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Seanad Éireann debate -
Friday, 24 Jul 2020

Vol. 270 No. 7

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

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

I welcome the Minister for Health, Deputy Stephen Donnelly, to the House. I congratulate him on his appointment and wish him every success in his tenure. The floor is his.

Before I speak on the Bill, I wish to say what a great honour it is to be here in the Seanad. I am sorry that we are all moonlighting in the Dáil Chamber but I am very much looking forward to stepping into the hallowed grounds of Ireland's Upper House at some point. It is a huge honour and privilege to hold the office and to be here with Senators today to debate this Bill. Thank you for your good wishes, a Leas-Chathaoirligh. There is quite the task ahead in healthcare in the Covid world.

It is my pleasure to introduce the Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020 to Seanad Éireann. I believe it is our obligation as elected representatives to look after those who need it most and I am therefore very pleased that this Bill provides for two key measures that will positively impact children and people over the age of 70.

The Bill provides for a welcome increase to the gross income limits for medical card eligibility for persons aged 70 years or older and, second, for a phased expansion of GP care without charges to all children aged 12 years and under. Sláintecare provides a necessary and long-awaited process for reorienting our health system from one that treats only sick people to one that keeps people well. That is why the measures provided for by this Bill are so important. They will enable us to take another important step forward towards achieving the health system the people of Ireland need and deserve.

A range of measures has already been implemented to expand access to people in receipt of medical cards and GP visit cards. This includes the provision of medical cards to people in receipt of domiciliary care allowance, which was done in 2017, the provision of GP visit cards to people in receipt of a carer's allowance and carer’s benefit, in 2018, and in 2019 the increase in the GP visit card income thresholds. All of this has resulted in 43% of the population now having access to GP care without fees. However, while these initiatives are very welcome, this Government recognises the need to do more. That is why we have committed in the programme for Government to implement new measures to expand access to GP care without fees and to wider health services. As Minister for Health I am delighted to be bringing forward this legislation for debate here today, and affording it the priority that it deserves.

The first key measure in the Bill is a welcome increase in the gross income limits for medical card eligibility for people aged 70 years or older. Everyone should have the opportunity to live a long and healthy life, and we all know the world is ageing and we are living longer. Increased longevity is a welcome indication of improved public health and social and economic development here in Ireland and in many other countries around the world. As many individuals age, however, they will face the risk of having at least one chronic disease, such as hypertension or diabetes, and we must ensure our health system is designed to meet the consequences of these continued and evolving demographic changes.

The World Health Organization defines healthy ageing as "the process of developing and maintaining the functional ability that enables well-being in older age". Functional ability is about having the capabilities that enable all people to be and do what they have reason to value. This includes a person's ability to access basic needs like healthcare. Currently, 75% of people over 70 years of age hold a medical card. Having regard to the prevalence and co-morbidity of chronic diseases in the population of people over 70 years of age and the benefits to be achieved through improved health and well-being, I wish to ensure, therefore, a greater proportion is afforded access to health services at a time when health needs are higher.

I should also highlight that this is the first increase in the income limits since they were reduced in 2014. Today's Bill therefore provides a very welcome increase. If the forecasted numbers of people to benefit from this measure materialise, it will result in approximately 87% of the population who are over 70 years of age having medical card coverage. The income limits we will discuss are an increase of approximately 10%, although we will get into the detail. This increase of 10% could see coverage extended to half the number of people who still do not have access to a medical card. The benefit is beyond what we might think if we just looked at the increase in limits.

I now turn to the second key measure provided by the Bill, which is the phased expansion of free GP care to primary school children. Senators will be aware that our programme for Government also includes a commitment to expanding access to GP care without charges to more children. It is an important deliverable for the Sláintecare implementation strategy, which commits to expanding eligibility for access to healthcare on a phased basis. Since 2015, all children under six years of age have been eligible to access general GP services without charges, along with periodic health assessments and the asthma cycle of care programme. This has been a very successful measure, with more than 250,000 children under six years of age eligible to access GP care without fees. The most recent Healthy Ireland Survey indicates four in every five children under six years of age had attended a GP in the previous year, which really demonstrates the welcome benefit of increasing access to affordable healthcare, or in this case healthcare free at the point of use. We must still pay for the service.

There is a clear rationale and obvious benefits to expanding universal access to GP care to children. It will bring important lifetime benefits both for our children and society as a whole, ensuring early intervention and healthy behaviour from a young age, as well as reducing long-term healthcare needs and the associated costs that come with this. Furthermore, evidence points to the importance of introducing policies to promote health and well-being and tackle inequalities in health, as they are likely to be more successful the younger the age groups targeted. The earlier and more quickly we can get to children, the better off they will be for the rest of their lives.

We also know the cost of GP visits acts as a barrier to accessing care. The Growing Up in Ireland study, for example, indicates that those who face out-of-pocket expenses to access GP care make significantly fewer GP visits, and that children from higher income families are more likely to visit the GP than children from lower income families. The measure being debated today will ensure therefore, that irrespective of the social and economic background of the children and how much money their parents earn, every child up to the age of 12 will have equal access to GP services without charge. It is a significant milestone and I am proud to welcome this beneficial public health measure.

As well as removing a potentially prohibitive cost barrier to accessing healthcare, the continued provision of the additional services already available to children under six, such as the asthma cycle of care, will help to improve children's health and well-being as they develop through middle childhood. Moreover, this progressive measure will also ensure continuity of care for children in the under-sixes cohort. This will now deliver a full continuum of care from birth right to the age of 12 provided by the GP. It is why I want to extend access to GP care without charges to more children.

Today's Bill provides a legislative framework to continue on this path of universal expansion. Already, nearly 200,000 children between ages six and 12 have access to a GP without charges either through the medical card scheme or other schemes. It is estimated that expanding GP care without charges to children up to the age of 12 will benefit an additional 300,000 children in our society, which would be fantastic. However, I recognise a move to a universal access system for health coverage is challenging.

The timing of implementation requires very careful consideration and the initial stage of the phased expansion will therefore be to all children aged six and seven, so as not to overwhelm the health system and general practice, which as we all know is struggling with capacity now. Specifically, the legislative framework in the Bill provides a roadmap for expansion. Phase 1 will be for children aged six and seven; phase 2 will be for children aged eight and nine; and phase 3 will be for children aged ten, 11 and 12.

GPs have been the first port of call for patients in the Covid-19 context and they deserve major recognition for the work they have done under extraordinarily difficult circumstances, so it is imperative that general practice continues to be in a position to provide healthcare to all patients in a sustainable manner. In that regard and taking account of the forthcoming winter in the context of Covid-19, it is crucial an expansion of GP care does not inhibit general practice from delivering ongoing care in the community for all patients. The implementation date for the expansion will therefore require careful consideration by officials in my Department and the HSE, as well as input from the Houses. That said, I firmly believe it is important to bring forward the legislation today as it provides the legal framework to enable expansion to be progressed and implemented when the timing is right.

The purpose of the Bill is therefore twofold. It will provide the legislative framework for the further phased expansion of GP care and to increase the gross income limits for medical card eligibility for persons aged 70 and older. Before I outline the main provisions of the Bill I note a miscellaneous provision in the Bill, which is an amendment to the 1970 Health Act to take account of the new governance structures in the HSE. Essentially, it is about switching the terms "director general" and "chief executive".

The main provision provisions are as follows. Section 2 amends the existing legislation relating to gross income limits for medical card eligibility for persons aged 70 or older under the 1970 Health Act. The amendment to section 45A of the Health Act 1970 provides for an increase in the gross medical card limits for persons aged 70 or older to €550 per week for a single person, where it is currently €500 per week, and to €1,050 per week for a couple, where it is currently €900 per week.

Section 3 provides a technical amendment to section 53C of the Health Act 1970 to replace the reference to "director general" of the Health Service Executive, HSE, with "chief executive officer" of the HSE. This necessary technical amendment ensures section 53C of the Health Act 1970 is consistent with the Health Service Executive (Governance) Act 2019, which amends the references to the director general of the HSE and replaces them with references to the chief executive officer of the HSE.

Section 4 amends the legislation under the Health Act 1970 that relates to the making available of a general practitioner medical and surgical service, or the GP card, without charges to persons who are ordinarily resident in the State under six years of age. The amendment of section 58 and 58B of the Health Act 1970 expands the availability of this service to persons ordinarily resident in the State and who have not attained the age of eight years. This is the first age category being provided with eligibility for free GP care under the phased system. This is a complicated way of indicating that children aged six and seven will become eligible for the scheme.

Sections 5 and 6 provide for making general practitioner medical and surgical services available without charges to persons who are ordinarily resident in the State and have not attained the age of ten years and 13 years, respectively. These are the second and third age categories being provided with eligibility for free GP care under the remaining two phases of expansion. In other words, section 5 is for eight and nine year olds and section 6 relates to those aged ten, 11 and 12. Section 7 provides for the Short Title to the Bill and for the introduction of both GP expansion and an increase in the medical card gross income thresholds by commencement order, as required, with the consent of the Minister for Public Expenditure and Reform.

I am personally pleased to bring this progressive measure forward and to debate it in the Seanad today. I am confident the Bill will bring about real change in our health service. More importantly, it will bring about real change for patients and members of the public who need access to care and who might not be getting the full access they require at present because of the cost. This will make a significant difference. I am sure many Members of the House have been contacted by people over the age of 70 years, the one in four who do not have the medical card, asking them when this change will be introduced. It will make a difference to them and it will make a world of difference to worried parents who were previously unable to afford to bring their children to the GP. I commend the Bill to the House and look forward to hearing the views of Senators.

Thank you, Minister, and I again wish you well in your tenure in office. Senator Clifford-Lee has eight minutes.

I am sharing time with my colleague, Senator Fitzpatrick.

I thank the Minister for bringing this welcome and progressive legislation to the House. I believe it deserves, and will have, broad support from the House. The Minister has a personal commitment to better access to public healthcare and this allows people to access healthcare at the point of entry with GPs throughout the country. It is very welcome. As a mother of two young children who has been fortunate to avail of free GP care since the day they were born, I am happy that this will continue for parents in Ireland.

The pandemic has impacted disproportionately on families with young children. This is a welcome measure for those families and gives them some extra relief. What used to happen is that parents would perhaps second-guess things and take a chance. We all know that children's health can deteriorate very quickly and if one takes a chance because one cannot afford €50 or €60 to bring a child to the GP, it can have devastating consequences for the long-term health of the child and the well-being of the family unit. This provision is therefore very welcome, as is the expansion of the income limits for people over the age of 70 years. Those people have contributed a great deal to this country and it is a good step to acknowledge that their needs are greater as they get older and to acknowledge the contribution they have made to the country.

The GPs of Ireland have played an amazing role over the past few months dealing with queries to their surgeries, assessing whether people need to be tested for Covid-19 and much of the time reassuring people that perhaps they do not require testing. They have been doing a great deal of work and, hopefully, in conjunction with today's measures, the Minister will be able to give extra support to the GPs who need it.

I am glad to support the Minister today and I thank him for the work he has done on this Bill and for the work he will continue to do. I wish him the best of luck in his role.

I offer my condolences to the family of Dr. Ali who died so tragically after looking after so many others. I also commend all the healthcare workers and professionals, and everybody who supports them to do their work.

I congratulate the Minister on his appointment to the health portfolio. I am sure he will do a fantastic job. It must be a great honour for him to lead such an important Department.

I was brought up in a GP's practice as my dad was a GP. The practice was in our home and for more than 40 years it was a community-based, medical card practice looking after patients from Cabra, Phibsborough, the Navan Road and the north inner city in Dublin 7. I therefore understand the unique relationship patients have with their GP.

It is incredible that although he has been retired for almost ten years people still talk to me about dad and mam every day, so what the Minister is doing here today is very valuable. It is giving people access to the GP and allowing every child under the age of 12 years to have the opportunity, regardless of who their parents are, to have access to GP care. I lived and worked in the United States and I was shocked by the commercialisation of it there. I remember a person collapsing on the street in front of me one day. Two ambulances pulled up and the first thing the medics did was go through the person's wallet and check for an insurance card.

I am proud that the Government has committed to the implementation of Sláintecare, which will bring about universal access to healthcare for people based on their medical need, not their ability to pay. I commend the Minister on bringing this legislative measure so swiftly to the Houses, and I urge all Members of this House to support and pass it. It is a step change and a strong signal of how this Government intends to deliver healthcare and make it available to people.

The Minister mentioned the GPs. As I said, I grew up in a practice so I know the enormous effort and commitment given by individual GPs, their families and support staff. GPs are under pressure. Far too many GP practices are struggling financially, and we do not have enough GPs. It is important that the Government has recognised this, is taking a phased approach to it and is addressing the issue in a managed way. We still have to contend with Covid-19 and it is great that the screening services are recommencing, but expanding the healthcare service and expanding access to it are important principles that the Government is not abandoning. It was not just an election slogan or something to put in the manifesto. It is real legislation that will be backed by action by the Minister and the Government. I commend the Minister on that.

I warmly welcome the Minister, Deputy Stephen Donnelly. Both of us were of the class of 2011 so I got to know him very well in the Houses. The one thing I always admired, and still admire, him for is his extremely sharp intellect, coupled with his compassion. He is certainly well qualified for his brief. I have known his aunt in Clare for practically all my life and I know how proud she is of his appointment. We all are delighted for him and wish him the best. We will be happy to give any support we can to the Minister, Deputy Stephen Donnelly, in this extremely important role.

It is fitting that the first Bill he brings to the House is one to open access for young people and old people to healthcare. That is important. I believe it is one of the last legislative measures approved by the last Government and the Bill is now before us. As I said, it is very appropriate that this should be the Minister's first Bill. As we have seen, the history of medical cards and eligibility over the years has not been pretty. We saw the controversies that occurred, particularly in 2013 and 2014 when medical cards were taken from children with disabilities. That should never have happened. We have learned as a society and as a political system from those terrible experiences. We are building a system that is fit for purpose and for our healthcare service in the future.

Anybody who needs access to healthcare and cannot afford it should automatically get it. Equally, people with a terminal illness should have access to a medical card straight away and not be put through hoops to get it. Every Member in our work in constituency offices has dealt with people who were diagnosed with terminal cancer.

Every one of us has experienced the challenges in advocating on their behalf to get them the medical card. This should not happen. I believe in the principle of universal healthcare. Even more I believe in the principle of giving immediate access to people who need it immediately. That is equally important. I still do not believe our system is foolproof in that regard.

The Minister may be aware of John Wall, a man with a terminal illness in my county of Clare, who has campaigned tirelessly in recent years to reform and improve the medical care eligibility structure, and how the Primary Care Reimbursement Service, PCRS, engages with people. He has had success with some of his initiatives.

We also need to consider the associated benefits that a medical card brings and the confusion it can create. Far too often I have dealt with people who have applied for a medical card not because they are ill or may become ill, but because having the medical card will secure other benefits, such as bus tickets for their children going to school. We need to decouple that system. Let the medical card stand on its own. It has its own critically important purpose. Somebody should not need to have a medical card to qualify for school transport or other benefits.

I would be shocked if anybody had any problem with passing the legislation. This House has always come together on matters of important legislation and everyone will recognise the benefits of this legislation. In summing up, the Minister might outline what will happen when the legislation is passed. What is the timeline to get it enacted? When can a couple aged over 70 whose income is €920 expect to have a medical card? Ultimately, we will pass the legislation, which will be signed by the President. At that stage it is up to the departmental officials to implement it.

It is an absolute pleasure to see the Minister in this role in this House. I look forward to working with him in future.

I warmly welcome the Minister to the House and I wish him well. I thank him even for the clarity and delivery of the content of the Bill.

The first time I spoke to the Minister it was not in Ireland. The first time I met him and had a chat with him was in the company of the current British Prime Minister, Boris Johnson, when we were on a trip to the UK. Boris Johnson came a bit late and offered us some refreshments. I think he suggested tea and we might have suggested something else. Anyway, he immediately picked out this red-headed fellow in the back. It was only a few years ago. He said that this was one smart guy and that he had worked with him when he was Mayor of London and the Minister was involved in consultancy. I had forgotten that and while sitting here I looked over at him and remembered that incident. He was very decent. He set up a few photographs of that evening in Whitehall. He said the Minister was a smart guy and I believe he was right. I would not necessarily have much in common with the key themes and messages the British Prime Minister discusses from time to time.

I thank the Minister for his clarity of message. We are in for an exciting time in health. From what I have observed of him, from what I have heard about him and from what colleagues inside politics and outside politics have said about him, he is extremely professional and focused. Some might say he is over-focused, but that is what we want. This is the person we want in the job as Minister for Health.

I very much welcome the Bill which when fully enacted will extend free GP care to children up to the age of 12 and increase the access of medical cards for persons aged 70 or older. The expansion of GP care without charge is an important health measure in line with the Government’s stated objective. However, it was the stated objective of the previous Government and we need to remember that Fine Gael has been in government for nine years. This is another extension of the previous Government, albeit with other parties. Let us not lose sight of where we have come from and the continuous stated objective and how long it has taken us to get there. However, it is positive that it is happening now on the Minister’s watch for which I thank him.

It is also a key objective of the Sláintecare implementation plan. Sláintecare will be a recurring theme for the duration of the Minister’s Ministry and well into the future of our healthcare system. We should never lose sight of the fact that where there are new reforms in health, we need to keep referencing them back to Sláintecare. Sláintecare has support across the House, both inside these Houses and in the greater health community.

As the Minister has said, the Bill provides a legislative framework; it will not all happen at one time. He has set out phases 1, 2 and 3 very clearly. I was going to ask him a question about that, but he has set it out here for me, so I do not have to ask him that question. It is important that we should say it is a legislative framework to get things done.

The Bill also provides for the implementation of an increase in the weekly gross medical card income limits for those aged 70 and older to €550 for individuals and to €1,050 for couples, which is currently €900. That is an increase, albeit moderate, and the Minister has clearly set it out. That is the sort of clear message without ambiguity we need. We want to clearly set out where there are benefits and we need to get the message out that these are benefits.

The legislation will significantly improve access to GP services for children and also increase the number of those aged over 70 who have access to medical cards. It is a framework, as the Minister has said. As Senator Fitzpatrick said earlier, it is about access to GPs. What is the story here? We know that with Covid, GP services are closed down. We know people need to make appointments. We know that people are waiting for up to ten days to get access to their GPs. We know that many people have left the medical services. We may have potential access for GPs, but we know that in many areas there are no GPs. I had contact from people in Blackwater in County Wexford, where the residents were begging a GP to stay because there was no other GP in the public system.

We have a problem. On the one hand we are talking about increasing access for different age groups. As the Minister said, we want to break down barriers for access to the health services for children. It will take time before we have the full roll-out of phases 1, 2 and 3 up to 12. Hand in hand with these measures we need to identify why so many GPs are leaving. Why do so many people find it unattractive to be in general practice?

How can we embrace new technologies in our health services? How can we expand the offering of the services? I had the experience of bringing someone to SwiftCare in south County Dublin. The person was in, looked at, X-rayed and out in 30 minutes. The private sector has led in this area. I do not necessarily like saying that. I am not an advocate for private medicine over public medicine. I am an advocate for good medicine. We need to look at clusters of clinics, shared practice, better supports, better IT services, centralising X-rays, blood tests, etc. We can speed all this up with technology. The outdated GP system that many of us are used to and that many of us are exposed to has not served us well. We need more investment in GP services and make greater efforts to keep GPs in public service. There are synergies. It does not necessarily need to be private versus public. Successful synergies work with private and public medicine. We want what works best for people.

I very much welcome this important legislation. In time the Minister should turn his attention to how we can open up and provide greater accessibility to the services for everybody. This is really positive legislation. I have every confidence that the Minister will deliver. The Bill introduces two important measures which are in the programme for Government, relating to the commitment for access. Let us keep the pressure on and see how we can improve GP services for everyone.

On behalf of the Sinn Féin team, I also welcome the Minister to the House. I have no doubt that he has a mighty task ahead of him but he will have our support in doing his job in the time ahead. I am not sure whether it is a compliment to be held in such high regard by the current British Prime Minister but I assure the Minister that I will not hold that against him in the time ahead.

I would like first to extend appreciation and my party's heartfelt thanks to all of the healthcare workers wherever they worked within the system over the past number of months. Their dedication and loyalty in saving people's lives and keeping them safe during this pandemic have been outstanding. We are in awe at the service that they and others have provided for us all at this dangerous time. Those people deserve more than just our thanks, appreciation and applause once a week. I, for one, never again want to be on the side and standing with strikers. In the past, people have rightly had to stand up for better conditions. We want to see all front-line workers being appreciated by this Government and all governments in the time ahead for not only the sterling work they have done over the past six months but that they do daily.

I am approaching this Bill on the basis that I believe that we now need a national health service for all of the people of Ireland. I want an all-Ireland service and system of universal healthcare, accessed on the basis of need, free at the point of delivery and funded by progressive taxation. While the increased co-operation with the health services, North and South, has been beneficial, it is now time to move to the full integration of services across the island, taking the best of both systems and maximising the healthcare benefits for all of the citizens across the island.

Over recent years, there have been excellent examples of how North-South co-operation has resulted in improvements in services for patients and their families. An obvious example is the North West Cancer Centre, which has offered a first-class service to the residents of Derry, Donegal and further afield who, until its establishment, had to travel for hours to access treatment at their time of need. We need more examples like that and begin to think big. We can no longer afford the duplication of healthcare services across the two states. It is beyond the time that we looked at healthcare on an all-island basis.

People need, deserve and want to know what an all-Ireland health service could look like. While I appreciate that the Bill will not resolve the fact that this Government needs to wake up to the fact that others are exploring options for an all-Ireland health service while it is not, I assure the Minister and his colleagues that I will, on every occasion, draw to his and others' attention the fact that partition has failed this country and its people. Partition also fails patients.

Primary healthcare and community care should be the cornerstone of our health service throughout the island. That applies to health services in this State and in the North. Such an approach will deal with the bulk of the healthcare needs of the population and take the pressure off acute services at times they are under stress.

The strength of this Bill lies in the fact that it aims to help to improve the health and well-being of two very important sectors of society, namely, the young and the elderly. Sinn Féin will support the Bill but it has one weakness, that is, that there are no specific dates attached to its implementation. The Bill has been further weakened by the comments of the Minister yesterday in the Dáil when he said that its implementation was conditional on finance being available, which is totally unacceptable. I heard the Minister in this Chamber talk about a phased approach, suggesting that it was in some way to do with ensuring that we do not overburden the health service. Let me assure him that parents will continue to take their children to see a GP only when they need to do so. The phased approach is based on finance and nothing else.

This Bill needs certainty in terms of timeframe for implementation and funding from the Government.

While I appreciate negotiations are under way with various stakeholders, that is not an excuse for not attaching a desired timeframe for implementation. I am calling on the Minister to speedily resolve this omission by attaching a timeline to the negotiations or, once they are completed, attaching an immediate timeline at that point.

In specific terms, the Bill will expand free GP care to children aged under 12 years of age and to those aged over 70 who are eligible. Of course that is a good thing.

The issue of the national health service as a necessity has become a part of the national debate around the provision of healthcare across the entire island. In last year's alternative to the budget, Sinn Féin proposed two free GP visits for everyone without a GP or medical card, as well as a medical card entitlement for all of those who are suffering from cancer. Our manifesto for the February election, which the Minister will remember saw Sinn Féin become the largest party in the State, committed to delivering free GP care over the term of a Government, commencing with our alternative budget measures. In the meantime, let the Minister sort out the timeline for funding of this Bill. These are manageable tasks for him and well within his remit. I ask the Minister if that is something he will do because that is the question to which people want answers.

I congratulate the Minister on his appointment and wish him well in his new role. This is the first Bill he has brought to this House, and what a Bill it is. It is welcome to see this Bill before the Seanad and the Labour Party and I will be supporting it. We will be doing so because the Labour Party has a long-standing commitment to free and accessible healthcare. We will be supporting it because we believe, as a party, that healthcare is a human right and should not only be expanded to those under the age of eight, 12 or 18, but to the whole population. We have seen the benefit of universal access to free GP care for those experiencing symptoms at the height of the Covid-19 crisis. We now know, more than ever, that free GP care is a crucial cornerstone of our health system. Money should be no barrier to seeing a doctor and nowhere is that more true than in the case of our children. Parents, regardless of income, should never be faced with a choice of whether to postpone or defer a trip to the doctor for want of cash in hand.

It is worth looking to the British National Health Service and its architect, Nye Bevan. When he founded the health service, he said that no society should call itself civilised if a sick person is denied medical aid for lack of means. I am sure that all of us in this Chamber would agree with that.

It is important to say that this Bill is welcome but must be the first step in rolling out universal access to primary care across this country. The reality is that this country stands shamefully apart from almost every other country within the developed world in rationing access to primary healthcare. We have a fully public system and universal access to our hospital or acute system of care. It does not feel like that at times because of the length of the waiting lists but there is universal access to hospital care. However, we have a semi-private system of access to primary care in this country. Over recent months, we have been listening to the pronouncements of the World Health Organization and its recommendations with regard to the pandemic. It is important to state that one of the WHO's key recommendations to health systems across the world is that there should be equity of access to all parts of health services. We do not have that. Ireland is the only country in the European Union that does not offer free primary care at the point of access for all persons, regardless of age.

I welcome this long overdue Bill. It is important to say that this journey began not in the lifetime of the current Government, as has been said, nor in the lifetime of the previous Government, but in that of the Government before that. At that time, the former Minister of State and my party colleague, Kathleen Lynch, secured access to free GP care for children under the age of six. It is also important to note and remind Senators that the move was not universally popular.

Members from parties within this Chamber opposed that move. They said it was unnecessary, that it was not the right use of scarce resources and that it would be too expensive. However, the then Minister of State, Kathleen Lynch, persevered and every family across the country would now say that opening up free access to GP care to those under six years of age was an important and good initiative.

My concern with this Bill is the timing of the implementation and the three phases of the extension of free GP care to children aged eight, ten and then 12 years. The Minister said that there was good reason for the phased implementation and that it would overwhelm the health system if we were to introduce it in one go. I judge a policy based on the evidence that is available and I ask the Minister to publish the evidence, which may or may not be available, of how the public health system would be overwhelmed if the Government were to implement this in one go. It did not seem GPs were overwhelmed in 2015. In fact, when I talk to GPs now, they tell me that most of the pressure comes when children are about to turn six because parents turn up about a month before that birthday and ask the GPs to look at them while they are still able to access the free GP care. That is when the point of pressure occurs, not when the care becomes available. We need to see that evidence because there is no point just saying that this is going to overwhelm the public health system when I and many others believe that it will not.

I appeal to those of us across the Chamber who have had the benefit of free GP care. I have three small children who have benefitted from it and there are a number of other young parents in this Chamber who have similarly benefitted. I appeal to them to ask the Minister to roll this out immediately and to take up Senator Conway's point about immediate implementation. The Minister has seen, albeit from the Opposition, what can be done in the Department of Health when there is willingness, particularly in the context of the changes that have taken place in recent months. We were told such changes were too big to happen, that they needed time and careful consideration but they were made happen. I ask the Minister to give urgent consideration to rolling out the implementation of free GP care to children under 12 years immediately. He should also do the same for people over 70 because we are facing into a winter of huge uncertainty and we do not need to be adding to the concerns of those over 70 who are currently relying on the free GP visit card, who are worried about being able to pay for prescriptions or accessing nursing homes. If the Minister were to act now and extend the thresholds, they would benefit from the medical card this winter.

I am sharing time with Senator Higgins. I welcome the Minister to the House.

We in the Civil Engagement Group support this Bill, although we feel it is a little rushed. I will make some points around the inequalities that still exist when it comes to health in Ireland today. I hope we will soon see the implementation of other vitally important elements of Sláintecare, including mental health and prenatal mental health services. As a young woman who has just had a baby and who has suffered from postnatal depression, I can categorically tell the Minister that the services for women going through prenatal depression are invisible, especially for women at the very end of Irish society. Our system continues to underperform around maternity care for women in Ireland.

We cannot have anything less than full national implementation of the maternity strategy which is still chronically underfunded. We are looking for better services and prenatal supports, including health, better development in midwifery, breastfeeding, parenting, and all the supports that go with having a baby and which are needed after having a child.

As a Traveller woman, I note that Traveller women live 12 years less than women in the general population, while Traveller men live 15 years less than men in the general population. Many chronic issues impact on vulnerable groups in Irish society, not only in the Traveller community but also those at the very end of society, such as working class people, refugees and migrants. We are also looking for equal access to these services and asking that every child and community will have equal access to them. I fully support this Bill. I hope we will see the Minister in the coming months and that we will be able to tease out some further policies and Bills for those at the very end of Irish society.

As my colleague said, it is a pity that we cannot debate this Bill in a bit more detail, not because anybody opposes it but because many of us have ideas about medical cards and how they operate and this would have been a great opportunity to address them. Having sat on the Joint Committee on Employment Affairs and Social Protection, I know that people have many concerns and fears around losing their medical card or GP card in respect of different employment. That is a huge area that could be worked on. Senator Conway spoke about the medical card being attached to other essential services on which people depend, and the concerns around that. In the normal course of events, we would have had the opportunity to suggest some additions to the Bill to the Minister. Nonetheless, we support the Bill. It is important and does good work. It is in line with Sláintecare, but as Senator Sherlock noted, it also follows what the World Health Organization tells us about equality of access. It is also in line with the Inter-Parliamentary Union's revolutionary motion last year on universal healthcare as a global commitment from parliaments and the idea of universal access.

Primary care in the general sense is one part of universal healthcare but it cannot simply be about an arrangement with GPs or doctors. It must focus on primary care. We talk about GPs being overwhelmed but one way we can prevent that is by putting in place more services to which GPs are gateways. For example, if we had public diagnostic services, not necessarily always within hospitals but public ones that were accessible at a local level, people who were worried about something for a few months and were still having the symptoms three months later would be able to get a diagnosis earlier. That would relieve pressure on GPs. If we had related services, such as mental health and physiotherapy supports, in place, people would have another point of contact. Such primary care is part of the Sláintecare picture and that is why we are keen for that to move forward.

I share other Senators' concerns about implementing this Bill slowly. We need to implement it immediately because there is so much else that needs to be done. We should not make this service conditional on resources. We know the financial reality of where we are and Ireland can borrow money to do what we need to do to have a healthy population and a new generation that comes up healthy. We know what we need to do and that we can access the resources to do it. We certainly do not want this to be an add-on, or for some nine year olds or eight year olds to get the help they need while some do not.

Others have focused on the six to eight year old age group, but inclusion of the ten to 13 year old age group in the Bill is important and positive. That shift from ten to 13 years old is important because that is when children are about to start secondary school and it is a huge transition point where GP care is important. For example, children with disabilities must plan around and manage their disability or health conditions in a new environment or school and they need to have that GP care. GPs do not just provide acute care, but handle chronic and ongoing conditions and all other parts of primary care.

That is why this is really important. It will be a very difficult return to school for many children this year. We have all seen those sad primary school graduation ceremonies before the pupils move on to secondary school. It would be really good if this was ready in September for those children who are facing mental health difficulties and other challenges at this time. It would be brilliant if in September, October or at some point this autumn, that support was put in place for children facing one of the most difficult transitions in their lives to date. I urge the Minister to implement it.

It has been said that some people do not even have geographical access to GPs. That is particularly the case in respect of reproductive healthcare. Many GPs around the country still do not provide the reproductive healthcare services women need. It is really important that is addressed so that women who rely on this card are able to access the services to which they are entitled.

I praise Ireland for something on which it and the UK have shown leadership, which is the provision of videoconferencing with GPs for those who need to access reproductive healthcare and abortion services. That was really useful and positive. I know that other European countries have looked at that when trying to ensure emergency access to GP visits in a time of crisis. I praise Ireland in respect of that video access.

I look forward to more engagement with the Minister and congratulate him warmly on his appointment. I am sure we will talk again.

I may not need a full eight minutes. I congratulate the Minister. He has an onerous task ahead of him so he had better roll up his sleeves. His role is a poisoned chalice which has been passed around over the years. Luckily, he has some good connections with Clare so we will do all we can for him.

I welcome the Bill. There are some very interesting and useful things in it. It will be really good for children in general and the increased threshold for those over 70 is good. A really important idea which the Department of Health and the new Minister need to consider is that of prevention rather than cure which not only saves the State loads of money but leads to people feeling happier and healthier, both physically and mentally. We have seen this during the Covid crisis. Many people discovered nature, walking and cycling and this made them feel happier in themselves. That has been wanting for a long time.

I have worked full-time on behavioural change with respect to sustainable transport with the Green-Schools programme and I have often struggled when working outside of schools because of the lack of access to any safe facilities, even a 500 m stretch of safe road. I encourage the Minister to work with the Department of Transport, Tourism and Sport and the Department of Education and Skills in this regard. It is really important that physical education be maintained in the curriculum right up to the leaving certificate. People need to be physically active at all ages, no matter how many exams they are doing and how important those exams are.

Since I have the Minister's ear, I will also state my deep concerns about the low rate of breastfeeding in this country. We have the lowest rate of breastfeeding in Europe and the highest rates of caesarean sections. A caesarean section is a traumatic major surgery. It is not what one wants to be dealing with having just become a mother, whether for the first time or having had children before. We really need to look at that. It is not a great start to life. Many of my friends and family members have had caesarean sections. Having been forced into major surgery makes it much more difficult to care for a newborn. The Minister should look at those figures and try to determine why this is happening and why the rate of breastfeeding is so low. When we know what is happening, we can look at solutions.

I have a 21 year old but I look at the lack of funding for mental health services for secondary school students. Much of the provision of such services has been left to charities. I have been raising funds for many causes for years but I sometimes feel we are raising funds for services that should be provided by the State. There is a family resource centre in my local area which is seriously struggling to meet the demand for mental health services subsidised by the State because private mental health services can often cost €50, €60 or €70 per hour. That is outrageously exclusive. I ask the Minister to look at the area of mental health very seriously. We should move towards including mental health in the curriculum and the induction process into first year of secondary school so that young people, and old people, will have the tools to manage their mental health in a preventative way rather than only being given help when it is nearly too late or sometimes is.

Mental and physical health cannot be separated from one another. I come from a very rural area and we have serious problems in attracting GPs. Dr. Gerald Wheeler has been my GP for the past 40 years. He is 71 years of age and wanted to retire but could not. He would not do it because there was no one to take his place. He worked all through the Covid crisis. I have to mention him because he is now finally retiring. GPs should not, however, be forced into those situations. Having given more than 50 years of their lives to medicine, they should not be trapped working forever because we have not solved the GP issue, especially in rural areas. GPs also need supports because more and more people are presenting to them with mental health issues. GPs cannot always refer them on. Mental health problems are an acute issue, like a broken arm or a broken leg; one does not put the patient on a waiting list for a year and a half. He or she needs help urgently. Mental health problems have to be seen as an emergency issue. I wish the Minister the best of luck.

I will just take a few minutes to make some comments on the Bill. There is not much point in repeating much of what has already been said. First, I give the Minister my sincere good wishes. He has great enthusiasm for the job. They say nobody wants the job of Minister for Health. When in opposition, he was always enthusiastic and listened to people's point of view. He came up with some very good suggestions. Every minister for health in the world faces a major challenge at the moment in respect of the pandemic. We should remember that the Minister and his predecessor, Deputy Harris, who I am sure have worries in their own lives, also have to worry about a whole population. They have had to explain why we need to stay the course and why we need to be careful. I want to acknowledge that here today. Being the Minister for Health is a challenging job in ordinary times but it is now very challenging.

I very much welcome the Bill. Section 2 increases the income limits for medical card eligibility for those over 70. For a couple this limit will be increased to €1,050 and for a single person it will increase from €500 to €550. I know from experience how often people who are just slightly over the limit will come to a public representative's clinic. Regardless of what one does, one cannot get their cases over the line. Staff in the medical card section are good at helping to get people across the line in special circumstances but on so many occasions people who desperately need the card cannot get it. I welcome this increase very much. I am sure the public will also welcome it.

Sections 4 to 6, inclusive, make changes in respect of free GP care for children. Again, when parents have to take a child to a doctor and then go to a chemist, €100 can go very quickly. Our children are teenagers now; they are not babies any more. We are thankful that we did not have to spend a lot of time running back and forth to doctors but these costs were significant in the past for parents, particularly lone parents, who were not eligible for medical cards. It is a very good progression and very welcome.

There are great challenges in the health sector for the Minister and for all politicians. The Minister has been very honest in saying that everything will not happen overnight. Like most people here, however, I hope we will be able to progress some of it pretty quickly and make some changes the public will welcome at a time when they are seriously challenged in many ways.

We have an ageing population. It is great to see people living longer and having a good quality of life. There is no doubt that, although we often criticise the health service, there is a better quality of life in Ireland in many ways. That is proven by the fact that people are living longer. Naturally enough, however, when people live longer, they will develop some ailments and will need more assistance and care. People's GPs are so important to them.

Senator Fitzpatrick mentioned her father and the GP practice in the house. Indeed, I can remember in my town of Strokestown one went to the doctor's house and there was a waiting room in the house off the surgery. That is all changed nowadays but there is that important link between the GP and the patients. For people, such as my mother and her friends, their visit to the GP when something is wrong is so important to them. They have such faith and belief in the GP and always feel comforted by him or her when they make that visit.

I wish the Minister well. It is great to have him bringing this Bill before the House. As I stated earlier, I would love to see some of it progressing as quickly as possible but I still acknowledge and admire the fact that he has stated it will be introduced in phases. I accept that. The Minister is being honest and upfront about that. It is very important because sometimes ministerial announcements are made and nothing happens for a long time. The Minister is pointing out that there will be a phased development and even though we want the legislation implemented as quickly as possible, I acknowledge his honesty in the debate on that.

I welcome the Minister and wish him every success in his role. It is a daunting task to take on at any time, but particularly at this time, and I admire thus far how he has carried out the role and his presentation of the Bill, which I very much welcome.

As Senator Murphy said, the GP relationship is such an extraordinary one of trust, and possibly one of the last bastions of our society that is standing and held up in such great esteem.

I believe access to GP care is a fundamental right. That is my position, full stop, from a just society perspective. I am very excited about the trajectory that we are on with Sláintecare. It is an extraordinary journey and I look forward to a day when we have universal healthcare.

I am one of these parents. I have a five year old. It has been an extraordinary journey with her that we have always had access. In my experience from constituency work, the feedback is that a floodgate did not open when under sixes were allowed free access to GP care and, consequently, I do not believe that. However, I accept we are in extraordinary times. I respect the Minister's position on that but urge him to give us an idea of timelines as quickly as he can.

On access, reflecting the Minister's positive words, early intervention and tackling inequality are fundamentally what this is about. In that regard, we have had a time when doctors and nurses have respond to Ireland's call. If we could keep them at home, not have them emigrate and create the jobs and the positions for them in the here and now, that would be fantastic. I urge the Minister to do that. That would assist in making sure that we have the supply of staff and healthcare professionals for early intervention and tackling inequality.

Senator Boyhan referred to facilities for cluster care. My party has called that the primary care centre and has had great joy in rolling that out. It is a long-held and cherished policy and one that has had support across both Houses. No doubt the Minister will also support that. That policy continues to be implemented so that we have primary care centres and we can roll them out as much as possible as the first point of contact with the healthcare service so that it is as close to the community as possible, keeps people out of hospital unnecessarily, can have a diversity and multifaceted response to people's health, and reduce waiting list and hospital waiting times.

We have two primary care centres - one planned and one nearly finished - in the constituency of Dublin South-Central. The first is the Rialto primary care centre on the South Circular Road. I am delighted that it was designated by the HSE as a Covid-19 triage centre. It received a special dispensation and works continued throughout the lockdown.

It looks, from the outside, good to go or virtually good to go. I would welcome an update from the Minister, although not today as I do not mean to catch the Minister on the hop. At some point, I would welcome an update on when that will be opened.

The second issue is the primary healthcare centre planned for Drimnagh. In that regard, I have written to the Minister, Deputy Stephen Donnelly. The Minister of State, Deputy Feighan, will be on to the Minister on my behalf as well because I am nagging him. I am seeking an update on that, if at all possible, and whether and to what extent the scheduled commencement of that project has been delayed by the obvious health crisis. In December last, the then Minister of State, Catherine Byrne, and the Minister's predecessor, Deputy Harris, went out and confirmed the green light on that project that a new primary healthcare centre was going in on the site of the Mother McAuley Centre and the Alzheimer's centre, and it was to go on the same site in Drimnagh. At the time the HSE capital plan funding was in place to begin it, it was to be a new building on that Catherine McAuley site. There is fantastic work already ongoing in there for the local community. The project was supposed to go to final design this year with construction starting in 2021. I would appreciate the Minister's feedback on that project.

I wish the Minister the very best and thank him.

I welcome the Minister to the House. Like my colleagues here in the Chamber, I will be supporting the Bill. There is broad support for this Bill here today.

I would like to raise something outside of this Bill. I appreciate the brief that Deputy Donnelly has got at this time, the humongous task that he has ahead of him and the pandemic times that we are living in but I want him to be remembered as the man who did something with the health services in this country. I want the Minister to take that out of here today. I want him to be the leader that we all need him to be to reform the health services of this country. I want the Minister to be the leader who will not have the terminally-ill people of this country begging for a medical card. I want him to be the leader who will not have our children with scoliosis waiting for years to have operations. I want him to be the leader who will not have the elderly dying on trolleys in our hospitals. I ask Deputy Donnelly to be that leader. I will do whatever I can to help him. I do not know what it is that I can do to help him but that is what I want from him. I want Deputy Donnelly to reform that health service.

I want Deputy Donnelly to be the leader who will champion women's health. People cannot get bowel cancer screening and breast screening now until September. That is wrong on so many levels. We have not even come out of the cervical cancer crisis. That has been the biggest scandal in this State. I ask the Minister to not let that happen to the women of the State. They are the future mothers of the generations to come. I ask the Minister to look after them.

I wish Deputy Donnelly the very best. I want him to be the leader who will lead the health service out of the horrible hole that it is in at this time. There are some fantastic people working in that service and I commend them for that. I beg Deputy Donnelly to be the best Minister for Health this country has ever seen and I wish him well in his portfolio.

I welcome the Minister to the House. I congratulate him on his appointment and wish him the very best in his difficult position. I very much welcome this Bill to the House. It marks another step in trying to achieve the Sláintecare principle of universal access to care at low cost or no cost.

It is a great sign of the way this Government is going when one of its first Bills through the House is to extend access to healthcare. Families all over the country struggle day in and day out. I know that. I was glad on a number of occasions over the past number of years that there was free GP care for children under five years of age. I have four children and there can be situations when they all get sick and drop like dominos and one spends a few weeks or a month in and out of the doctors' waiting rooms. That can put a family under serious financial pressure. One could have two or three children in that situation.

That would cost €150, and there could be the cost of antibiotics on top of that as well.

This Bill means that families do not have to take a chance on whether their children will be okay. They do not need to make the decision on whether to spend less on groceries this week or bring a child to a doctor. Too many squeezed families make such decisions every week and, therefore, I am glad to welcome this phased extension of free GP care for children, which will ensure that they do not have to make them. I also welcome the income limit extension for the over 70s. Many pensioners are struggling with the cost of living, which is on the increase even though their incomes are not. This will be a welcome respite for many.

As many Senators have mentioned, GPs are under pressure. Anyone who attends a GP's surgery knows that it will be an overstretched service and that he or she may need to wait for days just to get an appointment and, after getting one, wait in line for an hour and a half. I hope that we can work to support GPs in the lifetime of this Government and increase their capacity.

I welcome the Bill, but I would like its provisions to be implemented sooner rather than later, although that is a bit selfish. I look forward to seeing how the Minister progresses Sláintecare in his term in office and how he works with GPs to ensure we have a functional and effective primary healthcare system.

I join colleagues in welcoming the Minister to the House. I wish him the best in his new role in what remains a challenging time for the country in the face of the Covid-19 pandemic.

I welcome the opportunity to contribute to the debate on this important Bill, which seeks to expand on a phased basis eligibility for free GP care for children aged under 13 and to increase the income limits for persons aged 70 and over from €500 to €550 for a single person and from €900 to €1,050 for a couple.

My party and the Minister's have been strong supporters of the roll-out of free GP care for some time. As alluded to by my colleague, since 2015 when the current Tánaiste was Minister for Health, all children under six years of age have been automatically entitled to free GP visit cards along with periodic health assessments and access to the asthma cycle of care programme. In the past, we have received criticism from some quarters for the universal aspect of that provision. People have said that those who can pay should pay. I believe the Minister will agree that misses the point. The whole point of the measure's universal nature is that a family with a sick child can attend a GP without having to fork out €50 or €60 just to see the GP. It also gives families a return on the taxes they pay.

The Minister referenced an interesting statistic, one that not many people will know. Since 1 June, just shy of 2.1 million people in the State, or 42.6% of the population, have had access to free GP care. It is a significant number, but I do not remember it being acknowledged in the media or by Opposition parties. I look forward to that provision being expanded over time. The changes that we are bringing about with this legislation will benefit an additional 300,000 children in three phases, focusing first on six and seven year olds and then moving to eight and nine year olds before moving to ten, 11 and 12 year olds. It should be noted that 195,000 children in the six to 12 age bracket already receive free GP care at the point of access.

It is estimated that 56,000 persons aged over 70 will be eligible due to the increased medical card income thresholds being introduced in the Bill.

That is a significant change. As the Minister rightly stated, many of our older people will face increasing health issues as they get older. Given that this requires costly medication, a full medical card is more beneficial for them than the GP card.

I wholeheartedly endorse the Bill. It will ensure that our parents, grandparents, aunts, uncles and neighbours will qualify for full medical cards, but I ask that the Minister keep the income thresholds under review. We cannot allow another six years to pass before the limits are addressed again. Perhaps the thresholds could be reviewed on a 12 or 18-month basis.

I reiterate my best wishes for the Minister. If the Cathaoirleach allows, I will ask the Minister that, when Covid passes, he take the opportunity to visit my constituency of Waterford to open formally some of the fantastic health facilities that have been completed in recent months - the Dunmore wing in University Hospital Waterford, St. Patrick's community hospital and the primary care centre on the grounds of St. Otteran's Hospital. He would be more than welcome and we would like the opportunity to speak to him about other health issues, which have already been raised with him, in particular cardiac care for the south east.

I welcome the Minister to the Chamber. I congratulate him on his role and wish him the best.

I welcome the opportunity to contribute on this Bill, which will achieve two objectives, the first of which is the expansion of GP care without charge to children and young people. The Bill contains provisions to extend and expand this important benefit to children under eight years of age, under ten years of age and under 13 years of age on a phased basis. Second, the Bill will fulfil an important budget commitment to increase the weekly income limit for older people when applying for a medical card from €500 to €550 for a single person and from €900 to €1,050 for a couple. Both commitments were agreed by the previous Government and the decision to continue with them is welcome. The Bill is an important next step in the introduction of universal GP care, which is a recommendation of the all-party Sláintecare report.

The briefing notes that I have been provided by officials describe the health system as providing for two categories of eligibility - full eligibility, that being, medical card holders, and limited eligibility, that being, all others. The description in the Oireachtas Library and Research Service's paper on the Bill that says there are two categories - those with a medical card and those without one - is more appropriate. Every Oireachtas Member and councillor has spent time on healthcare issues, including medical card and GP visit card applications for constituents. Each of us has experienced cases where a person or family has been refused one card or the other despite experiencing genuine and evident difficulties. One goes around the houses trying to get information and letters from doctors and consultants, which are sometimes just one-liners and not appropriate in terms of expressing what the patient or family needs. These are important issues for people. As colleagues have stated, additional benefits derive from the medical card, or the miracle card as some people have called it.

We all should know that early intervention in medical problems is essential. It is next only to the pursuit of a healthy lifestyle. The real challenge for us as legislators and for wider society is deciding how to ensure the provision of timely and appropriate healthcare as and when it is needed. We made progress in recent years under Fine Gael-led Governments. This should be recognised. Free GP care was provided to children under six years of age, to all older people aged 70 years and over and to all children with disabilities and their carers.

Free GP care helps to ensure that children, older people and those with disabilities can access healthcare so as to achieve the best outcomes. Furthermore, it reduces pressure and worry on parents and guardians as well as older people on fixed incomes. However, we cannot ignore the serious challenges facing us. These include the cost of free GP care and the capacity of the GP system. There seem to be different views in the House.

That may be geographical. It may be based on people's real experiences. While some people may say genuinely they do not feel there are capacity problems in their constituency, town or locality, other people may say there are genuine problems.

The Department of Public Expenditure and Reform last year indicated that the expansion of free GP care to all children under the age of 13 would cost €50 million per year, which is not much in the context of some of the moneys that have been spent recently. In addition, the increase in income limits for medical card assessments for people aged 70 or older would cost an additional €30 million per annum. From the additional funding needed for these two measures, the substantial additional investment that will be needed to introduce universal GP care becomes clear. That is obviously where we want to be able to move to, but the move has to be incremental because the costs are somewhat prohibitive if large leaps are taken on eligibility.

The primary care reimbursement service, through which medical cards, GP visit cards and other GP services are fulfilled, was allocated €2.9 billion in budget 2020, a substantial portion of the health budget. The budget for primary care was €1.08 billion. We need to continue to direct more funding to primary care on the basis that it improves overall outcomes and represents the most sensible expenditure of public money.

The second major challenge is capacity, as I have said. While the number of people training to become GPs has increased in recent years, which is very welcome and encouraging, the general GP workforce is getting older, with retirements impacting the level of service, particularly in rural areas. Our population is increasing and our people are, thankfully, living longer. However, these facts place additional pressure on GP services across the country. Moreover, the policy decisions, welcome as they are, to increase free GP care invariably increase the number of people visiting GPs, although, again, I have heard different opinions on that here. That is certainly what has been relayed to me in my area.

Finally, the out-of-hours services provided by GPs are also very important and are under pressure. Westdoc in Galway is an excellent service but is under severe pressure in areas such as Moycullen and Oughterard, for example. Local doctors work on a rota basis to provide out-of-hours cover but they are doing so more frequently and more regularly. Westdoc needs additional resources to allow it to expand, something I raised with the Minister's predecessor and which perhaps the Minister may be able to influence over the coming year.

I welcome the Minister and wish him well in his new post. Objectively, and to give credit where credit is due, as an Opposition spokesperson he won the confidence of people on the front line, not only his supporters. They believe in Stephen Donnelly. They believe he understands the intricacies and challenges and they are backing the Minister to make a difference.

In the past we have had not so much false dawns as perhaps the tying of hands. Today we are faced with a Bill on free access to universal healthcare. Who in their right mind would not support that? I will not engage in repetition where my fellow Senators have covered ground, but in essence we are expanding access to GPs and the healthcare system for more children on a phased basis. I am just concerned that this is almost like a parallel universe. As we strive in unanimity to reach that laudable, noble goal, the promised land of Sláintecare, access for all, what does the Minister say to the children who cannot afford access and who have been waiting years for vital intervention? Do we say it is only €50 million to do more? We would all love to do it, yet children are being left behind as we relentlessly do our best to get to where we would all like to be. We therefore expand access to GPs. Is the Minister aware that many of them are overworked, understaffed and swamped with patients they can hardly cope with? Our brightest and youngest run abroad as soon as they qualify and do not come back. We cannot bring consultants back into this country. I put down that warning today. I am not getting carried away. I support the Bill. There is, however, a large bell ringing in the back of the room. The challenge is how the Minister strikes that balance. What is his prioritisation for vulnerable children?

This will give children whose parents are millionaires access. That is great because perhaps they would not have gone otherwise. We should get all the sociological studies on that. Who would not welcome as much access as possible for everyone? However, this comes at a time when our system is under massive pressure and when many in the profession feel they will not get the commensurate support to deliver and roll out this service. What does the Minister say to the people who will make this happen, who make the magic happen? We are the legislators and we can provide for today, but what support does the Minister have for those on the front line? The support provided in the context of Covid has left a lot to be desired. These people were on the front line. The advice was to contact one's GP. It was several weeks before we were told to phone the GP, not just to rock up to his or her surgery. We had a minute's silence in this House for the latest healthcare professional to lose his life protecting and caring for us. Where was the healthcare and personal protective equipment for our doctors? It came very late for some of them.

I have hope as the Minister starts on this challenge. He excelled in opposition, and it is not every Opposition spokesperson who immediately gets the first available opportunity to step into the shoes of the outgoing Minister and translate words into action. Now the country is looking at the Minister and wishing him well on his journey. I know that what I have said might not have come as news to him. I would love to know how he will balance this and square this circle - this major contradiction - as we strive at the pace we are striving. As Senator Keogan said, and I am glad she did, it is not a pretty picture. There are children who have been waiting years. The Minister cannot turn back the clock. They are being deprived of essential intervention, and they only get one childhood. There are adults who have been waiting years as well. As a result, I will be reserved in the context of my welcome for the Bill until such time as the Minister has ensured greater, fairer, more accessible balance and roll-out of the services whereby everyone will be treated equally.

I welcome the Minister to the Chamber and wish him well in his new portfolio. Everyone across the country is wishing him well for the coming months. It is important to acknowledge the welcome news about Covid-19 and the reduction in the R-nought number. It might be early stages yet, but this shows that the cautious approach the Minister recommended to Cabinet last week was correct. That will be judged again come 10 August, but the signs are improving and that brings confidence among the public that the measures and the cautious approach they are taking is working. There was a growing sense - I am sure the Minister got it in recent weeks - of a little pessimism that a second wave was almost inevitable no matter what we did, but the numbers over the past two days show the impact we can have in fighting this virus.

I am not as cautious as my colleague, Senator Martin. I fully support the Bill. It is very welcome and continues on from progress that was made before this Government was formed. I am particularly pleased with section 2, which seeks to increase the limits for those aged 70 and older from €550 per week for a single person and €1,050 for a couple. I think every public representative has come across cases of people being at €920, €925 or just barely over the rate who have totally missed out. Obviously, that will happen if we increase the rate to €1,050, but it is a large increase. I agree with some of my colleagues that it should be reviewed.

As Senator Cummins said, that should be reviewed more regularly than every six years. However, it is encouraging to see and it brings a certain level of comfort to people who need it.

It is encouraging to note, in sections 4 to 6, inclusive, the extension of free GP care, which is currently available to children under the age of five, to those aged six and seven in the first instance, with a possible phased extension to children under the age of 12. These measures will bring approximately 300,000 additional children into the system. That is to be welcomed but the key is to bring that in as quickly as possible. I know the Minister has challenges in his Department but that one is vital. Through my experience of the health service since the birth of my first child six months ago, I have witnessed at first hand the talent we have in the health service, from maternity care to aftercare. The policies we have brought forward for GP care provide reassurance that if anything happens to a child of that age, money is not a barrier to helping the child.

A week or two ago I was contacted by a mother who was hesitant to bring her daughter who was quite ill to the GP, essentially because of the cost. She did not realise at the time that, because of the age of the child, she was entitled to free GP care. It subsequently transpired that the child has a long-term illness but it is manageable. If we are introducing these measures, it is important to get the message out about them as quickly as possible. I am sure the Department will highlight as much as possible that free GP care is available for these children.

I fully endorse the legislation. As the first Bill the Minister has brought to the House, it is very good and I wish him well with it.

If I may, I will make a point on a local issue in Tipperary, on which I am aware the Minister has spoken previously. St. Brigid's respite and palliative care facility in Carrick-on-Suir, like many facilities across the country, is being used as a step-down facility for recovering Covid-19 patients. The Minister's predecessor, Deputy Harris, gave an assurance that it would return to its original use after the Covid-19 pandemic. Many people in Carrick-on-Suir are concerned about when that will happen. I know that question is almost impossible to answer because it depends on the progression of Covid-19. I have been working closely with a local councillor in the area, Councillor Mark Fitzgerald, to try to give as much reassurance as possible but it would be much appreciated if the Minister could give a reassurance that the facility will return to its original purpose. Very good people work in the facility. People in the town and local area understand the need for it. I would be grateful if the Minister could respond on that. I support the Bill.

I welcome the Minister to the House and commend him on his elevation to Cabinet. He is no longer the Joe Brolly of Irish politics; he is now the manager. The punditry is over and I wish him every success. As a former chairman of the Joint Committee on Health and Children, I assure him that the playing field is one he will be well able for.

I am struck by the revisionist comments made by some of my colleagues and friends in the House. I remind Members that it was the former Minister, Dr. James Reilly, under the Fine Gael-Labour Party Government, and the two Ministers for Health in the subsequent Government, Deputies Varadkar and Harris, who started us on the trajectory of universal health care. It was not just one party. The partitionist approach to politics around health always baffles me. This is about people, north, south, east and west, and accessibility. It is not about what is in the póca; it is about what we need to get done. That is what this Bill is about. It is about accessibility.

Previous speakers referred to the Minister's legacy. If he tackles the structural problems in the health service rather than taking a short-term, populist approach to trolley numbers or the latest crisis, he will leave an indelible mark on health.

It is about what he is doing today, which is long-term prevention. It is about building capacity and measures that are taking on the vested interests in terms of real reform in our health service. Unlike others who commentated, at least the Minister had the courage to say that he wanted to be the Minister. He is now the Minister, and I commend him for that. Others will take the "We know everything but we will not go into government" approach, but health needs reform. When he was Fianna Fáil's spokesperson on health, he was cautious about this approach in terms of accessibility. He needs to continue to bring GPs and the medical community with him because as Senator Martin said, they are faoi bhrú - under pressure. Numbers attending GP practices are increasing. For once and for all, we need to tackle this time immemorial issue of our best and brightest students leaving this country. I chaired a health committee at a time when the then Minister, James Reilly, had a trajectory in terms of placement and jobs but we must make sure that we can put the structure of that in place.

I remind the Members in the House that last year's budget contained the largest health budget in the history of the State at €17 billion. That was put in place by the previous Government prior to the pandemic. It is now up to approximately €20 million.

I welcome the intergenerational aspect of this Bill in terms of the amendment that provides for an increase to the medical card income levels for persons aged 70 or older to €550 for a single person and €1,050 for a married couple. I welcome also the provision for access to GP care for every child under the age of 12. A Member mentioned earlier the extension of access to children under the age of six. That is a critical age group, and I welcome that. Every child needs access to healthcare. Early intervention is what we should be doing, whether it is in education or in health.

I have to be honest with the Minister. Like Senator Martin, I am sceptical about Sláintecare. I ask him to consider a constitutional convention or citizens' assembly to look at that issue away from this political amphitheatre.

I say that because scaffolds need to be put in place to support our health system and I do not know that we can do it from here. I know the Dáil and the Seanad are the people's assembly but as a former member of the Constitutional Convention, I ask the Minister to consider taking a citizens' assembly approach to universal healthcare because we need more GPs.

Senator Kyne referenced the out-of-hours service in Galway. The Minister needs to look at SouthDoc, in Cork, and we need to ensure that we continue the out-of-hours service. The principle of universal healthcare is one all of us subscribe to and want. I am concerned that, in terms of Sláintecare, we will not get the buy-in. It is about capacity, resourcing, costings and timelines. I will not be parochial but I will talk to the Minister again about the need for the new hospital in Cork. I wish him every success.

As there are no other speakers offering, I invite the Minister to respond.

I will give my concluding speech but I have taken pages of notes from which I will try to pull some of the big themes, if the Cathaoirleach agrees.

Absolutely. The Minister has the floor.

Excellent. I thank the Senators for their valuable contributions. I have taken many notes, as have my officials. It has been a thoughtful and important debate, both on the Bill before us and on the issues surrounding the Bill. The Senators' keen support and observations are very helpful, and we will keep them in mind. As Senator Higgins said, it would have been nice to have had input into the Bill as the debate proceeded but we are compressing it. Nonetheless, the Bill has an implementation aspect to it and the various contributions will be kept in mind during the implementation phase.

The two measures are very important. They will ensure that irrespective of ability to pay all children of primary school age will have access to GP services, which we all agree is a profoundly important step in the right direction.

Expanding eligibility for the medical card among those aged over 70 is incredibly important. Everyone over 70 used to have a medical card whereas now everyone over 70 has either a GP visit card or a medical card; three in every four people over 70 years has a medical card, and the remaining one in four has the GP visit card. We are expanding the former. My intention, and I should discuss this with the Government-----

----- is to continue to expand that. I thank Members for their support for the Bill and what it is trying to do.

I have taken a lot of notes and I apologise in advance as, inevitably, I will not be able to speak to all the points raised. Some were local. Myself or the team will revert to Senators with updates.

Regarding Covid, public health officials have been increasingly worried over the past five weeks. The number of new cases per week was climbing considerably. A key number they look at is the cumulative number of cases in the previous two weeks per 100,000 population. Ireland was down to nine and that climbed up to 22 and was continuing to rise. An R-nought number of less than one means the virus is dying out in society and if it is much over one means that it is growing, while a little over 1 means that we are holding our own. We had it below one and it began to grow again. Approximately a week ago, their best estimate was between 1.2 and 1.8. They calculate this in multiple ways and when the numbers are low in Ireland the range widens because it is harder to calculate given the rate is low. That is why the Government decision was made to pause on phase four and introduce face masks on public transport and in retail outlets. It is why we pushed very quickly to get the app launched.

I have had long conversations with the acting Chief Medical Officer almost daily, including today and yesterday, about what happened in the past ten days. NPHET met yesterday. The good news is that things have stabilised in the last ten days. Critically, the R-nought number has come down. The latest estimate is between 0.7 and 1.4, with the best estimate at 1.1. There were seven new cases yesterday. Tragically, nine deaths were announced yesterday, which we mourn. Eight had become unwell during previous weeks and months, while one was more recent. Every death that can be avoided needs to be avoided. It is an imperfect science, but the sense is that the improvements we have seen, the stabilisation in the past ten days, the reductions in the R-nought number and the number of new cases, is largely due to the response of the public. We all remember that two weeks ago, there was a weekend when a relatively small number of people let loose and there was probably a week when people might have relaxed a little in following public health guidelines. One cannot blame anyone, after everything the entire country has been through. There was a big, positive response to that and public health officials made another big ask to everyone to wear face masks and comply with social distancing. People reacted and yet again they are doing the right thing. Even as we have opened up our society over the past ten days, things have stabilised. The people who deserve credit for that are the Irish people for stepping back up.

It is not an easy thing to do. That is very positive. There has been much comment recently about travel, which is fair. It is sorted out now and I hope the messaging is very clear.

There is something worth reflecting to the House. I had a fantastic conversation with one of the top advisers at the WHO. I asked him about Ireland and he could not have been more positive. He said it was obvious to look at what was happening and what needed to improve but he said that we are doing an incredible job, with one of the lowest rates of the disease anywhere in the world. He particularly singled out political solidarity. He said when the WHO looked around the world at the things that were important and working, Ireland was not unique but unusual in the political solidarity that has been shown right from the start in February. I was in opposition then. Deputies O'Reilly and Kelly and many others across the political spectrum and I got together and got the advice. Those in Sinn Féin and other parties and I disagreed, we brought things to each other and discussed them. We had great access to the HSE and officials and things worked.

I wish to extend the same offer here as I did in the Dáil earlier. It is fair to say that in the past week or two some of the solidarity has slipped a little. Some of the responsibility for that lies with me. It may have been unavoidable with the change of Government but the level of political interaction probably slipped. The briefings we all had stopped. No decision was made about that and there was no intention, but I made an offer to the Dáil earlier and say here that we need to get those conversations going again. That is not to say that there should not be criticism. The job of Members is to challenge, give ideas and call each other out, but I am making the offer that we should engage as much as possible and maintain the solidarity, because the public looks partly to us to see how we are leading.

It is important that we remember that, by international standards, we are doing incredibly well. The Irish people have done and continue to do an extraordinary job. The healthcare system has been incredible. Have mistakes been made? Absolutely, of course mistakes have been made, and we all know that. However, what our healthcare professionals, the Department, the HSE, section 38 and 39 organisations, and communities throughout the country have done in stepping up and mobilising around this one threat and helping each other has been incredible. We all remember the scenes in Italy and elsewhere where very sick people were being treated in the car parks of hospitals because their health systems were overwhelmed. Even though our healthcare system was over capacity before Covid arrived here, it created the capacity and the surge was dealt with. It is an enormous credit, first and foremost, to the people and families of Ireland, who stepped up, and to our healthcare professionals, some of whom lost their lives. There was a funeral yesterday of a doctor who was a front-line worker on Covid who passed away. They literally gave up their lives to keep us safe. The solidarity from healthcare professionals, the public and across the political spectrum has been fantastic. Sometimes we miss that we are doing really well. It is hard and it will be bumpy, there will be more outbreaks and some will almost certainly be bigger than we would like, but we are doing well and need to bear that in mind.

On the Bill, many Senators have raised the issue of the timing. I will deal with them separately. The context of these and other measures outside the Bill which do not require legislation and which were in the budget for this year is that they were contingent on savings. They had been agreed in the budget for this year but without new money. They were contingent on the HSE saving money in other areas. Obviously, that has not happened because of Covid. Not only has it not happened, but on my second day as Minister, I had to ask the Dáil for an additional €2 billion, and told it I would be back for more.

The savings had not happened. I need to ask for new money, which is obviously a difficult thing to do. That is what is required when it comes to the issue of people over 70 years, and it is my intention to do that. This is a decision of Government, as is any such decision requiring new money, and I will be pushing very hard for it.

The GP access is different because this is €50 million in a full year, and as Senators Martin and Buttimer have said, there is a philosophical question with all of this, which is what is the best way to spend €50 million? Senator Keogan referred to scoliosis and various Senators have referred to medical cards for terminally ill people together with many other very important things. The question for us all in health care is how we spend the money. There is not, unfortunately, any right answer to that question. We are in a particularly tricky spot where our healthcare system is over capacity. Before Covid-19 arrived, we had the longest waiting lists in Europe, the lowest number of hospital consultants, and the second lowest number of beds. I am not attributing that to any political reason but it has happened over many years with different Governments. What do we do? Do we deploy the money on the trolley crisis, on scoliosis, on mental health, on maternity care or on free GP access? There is no right answer to that question.

We are trying to do both at the same time, which is very difficult and costs a great deal of money. Senator Buttimer raised the strategic question on the approach to all of this. My approach is that we have three huge tasks to deal with at the same time. The first is Covid-19, and we understand broadly what is involved in that. The second is capacity and the resumption of services coupled with winter planning, and this is a massive task. We started with the longest waiting list in Europe. We have had a significant increase in those waiting lists because of the necessary pausing of elective care. On top of that there is a huge unmet care need within the community. Due to people not going into healthcare facilities as they normally would, there are many people who are sick and who should be on the waiting lists whom we do not know about and they do not know about it yet either. They need to be added to the waiting lists. On top of that, the HSE capacity is significantly reduced because of Covid-19. I had a briefing from HSE this morning that said that its operating theatre and outpatient capacity will both be down by about 30% and its diagnostics will be down by about 50%. We are taking a system that already did not have the capacity it needed and significantly reducing that capacity while adding significant demand to that, such as adding Covid-19, winter requirements and a significant domestic and global recession, all at the same time.

That is the second challenge, therefore, how we put a plan together to get the services back up and running immediately, deal with the waiting lists that are now even longer than they were, deal with the fact that winter is coming, and deal with the reduced capacity. As soon as I was appointed I sat down with the Department and the HSE and said that we need to put both a winter plan and resumption of service plan together but not like any we have seen before. This is not a question of looking at what happened last year and doing more or even twice as much of that. Everything must be on the table. The plan has been developed at the moment. It needs to be comprehensive and is going to cost a great deal of money. The challenge that we are faced with right now is immense. I sat in this Chamber in December and January decrying the trolley lists. This year, that simply cannot happen. We cannot have 85 and 95 year old men and women on trolleys for three days. We should not have anyway but certainly not in a Covid-19 world. This is the second task which is a huge challenge, as I am sure all of the Members understand.

The third task is universal healthcare, which is the long-term vision piece, and it has three tests.

The third task is universal healthcare which is the long-term, vision piece and it has three tests. Universal healthcare means that people get rapid access to consistently high quality care that is affordable. We are trying to deal with the Covid-19 pandemic and are advancing universal healthcare through this Bill, which is the Sláintecare strategy at work. At the same time we are putting a significant effort, which will require much resources, into dealing with the very serious capacity constraints that men, women and children are facing all over the country. That is where we are at strategically.

I will mention maternity care, which has been raised by a number of Senators. This is something that I am going to be pushing very hard. There is a brilliant maternity care strategy in place since 2016. The first place I visited as Minister for Health was the Coombe Hospital, which was intentional on my part. I wanted to visit somewhere which had maternity care and women’s healthcare and serves a great many people from disadvantaged areas as well and wanted to make a point of going there first as a demonstration of what is required. Maternity and women’s health is something that is going to be very important to me and which I will prioritise in this Government.

Scoliosis was also mentioned. I am going to meet Children’s Health Ireland in Crumlin next week and I have been back and forth with the Scoliosis Advocacy Network and will be meeting it at some point after that to see what can be done to help. There is no hierarchy of needs. Everyone is as deserving as everyone else but this is an issue that I and many others have been very affected by. I am going there next week to see what the Government can do to try to help. The good news is that we have a new surgeon starting in the third quarter of this year which should be fantastic.

Finally, regarding the Bill on GP capacity, the phasing of GP care for children is exactly to this end. If we already had what was needed in the existing capacity and if general practice was saying to us that we are ready to go, give this to the children as we have the capacity, the ask I would be making then - whether I would get it or not - would be for €50 million to allow us to do it now. The GPs are very clearly saying now that we need to be careful and that we do not have the capacity. They have stepped up incredibly during Covid-19, which we are still right in the middle of, and we are going to need our GPs like never before this winter. What we are looking for to a great extent in the winter plan is how we keep people out of hospital. Much of this is about giving GPs direct access to diagnostics that they do not have and to other care pathways and direct access for people with respiratory issues and so forth. I am meeting the Irish Medical Organisation, IMO, next week and we will be discussing these very issues. Our approach is that we need to grow capacity in general practice which we want to do very quickly, and as that capacity grows we expand access at the same time. That is the broad approach. I wish that the capacity was there and we could do it all now but the very clear message from general practice is that the capacity is not there now. Let us get the capacity in place. We are going to be negotiating a new GP contract and rewiring many care pathways so that GPs have far more options than they have now where, in many cases, they have to refer people to an emergency department.

I hope that covers at least some of the issues raised in the Bill and also the wider healthcare aspects. I thank the Members.

I thank the Minister and congratulate him on his elevation to high office. It is a very challenging portfolio. I am delighted that he has been able to outline that vision here, not just on the Covid-19 issue but on the vision for the future. Given his experience before politics, he will need it all to take on what is and has always been one of the most challenging portfolios in any Government anywhere in the world. I wish him all the very best in that and I know that everybody on all sides in this House and all of the Irish people are relying on him to try to deliver that plan and bring that vast experience from the private sector into this system.

It is very complex but nonetheless the Irish people deserve a system, as the Minister has outlined, where everybody regardless of their circumstances will be able to access world class healthcare. I wish the Minister the best of luck in that.

Question put and agreed to.

When is it proposed to take Committee Stage?

Is that agreed? Agreed.