Health Insurance Regulations: Motion.

I call Deputy Geoghegan-Quinn to move the motion and the Deputy has some 15 minutes.

Do I not have 20 minutes now that two hours has been allowed to debate this motion?

I will clarify that.

The Minister of State does not have any problem with that.

I gather it was agreed to extend the debate to two hours instead of one, but the number of minutes allotted to each Member has not been changed and still stands at 15 minutes.

Can a decision be made by way of agreement across the floor of the House as the Minister is willing to allow me 20 minutes if necessary?

I hesitate to accept a decision of this kind where no notice has been given and so many Members would be unaware of a promptly made decision of this kind. It should be done in a formal manner.

I do not want to enter into a debate with the Chair on the matter. At 4.20 p.m. the time laid down for a debate on this motion was one hour and nobody was aware until the Taoiseach agreed to allow a two hour debate that extra time would be allowed. Initially we were told last week that a 20 minutes time slot would apply to spokespersons. I would like the Chair to consent to that by way of agreement across the floor of the House.

I am only too happy to agree with the decisions of this House and to implement them faithfully, but I also have a duty to see to it that they are made in a proper manner. If and when an order is brought into the House to change the duration of speaking time, I will put it to the House. There is time to do that. In the meantime the Deputy might proceed.

I move:

That Dáil Éireann annuls the regulations made under section 3 of the Health Insurance Act, 1994, because (1) they constitute a serious discrimination against the psychiatrically ill as other patients are not singled out for such a limit; (2) the regulations give effect to a reduction of insurance cover for psychiatric patients from 180 days to 100 days a year; and (3) the regulations fail to reflect the actual cost to subscribers of out-patient services.

It is most unusual for motions to be moved in this House to seek the annualment of regulations. However, Fianna Fáil felt obliged to move this motion because of the serious implications of the regulations proposed by the Minister for Health. We moved the motion in accordance with section 3 (3) of the Health Insurance Act, 1994 which makes provision for the Dáil or Seanad to annual regulations within 21 days of the regulations being laid before the Oireachtas.

The Taoiseach has acknowledged the serious nature of this motion by granting Government time for its debate. I thank him for that and I appeal to Members on his side of the House to give this debate full consideration. Acceptance of this motion does not mean that the health insurance system will collapse overnight. It will only mean that the unsatisfactory regulations will be renegotiated and improved.

While there are many reasons for bringing forward this motion, Fianna Fáil's overriding reason is that the regulations represent a discrimination against people with psychiatric illnesses. Every health policy document brought forward by Government over the past 40 years has had, as a fundamental principle, the integration of the psychiatric and general medical services. The Department of Health has stated this principle in many reports on psychiatric care. However, these regulations turn back the clock. They single out psychiatric patients for a 45 per cent cut in the in-patient day care they can avail of. People with general medical disorders are not subject to such a limit.

The Minister is making a distinction between psychiatric disorders and general medical disorders. Does he not acknowledge that a recurring depressive illness is just as biological or medical as diabetes? Yet the Minister believes they require different insurance cover. Does he believe that somehow those suffering from psychiatric illnesses are at fault for being ill? It is bad enough that insurance companies discriminate against people with psychiatric illnesses but it is the Minister for Health and the Government that is enacting this discrimination.

What is the view of the Minister for Equality and Law Reform on these regulations? While he is bringing forward equal status legislation his colleague, the Minister for Health, is enacting discrimination.

Down through the years, enormous effort has been put into bringing mental illness into the main body of illnesses. Even the United States has now moved to the position of treating psychiatric illnesses on an equal footing with other illnesses. These regulations will set us back a step and are regrettable, especially at a time when depression is the most common illness in the world.

The regulations set us on a slippery slope in relation to cover for illnesses. Not long ago, psychiatric patients were entitled to one year's cover. Then this was reduced to 180 days. The result of these regulations will be to cut that 180 days to 100 days or to reduce cover by 45 per cent. While the Minister will no doubt argue that all he has introduced are minimum standards and that Fianna Fáil is exaggerating in saying the 100-day limit will become the norm, everybody in this House and outside it knows that insurance companies will provide only what they must. The level of cover will be reduced to 100 days before we know it.

Most purchasers of health insurance will not be looking carefully at the psychiatric provisions of health insurance policies. They hope they will never need them. This will not be the point on which competition in the health insurance market turns. However, those who will need them will quickly find that only 100 days cover will be offered.

I understand the Minister is already considering amendments to the regulations to provide an additional 20 day-patient days in respect of psychiatric treatment and care. Is the Minister already regretting these changes proposed in the regulations? If he is considering changing them even before they are enacted, that shows some element of concern on his part. If the additional 20 days materialise, the Minister will have to further amend these regulations once this is concluded. I welcome any improvement but any continuing difference between psychiatric and general insurance cover represents discrimination and means the regulations will still be flawed. As he plans to amend these regulations, and that the matter will again have to come before the House, why not postpone it until after a full examination of the consequences? When the Minister spoke about these regulations in the past he implied the European Commission was calling the tune and forcing him to accept these regulations. Many have been left with the impression that in Brussels the Minister negotiated the number of days cover from 40 to 100. I heard that the Minister accepted congratulations on such a fine negotiating job and on showing the EU his muscle. It is my information that the only body with whom the Minister negotiated was his own Department. The Minister has misrepresented the role of the European Commission in this regulations débâcle. The commission's only role was to adjudicate on whether the Government had the right to introduce regulations under certain directives. The EU did not comment on the detail of the regulations.

Why was the 40 days figure put forward? Was the Minister keeping it low so that he would claim later to have raised it, or had he misjudged the reaction to the 40-day proposals and had to start again? It is important that Members of this House object to this 100-day limit; eventually the Minister may see the folly of his proposals.

It is unfortunate that the Minister for Health did not work with the groups representing patients in regard to these regulations. The level of consultation was very poor to start, but improved. However, the groups remain dissatisfied with the regulations. Aware, the group working to fight depression, has written to all Deputies in this House pointing out that the enactment of these regulations will mean that Ireland is the only country in the European Union which specifically discriminates against psychiatric patients in respect of health insurance cover.

Much play has been made by the Minister's party of a letter written by Dr. Anthony Clare, the medical director of St. Patrick's Hospital, about the regulations. However, Members have quoted very selectively from that letter. In paragraph three of the letter, Dr. Clare writes:

The representatives of both St. Patrick's and St. John of God's Hospitals regret that the minimum cover guaranteed under the regulations is not the 180 days as provided for by the VHI and we have expressed our views to the Minister. We regret the introduction of a disparity between the cover provided for physical as against psychiatric disorders.

There is another area in relation to these regulations where the Minister has been economical with the truth. This is in relation to the impact of the regulations. The Minister, Deputy Noonan, suggested in a reply to a parliamentary question tabled by me on 18 April last that 92 per cent of psychiatric discharges from private hospitals occurred within three months. He used this statistic to try to imply, first, that he knows how many patients will be affected by this reduction in the level of in-patient care and, second, that the vast bulk of discharges will be within the 100 day limit. However, if one examines the statistics carefully, one finds that the figures apply only to perhaps the first time in a particular year that a patient might have been in a psychiatric hospital. The statistic does not take account of patients who have more than one admission per year. Therefore, the Minister does not know how many patients will be affected by these cuts. It is not 8 per cent. Given the nature of psychiatric illness, it is probably much higher. For the Minister to use a statistic in this fashion in answer to a parliamentary question was misleading in the extreme.

The change in the level of minimum cover will put pressure on doctors and other professionals working in the psychiatric services in relation to discharges. Doctors may feel under pressure to discharge the patient quickly given the new limits. This practice, regrettably, already exists in physical health care. In psychiatric care, we have already seen one court case over this matter of discharges. A few months ago, the North-Western Health Board was prosecuted by a family who felt their father had been discharged prematurely from a public psychiatric hospital. The man suffered from depression and committed suicide a number of days after being discharged. I am concerned that under these new regulations, pressure will come on these providing private health care to discharge people from hospital. Doctors could find themselves in a very difficult position if they feel that their clinical judgment could end in a court case. I would be worried that this is a first step on the road to precertification, that is where a doctor must get permission before a patient is admitted to hospital. I would like the Minister to give a specific assurance in relation to this matter.

As well as the legal implications, there could also be serious repercussions for the public psychiatric services with these regulations. If a patient is at his or her 100 day limit or near to it, and a doctor in a private facility deems they require further care, the person may be referred to public psychiatric care. No provision has been made by the Department of Health to cater for the overflow of patients into the public health care service in the likely event of the development of such a scenario.

Those likely to be disadvantaged by these regulations include patients who suffer from episodes of manic depression, schizophrenia, anorexia nervosa, psychiatric disorders which are associated with physical disease and psychiatric disorders associated with ageing, for example Alzheimer's disease, conditions which usually require long-term care. If these regulations are enacted, professionals treating patients will not just be under pressure to make discharges, they could also be expected to deliver short-term treatments.

There is another area where Fianna Fáil has major concern about the health insurance regulations. This relates to the provisions for out-patient benefits in the regulations which go against what good insurance should be about. The regulations as they stand put the subscriber to health insurance at risk, not the insurer. The provisions for outpatients are anti-consumer and should not be enshrined in law. The out-patient regulations are in conflict with the discussion paper prepared by the Department of Health in 1994 on the Health Insurance Regulatory Framework which recommended that the regulations should reflect the actual cost of procedures. Why was there such a shift between the discussion paper and the draft regulations? What changed the Department's position? Was it the fact that a new Minister arrived in the Department at the end of 1994? There are many areas where the regulations fall down. For example, in the out-patient provisions, a person can claim only for costs over £150 and under £650 in relation to services specified. For families, the thresholds are over £300 and under £1,300. These figures seem fine, but on closer examination one discovers that for each procedure, patients can only claim small amounts of the actual cost, in most cases, only half the cost of the procedure. This is allowed in the regulations which the Minister is trying to enact. This means, effectively, that one would have to undergo a huge number of procedures before being eligible even to claim. Even when a claim is allowed, the amount that can be recouped is pathetic. Here is an example. A woman who had a sports injury to her elbow visited a general practitioner twice, a consultant once and then had to go for ten sessions of physiotherapy. The cost of the GP was £30 for the two visits; the VHI allowed £10 per visit to the GP — this is better than the regulations which do not allow anything for GPs. The VHI allowed only £30 of the consultant's bill of £50 and only a small amount for each visit to the physio-therapist — of physiotherapist's the bill of £239, only £120 was allowed by the VHI.

There are many areas where treatment is on an out-patient basis. These include some breast cancer cases, some hepatitis cases, control of high blood pressure, diabetes, some cancers, rehabilitation after strokes, heart attacks, etc. The mechanisms proposed in these regulations for out-patient costs ignore the actual cost of the procedures to the subscriber. The annual cost of out-patient care is, therefore, wrongly calculated on fictitious or national costs of items of care. This is not what good insurance should be about. In general insurance, the purpose is to provide protection against unexpected costs. Subscribers to health insurance expect at least that statutory regulations safeguard this principle for them. The regulations now proposed do not constitute an insurance arrangement formulated in the interests of the subscribing public. They leave the subscriber with an open-ended liability at the level of each service and at the level of the annual total. There is no direct relationship with risk experienced by the subscriber. As proposed in the regulations, the insurer is fully protected from risk and the subscriber is fully exposed. This is surely an inversion of the principle of insurance.

A number of improvements should be considered for these regulations. On the psychiatric side, the Minister should work with Aware to see how the 180-day provisions can be reinstated. The Minister should consider not making any distinction between psychiatric and other illnesses and should just refer to health care. He should also consider the Aware proposal that all patients be given a certain level of financial indemnity per annum by health insurers, and whether this is expended on medical or psychiatric illnesses need not arise as a discriminatory issue. The out-patient provisions must be completely over-hauled. The regulations must reflect actual expenditure. The minimum threshold for benefit to kick in must be calculated on the basis of actual costs. The maximum amount for benefit needs to be seriously lifted. The cost provided for in the regulations should be index-linked and should rise by a percentage each year to reflect actual health costs.

One of my constant concerns about the health area is that the consumer rarely features in the formulation of regulations or in discussions about how services are delivered. Consumers are not directly represented on health boards. Consumers were never consulted on the formulation of these health insurance regulations. Will the Minister bear the consumer in mind when drawing up regulations and making provision for disputes about health care policies? Will he clarify if the insurance ombudsperson will have a role in relation to these regulations and how health insurance contracts operate? It would be a major step forward if the consumer was given priority in health matters.

It is regrettable that the Minister has absented himself once again when a sensitive issue of health is being discussed in this Chamber. I regret that the Minister of State, Deputy O'Shea, a member of the Labour Party has been sent in as he was during the hepatitis-C and Blood Transfusion Service Board debate to comment on behalf of the Department. That raises its own suspicions.

May I inform Deputy Geoghegan-Quinn that the time available to her is well nigh exhausted?

The regulations the Minister has formulated offer those who are psychiatrically ill a better deal than is available in many other EU countries but it is still discriminatory. It is worthwhile considering whether a patient may at some time take a case to test whether the Irish Government is behaving in accordance with the Irish Constitution in discriminating against psychiatric as opposed to medical illness.

I listened intently to the case put by Deputy Geoghegan-Quinn and agreed with everything she said.

I welcome the entry to the Irish market of a second health insurer because among other things it provides competition. In normal circumstances competition is welcome. It is said that competition is a healthy thing but ironically the introduction of the regulations to put competition in place has not been healthy for psychiatric patients. That is the reason for today's debate.

I accept that the Minister for Health, who is not present, has already substantially improved the level of cover from 40 days to 100 days since the regulations were first mentioned in the other House, but simply put, that is not enough. The question of discrimination which is the key point at issue in this debate and the bone of contention still remains to be addressed. I request the Minister of State to talk to the Minister for Health and ensure that the 180 days cover for psychiatric patients be reinstated and that psychiatric patients in this country be treated in the same way as patients suffering from any other illness.

It is a truly backward step in every sense of the word to seek at this point in our development of public health policy to discriminate in this fashion between psychiatric patients and patients suffering from every other illness. I would have thought that was the mentality of the 19th century, such approach is inexplicable at the tail end of the 20th century.

In fairness, I accept that in negotiating the regulations with the EU Commission the Minister did seek to protect our core values of community rating, open enrolment and lifetime cover. All of these aspects of health care are fundamentally important to all of us. I accept and commend the Minister for seeking to protect that system and maintain it in a newly emerging situation.

The discrimination is totally unacceptable. Is it not ironic at a time when another Minister is seeking to put in place equal status legislation, the purpose of which is to guarantee equal treatment in the provision of goods and services, and has promised to bring that into this House — though we do not know when — that another Minister is seeking to enshrine in law regulations that would have the opposite effect and would fly in the face of equality? This raises the question of whether there is coherence or cohesion on matters between Government Ministers.

I have a grave fear that if the Minister fails to reverse the decision that is under examination today, we will emerge with a two-tier health system. In the formulation of public health policy the Government has striven might and main to move away from a two-tier health system. We have sought to put in place a system that would give integration to patients of all kinds, whatever the nature of their illness and not try to create divisions between patients with psychiatric illness and those with other types of illness. It seems as if that trend will be reversed if these regulations are to be adopted and I see that as a major backward step, psychologically and morally as well as every other way. Inevitably, if these regulations are adopted many psychiatric patients who opt for private care and take out insurance provision for it, will be forced on to the public health service. Will that be a good thing? The public health service is already overloaded and there are waiting lists for all of the most essential and basic services. Is it in the overall interests of health policy to adopt regulations that would inevitably force hitherto private patients and patients who have the potential to continue to be private patients onto the public health service? If that is to be the result, we will live to regret it.

It might not be a bad time to have a broader discussion on how we deal with psychiatric patients generally. When institutional care was dismantled in other countries and there was a prospect of putting a network of community care provisions in place in the community, it was never made to happen on the scale on which it ought to have happened. Some 20 years ago I saw people who had been discharged from institutions sleeping in the public parks and subways of New York because there was no proper alternative system of community care for them. That is the way some cultures and societies treat their mentally ill. I hope we will not go down that road but I have grave fears that we will. We have not put in place a proper network of community care for people who had been in institutions 20 or even ten years ago. We must guard against exacerbating that problem.

We must be careful not to adopt regulations which will have the effect of pushing psychiatrically ill people who would otherwise be insured and given private care, back into the public health service. This may well be the result. The people we are talking about are among the most vulnerable in our society. They have the most brittle health, are sometimes greatly at risk and have a poor quality of life. Many of these patients and their families have contacted many politicians. The families have been disturbed, distressed and fearful at the prospect of this legislation being passed.

I understand the Minister's difficulty in trying, on the one hand, to protect our core values of community rating, open enrolment and lifetime cover and, on the other, to regulate the activities of health insurance companies. I understand this is a difficult challenge and task. However, it is possible to do both without discriminating against any specific group of vulnerable people in our community, such as psychiatric patients. I appeal to the Minister of State to speak to the Minister for Health about this issue and to seek to amend the regulation and put in place equality of cover for psychiatric and other patients. We should not introduce into our health system the kind of discrimination which would inevitably ensue if the regulation is adopted.

I call on the Minister of State at the Department of Health, Deputy O'Shea. I should have done this earlier and I apologise to him for not doing so. I did not have due regard to the special features of this debate in that the motion was moved by a Member of the Opposition.

I was touched by Deputy Geoghegan-Quinn's concern for my welfare. The Minister for Health was available last week to debate this issue but, because of the adjournment of the House, this opportunity was lost. He is unavoidably absent today on official business.

The health insurance regulations constitute a new and significant protection for the general public. The motion before the House is a far-reaching one and it is therefore crucial to understand the broad context within which we come to be considering the regulation of the business of health insurance here.

This country's regulatory structure for health insurance was devised in the context of the measures adopted by the European Union to create a Single Market in insurance through its Third Non-Life Insurance Directive. The central thrust and purpose of the directive is to bring about a free and competitive market. While it contains certain provisions particular to private health insurance, it is not a health services directive but relates to non-life insurance services generally. We must take a realistic approach to its implementation in terms of measures to admit competition to our market. It was not, therefore, open to the Minister, in devising such extensive and complex regulations, to take the exclusively domestic view of the measures which the proposers of the motion have taken.

The regulations were signed by the Minister and laid before the Houses of the Oireachtas on 28 March. In that context, the decision announced on 22 April by the major international health insurer, BUPA, to enter the market is seen as vital and positive development. Since publication of the regulations, the Department of Health has had inquiries from, or discussion with, other insurance undertakings interested in exploring opportunities in the Irish private health insurance business. Therefore, the prospect exists of further undertakings deciding to make available services in our market on the basis set down in the regulations. Annulling the regulations would mean creating uncertainty both for insurers already committed to the market as well as those who may be considering entering it.

In certain circumstances the directive allows for the adoption and maintenance of specific legal provisions by a member state which protect the common good. Through the efforts of the Minister and his officials, the EU Commission has accepted, in principle, this country's entitlement to regulate the private health insurance market. This involved considerable effort and persuasion and took place against the background of foreign insurance interests representing a contrary view to the Commission. However, the Commission will wish to see competition emerging in the market here and a genuinely competitive environment created in Ireland. It is critical that the regulations we are discussing today do not present a serious obstacle to trade. It is important, therefore, to understand that there is a very fundamental international business dimension to our private health insurance framework and that any belief that we can do exactly as we please, once the Commission accepted our entitlement to regulate the market, is absolutely misguided and dangerous.

Our system of private health insurance which is now almost 40 years in operation, was installed by the then Minister for Health, Mr. T.F. O'Higgins. His initiative and vision is to be commended as it led to the creation of a system which has served the Irish people so well for decades and which has gone from strength to strength in terms of the high percentage of the population covered against the unforeseen costs of serious injury or illness. That legacy is greatly valued and the Government will ensure it is properly safeguarded and developed.

The regulations include a statutorily guaranteed minimum level of cover in respect of a variety of hospital and consultant in-patient, day-patient and out-patient services. Overall, the regulatory framework provides a high degree of protection to the members of the public in the context of the opening up of our private health insurance market to competition. One of the problems which consumers can face is the small print of their insurance contracts where they are not fully aware of what cover or exclusions apply. The minimum benefit regulations require, on a statutory basis, insurers to sell a core level of services as a minimum. This will be of great benefit to the consumer.

The motion claims,inter alia, that the regulatory framework constitutes serious discrimination against the psychiatrically ill and gives effect to a reduction in insurance cover for psychiatric patients from 180 days to 100 days a year. In view of this, it is instructive to look at what the market has provided up to recently as a statutory entitlement to privately insured persons suffering from milk illnesses. The answer is nothing; the market was not obliged in the past to provide for such cover on a statutory basis. Until the regulations were brought into being, insured persons were entirely reliant on the customary practices of the VHI as the country's sole provider of private health insurance to the general public in a restricted market. No reduction in VHI cover for psychiatric in-patient treatment can be made without the agreement of the Minister under section 2 of the VHI (Amendment) Act, 1996, and he wishes the House to know that, unless there are clear and compelling reasons to do so, he will not agree to any such reduction.

Other insurers in the market provide indemnity cover within specific work-employee groups. I refer to the schemes operated by the ESB, prison officers and the Garda who, between them, have about 80,000 lives covered. Under these schemes varying insurance practices in relation to psychiatric benefit already exist and involve periods of indemnity below a minimum of 100 days in a year.

It is the general practice of major British insurers to limit and-or extensively qualify their exposure to liability for psychiatric in-patient benefit under their respective policies. Psychiatric benefit is not a common feature of UK health insurance and most insurers there do not cover it as part of their "budget" policies, the type of cover nearest to minimum benefit. Where insurers provide cover of this kind they heavily qualify it by measures such as specific pre-authorisation of hospital admissions, length of stay and exclusion of chronic disorders.

The period of 100 days provided for in respect of the guaranteed minimum level of indemnity under the regulations is not only reasonable, but substantial in the context of our market being opened up to competition. In addition, the Minister has given a commitment that the regulations will provide for a minimum entitlement to 20 day-patient days' services in respect of psychiatric treatment and care. Officials of the Department of Health have already begun the consultative process in this regard. The Minister was pleased to be able to respond positively to the concerns expressed by interested parties in the extensive consultations held prior to signing the regulations. He met the authorities of the country's two major private psychiatric hospitals prior to finalising the regulations and was pleased to obtain their acceptance of the proposals.

The 100 days minimum covers the vast majority of admissions in psychiatric hospitals. The Health Research Board's 1994 report on the activities of Irish psychiatric hospitals and units provides statistical information on discharges and lengths of stay in private psychiatric hospitals. Of a total of 4,209 discharges in that year, 3,871, or 92 per cent, occurred within three months. The major private psychiatric hospitals, which are the service providers, have agreed that the measures contained in the regulations represent a significant protection for the general public in the context of a competitive private market. In addition, there will be the minimum cover for day-patient services which I have already mentioned. Where circumstances arise in which an insured person requires treatment in excess of 100 days, later to be increased to 120 days, in a year and the insurance contract does not cater for this, it is open to him or her to avail of care in public psychiatric hospitals and public community-based facilities. Accordingly, persons who use up their insurance cover will have access to psychiatric care in the same manner as the majority of the population.

The Department of Health is not aware of any other case, internationally, where providers of private health insurance contract to make available cover for a period of 100 days psychiatric in-patient services without pre-certification and in an environment in which the entire population is eligible for treatment under the public psychiatric service. While the laws of some American states require that insurance companies provide, or offer, minimum mental health benefits, as far as the Department of Health is aware, in-patient hospital coverage range from 60 days per year to a more typical 30 days per year. Furthermore, the American system is firmly rooted in the delivery of services through managed care which does not allow unqualified access to services which is provided for under our system. Given the totally new context within which our private health insurance market is obliged to operate under our responsibilities as a member of the European Union it is considered that the safeguards enshrined in our regulations relating to a generally applicable minimum period of entitlement to indemnity against the cost of psychiatric illness do not constitute discrimination.

The concerns raised about the original proposals regarding the minimum period for treatment relating to alcohol, drug and other substance abuse have been met in the regulations. The original proposal has been enhanced from 40 days in a lifetime to 91 days in any continuous period of five years.

It is also contended in the motion that the regulations fail to reflect the cost of out-patient services to subscribers. This suggests a fundamental misunderstanding of the regulations. The regulations concerned are those relating to minimum benefits. They are concerned with core hospital and consultant services for which all insurers must cater, up to, at least the level of indemnity specified, in any policies they wish to sell in our market.

The regulations relate out-patient services to hospital and consultant activities which are appropriate to the package of measures involved. These are not intended to prescribe every health service offered to the public by an insurance company. Any attempt to do this under regulation would constitute a completely disproportionate restriction on the freedom of insurers entering the market in terms of their scope for policy design. The information available to the Department of Health is that budget plans, the plans that most closely resemble the minimum benefit provisions, offered by some overseas insurers exclude out-patient consultations and treatment; others cover out-patient costs only where they are linked to a course of in-patient treatment.

The regulations provide for excesses and maximum payments to operate in respect of a specified range of out-patient services. It is a matter for individual insurers to determine under their policy conditions whether these will relate to actual or eligible expenditure. The advantages of specific packages, as against the equivalent products of competitors, will no doubt be promoted by insurers as part of their normal commercial interaction and allow the discerning purchaser of cover to decide which company's policies offer the best deal. To suggest that we should go beyond the existing minimum provisions is to seek to limit, by use of legal compulsion, the flexibility of insurers to negotiate arrangements with providers. Once again, it is important to bear in mind that the rates specified in the regulations are a "base line" below which an insurer is prohibited from operating. It should also be appreciated that rates can be changed over time, but only in the context of constituting an appropriate minimum benefit. The regulations are not a vehicle to strike rates of payment for practitioners which should be negotiated between them and the insurers as part of the normal operation of the market. The interests of purchasers of health insurance will not be served by statutory minimum provisions that are inflationary.

The regulations do not put "a 100 day limit" on benefit for psychiatric in-patient services. On the contrary, they provide, for the first time, a statutory guarantee to a period of not less than 100 days' minimum indemnity cover. They do not give effect to a reduction of insurance cover for psychiatric patients from 180 to 100 days. They are appropriate as regards the provisions relating to core hospital out-patient services specified and do not constitute an inordinate and unsustainable interference in the free operation of the market. They apply equally to all purchasers of private health insurance in terms of the risk exposure which all insurers must bear, as a minimum, under the policies they sell here and they are not discriminatory.

The Minister is aware that the principle of inter-generational solidarity which underpins community rating may not sit easily with some interests who see advantage in other narrowly focused arrangements being made. He wishes to make it clear that any move which would threaten or undermine the core value of community rating will be met decisively either by use of existing laws and regulations or, if necessary, under new legislation. Community rating has served the people too well over a long time to allow any interference with it to be tolerated.

For the reasons stated, the motion is mistaken in its contentions and should be rejected on the grounds that the health insurance regulations meet our obligation to provide for competition; safeguard our core values of community rating, open enrolment and lifetime cover; and constitute a significant protection to the general public in an open competitive market.

I commend my colleague, Deputy Geoghegan-Quinn, on moving the motion to annual these regulations. I congratulate her and Deputy Quill on their contributions.

The Minister of State is a reasonable man and his speech was couched in reasonable language. He said "the regulations do not put a 100 day limit on benefit for psychiatric in-patient services". That is correct but having regard to a free, open and competitive market, the reality is that those insurance companies which the Minister is now introducing measures to regulate, will only prescribe the statutory minimum requirement of 100 days. They do not provide such psychiatric cover in most other European countries.

I welcome the recent announcement by BUPA and I am sure others will follow. When new entrants launch their products on the Irish market there is no question but that they will commence with 180 day psychiatric cover as does the VHI under our law. The VHI has given commendable medical and psychiatric cover to the public for many years.

This is the first attempt to introduce second class insurance cover which will be available to the public once the people with whom the Minister is negotiating come into the Irish market and start selling their products. That will immediately force the VHI, which is already under severe financial pressure, to bring in comparative competing products. Who will suffer but the public?

According to the Minister's statistics on the number of people admitted to and discharged from psychiatric hospitals, 92 per cent of admissions are discharged within three months, that is either within 90 or 93 days which is very near the threshold. At least 8 per cent of people admitted are hospitalised for more than three months. That 8 per cent could be affected in future by having to resort to their own private resources or, alternatively, by having to be transferred to public psychiatric hospitals.

Of the 4,209 discharged that year, were 3,871, or 92 per cent, discharged within three months? Is the Minister taking into account that in the treatment of psychiatric conditions people are called back for in-patient treatment whereas when a person is discharged after a medical ailment, invariably, one is not called back? The very nature of the treatment of psychiatric illness involves one going into hospital, staying there for a certain period, being discharged home for therapeutic purposes and coming back for further in-patient treatment.

The Minister should check the figure of 92 per cent. It may not show us the full picture. Given the cumulative number of days people have to spend in private psychiatric hospitals, those statistics are misleading. The treatment of these illnesses can take many years.

In my constituency I am aware of one family that suffered the untimely death of a parent. The family comprised young children who might not have appreciated the implications at that time for their health. Many years later, however, it was found that the cause of death was a chemical imbalance which results in depressive psychiatric-type conditions requiring prolonged treatment.

I am sorry to interrupt the Deputy but I fear that his time is exhausted.

I appreciate that, a Leas-Cheann Comhairle.

The first sensible things I heard about these regulations were said by the Minister for Health in the Seanad on 1 May and again by the Minister of State here today. There is a procedural aspect of this motion which gladdens me and I think Deputy Geoghegan-Quinn might be thankful for this. As far as I can remember in the 15 years I have been in this House, this is the first occasion on which a motion of this kind, setting out to annual regulations, has come before the House. These regulations are a particular hobby horse of mine, I am delighted the Government had the generosity to allow the motion to be debated.

After we backed it.

We could never get Deputy Geoghegan-Quinn's party to give time to discuss a similar motion.


Táimid go deas, táimid go h-an dheas agus tá mé ag tréaslú leat as an ocáid stairiúil seo a thabhairt dúinn.

The Minister for Health and the Minister of State said the first sensible things about these regulations that I have heard for a long time. That included much of what was in the correspondence that I, like other Members of the House, received from people who are very concerned.

Some months ago it was seriously proposed to us that whatever the Minister introduced in these regulations would become not only the minimum but also the maximum. That is patently absurd. Opposition Members spoke about a free and open market for health insurance but they should realise what a market is. If insurers find there is a market for a health insurance product that provides more cover than the statutory minimum, provided now for the first time, they will offer it.

Deputies opposite know perfectly well, as I do, that has always been the case for the Voluntary Health Insurance Board which produced plans to meet the needs of different segments and different pockets in the market. That will continue to be the case. Other insurers who come in here under the regulations providing for competition will also do that. For anybody to pretend that the provisions for a minimum in these regulations will, effectively, become the maximum is unfounded, absurd and does not deserve air time.

The Minister of State clearly pointed out that if these types of regulations were not made, there would be a danger of inferior health insurance products being offered. I am delighted to hear, incidentally, that the Minister for Health sees no reason he should agree to any reduction in the level of cover provided by the Voluntary Health Insurance Board. I hope that will continue to be the case. It is a sensible stand to take. It would be anti-competitive to require everybody else to provide that level of cover statutorily. The statutory minima inserted into these regulations will meet the vast majority of cases. If health insurers find a market for a greater level of cover, we can be sure they will introduce products aimed at those segments of the market.

I am glad that as a result of his discussions over the summer, the Minister for Health reached agreement with the two major psychiatric hospitals on what is now being provided. To those who are worried by this we should say loudly and clearly that the Minister, using to the full his powers under the framework of European Union competition legislation, has set out to make sure that the baseline being offered by any insurer who comes into the market is a reasonable one. The Minister is also using his powers of persuasion to ensure that the Voluntary Health Insurance Board continues to offer cover at current levels which have shown their worth for many years.

I compliment our spokesperson on Health, Deputy Geoghegan-Quinn, for calling for the annulment of these regulations which contain an element of discrimination. We treat all our citizens equally but in this instance psychiatric patients are not receiving equal treatment.

Initially the Minister's regulations provided for 40 days psychiatric cover, that was extended to 100 days and he then introduced the outpatient care service. That clearly demonstrates that the Minister is not happy with the regulations or, perhaps, it is the case that people outside his Department are informing him that all is not well with them. It is important, therefore, to re-examine the regulations, to see if they can be modified and improved. I have no doubt that following this debate the Minister will be in a position to do that.

We are advised the Minister was forced by the EU to opt for the 100 days provision but I understand the EU did not demand any specific regulations; it merely wanted to ensure there was competition here in regard to health insurance. This suggestion came from the Department because there was not any requirement on the Minister to introduce the 100 days cover regulation.

Psychiatric illness is different from other health complaints. We all know it may take longer for patients to recover from a psychiatric illness. Such patients often have a recurrence of problems in the same year as has been referred to by some speakers. It is important, therefore, to have the 180 days provision as a minimum.

The Minister commented on the two psychiatric hospitals in Dublin — St. John of God's and St. Patrick's — and said they were satisfied with the 100 days provision. If the Minister reads carefully what they said he would see they are not entirely happy with the provision. They were forced to compromise with the Minister. The organisation Aware, which provides counselling for people who are depressed, has stated it is not happy with the 100 days regulation.

Ireland is different from other countries. The regulations in some European jurisdictions provide only 40 or 50 days' cover. Ireland is special and cares for its people in a different way, particularly those who are suffering from a psychiatric illness. We have a good standard of medical care and have often led Europe in that regard. We should set the standard also in regard to psychiatric treatment.

The Minister mentioned other health insurance providers such as those granting cover to the Garda, the ESB staff and others. It must be remembered, however, that before a person is recruited into the Garda or employed by the ESB, one's physical and mental health record is scrutinised. The argument made by the Minister in this regard does not stand up because he is referring to a select group. When we talk about care for psychiatric patients we mean the total population; we are not being selective in any way.

I compliment my colleague, Deputy Geoghegan-Quinn, on tabling this motion to annual these regulations. Deputy Dukes made great play of the fact that Government time was provided for the debate on this motion but I suggest the Government should go the whole way and accept the motion.

Reference was made to discrimination in regard to these regulations. There is discrimination in regard to psychiatric patients in that general medical patients are covered for 180 days while patients suffering from a psychiatric disorder will be covered only for 100 days.

Many of the voluntary groups working with psychiatric patients such as Aware, which is doing excellent work with people suffering from depression, have drawn attention to the fact that Ireland differs from other member states in insurance cover for psychiatric patients. The Minister stated that 92 per cent of patients are discharged within three months of being admitted to hospital. If that is so and patients are not readmitted in the same year, there should not be a major cost implication in covering the remaining 8 per cent of patients hospitalised for periods longer than three months.

Reference was made also to EU regulations on a free insurance market. In this case, however, the EU gave the Irish authorities the right to regulate their own insurance.

The Minister of State, Deputy O'Shea, said that uncertainty will be created if these regulations are annulled, but uncertainty exists because psychiatric patients are being treated differently from general medical patients. The Minister has already changed his mind on the regulations and that causes further uncertainty. If psychiatric patients were treated in a similar manner to general medical patients the uncertainty that exists would be removed.

The VHI has served people well. I do not understand the reason the Irish Hospital Consultants Association constantly demand competition. The VHI, an efficient organisation, has served this country well for the past 40 years. It must be remembered that the market in Ireland is small — 1.2 million people — compared to other European countries, and if one takes account of the cost of maintenance, which cannot change to any major degree, the cost of medical fees, which is unlikely to change, and the cost of administration, which is low by international standards, the VHI has done an excellent job.

The VHI should introduce schemes to suit our people; we should not be led by what happens in other countries. The VHI should be concerned with what the people need. I accept it should not operate schemes that do not pay their way, such as the one it operated before I became Minister for Health under which a sick person could pay £120 to the VHI and draw £336 per year for the remainder of his or her life. I do not expect the VHI to operate such schemes but it should provide cover not only for psychiatric patients but for the elderly in long-stay institutions.

I ask the Minister to accept the points raised by my colleagues, Deputies Geoghegan-Quinn, Moffatt and Hughes. The Government should go all the way on this occasion, annual these regulations and bring in new regulations which will eliminate the discrimination.

I support the motion proposed by our spokesperson to which the Minister in reply said there would be a great uncertainty if these regulations were not passed. That of course is the usual bullying approach of a Minister. There need not be uncertainty. Regulations could be introduced tomorrow to provide for 180 days, there would not be a difficulty in doing that. The regulations are very easy to draw up; it is only a question of replacing "100" with "180". In any event the Minister knows that any uncertainty can be dealt with instantly. It is misleading the public in general to say there would be great uncertainty because there would not. It can be dealt with in the House and the Minister can deal with it in regulations very swiftly.

The Minister also said that some 92 per cent of psychiatric in-patients are discharged within a three month period. Again, as was pointed out to the Minister, this does not include or take account of people who have more than one admission per year. It would appear that the statistics offered are slightly misleading. It is important that the figures used in an instance like this are accurate, clear and fair because what is being done, for whatever reason, introduces inequity and inequality between psychiatric and general patients.

Over the years we have struggled very hard to bring about an equality of treatment between psychiatric and general patients, even to the extent of having treatment in our major new general hospitals for psychiatric patients. All the work over the years has been directed at normalising the treatment provided for psychiatric patients and equating it with that provided for general patients in our hospitals. This has been a successful programme. Indeed, a great deal of work, in which Deputy O'Hanlon participated, has been done in developing our community based services. None of this will stop.

We should continue the current development of services, but in doing that we should not introduce discrimination against any group, particularly people who suffer from psychiatric disabilities. It is reprehensible and I think I heard somebody say they would be concerned about the constitutionality of treating people differently. It could be subject to challenge.

It has been pointed out to the Minister by Aware, our spokesperson and others that there are other ways to provide indeminity. Aware states that one simple method is that health insurance providers should be required to give a certain level of financial indeminity per annum and whether this is expended on medical or psychiatric illness needs not arise as a discriminatory issue. This is something which has been mentioned by constituents and people who are involved in providing the services. We ask the Minister to take what they are saying seriously, even if he is not interested in what we are saying, and provide equitable treatment for psychiatric patients in line with that provided for patients in general.

The decision as to whether a person is ill and whether the nature of the illness is psychiatric or general is a medical one. No one will fool anybody. It is either real or it is not and, if it is real, people should be treated equitably.

I appeal to the Minister to accept this motion. I am a former member of a health board. It was always acknowledged that the psychiatric services were the poor relation of the health services. Naturally, acute services in general hospitals had to get priority. Then we developed the community care services which we have been promoting for many years, and rightly so. We closed all the large psychiatric institutions and this was welcomed by the community. Of course, it put additional strain on the community.

The regulations put in place by the Minister will cause much concern. Aware, an organisation which is helping to defeat depression, outlined its case in a letter to us. Even at this late hour it makes a strong appeal regarding the regulations and states that it is the only body opposing them. It does so simply because of their discriminatory nature.

Aware acknowledges that the Minister has done a good job in setting out a minimum level of in-patient hospital care of 100 days which health insurance companies have to provide for psychiatric patients. The letter continues.

But when he gives 180 days for medical disorders which have the same biological basis as recurring depression and manic depression one cannot but conclude that the regulations are clearly discriminatory. Aware believes that the Minister needs to explore how he can provide a similar level of in-patient hospital cover without it being discriminatory. One simple method is that health insurance providers should be required to give a certain level of financial indemnity per annum and whether this is expended on medical or psychiatric illnesses need not arise as a discriminatory issue. Such a form of indeminity is available in certain EU countries.

Aware goes on to list a number of concerns and states that the regulations discriminate against the psychiatrically ill in offering them a minimum cover of 100 days in-patient care in contrast to the 180 days for all other illnesses. The proposed reduction in the duration of in-patient care offered to psychiatric patients is a 45 per cent cut in that which is currently provided.

The letter further states:

The Minister for Health does not know how many patients will be affected by this reduction in the level of in-patient care. In his written response to Mrs. Maire Geoghegan-Quinn on the 18th of April, he stated that in 1994, 92 per cent of discharges from private psychiatric hospitals occurred within three months. However, these figures are based on the duration of stay per admission, rather than, as it should be, the number of in-patient days per patient per year. In other words, patients who have more than one admission per year will be significantly affected by these cuts and the Minister's statement does not take account of this... The reduction in the level of care for psychiatric patients represents another disruption of continuity of medical and nursing care, the very basis of a good psychiatric service.

The letter goes on to say that no provisions have been made by the Department of Health for the overflow of patients into the public psychiatric service if these regulations are implemented. The cost of maintaining a patient in a private psychiatric hospital is significantly less than the cost in the public psychiatric service. Psychiatric patients are discriminated throughout Europe by insurance companies and Ireland should take a lead in ending this discrimination. Aware also state: "To the best of our knowledge, the Regulations of the Health Insurance Act are the only pieces of legislation throughout the European Union which specifically discriminate against psychiatric patients in respect of health insurance cover."

The case is being clearly made by the people who are closed to the problem. We have an obligation as Oireachtas Members. I appeal to the Minister to examine the motion tabled by Deputy Geoghegan-Quinn because we are doing a disservice to psychiatric patients in the community. They are being integrated into the community more than ever before and we welcome that. These regulations will militate against these patients and are a source of concern to them and their families. I appeal to the Minister to accept the motion.

I join my colleagues in complimenting our spokesperson, Deputy Geoghegan-Quinn, who tabled this motion, which deals with those suffering from psychiatric illnesses.

I support the motion because of the serious implications of the regulations, proposed by the Minister for Health, for those suffering from psychiatric illness. Our main reason for opposing the regulations is that they patently discriminate against people who suffer from psychiatric illnesses. Every health policy document introduced by governments down through the years have had as a fundamental principle the integration of the psychiatric and general medical services. These regulations are contrary to all those attempts by governments over the years to do so. They are singling our psychiatric patients for different treatment from other patients. People who suffer from general medical disorders are not subject to such a limit. The Minister and the Government are making a distinction between psychiatric disorders and general disorders. Will the Minister acknowledge that a recurring depressive illness is just like any other illness? If he accepts that it is as important, he should allow cover for that type of illness. By doing what he has proposed to do, does the Minister blame people confined to psychiatric hospitals for being ill? It is a reprehensible decision by the Minister and the Government that they are blaming those unfortunate people who suffer psychiatric illness. The disease is the problem, not the individuals. It is reprehensible that the Minister is holding those people responsible and making them pay for such an illness when it does not apply to people suffering from other illnesses. In the past the Irish have been noted as a caring people but this decision will change that view. I am disappointed the Government has introduced this change.

The discrimination which will arise will affect psychiatrically ill patients who cannot work in the same way as the rest of us. They will be allowed cover for only 100 days as against 180 days for people with other illnesses. As well as imposing financial difficulties this reduction will result in extra pressures for individuals suffering from depressive illnesses. In many cases, every problem looms large and the financial pressures will not help their recovery. I ask the Minister to reconsider this most discriminatory and backwards step.

I strongly support the motion. This proposal by the Minister is an example of hypocrisy by the Government. On the one hand, we heard of anti-discrimination legislation being introduced by one Minister and on the other the Minister for Health is discriminating against a section of society who, through no fault of their own, are affected by an illness and are to be punished because they suffer from it. It discriminates against the psychiatrically ill in offering them a minimum cover of 100 days in-patient's care in contrast to 180 days for all other illnesses. Anybody who knows anything about psychiatric care will be aware of how vulnerable that section of society is.

I was born in St. Ita's Hospital in Portrane. My father worked in the hospital nursing the psychiatrically ill. I know very well the care and attention that the nursing and the medical professions provide for the psychiatrically ill. A person who suffers from a psychiatric illness needs care and attention and by the nature of the illness does not need the distress of worrying about payments for this treatment. The Minister is imposing further stress on unfortunate people who suffer from stress of the mind, psychiatric illness. The reduction in the duration of the in-patient care offered to psychiatric patients is a 45 per cent cut on that currently provided. What other section of society is being asked to bear a 45 per cent reduction? This is discrimination to ensure that the foreign insurance companies will have a greater welcome here against the interests of the VHI. How many patients will be affected by this reduction in the level of in-patient care?

In his written response to my colleague, Deputy Geoghegan-Quinn, on 18 April, the Minister stated that in 1994, 92 per cent of discharges from private psychiatric hospitals occurred within three months. Like most statistics these figures are based on the duration of stay per admission. They do not give the full picture. The number of in-patient days per patient per year is what we should consider. In other words, patients with more than one admission per year will be significantly affected by these health cuts, but the Minister failed to take that into account.

We are experiencing the worst ever health cuts, yet we constantly hear about large sums of money being spent on our health services. We are very fortunate to have such caring people administering the services, particularly the emergency services, but they are struggling to meet demands. A man who was recently admitted to a hospital with chest pains spent three days laying on a trolley because a bed was not available. He was then sent for tests and had heart surgery but, unfortunately, suffered a stroke. There are thousands of such cases due to health cuts. As these regulations will punish a most vulnerable section of our community, will the Minister reconsider the matter, even at this late stage? I do not believe members of the Labour Party or Democratic Left, from whom we hear a great deal on other issues, want to vote for these cuts. If they do, it will be remembered by the public and the families of a most vulnerable section of our community.

I support the views of our spokesperson on health on this matter because the regulations will have serious implications for many people. They are in stark contrast to what the health authorities are doing for sick people. In recent years great emphasis has been placed on ensuring that people with a psychiatric illness get the best possible treatment, but these regulations will discriminate against them. I recently met a person in business who had to spend a considerable amount of time in hospital during 1995 receiving treatment for depression and a psychiatric disorder. He told me he would not have been able to meet the costs involved if these regulations were in place.

In recent times psychiatric hospitals have been placing patients in hostels and other accommodation. I recall when the psychiatric hospital in Monaghan had 850 patients, but it currently has approximately 100, many of whom will be sent to hostels or other places of geriatric care. Some people are getting adequate treatment in psychiatric clinics which means they do not have to be institutionalised. Many of those who are under great pressure in business are covered by VHI, but they could be adversely affected by these regulations. Therefore, the Minister of State should re-examine the matter.

The Taoiseach must have had second thoughts about the matter when he allowed time for the debate. A previous call for such a debate was rejected. The Minister should not exacerabate the problems of those who are seriously ill by implementing these regulations.

I, too, congratulate Deputy Geoghegan-Quinn on tabling this motion to annual these regulations. They may not affect many people but they have left those whom they will affect, and their families, very bitter. Deputy Burke placed great emphasis on the word "stress" which is associated with psychiatric illness. These regulations will place additional stress on people who are unable to cope with any further stress. They will distinguish between psychiatric and other illnesses and imply that a psychiatrically ill person is different and that the illness is partly the person's own fault. That message is upsetting for the people concernd and their families. Even if the Minister decided to increase the number of days to, say, 130, it would still be discriminatory. Anything less than equal treatment would distinguish between psychiatric and other illnesses and it is unacceptable to label people in that manner.

Deputy Geoghegan-Quinn stated that the Minister for Equality and Law Reform is responsible for bringing equality into all walks of life, but these regulations will have the opposite effect. They will introduce discrimination into medical care. This is an extraordinary decision, particularly when one considers that this and the previous Government tried to bring equality into all aspects of life. There is a huge reduction in the number of days for which cover will be provided, from 180 to 100. Even if the period was increased by 20 or 30 days, we would still discriminate against the people involved. The rules and regulations must be changed so that people are covered equally for all illnesses.

In the case of the warrant that was discussed here last week, we blamed the British authorities, and in this case the attitude of the Government is to blame the EU. Whenever there is dirty work to be done it is a case of who we can blame. That is the trend promoted by various Ministers. Deputy Dukes spoke about the market. We have always taken pride in the fact that we are a sympathetic, caring society. It is unacceptable when dealing with people who are ill that we talk purely in economic terms such as "the free market", in callous, uncaring terms as if we were talking about the stock market. In this case we are dealing with people who live in very stressful conditions and we are frightening them by giving them the wrong message.

The regulations must be reconsidered with a view to bringing forward a different scheme. To increase the period of time by ten or 20 days will not solve the problem. The Minister may say that 92 per cent of these people will get out of hospital within three months, but some of them may have to go back into hospital a number of times during the year. While we would appreciate an extension of the period by ten to 20 days, it would not solve the problem. It would be perceived as discrimination and give a negative message to those involved.

I acknowledge the efforts of Deputy Geoghegan-Quinn in bringing this matter to our attention. It is an extremely important matter relating to psychiatric patients. We believe we are a caring society, particularly in relation to those who suffer from mental disorders. It is extraordinary that a differentiation is made between what we call general health and psychiatric problems. I am sure the Minister will agree it is extraordinary that he is on his own on that side of the House, that nobody from the Government benches came in to speak on this debate.

I listened to the Minister of State, Deputy Rabbitte, speak this morning about placing a ban on Shell products. Considering what he and his party represent, I wonder where Deputy Lynch and Deputy Eric Byrne are. They are the people who tell us they are concerned about those who need help and support, but they are not here. Much concern has been expressed by members of the Minister's party about people with this type of illness, but not one of them came in here to speak on a most important issue of discrimination.

The Minister is a very caring person and his Ministry would like to ensure equity in the health service. He is concerned about delivering an efficient, effective service to ensure people's health is looked after in the best possible manner. Despite all the regulations that have been put in place, the documents that have issued from the Department of Health and the recommendations on the integration of services — in three or four documents it has been indicated that there should be no difference between a general physical disorder and a mental disorder — the Minister is bringing in a measure that is discriminatory. That is inconceivable and insensitive.

Up to now the Minister and Minister of State have paid little heed to the recommendations of people working in the health service. A short time ago the people we are dealing with were covered by insurance for one year. It was then proposed that the period be reduced to 40 days. The Minister states that that proposal was put forward by the European Commission and that he succeeded in retaining cover for 100 days. However, he has simply magnified the difference between people with physical disorders and the mentally ill. I would have thought the day had gone when such a differentiation existed and that we cared enough to ensure that a similar insurance service is provided for everyone. The Minister should bear in mind that the people involved may have to return to hospital a number of times for treatment. Under this system there will be an increase in the number of suicides because of the lack of care for people who deserve better.

I am delighted to have an opportunity to speak on this matter. Originally this side of the House asked for a two hour debate, and that was granted last week, but for some reason the Government decided this week to curtail the time allowed. Despite repeated requests by me to the Government Chief Whip, one of which was made no later than this morning, the extension to two hours was refused. Then the Taoiseach, in a very petulant way, agreed to the two hours. I wonder if anyone is in charge over there. It is ironic that the Minister for Health, Deputy Noonan, has not come into the House for this debate and that there have been only two Government speakers. The Government probably thought there would not be sufficient speakers to keep the debate going for two hours but my door was almost knocked down by Fianna Fáil Deputies who wished to contribute. It is obvious that if more time had been provided it would have been availed of.

I agree with Deputy Geoghegan-Quinn that the Minister pitched the level of cover at 40 days so that he could claim to have done a good job if he raised it to a credible level. One of the reasons we put down the motion is that we believe it is discriminatory to distinguish between different categories in terms of medical cover. Some members of the Government claim to represent the underprivileged in society, people living on the bread line. However, these are the very people against whom the regulations will discriminate. I call on Deputies on the other side of the House to think again before they go through the lobbies.

The Government and the Minister are pandering to big business. I recently heard a radio interview with a woman who represents one of the health insurance groups which hopes to compete against the VHI. I smelled a rat when I heard her say her company would be able to enter the Irish market now that the regulations had been passed. This seemed to suggest her company and other medical insurance companies had made representations to the Minister and his Department about the level of insurance in this very costly area. The Government is, in effect, looking after the insurers rather than the down trodden in society. By voting against our motion the Government will vote in favour of big business and against the unfortunate patients.

I wish to share my time with Deputy McDaid. I support the points made by Deputy Geoghegan-Quinn. It was ironic to hear the Minister of State at the Department of Enterprise and Employment, Deputy Rabbitte, say today that he agreed with the Fianna Fáil position on the embargo on Shell when he does not agree with our position on the health insurance regulations. These regulations discriminate against people with a psychiatric illness. In his letter Dr. Anthony Clare states there is a distinction between the cover provided for physical as against psychiatric disorders. I hope even at this late stage the Minister will agree to look again at the regulations.

I have received many representations on this matter. People who attend the alcoholism unit in St. Bridget's Psychiatric Hospital in Ballinasloe are very concerned about these regulations and their effect on them. This unit has been under threat ever since the document "Planning for the Future" was published by a previous Government. People are concerned about its future and I hope the Minister will provide funding for it. At a recent meeting of the Western Health Board I was told there are fewer than 500 patients in St. Bridget's Psychiatric Hospital in Ballinasloe. It is important that better facilities are provided in this hospital. The many patients housed in the accommodation adjacent to Ballinasloe also need to be reassured that the regulations will not discriminate against them. These people have been discriminated against in the past and I am afraid the regulations will further discriminate against them.

The Minister quoted from European regulations and said some medical insurers in Europe do not provide psychiatric cover. This raises questions about the new insurance companies which propose to set up here. It is important that these companies provide cover for patients with a psychiatric illness. I have not been given this assurance in the House and I ask the Minister and the Government to ensure that the new companies which set up here provide this cover. I welcome the opportunity to contribute to the debate but regret that I do not have more time to deal with these matters in greater detail.

I thank Deputy Kitt for sharing his time with me. There is a perception that the VHI discourages treatment anywhere other than in hospital beds and has helped to create a new culture, the Blackrock Clinic culture. The regulations governing VHI payments have led to many patients occupying hospital beds rather than availing of outpatient services. Many cases could have been dealt with adequately without taking up space in hospitals and incurring extra expense for health boards. The VHI and the health services generally could save a great deal of money if they encouraged more people to avail of outpatient services rather than taking up hospital beds. If out-patient services included diagnostic services such as X-rays, physiotherapy and various consultants services, patients could be adequately treated without having to take up beds.

I have worked long enough in hospitals to realise that the health services could be used more effectively by encouraging people to prevent disease rather than waiting until they become emergency cases. The VHI could be said to be culpable in this regard by virtue of its rules. It is alarming that more suicides are occuring when long-term treatment could help prevent these tragedies. Limiting cover for these patients is the height of irresponsibility. In addition, child victims of sexual abuse, who take a very long time to recover, many of whom are institutionalised in hospitals, have been excluded from these VHI regulations. This issue has been discussed in this House on many occasions, has been the subject monthly if not weekly of "drip, drip" affair in the media and must be catered for by the Voluntary Health Insurance under the Health Insurance Act, 1994.

I thank all Members who contributed to this debate. One issue which has arisen several times in this debate is the fact that, while one arm of Government proposes legislation to end discrimination over a whole range of areas — and has been busily lecturing the rest of us in this House with professional bodies, groups and organisations outside it, urging the abolition of discriminatory practices — the other conservative wing of Government introduces blatant discrimination in relation to health care.

The performance of successive Governments and Ministers for Health in relation to psychiatric care led to psychiatric patients being isolated, locked away indefinitely in large, grey, forbidding buildings, their families, relatives and friends not encouraged to visit them and, for the most part, very heavily sedated by medical staff so that they could control large numbers in very large institutions.

Successive Governments and Ministers for Health have ensured that the psychiatric wing of medicine was incorporated into general medical practice so that we now have very modern, open, airy, bright units attached to most, general and acute hospitals nationwide. In addition, the community is encouraged to become involved in out-patient care and in small psychiatric units of care in rural and urban areas throughout the country. Families are very much involved in the treatment and care of psychiatric patients and spouses and children are encouraged to visit them while receiving in-patient care.

The traditional view of psychiatric illness has changed dramatically, from one in which only people with schizophrenia, or more acute symptoms of psychiatric illness, are hospitalised or isolated as the general public now has a much greater understanding of people with anorexia nervosa or those about whom Deputy McDaid spoke, victims of sexual abuse and their abusers. Alzheimer's disease has become more prevalent not only in our ageing population but in the 40s age group.

In the 21 years I have been a Member I have never received more correspondence from members of the public on any one single issue than on this one. I have received correspondence from patients worried and stressed, fearing that their insurance cover is under threat — which it is — and from their spouses, families, sons, daughters and physicians, all equally concerned that their level of health care has been reduced by 45 per cent.

Circumstances may well arise sooner rather than later in which a patient or his or her physician may decide to take a test case to the courts to ascertain whether this element of discrimination, being introduced by a Government which trumpets loudly that it is anti-discrimination, withstands legal scrutiny.

It is rather rich of the Minister of State at the Department of Health to read into the record that, of course, when the insurance for private health care expires, these patients can be transferred to the public psychiatric services. Has the Minister any idea of what is happening in public psychiatric health care services nationwide? They cannot cope with the pressure exerted on them by public patients. Therefore, how can the Minister expect people involved in private health care to be pushed over, exerting further pressure on an already over-pressurised public health care system? Private health care has an important, significant role to play, hand in glove, with public health care but is under attack by the Government and Minister for Health.

Above, all, this is the introduction of an element of discrimination in the area of health care by a rainbow coalition Government that I, Members of this House and the public thought had been abolished forever by successive Ministers for Health.

I ask Members to support the annualling of these regulations.

Question put.
The Dáil divided: Tá, 54; Níl, 63.

  • Ahern, Bertie.
  • Ahern, Dermot.
  • Ahern, Michael.
  • Ahern, Noel.
  • Andrews, David.
  • Aylward, Liam.
  • Brennan, Matt.
  • Brennan, Séamus.
  • Browne, John (Wexford).
  • Burke, Raphael P.
  • Byrne, Hugh.
  • Callely, Ivor.
  • Clohessy, Peadar.
  • Connolly, Ger.
  • Coughlan, Mary.
  • Cowen, Brian.
  • Cullen, Martin.
  • Davern, Noel.
  • de Valera, Síle.
  • Fitzgerald, Liam.
  • Flood, Chris.
  • Foley, Denis.
  • Geoghegan-Quinn, Máire.
  • Hughes, Séamus.
  • Jacob, Joe.
  • Keaveney, Cecilia.
  • Kenneally, Brendan.
  • Keogh, Helen.
  • Killeen, Tony.
  • Kirk, Séamus.
  • Kitt, Michael P.
  • Kitt, Tom.
  • Lawlor, Liam.
  • Lenihan, Brian.
  • Leonard, Jimmy.
  • Martin, Micheéal.
  • McDaid, James.
  • Moffatt, Tom.
  • Molloy, Robert.
  • Moynihan, Donal.
  • Ó Cuív, Éamon.
  • O'Dea, Willie.
  • O'Hanlon, Rory.
  • O'Keeffe, Batt.
  • O'Leary, John.
  • Power, Seán.
  • Quill, Máirín.
  • Ryan, Eoin.
  • Smith, Brendan.
  • Treacy, Noel.
  • Wallace, Dan.
  • Wallace, Mary.
  • Walsh, Joe.
  • Woods, Michael.


  • Ahearn, Theresa.
  • Allen, Bernard.
  • Barrett, Seán.
  • Boylan, Andrew.
  • Bradford, Paul.
  • Bhreathnach, Niamh.
  • Bree, Declan.
  • Broughan, Tommy.
  • Crawford, Seymour.!Lowry, Michael.
  • Creed, Michael.
  • Crowley, Frank.
  • Currie, Austin.
  • Deenihann, Jimmy.
  • De Rossa, Proinsias.
  • Doyle, Avril.
  • Dukes, Alan M.
  • Durkan, Bernard J.
  • Finucane, Michael.
  • Fitzgerald, Brian.
  • Fitzgerald, Frances.
  • Flaherty, Mary.
  • Flanagan, Charles.
  • Gallagher, Pat (Laoighis-Offaly).
  • Gilmore, Eamon.
  • Higgins, Jim.
  • Higgins, Michael D.
  • Hogan, Philip.
  • Howlin, Brendan.
  • Kavanagh, Liam.
  • Kenny, Enda.
  • Kenny, Seán.
  • Bruton, John.
  • Bruton, Richard.
  • Byrne, Eric.
  • Carey, Donal.
  • Connaughton, Paul.
  • Connor, John.
  • Costello, Joe.
  • Coveney, Hugh.
  • Lowry, Michael.
  • Lynch, Kathleen.
  • McCormack, Pádraic.
  • McDowell, Derek.
  • McGahon, Brendan.
  • McGinley, Dinny.
  • McGrath, Paul.
  • McManus Liz.
  • Mitchell, Gay.
  • Nealon, Ted.
  • O'Keeffe, Jim.
  • O'Shea, Brian.
  • Penrose, William.
  • Quinn, Ruairí.
  • Rabbitte, Pat.
  • Ring Michael.
  • Ryan, Seán.
  • Shatter, Alan.
  • Sheehan, P.J.
  • Shortall, Róisín.
  • Stagg, Emmet.
  • Taylor, Mervyn.
  • Timmins, Godfrey.
  • Walsh, Eamon.
Tellers: Tá, Deputies Dermot Ahern and Callely; Níl, Deputies Jim Higgins and Brian Fitzgerald.
Question declared lost.