.

The Minister might examine also the position of people in institutional or long-term community care who may find it difficult to meet that cost. I do not know what 50 cent would buy but it is not an excessive charge when the Minister has outlined to the House the number of items being prescribed for patients in receipt of a medical card.

The Minister can correct me if I am wrong but Senator Fitzgerald pointed out that Northern Ireland has lifted its charge on prescription charges but I believe that will now be reviewed, with the possibility of the charge being reintroduced. If it is reintroduced in Northern Ireland I am sure it will be reintroduced in Wales also.

I stated that I felt the IPU was somewhat high-handed when it referred to vulnerable patients. Every patient is vulnerable. The IPU was concerned also about the way this measure would work and the negative effect this charge might have on its relationship with patients. That is being disingenuous because I cannot understand how it would have any effect. I am open to correction but I understand this charge will be levied by a computer system the Minister has already put in place on which information is held on every medical card patient. It will be done by computer rather than having a person in a pharmacy or manpower from the HSE take time out to do it. The Minister might confirm when replying to the debate that there will be no cost to the pharmacy or the HSE, and that a computerised system will be used.

I welcome the Minister's plans regarding generic drugs. More than any other time in medicine, patients now have the upper hand in terms of their own care. The Internet has opened up the market greatly for patients, regardless of whether it is a good or bad thing. If we complain of some illness or have been diagnosed with a condition we immediately look it up on Google. Many patients visit their general practitioners armed with information they never had previously, and I am sure doctors wonder why they spent half their lives at college studying medicine when patients are almost telling them what is wrong with them. However, I welcome the fact that when patients visit doctors and consultants, particularly those who do not have a medical card, they will readily prescribe the generic form of a drug if it is available.

As we are aware, a pharmacist must prescribe exactly what is on the prescription. The doctor has the right to prescribe what he or she wants but I was happy to hear the Minister say that after September she will ask doctors, in cases where a generic drug is available, to prescribe that or to write prescriptions in such a way that if the original item is not available, a generic drug would be given in its place if the patient agrees. I look forward to that measure.

I have spoken about this issue previously. We were being health and safety conscience when we introduced a quota on the number of pain-killers that could be bought over the counter. One is not allowed purchase more than 12 Panadol, Disprin or whatever in a supermarket or pharmacy yet I have seen and heard of medical card patients being prescribed 100 pain-killers a month on a prescription. I am aware of a lady who went to clean her mother's house after she had passed away and found 600 Panadol. I hate to think what could have happened if those Panadol had got into the wrong hands. There was enough Panadol in the House to take the lives of ten people. That is where the waste is, and I support the Minister's Bill in trying to clean up what has been going on in that regard.

I look forward to the introduction of prescriptions for generic drugs. We can all go abroad and buy pain-killers for a fraction of the price they can be bought here. One can buy 100 Panadol in France, Spain, Portugal or wherever for as little as €2 but we pay €3.50 here for 12 Panadol. The Minister gave an undertaking when she took on the health portfolio that she would reduce prices and she has kept her word on that. I welcome the Bill and look forward to the debates on the remaining Stages later.

I welcome the Minister. I am pleased to have this opportunity to contribute to the debate. The Labour Party is opposed to the proposed charge as it represents hardship for people with long-term illnesses.

Will the projected savings of €2 million per month mean there will be a review of cuts to respite care, home help hours, special needs assistants in schools and home care packages? A total of 467,926 people are aged over 65 years, with 8,959 in receipt of home care packages. I question whether this proposed measure will have positive implications at local level because different areas of the country have differing medical needs. For instance, people in some areas are more prone to chest conditions.

I refer to the point made by Senator Fitzgerald. Patients requiring medication may become reluctant to ask for the medication because of the charge. Senator Feeney referred to the 2% of families with prescriptions for more than 20 medications. The important word is, "prescribed". One has to allow for the fact that doctors, pharmacists and nurses can prescribe and no patient will be prescribed medication which they do not need. Medications are reviewed constantly to take account of changing needs of the patient or as new medications become available. If a patient requires additional medication because of a developing condition, this may necessitate a review of all pharmaceutical effects of his or her combined medications.

This charge is a tax on illness and is an extraordinary measure. How was the charge arrived at? I have some questions about some of the aspects of the Minister's contribution. A total of 80% of prescriptions are written for the branded form. Will the Minister change this practice? Drug companies make patent drugs to retain their exclusivity. Will there be a change in manufacture? I question why the end-users must pay this charge when this charge could best be levelled higher up the chain rather than on the people who need the medication. A charge of 50 cent could easily be absorbed higher up the chain without affecting the people, the end-users.

Senator Fitzgerald made the point whether there is an administrative cost to this charge. I question whether it will involve form-filling and whether there will be a review or appeals system if people believe they have been unfairly levied. Will the implementation of this charge require additional staff or will staff be relocated from other work? This is what happened with regard to the cervical vaccine and the H1N1 vaccine programmes where nurses have been reassigned to implement these programmes and child developmental assessment clinics have not been held. The moratorium on staff recruitment has prevented the filling of 120 public health nursing positions and is having a significant impact on primary care.

I refer to subsection (1A) of the Bill:

Subsection (1A) provides that a person who is supplied by a community pharmacy contractor with a drug, medicine or medical or surgical appliance on the prescription of a registered medical practitioner, registered dentist or nurse (who is entitled to prescribe) shall be charged 50 cent per item.

Will the Minister comment on the fact that where crutches are given to people requiring them and for which there is currently no charge those crutches cannot be used again by anyone else. Will the Minister clarify why this is the case? I researched the cost of a pair of crutches. I could only find a price in England where they cost £16.99 a pair. I presume this would translate to €50 a pair, given the difference in VAT and the fact they may be used on rough terrain here. I know from personal experience that many households have crutches which cannot be used again. It seems extraordinary that it this seems to be the policy not to recycle this genuinely reusable medical appliance. For instance, there are currently three sets of crutches in my house and I would be very happy to bring them anywhere they are needed if there is a crutch amnesty. I tried to return them but they were refused.

They are required to be sterilised.

I have worked in the health service for many years and I know there are many crutches needed in the health service. I suggest there should be a more appropriate means of raising funds without putting a tax on people who can least afford to pay it. This charge would be levied on people who are already at a disadvantage, even a charge of 50 cent. This is not about the level of the charge; it is the fact that vulnerable people who are already feeling perhaps low or depressed or sick or just not well are being charged a charge which, rightfully, should not be levied on them.

In my work as a midwife I am aware of the high costs associated with some treatment programmes, for instance, the treatment of endometriosis can cost more than €700 a month. I speak sensitively because quite a number of pharmaceutical companies are located in south Tipperary and they provide significant local employment. I do not speak against companies but I suggest if the Minister is proposing to levy a charge on the end-users who are already suffering disadvantage, it seems extraordinary that this cost could not be charged elsewhere, by some means. The Minister is most innovative in how she is able to broker agreements or disagreements so there should be some better means of covering this cost so that it is not levied against the disadvantaged.

This measure may have an implication for prescribing practice and I agree. Patients will know a drug with a different name has the same effect and qualified people can offer advice in this regard. Has the economic cost of private patients in public hospitals been analysed? Has the role of tax reliefs been examined? How much is being expended on the National Treatment Purchase Fund? I await the Minister's response to these questions.

With reference to crutches, I used this as an example. I note that walking aids or commodes are often left in houses when the user has passed away or as a result of other changing circumstances. As I do my clinics, door to door, I am very aware that many people could benefit from——

Is that a medical or a political clinic?

This is not a midwifery clinic. Generally speaking, unless poor women have had symphisiotomies or pubic symphysis dysfunction they do not need walking aids or crutches——

The Senator could double up in her work at this time of a moratorium.

If anyone needs a midwifery clinic I am still on the register and if someone should spontaneously erupt into labour, I would be quite happy to attend to her.

I do not think we will be going into labour in that way.

I could use the Senator during the moratorium.

I get people out of labour and I hope I also get people supporting Labour.

That is called double-jobbing.

I appreciate we are in difficult times and that we need to look at everything but a levy of even 50 cent on people who are the end-users is not the right way to go about it. I acknowledge it is a small sum but for some people it is too much and there is scope within the system to influence a change in prescribing practices or the use of generic drugs instead of proprietary drugs. We can review other waste in the health services.

I am interested in what the Minister said about crutches because my house is full of crutches. I am sure many people who worked in the health services, not just those in the same role as me, could advise the Minister of other waste in the health services. Targeting vulnerable people with a charge such as this is not the way to go about it. She would find greater savings if the HSE had not lumped together all the grades of staff, which has taken away from or diluted frontline services. This has created an additional load and means that everyone in the HSE is proving they did not do wrong in the first instance. There is good analysis of how the HSE is not functioning and it is mentioned in this House most weeks by Members on both sides. The point is made by Members of all parties and none who have certain reservations about aspects of care and where quality is not met or a good outcome is not provided. Much savings can be made in the HSE. This charge is not particularly good for patients.

The Bill allows for the imposition of charges on medical card holders for prescription items dispensed by community pharmacy contractors. The proposed charge will be 50 cent per item dispensed, to a maximum of €10 per month. The Bill allows for the possibility of higher charges in the future and lists two classes of people exempt from charges — children in care and methadone users. It also provides for further exemptions in the future. The Minister's intent is that this will be consistent with patient safety and continuity of supply of medication.

I have admiration for the Minister for Health and Children in her determination to address rising health costs. Most agree that the expenditure of nearly €20 billion on health services does not provide a reflective service. There are many areas where expenditure could be curtailed and this would not have an impact on the provision of services or take money from people on low incomes. Let us not lose sight of people who qualify for a medical card and are deemed to be on low incomes. Other speakers referred to these as the poorest and most vulnerable in society. Now, we want to impose a charge for required medication. Senator Prendergast expressed her view on crutches and if others have views on other areas, the Minister needs to clarify the safeguards for those who are not listed as exempt users in order to ensure consistency in respect of patient safety and continuity of supply of medication. What safeguards are in place if a person has a medical card, is on a low income and is fond of a pint or a pound on the horses and cannot afford regular medication even though this will have an impact on his or her medical and mental well-being?

The public is aware of the state of the national finances and looks at the performance and delivery of our health services when we speak of these issues. The public has a legitimate concern that, on one hand, people are being asked to contribute more and, on the other hand, the question of value for money in the delivery of health services arises. It is a legitimate question and the public are asking the question. I record the tremendous commitment of administrators, doctors, surgeons, consultants, dentists, nurses, social workers, physiotherapists, occupational therapists, speech and language therapists and all therapists. Most give an amazing commitment and are dedicated to the delivery of services. Most will also let one know of the shortcomings in the system and the need for improvement. They can indicate where money can be saved and where improvements in services for patients can be obtained.

For example, Senator Prendergast referred to the elderly. The Minister has been down the road that I am currently on with my mother. One asks why families are put under immense pressure where an elderly person is occupying a bed in a general hospital and has been assessed as requiring long-stay accommodation. Why do so many family members have difficulty understanding what is happening to their elderly parent or relative? People will jump to say that this is emotion but I do not believe it is. I suggest the Minister creates a one-page document to make available to family members detailing the procedures. The Minister referred to the holistic approach to the appropriate provision of care of the elderly. The message is getting lost at some stage. The families are put under pressure.

One questions productivity and value for money in so many other areas. Why are patients normally given the same time to attend a hospital consultant? Some 30 patients all arrive at 10 a.m. and they complain about queuing and the lack of other facilities. Where is the connectivity between the patient's doctor, the patient's regular pharmacist, the local hospital, the local HSE health centre, the regional HSE office, patient care, the occupational therapist, the social worker, the public health nurse, the home help organiser, the home helper and the family of the patient? The vast majority of people regard connectivity in these situations as unsatisfactory. This does not only involve patients and their families but also those working in the services, who are also frustrated.

There is a major demonstration of positivity on all sides and we should tap into it. It could have enormous beneficial consequences. One simple suggestion is to increase the use of modern technology between service providers. This could bring significant benefits. The Minister knows my view on the HSE as a single entity of service provision. I have covered that ground before. There is a lack of confidence and demoralisation arising principally from a feeling that there is no connectivity between service providers and that the HSE is at a loss and unable to cope. There are no insurmountable issues that should prevent us from realising our best effort in the delivery of health services. I support reform of medicine supply and price. The key is to achieve best value for money for patients and the taxpayer. We need to have a broader debate on the current structures and agreements. I am at a loss as to what these are but I know agreements and structures are in place between the Government, the Department of Health and Children, the HSE, manufacturers, wholesalers, the IPU, the IHCA and pharmacists. This is what sets the cost of medication in Ireland. Members will be aware that I had an interest in the pharmaceutical industry as an employee and I am delighted to record I brought one of the manufacturing companies which operates from Arklow to Ireland in the late 1980s. I note that only four of the top 20 manufacturing companies in Ireland with a turnover of approximately €100 million manufacture generic drugs. Pharmaceutical companies have made an immense investment in Ireland, in the process providing huge employment. I would love to know how all of this will be sorted out, in producing generic products, as well as continuing to attract the blue chip research and development activities of pharmaceutical companies to Ireland.

I do not suggest I have the answers, nor do I suggest there is a magic wand with which one may resolve all the issues. However, there is waste. Senator Feeney mentioned the quantities of medications to be found in people's homes, while Senator Prendergast made a simple point regarding crutches. The same point could be made about wheelchairs. Moreover, the Minister is aware of the provision of a tremendous service by the HSE, when a person who had been ill for some time with cancer was provided with an array of equipment and medications but who sadly died in January. Members must again ask about the issue of connectivity. They must ask about the best use of the resources available and where best value for money is being obtained.

I do not wish Ireland to lose the aforementioned 20 pharmaceutical manufacturing companies which are creating blue chip employment and investing hugely in research and development. They are the companies which have been identified as the ones we should be chasing to create employment. While I acknowledge there is research and development activity in the generic drugs sector, it is not being done to the same extent. All Members know how the system works; when a patent runs out, a company will jump on the bandwagon and create a generic product.

While I wish the Minister well, I am unsure whether taking what could be considered as the low hanging fruit route is the answer to the problem. Moreover, I do not believe the Minister believes this to be the case either, as she is aware of the bigger picture. While I would love to come up with the answer, unfortunately, I am not in a position to do so. The Minister is in such a position and this is the option she has chosen. Given all the mechanisms and ingredients she might put on the table for consideration, I hope she will answer a fundamental question. What safeguards will be in place for those who will be unable to afford the charge to ensure continuity of supply?

I welcome the Minister and thank her for her attendance. I compliment her on the legislation dealing with sunbeds, which is very worthwhile.

More preventive measures such as this might save massive amounts of money.

The number of items dispensed under the GMS and long-term illness schemes increased from 35 million in 2004 to 48.2 million in 2008, a very significant number. Like other Members, I accept that we are in very challenging economic times, but a 50 cent charge per prescription item, subject to a monthly ceiling of €10 per family, constitutes a serious expense for those who have absolutely nothing. While the Minister expects to raise a sum of €50 million in 2010 and €25 million in 2011, Fine Gael believes the prescription levy will mean that some of the poorest and most vulnerable patients with serious illnesses may be obliged to go without their medications, despite what Senator Feeney said. While the levy of 50 cent per item may not appear much to the Senator or me, if one is in receipt of a weekly social welfare payment of €160 and must budget for everything from that small amount of money, it constitutes a great sum of money. Senator Feeney should note that it can mean the difference between food on the table and medicine. International research shows that any disincentive to take medicines should be avoided, as some patients inevitably will end up in hospital or in care.

One parent families are seriously threatened in this regard. I refer to the intention in the budget to cut the single parent family allowance when the child concerned reaches the age of 14 years. Such persons are in the category most at risk in Ireland of being in consistent poverty, which means their basic necessities cannot be obtained. They will forgo medicines either for themselves or their children.

I accept there is huge waste and that methods must be figured out to avoid costing the Exchequer lots of money. However, I note that in other jurisdictions the prescription levy has been abolished. Senator Feeney suggested consideration was being given in the United Kingdom to the reintroduction of such a levy. However, I find this to be strange. As the levy was only abolished on 1 April, I hardly imagine the authorities there plan to reintroduce it so quickly. The British Medical Association has called for the abolition of prescription charges because it claims such charges are outdated, detrimental to the health of patients and, as I pointed out, act as the barrier to taking necessary medications. I wonder why the Minister is going against the tide of international experience in this regard.

As I stated, I accept savings must be made. However, the assessment of Cochrane Collaboration, a United Kingdom-based organisation, is that charges do not reduce the cost of the drugs bill in the short term. Moreover, some reviews and studies have shown that there are increases in admissions to accident and emergency units and hospitals because patients who cannot afford to take their drugs stop taking them entirely. Consequently, this will have an adverse effect on people's health. In particular, I refer to the health of patients on long-term medications such as those with mental health issues. There is a psychological impediment in respect of such vulnerable patients, as a number of speakers noted. They may stop taking their medications altogether. Having worked in this area, I know this to be the case.

Section 1 of the Bill contains room for exemptions. In common with other Members, I ask whether the Minister intends to exempt patients with cancer or pregnant women. Alternatively, a patient who has recently presented with diabetes and is being regularised may be obliged to obtain different drugs to establish a regime. Will the Minister consider an exemption in that regard? I do not advocate that one should support pharmacies because they are a well organised profit-making body, but last year their representative organisation introduced and suggested a great number of ways of prescribing generic drugs.

Has the Minister considered any of their proposals?

The other question relates to pharmacies having to collect the money. What will happen where a patient refuses to pay? Has the Minister considered this possibility? If patients exceed the figure of €10 in a month, how will the amount overpaid be paid back. How will the scheme be administered? In a 12 month period the cost could amount to €120. What system will be put in place to refund any moneys overpaid? The Minister tried to introduce a system to take back the medical card from the over-70s and now she is introducing a levy on prescriptions.

To catch them anyway.

Senator Fitzgerald referred to reference pricing and the cost of generic drugs. Senator Feeney made a good point about GPs being mandated to prescribe a generic drug alternative, as should pharmacies, rather than the more expensive branded drugs. I am in favour of monitoring repeat prescriptions. People have massive quantities of medications in their homes which are returned when, sadly, a patient dies. These can only be disposed of as, legally, one cannot do anything with them. The monitoring of repeat prescriptions should be considered and GPs encouraged not to prescribe so many medications in the first place.

I assure Senator Prendergast that I will not spontaneously erupt into labour any day soon. That is an important point to make.

That would be a little difficult.

Senator Ó Brolcháin is talking politically, of course.

I was not. I believe in equality of the sexes.

Home birthing is very important, as I have mentioned to the Minister in the past.

I recently watched an episode of the medical drama "House". I do not know if anyone else has seen it. It is an American series, with the actor Hugh Laurie, and quite interesting.

We did not have time to watch it.

I know. Sometimes it is important to look at what people are watching on television. The episode in question was interesting. The doctor was talking to a patient for whom he did not have much time and with whose views he did not agree. He went to the canteen to get sweets from a sweet dispensing machine which he gave to the patient in a bag. The patient went away extremely happy. The use of placebos is well known throughout history. They have an effect and work for many. There is a tendency for patients to feel cheated when they leave a doctor's surgery if they have not been prescribed something. If I am correct, that could to some extent be behind the Minister's thinking on the Bill. I would be interested to hear her views on the matter.

I have talked to various people and heard differing views on the 50 cent levy. I accept the Bill is not purely about the levy. However, we should consider whether it will stop people from buying medications. We must examine whether the introduction of the legislation will act as a deterrent to people who would previously have bought medications. I do not know if that is the intention behind the Bill, but I suspect there is an element of such thinking behind it. It is certainly a revenue-raising provision. Some believe it will stop people from seeking unnecessary prescriptions, but the issue is whether it will stop those who need medications from getting them.

There is an overuse of antibiotics, especially to treat viruses or illnesses. We need to change our culture in this regard. We must consider measures not only in terms of the financial considerations but also in terms of working with those involved in primary care to ensure doctors consider it acceptable not to prescribe. People should be educated at school to the effect that it is not always necessary to take medicine to cure an illness. The response to some illnesses should simply be going home, resting and taking care of oneself and perhaps having a nice cup of tea or TLC. There is nothing wrong with a person being told by his or her doctor to go home, have a hot drink and go to bed for a few days and for the doctor to write a certificate of illness. However, I would be concerned if the imposition of a 50 cent levy meant people who genuinely needed medication were prevented from getting it, but I do not believe that will happen. Perhaps a review mechanism could be built into the legislation. Being a responsible Minister, I am sure the Minister will do this. The levy should be examined over time to see what effect it is having on patient care and whether people are struggling in not taking medication because the levy is acting as a deterrent.

It was pointed out to me that a number of categories were exempt from the charge. It might be more useful if that was a matter for the Minister to decide. Other groups may emerge in the future which we have not thought of who could be exempt. I favour expanding the categories of persons exempt rather than limiting them to the two groups referred to in the Bill and giving the Minister discretion in that regard.

I was intrigued by the comment made by Senator Prendergast on crutches. I am not aware that it is especially relevant to the Bill.

They are considered to be an appliance.

It is related, therefore, in a roundabout way. There is much waste in the health care sector. In these difficult times we should consider ways to reduce costs. That is one possible way. We could improve the provision of wheelchairs. The issue of prosthetics was raised with me recently. It is my understanding there is a possibility that prosthetics will be imported from now on. Work in that regard is ongoing. It is important that the cost of prosthetics is kept down through increased competitiveness, of which the Minister is very much in favour.

Overall, the Bill is an interesting one. My main point is that a review of the effect of the measures proposed should be built into the Bill, perhaps in a year's time. Members of the Opposition have suggested the introduction of the levy might prevent people who need medications from getting them. Therefore, it is important that there be such a review. There is a need for empirical evidence in health care. I commend the Minister for being innovative. She will continue to be so. The provisions of the Bill are certainly worth exploring. As such, I will be supporting the Bill.

Cuirim fáilte roimh an Aire.

The prescription charge in the Bill will not make the healthy choice the easier choice, particularly for vulnerable groups. We must remember it is doctors who prescribe, not patients. Perhaps the Minister should target the doctors rather than making patients pay.

Let us look at the facts. I am basing all my points on evidence. Thirty per cent of the population currently hold medical cards. There will be a charge of 50 cent per item prescribed and a maximum charge of €10 per family. Those who will be most affected will be the vulnerable, including the elderly, patients with chronic illnesses, the homeless and people in sheltered accommodation.

The Minister has justified the charge on the basis of the need to raise money and to discourage over-prescribing and the overuse of medication. Although she is discouraging over-prescription and overuse of medication, it is the doctors whom she should educate and target. Patients do not prescribe; it is doctors who do.

I am concerned about the effects on people's health if they stop taking medication. Senator Feeney said 50 cent is very little. While I accept that, it does depend on whether one is in one of the vulnerable groups. One never knows what will prevent a person from obtaining his medication. Consider what occurred in respect of warfarin, for example. Warfarin is an essential blood-thinning drug for people with particular heart complaints. Since the affected had to go to a general practitioner to get their blood levels checked, they did not do so. The cost of going to the general practitioner mitigated against their doing so.

There are warfarin clinics all over.

Not in Galway. Galway is unique in not having a warfarin clinic. This is because of the glut and the need to get it into the community.

The health promotion evidence is all about making the healthy choice the easier choice. Cochrane Collaboration, an international drugs review body that assesses health systems and the effectiveness of drugs, found that introducing prescription charges reduces the cost of the drug bill in the short term. However, it found that introducing charges for people on low incomes, and even high incomes, leads to a reduction in drug use for life-sustaining drugs. These are the drugs that count, not the ones Senator Ó Brolcháin referred to, which drugs would not be necessary if one simply went to the doctor, went to bed, had a hot drink and got some rest. I refer to life-sustaining drugs for chronic illnesses, diabetes, asthma and psychological conditions.

The Cochrane Collaboration report found that those with mental health conditions are more likely to stop drug use for financial reasons. The Cochrane Collaboration is an international drugs review body that assesses health systems internationally. It found there was an increase in admissions to accident and emergency departments, hospitals and nursing homes because patients had reduced their intake of drugs because they could not afford them.

The Minister is imposing a charge of 50 cent in the short term but it will cost the health system more in the longer term. Six years ago she said she wanted a world-class health system. This is not the way to do it. She will clog up accident and emergency departments further. Her approach is not workable because there are no primary health care centres in the communities.

We have heard that before. I was involved in health promotion with the Midland Health Board from 1998 to 2002. I was at that point involved in a review of primary health care units. We still do not have one in Galway.

The review also found that the failure to take prescribed medicine has a direct adverse effect on health and results in increased use of health care services and higher health care expenditure. All my points show that the 50 cent charge is short-sighted and is merely a Band-Aid to a bullet hole.

The conclusion of the Cochrane Collaboration review is that "increasing cost-sharing may present a financial barrier to poor households for patients with chronic conditions who need high volumes of pharmaceuticals" and that pregnant women, children and older people are particularly most likely to be negatively affected. Harm is less likely if charging is introduced for non-essential drugs and if exemptions are built in. There is some sense in bringing in the 50 cent charge for non-essential drugs. I ask the Minister to consider seriously not introducing it for drugs that are life sustaining and drugs for chronic illnesses. Has she considered this?

The journalist Sara Burke states: "In most European and OECD countries, there are some charges for prescriptions, but not for the poorest 30 per cent of the population. In Wales, there have been no charges since 2007. In England, Scotland and Northern Ireland, certain groups are exempt from charges, such as people on low incomes, people with chronic diseases, pensioners, pregnant women, children and cancer patients. In England, more than 85 per cent of the population is exempt." Northern Ireland and Scotland are phasing out charges for everyone in the next two years.

The British Medical Association chairman stated: "Abolishing prescription charges is the fairest and the simplest option [...] if all patients could get the treatments they needed via free prescriptions it may reduce hospital admissions and costs for the health service in the long run". While the Minister will save a certain amount for the Exchequer in the short term, she will impose a cost on the health system in the longer term. Her record and reputation in the health system are not strong; they are notably weak. Why do more damage and harm further her reputation and that of the Government?

The amount expected to be raised through drug charges this year is €42 million and it is expected to be €52 next year. Medical card holders comprise the poorest 30% of the population and increasing charges from €100 to €120 per month will hit those on lower incomes the hardest.

The Minister says she wants to discourage over-prescribing, for which I applaud her, but I reiterate that patients do not prescribe drugs. If one wants to change prescribing and dispensing practices one must speak to doctors and pharmacists, not the patients. This very point was supported in last week's article in The Sunday Times by Sara Burke.

I wish the Minister well but ask her to think about those with chronic illnesses and those on low incomes, whose lives she may be risking. That is what we want to prevent.

Cuirim fáilte roimh an Aire go dtí an Teach. The week that is in it, I feel like shouting "Tally ho" across the benches.

"Stop it" is right because we are at the core of what the Bill is about. It is about the imposition of a fee on people. The Bill, its explanatory memorandum and the Minister's speech all state this.

The charge is 50 cent i dtús báire. The Members opposite, as former members of local authorities, will know well that what starts small can increase incrementally. I remind them that the charge will be imposed on the elderly and the vulnerable. Thanks to the policies pursued in the main by Fianna Fáil, ably assisted by the Green Party and the former Progressive Democrats, there is a new poor in society, the middle class. It is expected to pay for everything. It is, in many cases, in trouble financially because of no fault of its own other than that it bought property at the peak and has lost jobs because of the financial crisis and the lack of employment opportunities in this country.

We in Fine Gael have put forward a model called FairCare the basic principle of which is that the money follows the patient, but we have also advocated a role for pharmacists in the treatment of minor illnesses. The bottom line here is it is about the safe, timely and efficient delivery of services. In this case, I am concerned we are accentuating a divide in society.

I agree with the Minister to a point that there is a need for reform and change. I have no difficulty with that and I admire the Minister's bravery in many ways in what she is doing and trying to do. However, this is an unfair imposition.

I listen to people talking about what is best for society and what is best for people. I canvas four days a week and I meet people more than most Members of this House. I say this not in an adversarial manner at all, even though I could. I have seen women and men, predominantly elderly, making the choice whether to skip taking tablets. They have shown me half tablets and quarter tablets. I have seen them going to their general practitioners who, to their credit, have given them free samples——

——because they cannot afford to pay for them from the pharmacy. I have seen pharmacists giving prescription medication on tick or letting people pay back so much per week. These are not living on Aylesbury Road. These are not people living in big flash mansions or those who have vast amounts of money. These are people who have worked hard and who are on pensions, such as retired teachers, who are struggling. Is the Minister seriously saying here that we are making people make choices regarding their medication? I agree with what Senator McFadden stated earlier, that we are frightening people and the Department is doing a bad job of explaining and communicating. I fully agree with the Minister regarding waste. I am with her 100% on that, but the way to avoid that is not to come in here with this prescription levy and penalise people.

I listened to the arguments being put forward by the other side. It is unfortunate the two Members opposite are here because I do not want to aim my fire at them.

There is a responsibility on the HSE and I do not know if it understands the word "responsibility". This morning in this House I sought an Adjournment debate regarding the NRA and I was told the Minister has no responsibility and cannot come in. I have sought Adjournment debates here regarding the HSE and I have been told the Minister, Deputy Harney, has no responsibility. The line Minister, in the case of the HSE or the NRA, is either responsible for the body concerned or not.

We speak of cutting costs. God bless Mr. McCarthy, but he does not seem to understand the concept of society, which should be people centred. Where I have a fundamental disagreement with the Minister, although I inherently believe she is an honourable, decent and caring person, is on the ideology she is pursuing which does not put the patient first, which does not put people first and which puts profit and reduction in expenditure before anything else. I ask the Senators opposite if they seriously believe this Bill is the correct way to go. How will we make assessments?

The Minister will be aware that every day of the week there is a reduction in the number of medical cards and in GP medical cards. She might shake her head but I can give her a file of people who have had their applications refused and who are not millionaires or rich people. I genuinely want to hear an answer to that because the reality is there are ever more people now being refused, not getting access to services and having to wait longer.

I do not want to see this country having a dependency on prescription drugs — far from it — but we need to look at the implementation of reference pricing and tackle the cost of generic drugs, which Fine Gael states will save ten times as much.

The Minister, despite her protestations to the Members opposite, states the Bill is the way to go, but it is not and no amount of statistics or spin can prove otherwise. I am disappointed we are here debating this Bill. Fine Gael will oppose this Bill and we will call a vote on Second Stage. The savings are at a cost, which is quality of life.

I welcome the Minister for Health and Children, Deputy Harney, and welcome the opportunity to speak on the Bill.

There are three aspects to this Bill. First, it is a significant attack on the poorest people in this country; second, it places an extra burden on the pharmacists; and third, it increases the workload of the HSE. Those are the three areas into which I have broken up this Bill.

No doubt it is an attack on the weakest and poorest in society. The Government has stated over the past two years that with the financial crisis, into which it has led this country over the past 12 years, it would protect the weakest and the most vulnerable. This is an attack on them. To those people, €10 is quite an amount of money. Those people, in most cases, are hard done by in any event and they are the weakest and poorest in society.

Second, it puts an extra burden on the pharmacists who must keep extra records and take on extra staff. I would ask the Minister to state how this will affect their businesses. Over the past year and a half, the Minister put her own views on pharmacy and pharmacists on the record. They have been severely hit financially. Some of them have been in a terrible financial crisis over the past number of years. However, this places an additional burden on them.

In addition, new regulations state that pharmacists must have interview rooms. Some pharmacists throughout the country have premises with small square footage and to put in interview rooms will be difficult in some cases. It would be okay for big outlets such as Boots but for small family-run pharmacists, who provide a significant service, particularly in rural areas and who know the people and know what they want the minute the come in the door, to have to put in a private interview room will place another burden on them. I ask the Minister to get whoever is responsible for this to have a fresh look at it because it is unwarranted in many cases.

Third, the Bill puts an extra workload on the HSE to keep all of these records and go through all the costs and savings the Minister states will be associated with it. Will it require additional staff for the HSE? Will the HSE have to take on more staff or will it redeploy staff from within the Civil Service or the HSE? No doubt it will involve a good deal of bookkeeping and record holding, and probably visiting pharmacists and going through their books. That will require additional staffing. I hope the Minister will not employ extra staff and that staff will be redeployed instead. Several initiatives introduced by the Government in recent years have entailed expansion in the Civil Service and its various offshoots. This places a sizable burden on the businesses associated with them. I hope the Minister will be able to tell us the Bill will not lead to further employment, but that staff will be redeployed. We all know there is waste within various sections of the Civil Service, the HSE and other bodies. I hope the Minister will outline the situation before we adjudicate on the Bill.

I am happy to respond to our debate on this Bill, the purpose of which is to impose a prescription charge. As to the administration, a number of Senators seem to be under the illusion that a host of people in an office will go through various files to ascertain how to collect 50 cent. All payments for items through the general medical services, GMS, are computerised. If one uses a medical card in a pharmacy, this computerised transaction is sent to the HSE for payment. The HSE knows how much medication every medical cardholder gets each month. This is the basis on which I gave the figures. The number of prescriptions has increased by 4 million and the number of items prescribed has increased by 15 million in recent years to nearly 60 million. Notwithstanding our aging population, there is no correlation between these figures.

Through computerisation, the HSE will know when a family hits the €10 mark. If someone goes to €10.50 or €11, it would be sensible to repay the amount every two months, for example, instead of sending people cheques for 50 cent. We are discussing a computer transaction, so a host of people will not be employed at the GMS payments board or in pharmacies. When someone with a medical card visits a pharmacy for medication, it is not unusual for him or her to buy something else as well. The pharmacist is used to engaging with people.

Last year, I was in the Seanad when we discussed reducing the wholesale margin and fees to pharmacies. Members, including the Senators opposite, predicted that 300 to 400 pharmacies would close in the coming period. I am happy to say there are more pharmacies now than there were before we introduced the changes. This is a fact.

A number are under pressure, but not because we are not paying them much. By international standards, we are paying them a great deal. However, many pharmacies, particularly in urban areas, got caught up in the property boom. Some of them paid an exorbitant amount to enter a business that the health service cannot sustain or be expected to sustain. I have considerable sympathy for those pharmacists, but that is a separate item from the manner in which the State reimburses pharmacies.

Reimbursement under the GMS increased from €748 million in 2004 to €1.2 billion in 2009. It is because of my great respect for pharmacists that there will be a regulatory body under the new legislation. Until we passed the 2007 Act, pharmacies were effectively unregulated. They operated under an Act that was 180 years old. The pharmacy interests, particularly the profession, were beating down my door and the doors of many of my predecessors because we needed modern legislation to regulate their profession, as they did not have the capacity to take action where there was inappropriate behaviour in the profession.

The regulatory body has decided that pharmacists should have a separate space in which to talk with patients.

Pharmacy is unlike any other retail business. Patients are entitled to engage on a confidential basis with pharmacists.

I attended a recent meeting with Dr. Barry White, the new director of clinical care and quality at the HSE concerning the roll-out of new clinical care pathways. Some 24 clinicians, all leaders in their fields, have been appointed to roll out a new clinical care pathway through which things will be done differently in their respective fields. The money saved will be invested in new services. The clinicians are a fantastic bunch, some of the best in the country. Professor Peter Kelly in the Mater Hospital will lead on stroke, Professor Kieran Daly in Galway will lead on acute coronary syndromes and Professor Michael Turner, a former master of the Coombe, will lead on obstetrics so that we can have standardised care across the country.

There will also be clinical leads at general practice level because we badly need protocols for prescribing. As the House knows, 63% of prescriptions in the UK are for generic medicines. In Ireland, the comparable figures are 18% on the GMS and 12% on the drug payment scheme, DPS. There is no justification for the difference. Pharmacists should be involved because they are an under utilised resource in the health care system. They must be among the brightest in their classes to get into pharmacy school.

They have considerable potential that we have not tapped. Sometimes, we seek to include new professionals in providing services. For example, I have provided for nurse prescribing in terms of X-rays and medication and for the involvement of nurses in the forensic examination of sexual assault victims. These initiatives are greatly enhancing the role of nurses and make more sense, as nurses comprise 35% of health care professionals.

The new legislation on generic substitution and reference pricing will provide pharmacists with the opportunity to substitute. For example, if a doctor prescribes the branded name, the pharmacist will be able to substitute and will only be paid where there is an appropriate substitute. That legislation will be before the House later this year. While it will enhance the role of pharmacists, I want it to do more. They could play an important role in the management of medication. For instance, they are equipped to administer vaccines. At a time when there is a recruitment moratorium and staff shortages in the public health care system, we need to avail of expertise in the most sensible way possible. I intend to do so and we had a good meeting with Dr. White on these issues. When one engages with professions about new services, people sometimes raise the question of additional money. In this case, it must be a question of switching the money around so that it can be provided elsewhere.

There are a number of exemptions and the Minister has the power to award further exemptions. There are few places in western Europe, North America or Australia where co-payment is not found. For many years, Senators told me there should be a small charge for going to a general practitioner. Senator Feeney made an interesting point. If we say that people will not take their medication because they must pay 50 cent and the amount is capped, it is like saying people will not eat food or drink water if we begin to charge for those. This aside, there are a number of exemptions.

As to the 50 cent, Colm McCarthy recommended €5 per prescription, but that would have been too much. A small amount would collect for us €2 million per month. Putting this in perspective, we were able to invest an extra €10 million in home care packages this year. Would it not be great if we could have invested an extra €24 million? Some €12 million is not an inconsiderable amount, although it looks small alongside €15 billion. It is amazing what this type of money can do. We will probably deal with this matter on Committee Stage. Senator Healy Eames cited the literature, but literature is like statistics, in that there is plenty around to support both sides of an argument. The literature equally shows that people do not reduce essential medication and that the charge will change prescribing behaviour. Clinicians will take into account costs in respect of the number of items being prescribed. There is no doubt that we have a high level of antibiotic prescribing. This has contributed to our high levels of MRSA and other health service-acquired infections in recent years in comparison with the Netherlands, where the level of prescribing is relatively low.

Everyone on a long-term illness card will be exempt, including diabetics, people with mental illness, people aged less than 16 years, people with a mental handicap, haemophiliacs and people with cerebral palsy, phenylketonuria, PKU, epilepsy, cystic fibrosis, multiple sclerosis, spina bifida, muscular dystrophy, Parkinson's, acute leukaemia and so on. I will also exempt children in care and people on methadone. If the evidence suggests we should exclude other categories, I will be more than happy to do so. We will discuss homeless people later. It is not for me to be to be able to distinguish when somebody has a medical card whether he or she is homeless. There are practical difficulties around some of the amendments that have been tabled.

On crutches, I have had discussions recently with the HSE around how appliances may be used. Obviously, they have to be sterilised. In some appliances there are safety issues, as well as the question as to whether the manufacturer will guarantee them if they are passed on. We are trying to address these issues because every single saving matters. Not alone does it matter from a money perspective, but also from a perception perspective, if people believe there is a non-utilised pair of crutches, wheelchair, chair for stroke patients or whatever.

Many years ago after my father died, I gave a chair to a neighbour which I thought would be very comfortable for him, as we no longer needed it. This was before I had become aware of all the infection and sterilisation issues, prior to coming to the Department of Health and Children. However, that neighbour was very grateful for that chair, for which we had no use, and it was great. I felt very good about it and the neighbour felt very good as well. We need to do more, and much of it has to do with points of collection, sterilisation and so on. In an environment where we are constrained, we have to look at all these issues.

I will not address Fine Gael's FairCare programme, except to say that I look forward to having it costed. I wish Fine Gael would submit it to the Department of Finance to be costed, and then we could have a real debate.

If we were not constrained by the financial environment, would we do this? Probably not, to be honest. We have looked at all aspects of the pharmacy chain. We have reduced the wholesale margin, from 17.6% last year to 10%. We have reduced the manner in which we remunerate pharmacists, from a 50% mark-up to 20%, and we have changed the manner in which we pay for prescriptions in the GMS. The first 20,000 are paid at a higher rate than the subsequent number. We have reduced the off-patent price paid to the producers of medication by 39% this year. That alone is €100 million. The irony now is that generic products are dearer in Ireland than the off-patent products. That contract comes up for renewal in September, and we intend to drive further reductions there.

The reason the generic market is small in Ireland is that the products have not been prescribed, or dispensed. With the changes we are making, the market will grow, and we should get better value. The whole market is only worth €300 million, although I have heard people argue that if we opted for generic substitution, we would save €300 million. We could only do that if we got them all free. That is the total size of the market. However, the market will grow when we bring in reference pricing and generic substitution. A bigger mark-up obviously leads to additional savings.

I welcome the debate on Second Stage and I look forward to Committee Stage. I hear what the Senators opposite are saying, to the effect that they will not support it. However, and I say this very genuinely, it is important that all of us think about the medication we take. Doctors frequently tell me that if they do not give prescriptions, the patients believe they are not doing their job, although that argument has not been advanced by the professional organisations per se. Sometimes as patients we believe we need things that we do not. Often I am amazed at the number of items people get on prescription, and the amount of medication they are holding as a so-called “crutch” in the event of needing it. Most of that is wasted, and subsequently dumped.

On medical cards, Senator Buttimer is incorrect. Some 140,821 new medical cards were issued between June 2009 and May 2010, and an extra 16,336 doctor-only cards. More people now are on medical cards than ever before in the country's history. There are 1.622 million on full medical cards, until the end of May and 115,900 on doctor-only cards, equivalent to 1.7 million cards. Some people are losing their cards as we centralise medical cards. There was one case where somebody had something like €3 million in the bank, and for some reason, under the old health board system, that person managed to get a medical card.

We are adhering to the criteria. Whether one lives in Donegal, Galway, Dublin or Kerry the same criteria are used. That is fair. That is what happens with the welfare system and there is no reason the health system should be different. Clearly, hardship cards are given in genuine hardship cases, particularly to people with difficulties that cannot be defined in legislation. Some 70,000 hardship cards are given on the basis of the particular circumstances at the time of an application.

Question put.
The Seanad divided: Tá, 29; Níl, 19.

  • Boyle, Dan.
  • Brady, Martin.
  • Butler, Larry.
  • Callely, Ivor.
  • Carroll, James.
  • Carty, John.
  • Cassidy, Donie.
  • Corrigan, Maria.
  • Daly, Mark.
  • Dearey, Mark.
  • Ellis, John.
  • Feeney, Geraldine.
  • Glynn, Camillus.
  • Hanafin, John.
  • Keaveney, Cecilia.
  • Leyden, Terry.
  • McDonald, Lisa.
  • Mooney, Paschal.
  • Ó Brolcháin, Niall.
  • Ó Domhnaill, Brian.
  • Ó Murchú, Labhrás.
  • O’Donovan, Denis.
  • O’Malley, Fiona.
  • O’Sullivan, Ned.
  • O’Toole, Joe.
  • Ormonde, Ann.
  • Quinn, Feargal.
  • White, Mary M.
  • Wilson, Diarmuid.


  • Bacik, Ivana.
  • Bradford, Paul.
  • Burke, Paddy.
  • Buttimer, Jerry.
  • Cannon, Ciaran.
  • Coffey, Paudie.
  • Coghlan, Paul.
  • Cummins, Maurice.
  • Donohoe, Paschal.
  • Fitzgerald, Frances.
  • Healy Eames, Fidelma.
  • McCarthy, Michael.
  • McFadden, Nicky.
  • Mullen, Rónán.
  • Phelan, John Paul.
  • Prendergast, Phil.
  • Ross, Shane.
  • Ryan, Brendan.
  • White, Alex.
Tellers: Tá, Senators Niall Ó Brolcháin and Diarmuid Wilson; Níl, Senators Paul Bradford and Maurice Cummins.
Question declared carried.
Sitting suspended at 2 p.m. and resumed at 3 p.m.