Health (General Practitioner Service) Bill 2018: Second Stage

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

It is my pleasure to introduce the Health (General Practitioner Service) Bill 2018 to the Seanad. I was pleased last December when the Government announced that eligibility for a general practitioner, GP, service without fees was to be extended to all people in receipt of a carer's allowance payment. Following further examination of the proposal, the Minister for Health, Deputy Harris, confirmed in April that this measure should also be extended to persons in receipt of carer’s benefit. The purpose of the Bill, therefore, is to provide a general medical and surgical service free of charge to persons in receipt of either carer’s allowance, both full rate and half rate, or carer’s benefit. This Bill will result in approximately 14,000 additional people being eligible for a GP visit card. It will enable them to access vital GP services without having consider their ability to pay for the service.

Becoming a carer for a loved one is a life-changing experience. Each day can bring new demands, new highs and new lows. The 2016 census noted that over 195,000 people, that is, 4.1% of the population, provided unpaid assistance to others. This amounted to a total of 6.6 million hours of care per week. Some of this care is provided on a 24-7 basis by family members or unpaid carers. Carers come from different walks of life and enter into their caring responsibilities at different stages in their lives. Their reasons for beginning this journey, however, are the same. They are all motivated by their love for the person they are looking after and they also have an expert knowledge of the person that no one else could have. While there are many positive and rewarding aspects to caring, it can also place physical and emotional demands on carers who are trying to balance their own well-being with the needs of those for whom they care.

It is also recognised that being a carer can have financial consequences, with many carers having to either reduce their working hours or even give up work entirely. This is, of course, often done unselfishly but nevertheless it is important to recognise that this can create a burden on carers in a variety of ways. In recognition of the significant contribution and commitment that family carers make and the concerns they face, the Government developed Ireland’s first national carer’s strategy in 2012. The strategy sets the strategic direction for future policies, services and supports provided to carers by Departments and Government agencies. On healthcare, the strategy recognised the need to support carers in maintaining their own physical and mental health.

We do recognise, however, that both time and money constraints can sometimes make this very difficult. The question often asked is, who cares for the carers? There is no doubt they need and deserve acknowledgement, understanding and support from their fellow citizens and from their Government. To that end, a number of initiatives have been progressed in recent years to aid carers. These include increases of €5 in the social welfare payments made to carers in budgets 2017 and 2018 and an extension from six to 12 weeks for the continuation of these payments after the death of a person who was cared for or his or her entry into residential care. This has gone some way to ease the financial burden on the shoulders of carers.

Last December, it may be remembered, an additional investment of €10 million in respite care services was announced. This will deliver greater provision in respite care for people with disabilities, enable more carers to take a break from the daily caring routine and provide them with much needed time to maintain their own health and well-being. The provision of a free GP service is another important milestone in the Government’s continued support for carers. It is another major step. The provision of high-quality GP care, centred on the needs of carers, is essential to ensure that carers' own health does not deteriorate. This is particularly the case because we know that their health tends to deteriorate gradually as their hours of caring increase over time. The Health Service Executive has indicated that carers will be able to apply for a GP visit card from 1 September 2018. If we do this today, we can move fast. Applicants will be facilitated to make either a paper or online application.

The provisions of the Bill are straightforward and I will outline the main provisions. Section 1 provides the relevant definitions, section 2 provides that the HSE’s appeals process be extended to encompass this service and section 3 provides that the HSE’s current "ordinarily resident" framework be extended to this new service. Section 4 provides for a GP medical and surgical service to be provided free of charge for persons in receipt of either carer’s benefit or full or half rate carer’s allowance and for the assignment of a GP of choice, where practicable. That enables the HSE to request the necessary documentation from applicants to establish if they are, or continue to be, eligible for this new service. Section 5 of the Bill provides for the Long and Short Titles of the Act and the relevant commencement provisions.

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

I welcome the Minister of State to the House and I am very happy to support this Bill, which will provide for eligibility for GP services without charge to be extended to all those in receipt of carer’s allowance or carer’s benefit. Carer’s allowance is a payment to people on low incomes looking after a person who needs support because of age, disability or illness, including mental illness. Similarly, carer’s benefit is a payment made to insured people who leave the workforce to care for a people in need of full-time care and attention. The carer’s allowance, carer’s benefit and the respite grant, now the carer's support grant, were introduced by a Fianna Fáil Government. I spoke to the Minister earlier about an issue that I have also spoken about to our health spokesperson, Deputy Donnelly. I have also been working on it with Senator Murnane O'Connor, who has been doing great work with Ms Catherine Cox, who looks after the carers in Carlow.

A cohort of people lose the carer's benefit after 104 weeks, but, of course, they continue to care for people. This cohort, which numbers 6,000 to 8,000 nationally, should also qualify under this scheme.

In seeking submissions from the general public to the loneliness task force we received a significant volume of correspondence from carers. According to the Central Statistics Office, CSO, there are 360,000 family carers in Ireland. Family carers provide care and support to a person with a disability, chronic condition, mental health concern or long-term illness. They care for the person in their own home and as a result are usually confined to the home unless there is a suitable respite service, or another family member is available at that time to take over caring responsibilities. The majority of family carers in an Irish study reported major restrictions on their social or leisure activities, with isolation being a problem for many. They take up the mantle of caring for others with their own health often suffering as a result.

The Bill intends to remove the financial barrier to accessing a GP to encourage people to seek treatment at an earlier stage, rather than delaying the decision to seek care until the point at which the illness has progressed to the point where it requires hospitalisation, which is a much more expensive form of care. In the next 30 years, the number of people in Ireland aged over 65 will double and the number aged over 85 will almost quadruple. We are living longer than our ancestors could ever have envisioned, but inevitably as we grow old we will all experience the ailments and disabilities which are part and parcel of ageing. We need to look after our most vulnerable and those taking care of them.

Despite my bias, it would be remiss of me not to acknowledge the horrendous condition of general practice and how it is being crippled under the current Government. There is no point in giving GP visit cards to carers if there are no GPs to look after them. GPs have faced repeated cuts. There is an almost complete breakdown between GPs and the HSE with regards to retention and recruitment. According to some estimates, seven out of ten GP surgeries are no longer taking new patients. This is an important aspect of this Bill; it is not a tangent. If we are to provide carers with GP visit cards, we need to have doctors to see them. An inclusive process is needed. Contract negotiations are meant to be under way with one union, the Irish Medical Organisation, IMO. However, the National Association of General Practitioners, NAGP, services 2,500 GPs. We are not going to get unilateral support, and we are not going to get a contract negotiated and agreed unless all stakeholders are at the table.

In August 2016, the Minister for Health stated: "I think it is absolutely essential that we have the new contract negotiated and I want to see the NAGP as part of that... what I am doing is saying very clearly that when we get down to negotiating the GP contact, which I expect to happen by the end of the year, that the NAGP need to be in the room". That is not happening.

Cuirim fáilte roimh an Aire. Dar ndóigh, tacaím leis an reachtaíocht seo. I would also like to welcome the Minister of State.

This is welcome legislation. The extension of the GP visit card to these categories of people is a welcome development, and the Minister of State has spoken clearly about the importance of carers to us as a community. I speak from personal experience, like many others here. I live with a person who is being cared for by my mother. Everything the Minister of State said about the need to care for carers resonates strongly with me. It relates to the interconnection of the physical, emotional and mental needs of carers and the inevitable stretch on the welfare of the primary caregiver that can make a dramatic difference in people's lives.

The carer's allowance is a means-tested payment extended to 77,000 people on low incomes. As countless reports and investigations in recent years have indicated, these people are under enormous physical, emotional and financial pressure as they care for loved ones. Many of us watched the "Prime Time" special on this topic last December. It shocked many people, showing as it did the problems faced by carers in stark terms. I fully support the move to grant GP visit cards to people on the carer's benefit or the full-time or half-time carer's' allowance.

However, in light of the concerns expressed by Family Carers Ireland and no doubt expressed to the Minister of State personally, does the legislation go far enough? Family Carers Ireland points to a larger cohort of people, those in receipt of the carer's support grant. The grant is not means-tested and it results in a €1,700 annual payment to 105,000 people. There are many people in receipt of that grant who do not qualify for the carer's allowance due to their income exceeding the means test., yet, in many cases, their need for additional supports may be just as urgent. Would the Government consider extending the GP visit card to this cohort of people as well. It is a larger cohort; it would no doubt cost extra were it to happen. I do not know whether it has been costed or how much is envisaged. The proposal before the Seanad will cost €10 million per annum. How much more would it cost to extend the GP visit card to those in receipt of the carer's support grant, formerly the respite care grant? How much is involved? Is it within the Government's plans? Does the Minister of State think it will happen, and if so will it happen soon?

We also have to be mindful of the problems facing GPs, even as we seek to widen access to GP visit cards. The NAGP has pointed out that GP practices are badly stretched, with widespread reports of people having difficulty finding a GP to take them on as patients. The president of the NAGP, Dr. Maitiu O'Tuathail, spoke eloquently about these problems during the recent referendum campaign, as the Government sought to place even more pressure on GPs through the new abortion proposals. His predecessor as president, Dr. Andrew Jordan, said that GP services could be as extinct as the Tasmanian tiger unless the Government intervened. The Minister for Health has repeatedly said that GP services should be at the heart of a new community-based system of healthcare, but where is the investment to make that aspiration a reality? The scheme proposed in the Bill, and any extension of this scheme in the future, which I would strongly support, must be accompanied by a significant rethink of the way GP services are resourced currently and in the future.

Before I call on the next speaker, I would like to welcome our visitors to the Gallery, Aislinn, Julian and Rosa Pearl. They are very welcome.

I welcome the Minister of State to the House and I thank him for bringing forward this important legislation. The 2016 census recorded 195,000 carers in this country, providing more than 6.6 million hours of care. That highlights the extent to which care is being provided within the community. In a lot of cases they are not getting all of the necessary supports.

One thing about carers is that their work is not just about providing care. They also follow up about services for the people they are caring for. That can include trying to access services, working with services, arranging a GP call for the person they are caring for, taking them to the GP or the hospital or attending clinics on an ongoing basis.

The people being cared for need ongoing support within the health services. The proposal that carers, who are getting the carer's allowance, should get support themselves is very welcome. The cost of providing a nursing home bed is approximately €1,000 per person per week. In many cases, care is being provided seven days per week so there is no break from it. It is important, therefore, that we recognise carers and give them the support they require.

We need to do a lot more long-term planning. I introduced a Private Members' Bill seeking to regulate home-care providers properly. We are to have an increase in the population. An additional 20,000 people per annum will reach the age of 65 and an additional 2,500 per annum will reach the age of 85. That will pose challenges in itself. The health system, as structured, will not be able to accommodate that increase. Therefore, the people who provide care must be given support.

We also need to examine other areas. I recently raised home care provision with the Minister for Employment Affairs and Social Protection. Representatives of home care providers whom I met reckon we need up to 10,000 additional home carers within the next few years. We need to examine the social welfare system. Someone working for three hours per day for five days per week will automatically lose any allowance he or she is getting under the social welfare system. We need to restructure the system to encourage more people to up-skill and train to provide home care. I refer to those who do not want to work 37.5 hours per week who would provide home care to people who do not have the benefit of somebody living in their house and caring for them. This Bill, however, provides important supports for those who are so dedicated and committed to providing care to people, whether the latter are family members or others to whom they are very close.

It is interesting to consider the census data. Over 60% of the carers are women. Over 40% are aged between 40 and 59. If one is in that age category and the person in care passes away, it is extremely difficult to re-enter the jobs market. It is a huge change in life. One must take time out of one's career to provide full-time care to a family member or close friend and one is at a huge financial loss in doing so.

I welcome this legislation, which offers the necessary support. We need to reconsider what additional supports we can give to carers to make sure they receive the necessary recognition for the work they are doing. Until quite recently, we were not giving that recognition. We need to do so. I thank the Minister again for introducing this legislation.

I welcome the Minister of State. I welcome the Bill and its improved provisions for carers. Carers are unsung heroes. Sometimes they get fed up. I say that because behind the unsung heroes is the hard reality of how they live and how we support them in what they are doing. They deserve our respect, compassion and support. They are the very reason for our amendment. The contribution they make to our society is unquantifiable from social, community and financial points of view. It is welcome that this Bill aims to improve the State services that are afforded to carers.

Our carers deserve full access to all medical services. Providing for medical and surgical services only, as this Bill does, is not enough. Sinn Féin supports a full transition to universal healthcare for all citizens. We need a national health service based on need, readily accessible from the cradle to the grave and funded by progressive taxation. Fine Gael supported this concept in 2007. It was in its famous, or perhaps mythical, five-point plan. Two Fine Gael health Ministers have since come and gone: current Senator and colleague, Dr. James Reilly, and the current Taoiseach, Deputy Leo Varadkar. It was, in fact, the current Taoiseach who scrapped the plans. The problem with the plan was that it involved privatising our health system through insurance contributions. It was selling off our health practices to the highest for-profit bidder while leading to higher and higher prices for patients through premiums. That is evident from the deterioration in care given in some cases, as in the case in the headlines early in the week. Sin scéal eile, however.

This plan was flawed, unfortunately. Sláintecare came along and recommended a universal single-tier health and social care system in which everyone has equitable access to services. This is the correct approach. We support it and have advocated this model for considerable time, best referenced in Sinn Féin's better4health document, which we launched two years ago.

Where is Sláintecare? There is a fear that civil servants are now watering it down. This is unacceptable. The cross-party committee will not accept it and the people, or all the people we represent, will not accept it. In planning for universal healthcare, we should be transitioning as many qualifying people as possible over to full medical cards. There can be no half medical cards, no GP-only cards or any other watered-down provisions. It needs to be all or nothing. Every week we deal with people trying to gain access to a medical card, including the gravely ill. I was dealing this morning with a woman in her 40s diagnosed with breast cancer. She has no job any longer because of her illness. She has had to jump through hoops trying to access her health entitlements.

The Minister will know that I tabled an amendment in this regard that would allow for a provision within this Bill to give access to drugs and medicines to carers on top of the proposed services. This amendment was ruled out of order due to a cost to the Exchequer. I understand this but I want to outline to the Minister today why this amendment is important. Many carers give up work entirely to care for their loved one. They cannot feasibly continue a career while giving 24-7 care. They devote their lives to keeping their loved ones – our citizens – at home and with their families. At times, this is a really difficult decision to make. It involves a complete change in lifestyle. As Senator Swanick alluded to, it often results in a life of isolation and being hidden away.

This is about a lot more than money; the time that carers save the State is colossal. There should never be a situation in which carers, because they have had to give of all or part of their income through leaving the formal workforce, cannot afford prescription costs and medicines. It is a fairness issue. Considering how much carers save the State, the very least we could do in return is offer a safety net to them. They should never be counting pennies in an almost empty purse. The €5 increase that the Minister referred to has completely vanished. The profits of the gas and electricity companies and the increases in rent have completely negated any €5 increase. The cost, according to the research document, is €2.8 million per annum. What I propose would be fairly cost-neutral if the efforts and everything done by carers, who effectively have mini treatment hospitals or centres at home, were accounted for.

I ask the Minister of State to reconsider the amendment. We will be strongly pushing for support from across the House. The amendment will be resubmitted in the Lower House and I ask the Minister of State to give it consideration.

Overall, I commend the Minister of State on the Bill. More than that, I will take a moment to thank sincerely all the carers for the Trojan compassionate work they do. They are the warriors at the front line. We are starting the process of looking after them but we could do a lot more. I hope the Minister of State will take seriously the suggestions made today.

I welcome the Minister of State, Deputy Finian McGrath, and his officials. This is a good day in terms of giving much needed support and respite to people and families. It also has great benefit for the person who is being cared for, because the burden that is on their loved one weighs heavily on the person who is being cared for. That is also to be acknowledged today.

I want to go back to a very useful document, namely, the Bills Digest written by Diarmaid O'Sullivan, which includes the policy background. The documents notes that the "Prime Time - Carers In Crisis" special in December and the work by Rosita Boland in The Irish Times highlighted issues, including insufficient respite care, insufficient home care, dealing with challenging behaviour, which is one to let our minds rest on for a while, the detrimental impact of caring on carers' mental and physical health and concerns about what will happen to those cared for when the carer passes away.

We are making an important step today, but it is important to contextualise it in what still needs to be done. A Programme for A Partnership Government states:

Carers are the backbone of care provision in this country. In 2012, the first ever Carer's Strategy was published. We are committed to implementing it in full. We wish to see greater involvement of family carers in the preparation of care plans, aiding the provision of care, together with more accessible training and respite care, to facilitate full support. We also support an increase in Carer's Allowance and Carer's Benefit as well as improved access to counselling supports for carers.

I want to draw a relationship between this statement in 2016 and the fact, it would seem, that a "Prime Time" programme delving into the crisis was what spurred this very welcome move. Perhaps that is not the case, but it is the way it looks. We have seen issues that have come into the public domain where families have made their personal situation public and where there has been a response. I simply want to say that if there is no correlation between one thing and the other, the Government really needs to come out and show this is the case. For a lot of people, there is still a sense that things will get responded to in some way when people are out there in the media, and that is not helpful.

We all know Family Carers Ireland, which was the Carers Association. We have all benefitted not just from its advocacy work but the very practical work it does in every parish and townland in the country keeping people and their situations together. One of the key issues it has, while welcoming the Bill and recognising it as a positive step, is that it is very frustrated at the decision to limit the card to carers in receipt of carer's allowance. This imposes a means test by virtue of the fact the carer's allowance is means tested. As such, this decision is at odds with the Government's commitment to introduce universal free GP access to all ages. This means that while children under the age of six and those aged over 70 are granted a GP visit card regardless of their means, carers are treated differently. This point has already been made by Senator Rónán Mullen and others.

I want to focus for a moment on people who receive the carer's support grant. They are often what might be described as the squeezed middle. They do not meet the means test. In Diarmaid O'Sullivan's work we see that the majority of carers are women and most of them are between 40 and 60 years of age. They are significant years, particularly for women but for adults in general. They are looking over their shoulder in terms of children and family development and looking at ageing parents. It is something that needs to be taken account of.

There is also the issue of the number of years that some people spend caring. For some it is a two, three or five year stretch and for others it can start in their 20s or 30s. I know the Minister of State is live to this issue, and it comes back to the idea of families being squeezed. Many of the people being cared for need their houses adapted in some way or other. We are not dealing with that today, but the housing adaptation grant is highly means tested. If people have reasonable, but not great, means it is another thing they cannot get their hands on too easily. There are issues that relate to the carer's support grant. Often, one of the adults in the house has already had to give up work and forgo significant income that would help that household. These are people of working age. There is a squeezed group of people who do not meet the means test but who are really under pressure. Having said that, I am very happy to see this and I welcome it very strongly.

Cuirim fáilte roimh an Aire Stáit agus an Bille tábhachtach seo. I welcome the Bill because it is a very good step in the right direction. As others have done, I acknowledge the tremendous work done by carers in this country. They provide care out of regard and love in many instances for those for whom they care. Others do so through a commitment of wanting to help others. It is important that through the Bill we have another small acknowledgement of the great work they do. As has been pointed out by Senator Colm Burke, many give up their most productive years and find themselves trying to re-enter the job market in their late 50s and 60s, which is a daunting task, yet they do so willingly and knowingly.

There are many other carers who will not be included in the Bill, and I hope that will be the next step in expanding free GP care without means testing because they also need help. As others have pointed out, it is not so much a case of the money and the relief, it is also the acknowledgement of what they do.

I hope the resources will be put in place for GPs to provide this care because, as others have pointed out, we know there is an issue with a lot of GPs retiring and others closing their lists out of fear of not being able to provide a safe service because of the numbers they are increasingly being asked to cater for. We need to attract back some of our younger doctors who have left this country.

With regard to the contention of Senator Devine that universal healthcare was to privatise our health service, it certainly was not. It was a realisation and recognition of where we are now and how the two systems are intermingled. It was to allow those who cannot afford insurance to be supported by the Government to have insurance and have it paid for by the Government in many instances.

I worked in the system for all of my adult life. I know that hospitals see private patients as a resource and look upon public patients as a cost. I will be criticised for saying what is true but it is the reality. If a hospital is given a fixed budget, once that budget runs out, how is it supposed to look after people? If we had a money-follows-the-patient system, which I was promoting and which had started, every patient who comes through the door would mean more income for the hospital, more support for staff and more resources to deal with the situation. That is what we need. We cannot continue with budgets that can be blindly broken without any regard for how many patients have been seen or treated and without any regard for whether those patients are the longest waiters or not.

I want to come back to what is a very good news story, a very good day for carers and a day I hope will lead to more free GP care for all people on this island. The next group we should be looking at in the budget is the other carers who are means tested. The other groups, the over 70s, under sixes, those with cancer diagnoses and those with disabilities, are not means tested and that is right. This group is entitled to the same consideration.

I thank the Minister of State.

I join with others in welcoming the Bill. It is a small but significant recognition of the work of care in our society and the fact that the care given in so many homes across Ireland is a contribution to the State and to our shared common good. The State bears a responsibility to acknowledge and support carers in their work. There are many positive elements in the Bill. That is why it is passing with such speed through the House. We will come to it at a later Stage but it is a positive step that those on the half-rate carer's allowance are likely to be included.

I will further underline some of the concerns of those on the carer's support grant. There is a practical question and a question of principles. When the Minister, Deputy Harris, announced the beginning of the process last December, a cost of €11 million was talked about. Many people who were on the carer's allowance, because it was means tested, already qualified for the medical card, which has perhaps been what allowed those on the half-rate carer's allowance to come into the mix. Might there not also be scope, even within this Bill, to include those in receipt of the carer's support grant? If there is a space in what was originally envisaged fiscally, I urge the Minister of State to try to make it happen as it goes through the Dáil. We cannot table a money amendment ourselves.

It is really important for all the reasons that were mentioned but also because there are issues in the means testing. There are issues around financial independence. When a person gives up his or her work to care for another person, the fact that his or her partner may continue to work means there is money for the household but the person who is perhaps taking a decade out of his or her career to deliver care also needs financial independence and not simply income. That is a concern I have about the adequacy of the carer's support grant. This includes a level of independence. People will not have to ask their partners for the money to visit a GP or to access prescriptions. They will not be asking for that money. People may seek to re-enter the workforce in their 40s or 50s and will have a capital basis for a restart. We all know the efforts that restarting takes.

There is another related concern which I realise touches more on the area of social protection but it overlaps. There are many who are caring in Ireland who are not having contributions made by virtue of the way in which they started caring. There is a hole in our system whereby those who were not making social protection contributions before starting to care can sometimes not have contributions made on their behalf. They face issues when re-entering at a later point and also in terms of pensions in the longer term.

I will touch briefly on another related issue. I join with others in saying-----

The Senator is running into injury time.

I am into my final time.

The Senator has gone past it.

With my colleague, Senator Dolan, I had the opportunity to co-host a joint meeting of the Joint Committee on Employment Affairs and Social Protection, Joint Committee on Education and Skills and Joint Committee on Health. It was an opportunity to bring together persons with disabilities. The medical card system was brought up as a real concern and a fear for those seeking to access employment or education. In the year when the Minister of State is ratifying the UN Convention on the Rights of Persons with Disabilities, which I applaud him for, we need to move towards emancipation as well as care. Many carers want to see those they care for supported and emancipated. That is where that join-up is important. We should applaud them for their work and let that work not be invisible. Let us consult with them on the routes to opportunity for carers and those cared for.

I thank our colleagues for the detailed responses and their great support. Senator Swanick raised very important issues on the 104 weeks and the cohort of people who miss out as a result. As the Senator said, there are 68,000 people. It is something I am prepared to look at and something I will discuss with the Minister, Deputy Harris. I am open to the constructive suggestions that have come from the Seanad today.

The GP issue is a very important part of the debate because if we are doing GP cards we have to ensure the infrastructure is there and the GPs are there. I have met the NAGP on a number of occasions since I took over as Minister of State with responsibility for disability issues. It has been very supportive of me. I take the Senator's point about inclusive negotiations. It is the direction we should be going. That is something I will push within Government. I have met the NAGP on two occasions. I have spoken at one of its conferences. I also got massive support from it for the issues I want to drive in disability services. It is important that Senators know that as well. I believe all stakeholders should be around the table. That is my plan.

I thank the Minister of State for that.

Senator Mullen's point on the importance of carers and the issue of respecting and appreciating them in society is important. Does it go far enough? Can we extend it? I have a vision that this involves a step-by-step approach. I see this as a small recognition of the amount of work carers have done. I also see it as part of four other things I have done in the past 12 months. They are: the restoration of the carer's grant to 105,000 people; the medical cards for the 11,000 children who were on the domiciliary care allowance; the €10 million for respite care; and the €14 million announced last Monday for the housing adaptation grants. I see it as part of the overall national disability strategy and as supportive of that issue.

With regard to Senator Colm Burke's point, I welcome the support. The Senator played a very important part in the nursing homes issue. When one looks at the costs of €1,000 - and it can go even higher - we need to be radical and creative and we need to see where we are spending the money. If we are not spending the money sensibly, it is important. Senator Burke also suggested we revisit the social welfare system.

Senator Devine gave her very strong support to the carers. I accept the point she made on her amendment. In an ideal world, I would love to broaden out the legislation and hers is a viewpoint I listen to. I also accept her point about the universal healthcare system. We have to go down that road and if we are going in that direction, we have to implement Sláintecare and stick to the plan. We have a plan here and that is a very important part of the plan. I mentioned the four or five things I have done in my portfolio on disabilities and carers are all part of the broader plan.

I thank Senator Dolan for his support on many issues. He sees this as an important step.

I disagree with him slightly on the role of the media. I hope I do not get into trouble, like the Taoiseach the other day, and I take the Senator's point on the perception. As for the people who influence me as Minister, for example, I have heard loads of ideas in this Chamber from Members. Carers influence me, as do the disability groups. When I meet the Disability Federation of Ireland, DFI, or Inclusion Ireland, they influence me and I bring those things into the pot and to the Government as well. I listen to carers and try to implement what they are concerned about.

Senator Dolan has a valid point regarding people in those middle-income areas and I understand the limit in respect of the housing adaptation grant is €60,000. There are people who at times believe they miss out on supports, in particular with regard to carers, and we have to face that reality.

Senator Reilly has mentioned carers and acknowledged their achievement. He, like a lot of he Senators, envisages a role for an expansion of the scheme. He mentioned the importance of GPs and that we must make sure the carers are looked after.

Senator Higgins mentioned a lot of key things. She acknowledged the recognition of carers, which we all do, but we have to back that up. In respect of looking after carers, I totally agree with the Senator on linking into the United Nations Convention on the Rights of Persons with Disabilities. The Senator also mentioned the half-rate carers issue, the carers support grant and the inclusion of carers in this scheme as well. These are issues on which I have an open mind and I take the point about people who feel left out of the system. If we are talking about inclusion, we have to look at that system. The Senator mentioned the medical card system as well. I was delighted to hear the Senator use the word "emancipation" because we have a long way to go. I know, from working with the National Disability Authority, that we also must bring the broader society with us, as regards their attitudes to people with disabilities and to carers. We need to ensure these people are respected and their rights are respected as citizens of this State and as people who want to make a contribution. The Senator mentioned the medical card and I just reflected on the fantastic people I met recently with disabilities who are in employment and who are not in receipt of a medical card because their salaries are high. The cost to them, because they have a disability, is much higher than the costs to the average person. That is something about which I have talking to the Minister for Health, Deputy Harris, in recent weeks and on which I have presented. We kicked off recently on the figures for the Estimates for budget 2019. I met representatives of the HSE and Department of Health officials the other day and we had our first meeting.

When talking about carers, another issue that is often forgotten about is the quantity of urgent need for people with disabilities who want to have their own independence and to have their own personal assistants. This is something I discussed before with Members, including Senator Dolan, and others. We need to ensure we increase the personal assistance hours for people with disabilities in order that they can be more independent and not dependent, as they want to get on with their lives like the rest of us. Let us look in that direction as well.

Let us be radical and creative. I thank my colleagues for some of the fantastic ideas I pick up here on the disability issue. I also acknowledge Members' support over the past two years regarding the vision of the rights of all persons with a disability and the rights of people as citizens, as well as to ensure we invest in the services and to make sure these rights are protected by implementing quality services.

Question put and agreed to.

When is it proposed to take Committee Stage?