Dáil Éireann díospóireacht -
Thursday, 12 Oct 2000

Vol. 524 No. 1

Health Insurance (Amendment) Bill, 2000: Second Stage (Resumed).

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

Minister of State at the Department of Health and Children (Ms Hanafin)

Subsection 6 provides that the protection for individuals against re-serving waiting periods on transferring between insurers shall not apply in the case of members of restricted membership undertakings which have decided not to participate in risk equalisation. An exception to this measure will apply where the person transferring is under 23 years of age. This will safeguard the position of dependants of members of such restricted membership undertakings who, under their rules, can no longer be covered on attaining a certain age.

Section 9 substitutes section 12 of the 1994 Act which provides for risk equalisation arrangements between insurers. The main changes from the provisions made under the 1994 Act are that restricted membership undertakings will have an option in regard to participation in risk equalisation; the Health Insurance Authority will have a key role in determining the timing of the commencement of risk equalisation, that is, within a prescribed field of discretion related to levels of material instability in the reported risk profiles of competing insurers; arrangements for the making of representations to the authority or the Minister in relation to the commencement of risk equalisation; and new entrants to the market will have the option of availing of a three year exemption from risk equalisation transfers between insurance undertakings.

Subsection (1) provides for the Minister to prescribe a scheme of risk equalisation which will set out the details relating to the conditions for its commencement and the terms of its operation. Subsection (2) addresses the undertakings to which any risk equalisation scheme will apply. It also provides for the established restricted membership undertakings to exercise a 'one off' choice to be permanently excluded from risk equalisation. The 1994 Act gave such undertakings an exemption from risk equalisation up to 30 June 1999. Subsection (3) maintains original provisions relating to arrangements for making statutory returns by insurers to the authority. It is the data contained in these returns which will be central to consideration of the commencement of risk equalisation and on the basis of which the magnitude of any transfers will be determined.

Subsection (4) provides for arrangements relating to the making of payments to the authority by insurance undertakings and by the authority to undertakings by reference to matters to be specified in the scheme. It also provides that the Minister shall determine the day when such arrangements are to have effect. In this regard the scheme shall require the authority to evaluate and analyse the returns made to it, prepare and furnish reports to the Minister and recommend, where conditions specified in the scheme are fulfilled, that the Minister ought or ought not exercise the power to determine that risk equalisation payments should commence. The subsection will enable the statutory scheme to provide that, up to a certain specified level of material instability in the risk profiles of insurers, the Minister may only authorise the commencement of risk equalisation transfers between insurers on foot of a recommendation to that effect from the authority. Beyond the specified level the Minister shall authorise such commencement unless there are good reasons for not doing so.

Under subsection (5) the authority, if it considers that a recommendation to authorise the commencement of risk equalisation payments is warranted, shall inform each undertaking of its proposed recommendation. Each undertaking will be entitled to make representations concerning the recommendation and the authority must take account of such representations before deciding the recommendation to be included in its report to the Minister under the scheme.

Under subsection (6) a scheme shall require the Minister to inform registered undertakings of a proposed determination to commence risk equalisation arrangements. Undertakings will be entitled to make representations on why such a determination ought not to be made by the Minister and he or she shall take such representations into account before finally deciding whether to make the determination which would commence the process of risk equalisation payments between insurers.

Subsection (7) requires registered undertakings, when requested, to provide information or details to the authority relating to returns they have made. It also provides that the Minister is entitled to specify the form of, and particulars to be included in, reports being made by the authority concerning its periodic evaluation and analysis of returns from insurers. Subsection 8 provides that registered undertakings which have made representations to the authority or the Minister relating to commencement of risk equalisation shall, when requested, provide information or documentation in support of their representations within a specified time.

Subsection (9) maintains the provision relating to the establishment and maintenance of a risk equalisation fund into which insurers would make payments to the authority and from which it would make payments to insurers. It also maintains provisions concerning the keeping of accounts relating to this fund by the authority. Subsection (10) provides that conditions to be set out under a scheme requiring the authority to make a recommendation in relation to commencement of risk equalisation can differ from conditions under which the Minister shall, unless there are good reasons for not doing so, commence risk equalisation. It also provides that these conditions can be expressed by reference to the amount which would be raised for payment in accordance with the terms of a scheme on account of the nature and distribution of insured risks amongst the undertakings.

The effect of this subsection is to allow for a scheme to specify different trigger points based on the level of market instability evident from the differing risk profiles of competing insurers, as derived from the analysis of their respective returns to the authority. The capacity to set different triggers will enable a scheme to contain a significant field of discretion within which the commencement of risk equalisation can only occur on foot of a recommendation to that effect from the authority. The development of a higher level of instability will require the Minister to authorise the commencement of risk equalisation unless it appears to him or her that good reasons exist for not doing so.

Section 9 also inserts a new section 12A in the 1994 Act. This new section enables the authority to disclose aggregate information derived from statutory returns made to it by insurers but provides that such data related to individual insurers may be disclosed only where necessary for the functions of the authority or the Minister. The intention is to enhance the transparency of the system and to assist the financial planning of insurers. It also includes original provisions enabling the Minister to retain professional advice in relation to his or her functions under a scheme and provides for the manner in which payments due to the authority under a scheme may be recovered.

Section 10 inserts the option for insurers entering the market to avail of a three year exemption from risk equalisation from the date of commencement of health insurance business. The White Paper set out the need for an exemp tion for new market entrants and stated that an 18 month period would be provided. However, it became apparent that a longer exemption period would be required with a view to attracting new entrants. The entry of additional insurers to the market would have the potential to yield significant benefits to consumers, in terms of competition on price, service and insured benefits available. However, to achieve this greater competitive state it is necessary to give practical recognition to the fact that, in order to establish itself with a reasonable prospect of sustainability, a new entrant to the health insurance sector faces considerable marketing, development and operational costs in competing with the two major insurers already operating here. The exemption will not apply to companies that are associated companies of registered undertakings already having availed of the exemption nor to new restricted membership undertakings.

Section 11 deals with miscellaneous amendments such as changes consequent on the deletion of the definition of "ancillary health services". Section 12 is a standard provision which gives the short title and collective citation and provides for the commencement date or dates to be appointed by ministerial order as considered appropriate.

The proposed removal of ancillary health services from the regulatory framework has been carefully considered in the context of facilitating the development of insurance cover in this area. The proposal does not affect the existing eligibility arrangements for health services under which persons are given access to primary care services on the basis of need. It is aimed at giving people who fund their primary care needs on a ‘pay as you go' basis the choice of financing their care by means of insurance.

Under the 1994 Act the definition of a health insurance contract embraced ancillary health services and those associated with a hospital stay, whether in-patient or day-patient. Ancillary health services were defined as including out-patient, GP and dental care. All contracts, whether they provided ancillary cover only, hospital cover only or both, were required to observe the principles of community rating, open enrolment and lifetime cover. In practice, few contracts with anything other than a nominal level of ancillary cover have emerged and there are no contracts that provide full indemnity exclusively against the cost of these services, such as exist in respect of hospital in-patient services. It was considered that steps needed to be taken to encourage the development of new products to fill a clear gap in the market and bring a level of service and choice to the consumer which was not emerging as matters stood. Accordingly, under the provisions of the Bill, any new contracts which solely relate to indemnification against the cost of ancillary health services will not have to be community rated.

The Government stated in the White Paper on private health insurance that the further evolution of private health insurance should include steps to promote the position of primary care in the system. The relatively minor coverage of primary care in health insurance was seen as promoting an orientation towards most costly hospital based treatment by those with health insurance and it is desirable to address this. I hope that it will be possible for insurers to develop plans that will cover areas such as dental care and other health care services where consumers can be open to liability for sizeable expenditure. There is also the prospect that the new arrangements will provide scope for development of preventive and early detection services, which have not been a significant feature of insurance arrangements to date where the focus is on acute care. I have outlined the technical aspects of the Bill which allows for late entry loadings in circumstances to be prescribed. The proposals will impact positively upon those who hold health insurance and the health insurance market.

The advisory group on risk equalisation forcefully indicated that if the flow of young healthy lives into the system was to taper off, the community rates insurers charge would be higher as they would be based on worsening risk profiles. This could have a compounding effect as the resulting higher premiums could cause young healthy people to question the value of their insurance and terminate their cover, thereby accelerating the premium increase spiral. The Government has, therefore, formed the view that there should be an incentive for those who will purchase health insurance at some stage during their lives to join the system at the earliest possible age. This is fairer than the current system because it will reward those who take out private health insurance, place an appropriate premium burden on those who enter health insurance later in life when the prospect of claiming benefits is higher and consistent with the general principle of community rating because a 70 year old person who originally joined the system at age 25 will still pay the same premium as a new entrant aged 25.

The Government has decided to introduce the principle of lifetime community rating. Under this principle insurers will be allowed to charge an extra premium in the form of a permitted percentage loading on their standard community rate to those who join private health insurance for the first time at an older age. For the reasons mentioned, this form of community rating is considered inherently more stable than the current system.

The proposed arrangements aim to ensure late entrants will be liable to pay sufficient extra premiums to make up the surplus they would have contributed to the system if they joined at an earlier preferred age. Regulations to be made pursuant to the proposed legislation will ensure late entrants will not be charged disproportionate premiums and specify the maximum loadings on an insurer's normal community rated premium which will be permitted. Based on actuarial advice made available to me, such maximum loadings will range from 10% between the ages of 35 and 44 to 80% at age 65 and over. Those who hold cover at the time of enactment of the proposed amending legislation will not be liable to the extra age at entry premium loadings allowed.

Though the proposed age loadings will not apply to persons who have private health insurance when the proposed legislation is enacted in respect of their existing level of cover, insurers will be permitted to apply a loading in respect of additional cover taken out where persons move to an insurance plan which offers higher benefits. Any loading in such circumstances is to be limited in its application to the difference between the levels of the plans involved and the maximum level of loading will be prescribed in legislation.

I have outlined the revised arrangements for risk equalisation proposed in the Bill. I will now address the need for risk equalisation in a health insurance system such as that which operates here. Our private health insurance system operates under the widely accepted principles of community rating, open enrolment and lifetime cover. With some exceptions, this means that insurers must accept all comers, irrespective of their age or health status and charge them a standard premium for a given level of cover. In other words, insurers cannot be selective about the risks they will cover or the price they will charge. This is fine so long as all insurers' risk profiles are broadly similar. There is a serious danger, however, that the market could be destabilised if significant variations in risk profiles emerge. For example, if some insurers, by accident or design, end up with a younger/healthier population, they will be able to charge a lower premium. The other side of the coin is that premiums will rise inevitably for those insurers left with a higher proportion of less healthy individuals.

It can be argued that in this scenario the market risk equilibrium would be restored by people switching from the higher charging insurers to those with lower premium rates. This is fine in theory but in practice those who are most likely to switch in this way are those at the lower end of the risk spectrum. This would have the direct effect of pushing up rates even more for the less fortunate insurers, ending up in what could easily become a self-destructive rates spiral and the risk, in extreme cases, that one or more of the affected insurers would collapse. This would seriously undermine the public trust and confidence in the stability of the system which is vital in a voluntary community rated environment such as ours. Risk equalisation is the mechanism which will ensure this type of potential destabilisation does not occur. It simply aims to equalise differences in health insurers' costs which arise due to significant variations in their risk profiles.

The need for risk equalisation in a private health insurance system such as ours is supported by a wide range of national and international expert opinion and experience. In particular, it was supported by the independent advisory group on the risk equalisation scheme which reported to the former Minister for Health and Children in April 1998. The European Union's third non-life directive opens the possibility for member states to introduce specific legal provisions, including risk equalisation or loss compensation as it is referred to in the directive, in the regulation of health insurance business. The purpose of section 9 of the Bill is to enable implementation of significant changes in the arrangements for risk equalisation as originally envisaged under the 1994 Act with a view to addressing concerns about its commencement and impact.

The Department is satisfied as to the necessity for risk equalisation to ensure the stability of our community rated system. Adequate risk equalisation is a necessary complement to community rating. Without adequate risk equalisation, community rating and open enrolment in a competitve market create large incentives for risk selection which would have the adverse effects described. This is not just theory; it occurred in Holland during the 1970s and 1980s when, due to the absence of risk equalisation, several insurers had to be saved from bankruptcy due to being caught in a deadly premium spiral of a worsening risk pool and increasing premiums. Risk equalisation offers the most effective method for reducing cream skimming because it reduces the incentives for risk selection.

In preparing the relevant section of the Bill account was taken of the many views expressed. The Minister is satisfied that the proposed risk equalisation arrangements represent a prudent, fair and balanced approach to a contentious and complex matter. I commend the Bill to the House.

Mr. G. Mitchell

The Minister of State claims that the Bill proposes key amendments to the Health Act, 1994, but these do not meet the amendments that need to be made to the Act. A golden opportunity is being missed to deal with what is an unprecedented crisis in the health service. Ireland probably has the worst health service in Europe, not because we do not have the ingredients for a good service – we do; we have the necessary staff, including professionals, who are both willing and good, and the money – but because we do not have a strategy, vision or leadership. Nor do we have the courage or sense of justice needed to completely overhaul the system.

I was struck by an article on the front page of the Irish Examiner this morning in which reference is made to an eminent oncologist who has spoken out in public as he simply cannot tolerate a situation where patients of his who are dying of cancer cannot be admitted to hospital. The apartheid we have introduced to so-called health care is appalling and would not have been tolerated in South Africa at the height of the apartheid regime. If one has money, one does not suffer; one can be admitted to hospital to die in peace, but if one does not have money, one is left at the mercy of the system.

A lady who visits me at my advice clinic is on the urgent admissions list for treatment. Athough her knees and arms are turned in and she is stooped and in pain, she cannot be admitted. Each time she goes to the hospital the appointment is deferred. If she could afford to pay, she would be seen. At a time of unparalleled economic development, with record budget surpluses, those who cannot afford to pay are left crippled in pain while those who can write cheques go to the top of the list.

The Government does not have a health strategy. It is focused on the latest operational trauma. Task forces, reports, committees, inquiries into various matters, all stand in place of a real strategy. We need a plan for health. We need to plan the work and work the plan.

This major overhaul cannot come about without confronting vested interests, which contribute to the chaos, even though they are meant to be part of the solution. The Hippocratic oath states in part: "The regimen I adopt shall be for the benefit of my patients according to my ability and judgment, and not for their hurt or any wrong." It goes on to state: "Whatever house I enter, there I will go for the benefit of the sick,..". Some medical doctors and certainly some medical administrators and politicians need to read that oath because we are failing those people. We are not providing a fair and equitable health care system, even though we have unprecedented resources to do it.

We especially need to bring the content of the Hippocratic oath to the attention of some hospital consultants. Most hospital consultants are very hard working and sometimes do more than is expected of them, delivering a service in very difficult circumstances. However, others do not meet their commitments to public care and to the remuneration they receive for it. The problem is we have no way of measuring who are the good and the bad consultants because in most cases they refuse any kind of supervision. That is not right or proper.

Efforts have been made in the past to bring about greater equity in the treatment of public and private patients, but widespread concern continues that doctors favour those who increase their incomes. That has been said in an official Government report. If I recall correctly, five consultants sat on the committee that wrote the report. Some might say that is fair enough, but is it? Hospital consultants receive a fixed salary for their treatment of public patients, but they also receive an individual fee for each private patient. In a recent series on the health services in The Irish Times one health administrator said that if one was paid per customer in the bar but by per pint in the lounge, all the business would be done in the lounge.

The White Paper on private health insurance concluded that:

Rational economic behaviour would suggest that a stronger incentive exists for those consultants who are significantly involved in private practice to concentrate a disproportionate amount of time on these private patients. The situation is exacerbated by the fact that the private hospitals employ relatively few consultants or other medical staff of their own, relying to a great degree on the availability of doctors who hold public contracts.

If anybody wishes to take me to task on what I have said I would have to respond by asking why they did not take to task the White Paper? Why is the Government that produced the White Paper not doing something about it?

More than 80% of consultants are engaged in private and public practice. The cost of consultants to the Exchequer this year will be approximately £200 million, plus approximately £110 million from the VHI and somewhere between £69,000 and £86,000 per consultant paid directly from the Exchequer. They are contracted to work 33 hours per week with public patients. Most do that, some do more. Some go out of their way to meet people in their private consultancy room to help public patients. We must acknowledge and be grateful for that.

However, the 33 hours per week consultants are contracted to work with public patients is unsupervised. While I have no doubt most consultants meet their obligation, some do not. I also have no doubt that most work very hard. I have no difficulty with them being well remunerated. They should be well remunerated for their skills and the efforts they have made to qualify as consultants. If we want to give people an incentive to enter the profession, which is very demanding, we must remunerate them. I have no difficulty with that.

Even the good consultants, those who are more than pulling their weight, must know that there has to be a reform of work practices. A Government review group comprising 12 members, five of whom were consultants, which reported on waiting lists stated: "Some hospitals or consultants may find it attractive to maintain a public waiting list because a proportion of those waiting may opt to be treated privately." That is an extraordinary indictment of the medical system. Could anybody in this House make a statement to indicate more acutely the need for a total overhaul of the health system and for a completely new strategy?

No strategy applies. We have a piecemeal approach to health, one that has destroyed what was an excellent health system. It has made a horse's collar of the system for those who cannot afford to write a cheque. According to the Minister's statistics, which are usually understated, 31,000 are on hospital waiting lists, many of them in great pain. Is there any greater indictment of this apartheid ridden system and of those who practice within it than the statement I have just quoted?

Consultants are allowed use of public hospitals for their private patients. We have given an incentive for this medical apartheid. Some doctors continue to conspire to ensure that the system prevails. All the time the Government prevaricates and poorer patients suffer. In the Irish Examiner this morning an oncologist had the courage to state:

This practice is being funded by public money. More than 90% of the money spent on health care comes directly from the Exchequer. Only about 9% comes from private insurance.

I propose that the Committee of Public Accounts be given similar powers to those it has been granted to conduct the DIRT inquiry to praise those consultants who work hard and to identify those referred to in the Government report. I also propose that the committee call politicians, civil servants, health board and hospital administrators, medics and others to account under oath so that the committee can make recommendations for the ending of this incentive against the poor.

Not all the reasons for the waiting lists can be blamed on the work practices of consultants. If it were not for the work rate of some of them the entire system would collapse. However, any inquiry by the Committee of Public Accounts should examine the use of resources within the health system. I have been told by a leading firm of specialists that up to 20% of expenditure on health – which in total amounts to a little more than £4 billion per year – may be wasted. Do we have energy controls? Are materials properly used? Are X-ray and laboratory departments so disorganised that patients are unnecessarily kept in hospitals awaiting test results?

If we identified only 5% of waste within that total expenditure of more than £4 billion, we should consider the amount of money that could be realised for expenditure elsewhere within the health system. We should not say it cannot be done. It can be done if we have the vision, commitment and courage to do it. However, we have a ‘smart Alec' mentality which says that if a person is from Cork, he or she can be appointed to the board of the Irish Blood Transfusion Service. They are not there to serve the Minister but to serve the people. It is the Minister's job to ensure the resources are used to serve the people and that is not happening.

Consultants could head off imposed solutions to the hospital crises by entering into partnership with the Government to make the system work. If partnership does not evolve, will the Government have the bottle to take on vested interests? When will we have real reform of the health service?

The Minister half heartedly takes on only soft targets, such as his recent tilts at the tobacco industry. It seems extraordinary that he can get away with his publicity stunt in relation to the tobacco industry at the same time as the Government is extending drinking hours. This was not asked for by public representatives in Dublin or anywhere else and parents do not want it. The Government has allowed alcohol to be glamorised to the extent that the national hurling game is now sponsored to the strength of Guinness. It is trying to fool the people that it is concerned about their health by using gimmicks about tobacco. I am concerned about tobacco but I will take the Minister's concerns more seriously when he is prepared to look at what we are doing in the area of alcohol.

It is an absolute disgrace that Guinness Ireland is allowed to use a series of advertisements which suggest that alcohol is good for everything from boosting a person's confidence, to a hangover the next day or to improving the hair of the dog. It has now attached this to the national game of hurling. The GAA, Guinness Ireland and the Government think it is a great idea, while the Minister, Henry Winterman himself, wants to take on the soft target of the tobacco industry. When will we take on difficult targets? When will we take on the people who are inducing people to take alcohol at an increasingly young age? The Eastern Regional Health Authority has carried out research in this area. Approximately 50% of children from 14 years of age upwards admit they have indulged in alcohol. I will produce statistics if the Minister thinks that is an exaggeration.

Why are we unique in Europe for the unprecedented numbers on waiting lists for hospital treatment? Why do people in Ireland die younger than those in other developed countries? A comparative population of 3.7 million in France would live 13 million years longer. Why, according to the ESRI research carried out by Professor Brian Nolan, do higher professional men aged between 55 and 64 have a death rate of only 13 per 1,000 compared to 22 per 1,000 for semi-skilled workers and 32 per 1,000 for unskilled manual groups? Is it too dramatic to suggest we have a form of social apartheid and that the health system, among other services, contributes to that? When will the Government act to bring an end to an unacceptable system?

I understand the VHI and BUPA have made formal submissions to the Department of Health and Children on this legislation. The VHI suggests that a reduction in the length of the opt-out period from 36 months to 18 months for new entrants to the market in respect of participants in risk equalisation should be considered. The Minister of State made a case for the alternative to that. Why was a period of 36 months chosen? I understand the original documentation published by the Government suggested 18 months.

The VHI also suggested the inclusion of a new provision in the Bill to expand the powers of the VHI as set out in the Voluntary Health Insurance Acts, 1957 to 1998. I am informed that the VHI is extremely concerned about the proposal in the legislation that new entrants to the insurance market would be entitled to opt out of any risk equalisation scheme for a period of 36 months following entry to it. Perhaps the Minister of State could tell the House if any potential entrant asked for this 36 month period or if it was decided by someone in the Department. Does the VHI have a reasonable case in suggesting that 18 months is a sufficient lead-in period?

The 1999 White Paper on private health insurance set out the reasons risk equalisation is required in a community rated private health insurance market. The Government's view, which is supported by a wide range of independent experts and interests as set out in the White Paper, is that risk equalisation is essential to underpin and protect the stability of community rating. That is fair enough but the White Paper indicated that to further encourage competition, it was proposed that an insurer entering the health insurance market would be given the choice of availing of a temporary exemption from participation in the proposed risk equalisation scheme for a maximum period of 18 months from the commencement of trading.

Out of the blue, the White Paper is now being ignored and the Government is proposing 36 months. Why? Who has asked for the 36 month period and why has there been a change in policy? The stated reason for the exemption was the recognition of the value in terms of the enhanced competition new entrants would bring. I accept that is a reasonable point. However, what has happened between the publication of the White Paper and the publication of the legislation to increase it from 18 months to 36 months? I understand the VHI disputes the need for an 18 month lead-in period, but it accepts it is not unreasonable.

I understand the Department is striving to achieve a balance between underpinning community rating and encouraging new entrants to the market. However, I do not understand why we need to have a three year lead-in period. Is it possible, given that three years is a long time, that a company could come into the market, make a killing for three years and then leave once the three year period is over and it must play on a level playing field? Meanwhile, it has weakened existing players, such as BUPA and the VHI. I would like to know the reasoning behind this proposal and who has asked for it?

The VHI's powers are currently limited to the provision of health and health related insurance schemes. The 1999 White Paper on private health insurance indicated the Government's intention to implement legislation to give greater commercial freedom to the VHI to enable it to meet the challenges of the competitive environment in which it operates. The VHI states that it has developed a comprehensive corporate strategy in the past year and a half which focuses on broadening the organisation's product and services range in health care and other related sectors. It states that the aim of this strategy is to develop and transform the VHI into an integrated health care service provider.

Until now the VHI has operated on the basis of the provision of a single core product. A number of new products, services and business areas have been identified by the VHI in respect of which the organisation's experience to date in the health care business would make it an ideal provider. It also claims there are compelling reasons it should be given powers to enable it to exploit new business opportunities while continuing to provide community rated indemnity insurance for private health care.

What is the Minister's view on the VHI's proposals on the provision of child care services and the development of e-commerce initiatives in Europe in the health care area? Is he prepared to consider extending the powers of the VHI and, if so, why has provision not been made in the Bill?

It will be a long time before we have legislation dealing with medical insurance providers before this House again so we should take an opportunity on this occasion to determine what is actually needed in the market and the reason the Minister has not acceded to what appears to be a reasonable suggestion from the VHI. I want to share my time with Deputy Deenihan, with the agreement of the House.

An Leas-Cheann Comhairle

Agreed.

Mr. G. Mitchell

I am not prepared to accept a piecemeal approach to health policy. I am not prepared to accept a health system that does not have a strategy. I do not see any strategy. All I see are sticking plaster policies and public relations gimmicks every day of the week. Whenever a judge states in court that he will not tolerate the way children are being treated, or something in relation to autism, a task force is immediately set up. When are we going to stop this operational approach to dealing with the latest crisis? When will we have a strategy? When will the 31,000 people on the list, many of whom are in pain, be seen? When will my constituent who comes to see me on Monday evening, bent and in agony, get her appointment?

We have to get it through to this Minister in particular that the health service is not in place to buttress him and ensure his return to a seat in this House. The most disgraceful abuse of power ever exercised by a Minister for Health was that exercised by Minister Martin in appointing ten of the 12 Irish Blood Transfusion Service board members from his own bailiwick and sphere. To do this to a service as vulnerable and as sensitive as the IBTS shows a total lack of judgment on the Minister's part. How will the five member health insurance authority be appointed under this legislation? How many of them have to be pals of the Minister?

Mr. Ring

They will be all from Cork.

Mr. G. Mitchell

Will the Minister assure the House that this authority, which he is proposing to set up, will not be confined to his old school chums or those who might be helpful to him as a stepping stone in his political career? Will he ensure that like all appointments to State boards and the proposed parliamentary reform which the Taoiseach referred to in the House earlier, those proposed for appointment to this authority will appear before an Oireachtas committee to prove their credentials before they are so appointed? I have a lot more to say but the Bill will be considered on Committee Stage.

Mr. Deenihan

This Bill is about introducing competition to the private health insurance area. I have examined two surveys carried out over the past two years which show that Ireland is the least competitive country in Europe as regards private health provision. On a scale of one to ten, the Indecon international economic survey of European and US insurance companies show Ireland at 9.5, where one is extremely competitive and ten is least competitive. The private health insurance market in Ireland is now the least competitive in Europe. The most competitive is the UK which came out at two on the scale of one to ten. The survey showed comprehensively that the potential benefits of competition reduces costs to the consumer, results in product innovations, provides incentive for new delivery mechanisms and incentivises preventive initiatives. It also indicated that people rated the element of competition as being very important and considered that it reduced costs to the consumer.

A survey carried out in Ireland by BUPA Ireland showed that Irish people placed a substantially higher rating on quality rather than price when considering products or services. In fact, nine out of ten rate high quality as important while the equivalent for low prices is six in ten. That survey, carried out by Lansdowne Market Research, showed clearly that increased competition in the health insurance market is considered important by two out of every three adults. That is higher than even the telephone or banking services and is well ahead of markets such as mobile phones or postal services. It showed that people want more competition in the health insurance market despite awareness that some competition already exists. More than six in ten people are aware that there is some competition in the health insurance market, although it is generally felt that there is a little rather than a lot. The survey also showed clearly that it is widely acknowledged that there is not enough choice in the health insurance market both in terms of companies and products.

I am a long-term member of the VHI. I am very loyal to the company and would find it difficult to move but as a rural TD I have great respect for BUPA Ireland, which set up in Fermoy and which has been a wonderful addition to corporate Ireland. It gives a quality service, provides good quality employment and supports the community in terms of healthy pursuits. For example, BUPA has sponsored Sonia O'Sullivan through lean and good times.

In looking at the Irish market in private health insurance there is only one competitor, namely, the VHI. That makes our market the least competitive in the European Union and that cannot be good for consumers. Many commentators have said that the White Paper, and indeed this Bill, give VHI everything it wanted. That must be of concern given that the VHI reports directly to the authors of the White Paper. On my reading the Bill appears very restrictive and much like the 1994 Act which failed to allow any significant competition to develop. Competition has been good for everyone here along with the option of different products and lower prices, something which should be encouraged.

Is the Minister willing to consider amending the Bill to ensure that the market is more competitive? In particular, I ask him to answer the following questions. In order to protect and enhance competition in the market, will the Minister make it more transparent so that there is no hidden and unfair cross-subsidy of products? Will he amend the Bill to ensure that the Health Insurance Authority acts in a manner which conforms to Community law, generally advances the consumers' interests and does not stifle competition? Will he limit Government intervention in the market to the minimum necessary, in particular recognising that risk equalisation should be a genuine reserve power? Will he take account of the fact that risk equalisation is not a panacea and that it will discourage entry to the market, reduce consumers' choice, increase their costs and in the long-term may harm the principle of community rating? I ask the officials to ask the Minister to address the matters I have raised. I can pass on my notes if they are needed.

Ms McManus

This Bill is being debated against the background of a health service in crisis. It deals with the regulation of private health insurance but does not deal with the gross deficiencies that are increasingly evident to the public who receive health care and to the professionals who deliver that care.

A Bill to amend the Health Insurance Act could have been a major step forward for the health service. It could have been the outcome of a policy for change based on the principles of access and excellence. Instead, it is bolstering the dysfunctional aspects of our health insurance system. It will further separate primary care from hospital care by removing cover for general practice from community rating. This is a retrogressive move. Community rating is a safeguard against cherry-picking which is as much a factor at primary care level, or will become so, as it is at secondary level. In some respects the Bill is likely to deepen the inequality that is already pervasive in our system of health care. Therefore the Labour Party cannot support this legislation.

Our health service could be the finest in the world. We have the highest professional standards in medical and support care staff but it is a service in serious difficulty, characterised by waiting lists, staff shortages, under-funding, low morale in our hospitals and services being stretched to breaking point. In many ways, matters are worse now than they were in the early 1980s.

Today I received a letter from a neurosurgeon in Beaumont Hospital, following a letter I wrote to him about a young man who is living in constant agony and pain. He pointed out that since 1998 there has been a 25% cutback in theatre time and that almost three-quarters of admissions in 1997 were emergencies which left no spare capacity for elective surgery. In his words, "It is simply a fact that the amount of operating time per week in your surgery is less than that available in the early 1980s". This has been confirmed in the annual report by the Mater Hospital, where cutbacks are affecting procedures and ensuring that waiting lists are being lengthened rather than shortened.

Last week the Exchequer returns showed a surplus of almost £200 million over and above estimates for the year. We are awash with money, yet our hospital theatres are being closed and beds are being kept vacant or inappropriately occupied while patients suffer and wait for treatment. Nursing posts cannot be filled and vacancies are occurring in junior hospital doctor posts. The Government's response to these shortages is to go abroad for recruitment purposes. It is a short-term and morally suspect response. Plundering the developing world for skilled medical staff is hardly a solution of which we should be proud. It is hardly the way to deal with structural problems that so deeply affect patient care.

The Minister's speech dwelt on the increased spending in health care in recent years. When the coffers are choked with money, increased spending on health from a notorious low level that pertained in the 1980s is hardly news. This is not the first Government to significantly increase spending on health. How that spending is allocated is the issue – how to spread the benefits to those who need them most, regardless of geographic location and of their ability to pay. That is the challenge this Bill could have begun to address, but instead it is driving health care further into a straitjacket of a two tier system that is unfair and inefficient.

Inequality is at the heart of our system. Despite the best efforts of health professionals to ameliorate the two tier nature of health care, inequality not only persists but is getting worse. We all know that everyone has a statutory entitlement to public hospital care, but this entitlement cannot be met under the current regime, the existence of long hospital waiting lists is testimony to that. There is a gap between entitlements to elective procedures and performance and only those who can afford to pay are able to bridge that gap, and they are doing so in ever-increasing numbers.

In 1979, 21.8% of the population had private health insurance, today 45% of the population have it. According to the ESRI, the main reason for this is to get quick access to hospital, in effect, to jump the queue. In the meantime people on low incomes, who often live in poverty, die at a younger age and suffer more illness than those on higher incomes. That is an outcome of socio-economic conditions. In Ireland, uniquely in the European Union, those on low incomes who live in poverty suffer further scandalous disadvantage. The nation's health service is heavily weighed against them. At general practitioner level, only the poor can get free care under the GMS. Those on low or modest income pay as much as those on high incomes. For many this presents desperate choices when a family member is sick. Even children are denied the security of medical care on a guaranteed basis free at the point of delivery. Withdrawing community rating and ancillary services, as the Bill proposes, will create, in effect, a three tier system at primary care level, those on GMS, those who will have private health insurance and those who will fall between both categories.

Currently at hospital level the service is grounded firmly in the iron rule of ability to pay. While emergencies are dealt with on an equal basis, speedy access to other acute hospital services is provided for those with the money to pay for private care. Those who cannot afford private health insurance are often forced to wait on long waiting lists. Some of them die before they get the care they need.

Our health service is built on apartheid, pure and simple. It is as unfair and immoral as any system of racial apartheid. I am pleased this description, originally coined by the Labour Party, has gained common currency. Unfortunately, it is a fair description of how our health system works.

The Government, with overflowing coffers at its disposal, has thrown vast amounts of money at the problem often to little or no avail. Approximately £35 million was spent in a year on the waiting list initiative and what have we seen as a result? The waiting lists are practically at the same level as they were when the Government took office three years ago. They increased and while they have decreased somewhat there is not a marked difference. If waiting lists were reduced it had as much to do with the fact that people got tired waiting and went privately, moved away or died rather than by any initiative taken by the Government. Even the number of in-patient hospital procedures has not increased significantly. This is the record of a Government that pledged, on taking office, it would tackle the waiting lists.

We have the worst premature death rate from heart disease in the EU, almost twice the European average. We have one of the highest cancer rates. Our life expectancy, in many cases, is lower. Irish women, on average, have seven fewer years of life than French women. In part at least the inequality inherent in our health service is a key factor in our poor health status.

We cannot be proud of our health system, as it is currently constructed, but we can change it. Yet the Government is unwilling or unable to meet the challenge. Instead there is a determination to defend the indefensible, to shore up the iniquitous system of public-private mix rather than reform it fundamentally.

This Bill is part of that thinking. The same applies to the White Paper, which avoided tackling the issue of inequality. It states, "The Government therefore consider that a fundamental departure from the existing system of voluntary private health insurance is not warranted in view of reforms envisaged to improve resilience and operation of system." In other words, we will perpetuate the current two tier system and attempt to ameliorate its worst effects by throwing money at it.

In October 1999, the health economist, Joe Durcan, of University College Dublin, outlined the reality of health care in Ireland. He said:

The public/private mix in the Irish healthcare system is often seen as not only unique in terms of scale but also a major advantage. The particular advantage claimed is that it allows the best physicians to function in both areas of the market so that the public system is not adversely affected by the loss of the best to the private system. [That is a fair comment.] Their public hours of work are governed by contract. Once the contractual obligation is met, they can function as private agents. [That is the important point]. There is thus an incentive for consultants to create waiting lists for treatment, in the expectation that since a significant proportion of the population have health insurance people with a public entitlement to care will use their health insurance to pay for treatment. Such queue-jumping is now an integral part of the Irish healthcare system.

This public/private mix also affects public hospitals. They are allowed to take private patients up to certain limits. (These limits are unaffected by the closure of public wards.) Private patients enhance hospital earnings, given their budgets from the State. This is thus an incentive for hospitals to increase the number of private beds, even though there is a public waiting list.

His judgment is vindicated by the figures. The inverse incentive for consultants and hospitals that he described has created a giant growth in private health insurance. A total of 45% of people are now privately insured. The private work of consultants in hospitals has grown proportionately to meet the demand for private care. One argument put forward in support of the present system is that private health insurance provides an important source of income, but it actually contributes a significant proportion of overall health spending that is not that large. If one goes back to 1998 the Government estimated an overall spend of approximately £2.7 billion, while the total VHI claim was approximately £304 million. Furthermore, this latter figure must be netted down to reflect tax relief on private health insurance premia and the indirect subsidy of private health insurance through pricing private beds in public hospitals as less than the full economic cost. It is a significant figure, but it hardly justifies the gross inequity that it entails. Moreover, reform of the system can take place in a way whereby these contributions are not lost to the system.

In the meanwhile, we should remember that the public system continues to fail to deliver. As they wait, public patients are forced to endure illness, disability, incapacitation and danger to life. Those people are our least well off: the elderly, the powerless and the most vulnerable. The current system depends on these waiting lists and feeds off them. If there were a serious effort made to tackle waiting lists and if it were done without the necessary structural reform, it would create new problems without solving old ones. Injecting massive resources needed to counteract the fundamental inequities of the current system on its own without the necessary reform would destabilise the current market. People would withdraw from private care back into the public system and there would, as a consequence, be further additional costs accruing to the State. This is the logical outcome of the policy the State is putting forward.

We need to remind ourselves that this system we have inherited was not designed to take the form it has taken. Things are worse in the health care area in many ways than they were 20 years ago and we need to remember that. Honest efforts have been made to ameliorate the hardship being caused. Nobody designed the health care system to be deliberately run on apartheid lines; theoretically it is based on a universal entitlement to hospital care. However, we are all acutely aware that this is an entitlement we cannot rely upon. Almost half of the population are in the fortunate position of being able to choose private health insurance and have chosen that; at a guess, I imagine the vast majority if not all Members are private health insurance subscribers.

This is the system we have, but it has developed for historical and political reasons and is now in crisis and is crying out for reform. Until there is a framework and a new dispensation whereby the patient, regardless of income, is central to the system, we will continue to muddle along while too many lives are blasted and lost unnecessarily and thoughtlessly. The ways and means of creating such a new dispensation is what we should debate today. We should discuss the means whereby everybody will have equal access to necessary health care and moreover, the means whereby everyone will have access to integrated health care, which incorporates both primary and secondary care, in order to maximise the quality and efficiency of the service.

We should consider the possible development of a universal compulsory insurance scheme providing choice of insurers for all. It is interesting that there is a growing consciousness and debate outside the House about such an option. If we created this kind of universal insurance scheme, I do not doubt that it would create a modern and just health service to meet the needs of the 21st century, but this debate is not occurring within the Government. Despite all its resources, the Department and the Minister have skirted the challenge. The White Paper, as Mr. Joe Durcan pointed out, simply did not reach the mark. He said:

The White Paper does not fully appreciate that a compulsory health insurance scheme would be essentially a private scheme. The reasons for the rejection make it clear that the point has been missed.

He was commenting on the fact that the White Paper simply rejected the idea of a universal scheme on the basis that it would be a social insurance scheme. Disgracefully, the White Paper on private health insurance failed to explore the possibilities of change and ducked the question implicit in its criticism of the current arrangements when it stated:

Rational economic behaviour would suggest that a stronger incentive exists for those consultants who are significantly involved in private practice to concentrate a disproportionate amount of personal time on these private patients. The situation is exacerbated by the fact that the private hospitals employ relatively few consultant or other medical staff of their own, relying to a great degree on the availability of doctors who also hold public contracts.

Even the Government's review group set up to examine the waiting lists made the same point: that there is an inbuilt incentive for hospitals and doctors to maintain public waiting lists. The economic relationship between the consultant and the private patient is very different from that between the consultant and the public patient and this fact determines the distortions in the system. However, unlike Deputy Mitchell, I do not see this as a question of bashing the consultants. It is to a large extent to their credit and to the credit of the professionalism of individual doctors that it has not led to even greater inequality. This different relationship between two classes of patient is the point where change must occur and the question that the White Paper should have posed – given its work – is how we tackle that difference in a way that delivers quality care for all. The White Paper failed to do so and dismissed in very few words the possibility of a universal social insurance based system. It is silent on the possibility of any other universal system based on private insurance. There may be other ways to resolve the issue of equal access to quality care, although we in the Labour Party have spent a great deal of time in consultation and debate with interested parties in order to find alternatives to the one we propose. So far it appears that our proposition is sound. However, it is disappointing that the Government is dismissive without engaging with the issues raised by our proposals. Why? Why is this Government incapable of exploring the possibilities for reform that are open to us as a society? Instead we are presented with this Bill which will not make things better and may well make things worse. The Minister said this Bill will provide a framework to support the development of a vigorous and competitive private health insurance market, but even by this criterion the Bill is open to criticism. Dr. Michael Moore, in his critique published in the Irish Medical News is scathing, stating:

It is unclear why the Government has come forward with a strategy that, if it promotes competition at all, will promote competition which destabilises the market and undermines the insurance market, healthcare delivery system development and consumer welfare.

He continued:

Freedom to price and offer ancillary service products in any way they see fit presents health insurers with tremendous opportunities to use discriminatory pricing and product development techniques to cherry-pick the main health insurance market. Given the very uneven distribution of illness and healthcare costs, the incentives to cherry-pick are great.

He also stated that the inevitable outcome of this deregulation is that the market will become unstable and consumers classified as high risk, such as the chronically ill and the aged will find difficulty in gaining access to good and affordable coverage. Dr. Moore concluded that:

Government policy lacks coherence. On the one hand it is giving insurers the opportunities and incentives to attract best risks and undermine community rating, curtailing access for vulnerable groups. On the other hand it is seeking to bolster community rating through the introduction of risk equalization and late-entry premium loading and improve access by expanding the open enrolment provisions to cover the over 65s. Furthermore, if two separate systems of community-rated hospital services and deregulated ancillary services are sanctioned it will be almost impossible to plan overall health services in an appropriate manner, which includes effective prevention and disease management strategies. This will have major implications for the long-term development of general practice and is at odds with the Minister's well publicised preventative health strategy.

These are very important points and they must be answered. The argument for the integration of primary care and secondary care is paramount if we are to ensure both quality and efficiency in our services. What this expert says, and we must pay attention to it, is that the future possibilities of that integration are seriously damaged if we proceed down this route. According to the same expert, even in its short-term goals the Bill has deficiencies. He says: "Apart from enticing cherry-picking health insurers to the market through the deregulation of ancillary services, the Government policies will do little to promote competition".

He is also critical of the risk equalisation measures. The point about the 18 months and the 36 months was made by Deputy Mitchell and it requires an answer since it appears to conflict with the White Paper. The point Dr. Moore makes, which again needs to be answered, is that, while he has nothing against risk equalisation and it is a very important measure which must exist in any legal framework, it can serve to subsidise inefficiency. He says:

Under the proposed scheme, health insurers that are effective in keeping hospitalisation costs down through prevention and disease management programmes and coverage of services in non-hospital settings would have to transfer at least 40% of any claims cost savings that they generate. The Minister promotes prevention and disease management strategies yet subverts health insurers intent on pursuing such approaches through this deregulation of ancillary services and the proposed risk equalisation scheme.

It is very important that, when the Minister returns to the House, he answers the points made by Dr. Moore to the satisfaction of the House. There is a great deal of fuzziness in the Bill and he needs to be clear as to the outcomes of the changes he proposes, especially regarding the changes in general practice and the further relationship between it and secondary care.

The Labour Party has put forward its own proposals for reform based on a universal health insurance scheme designed to bring the benefits of competition not just to some citizens but to all. We propose that, as a society, we need to progress beyond the current system not by eliminating the advantages given by health insurance but by ensuring that those advantages are extended to everyone. We propose the establishment of a national forum on health to engage all those involved in health care, including patients, in debate and policy making for the future.

Interestingly, the Government is silent on our proposal but, in its White Paper, undertakes to promote and facilitate not a national health forum for all but a private health care forum which will exclusively bring together interests delivering private health care for some. How the great traditions of Fianna Fáil that produced progress like the GMS scheme and universal secondary education for every child in the State have shrivelled and died. We are seeing policy being produced by political pygmies in a party that once produced political giants.

What we see is a tinkering with the status quo. It is a watering down of the safeguards established by a previous Government. It is based on free market principles, to an extent, yet it denies many free access to that market. This Bill is not about the future – not even a small part of it. It does not reflect any policy development of any significance. Measured by its own lights, it reflects confusion in the Government's approach. What is so dispiriting is that it is being introduced by a Government that has possibilities and resources undreamt of by any previous incumbents. We should remember that the times are propitious for great change for good.

The Minister for Health and Children is clearly not a reformer. He is keen on initiatives for individual aspects of health, such as smoking, for example. We in the Labour Party have no problem in supporting him fully in those initiatives. However, there is a deep conservatism at the heart of the Government that resists reform. The Minister for Finance, Deputy McCreevy, rewards the rich while inflation wipes out any social welfare increases granted in the previous budget. The Minister, Deputy Martin, tinkers with initiatives while the big picture passes him by. This Bill is about tinkering. It is not about change or reform. It is vague and, where it is not vague, it is retrogressive. In terms of the fundamentals, the Minister spoke recently on radio about the way he saw health care from a fundamental perspective. There is no evidence from this Bill that he is thinking in this way. Sadly, the converse may be true.

This Bill will remove the provision of so-called ancillary services, including general practice, from the safeguards of the Health Insurance Act. Unless the Minister can prove me wrong, it seems to me that cherry-picking will result. Inevitably, the disconnection which characterises the relationship between primary and secondary care which we all recognise is not to the advantage of the patient will be exacerbated rather than being brought closer together.

The development of the private health insurance market in Ireland will be in the public interest. I want to see insurers providing the type of competition and efficiencies they can. I recognise they have a role to play and that they can take different forms, such as not-for-profit or privately owned. However, they will only provide that kind of good in terms of the public interest if the legal and regulatory framework is right from the outset. Regrettably, the Government has not provided that framework in this Bill.

Ms Cooper-Flynn

I wish to share my time with Deputy Batt O'Keeffe and perhaps the Leas-Cheann Comhairle will indicate when ten minutes have elapsed.

An Leas-Cheann Comhairle

Yes.

Ms Cooper-Flynn

I welcome the opportunity to speak on the Bill which is yet another positive step being taken by the Government in the health area. More money has been spent in the area in the past three years by this Government than by anyone before and a serious attempt is being made to address the grave problem of waiting lists throughout the country. I am well aware of the position as a former chairperson of the Western Health Board. However, I now see, by virtue of the dialogue which has taken place between the board and the Department of Health and Children, a Government which has decided for the first time ever to seriously address the waiting lists problem.

I welcome the opportunity to speak on the Bill because private health insurance is a fundamental element of the health system we operate and that is evident by the fact that 44% of people avail of private health insurance. Deputy McManus said private health insurers have a role to play and that is certainly the case. It is in everyone's interests that as much competition is brought into this market as possible to ensure we receive the best possible service in this area. I welcome the Bill because it goes a long way towards encouraging competition in the private health market. It also brings in a significant amount of health insurance premiums of the order of £450 million per annum.

The system works so well probably because of the Health Insurance Act, 1994, which incorporates a number of core fundamental principles which are very important. First is the community rating principle which requires that the same premium be charged for a specified level of cover regardless of the age, gender or sexual orientation of the individual. It has always been the position that the premiums of young people have gone towards providing services for the old. Many subscribers to the health insurance system fully understand that they are paying a premium now which will remain at the same level in the future, provided they continue to retain the same level of cover. We are prepared to pay such premiums to benefit in our old age. That is a core principle which must be retained.

I value the open enrolment principle in the Bill under which health insurers are required to accept all individuals aged under 65 who wish to enrol in any health insurance scheme. It is vital that the system should be open to allow any individual who wants to benefit from private health insurance to do so. I also value the core principle of lifetime cover where an insurer cannot refuse to renew a contract of any member. It is a fact of life that many of us may contract a serious illness at some stage. In that context, it would be a backward step to allow insurers to refuse to renew people's contracts. These are the type of core principles that have been in existence since the implementation of the Health Insurance Act, 1994. We want to retain, improve and strengthen those principles by passing the Bill before us.

It is critical that insurers should provide minimum benefits and participate in risk equalisation. I listened with interest to Deputy McManus who stated that many private insurers might try to engage in cherry picking. I have no doubt that, without the correct regulations being in place, this will be the case. However, if anything, the amendments in the Bill are designed to avoid that.

It is amazing to hear the Deputy refer to the health policy document which was launched a number of months ago by the Labour Party. I recall Deputy Howlin, during the week it was introduced, stating on "Morning Ireland" that it was the most well researched document he had ever seen come before the Labour Party. I do not believe the document saw out the end of that week as far as discussion in the media was concerned because it was attacked by literally everyone involved in the health services and the media. It has been confined to the filing cabinet and has only been resurrected today during Deputy McManus's contribution.

Deputy McManus referred to fairness and equity in the system. However, the policy her party wanted to see introduced would have meant the closure of many district hospitals throughout Ireland. As a person who lives in a rural constituency, I could not support a policy of that type. However, such a policy is only what I expected because the Labour Party has been opposed to regionalisation, Objective One status and other initiatives that would benefit rural counties such as Mayo. I was delighted to see the document in question being confined to the graveyard of other discarded Labour documents. However, it has re-emerged today during Deputy McManus's contribution.

The aim of the 1994 Act was to safeguard the core principles of our health insurance system while encouraging competition in the market. The VHI held a monopoly until a few years ago and only one other major insurer, BUPA Ireland, has entered the market. While this company provides cover for 160,000 people, it is important to promote and encourage other competitors to enter the market. In that context, it is the reason we are debating this legislation today as a result of the European Union's third non-life insurance directive which necessitates the further opening of the market.

Fianna Fáil has taken on board the challenge of encouraging greater competition. We want to see the common good being catered for, but we also want to see a competitive market develop. Striking a successful balance between the two and providing consumers with fair choice at a competitive price are our main aims. The Bill goes a long way towards achieving those aims.

The purpose of the Bill is to strengthen the core principles in the 1994 Act to which I already referred. The first thing we must do is consider the definition of a health insurance contract. Traditionally, the reason people take out private health insurance is that we are all terrified of the grave illnesses which might befall us during our lifetimes and the huge expenses we might incur as a result. People pay their insurance premiums in order that they will be covered for that eventuality. Most people who take out private health insurance do so for that reason. As a result, the types of facilities that are available in acute hospitals, in-patient services and the ancillary services have not been considered in the same way by people who take out private health insurance. I refer here to out-patient services, GP services, dental and optical services. We are faced with a situation where people are covering themselves in respect of catastrophic illnesses but the market relating to ancillary services has not developed.

The Bill provides for ancillary health services to be removed from the ambit of the health insurance legislation with a view to encouraging greater activity and growth in that area. That is a positive step. The Bill also makes clear the distinction between health insurance and long-term care insurance, a different product which requires different financing and benefit structures. It is important that the two should not be confused.

The Bill extends the provision of the regulatory system to any self-insurance arrangement that may be developed. Large employers have traditionally carried the risk for the health care of their employees, people such as prison officers, gardaí and the staff of the ESB. This can have serious consequences because many young people are employed by the companies to which I refer. If we are to introduce a system of equalisation, it is important to realise that many young people are involved in schemes of this sort and we could find ourselves in a situation where many elderly and sick people are left in the risk pool catered for by private health insurers. It is vital to balance the system between insurers in a fair and equitable way and the Bill makes provision in that regard.

I will now look in detail at some of the core principles to which I referred earlier. I will first deal with community rating which involves paying an even premium throughout one's life for health insurance. The reality is that everyone does not enter into a private health insurance contract in their twenties. In an ideal world, that is what would happen. There has been considerable debate about this issue in the media this week. If one begins paying a premium in one's twenties, it is fair and equitable throughout one's life.

It is important that if a person does not commence paying insurance at an early age and decides to enter the system later, he should be allowed to do so. However, to be fair to those who have paid premiums throughout their lives, it is only right that some sort of loading would be put in place to ensure equity in the system. While provisions in respect of late entry are not set out in the Bill, the White Paper outlines the loading which should apply to people who are over 35 or over 65. We should encourage the introduction of such loading mechanisms. In addition, it is important that insurers should have the discretion to provide a reduced premium for subscribers under the age of 23.

I welcome the provisions in the Bill which are designed to encourage open enrolment and even to extend the offer of cover to people over 65 years of age, bearing in mind that to enter the system at that stage they will be obliged to pay a loaded premium. However, it is important that these people should be eligible to avail of private insurance should they wish to do so.

One of the key and most controversial aspects of private health insurance is the area of risk equalisation. We must avoid cherry picking, we must bring stability to the system and we must encourage as much open market competition in this area as possible. The Bill attempts to address that matter by putting in place a fair system which will benefit everyone. Sadly, as stated earlier, our Labour colleagues seem to believe the provision of a fair and excellent service does not always extend to people living in the regions. That is regrettable.

The Government has placed more capital grants and revenue at the disposal of the health boards to allow them to deal with the waiting lists and improve and enhance services, than has any other Administration since the foundation of the State. It is to be commended for doing so. We are moving in the right direction with the introduction of the Health Insurance (Amendment) Bill and I commend it to the House.

Mr. B. O'Keeffe

When we speak of a private health insurance Bill we must also consider what the Government is doing for the public health sector. It is commendable that the Government has put £1,500 million in extra resources into the health service. This investment was badly needed because the health service had been neglected. The Government is committed to continuing this investment in the seven year period of the national development plan when a further £2 billion will be invested. I welcome this.

I hear much criticism of the health service but very little account is taken of the excellence of the service being delivered in our hospitals and GPs' surgeries. It is easy to criticise the health service. Health is such an emotive issue that headline grabbing issues will always evoke a response. If money were the answer to its problems the health service would be perfect.

Some elements in the administration of our hospitals must be examined. I am currently engaged in a study of performance appraisal. Have we ever examined the mean for operations in various hospitals? For example, if two consultants in one acute hospital carry out 500 heart by-pass operations in one year and in another hospital five surgeons carry out 750, questions should be asked. In an era of openness and accountability details of all private operations should be made available to the public. The public should know how many private operations are being carried out by surgeons who also have a public remit and if a surgeon's public contract is being honoured. We have never conducted such a study which would give an indication of what is happening in the private and public health sectors.

I commend the VHI which has given good private health insurance cover for many years and I also welcome the element of competition which has been introduced with the arrival of BUPA. Can the Minister of State explain the risk equalisation element of the Bill? When Deputy Cowen was Minister for Health and Children he revoked the risk equalisation element in the 1998 health Bill. It was said at that time that the market would reduce in size and that people would not get insurance. It was also predicted that VHI would go out of business. It was feared that disaster was about to befall the private health sector. None of these things happened and the market has expanded from 33% in 1994 to 46% currently. There was never a greater number of older people in the private health insurance market, VHI was never more profitable and its profits are even greater than BUPA's total income in Ireland. Some contend that risk equalisation makes competition impossible but I remain to be convinced of this. I hope the Minister of State will give an informed opinion on this matter. In the United States and Australia risk equalisation has disappeared. It could be argued that if risk equalisation is removed from the market better competition and greater cost effectiveness will result. I hope the Minister of State will refer to this matter when she replies to the debate.

The establishment of a health insurance authority is a welcome development but its terms of reference must be clearly outlined. It must preserve community rating and pricing policies must be monitored to ensure transparency. Such monitoring would facilitate the operation of the sector and provide greater stability.

Are the Minister's hands tied by the Bill? Will it be necessary to amend the legislation frequently as the private insurance market evolves? Can the Bill not allow regulations to be made without the need to return to the House every time a change is to be made?

I support the main thrust of the Bill and I look forward to a better system of private health insurance as a result of its enactment.

Mr. Neville

At a time of unprecedented economic boom and a bulging Exchequer it is necessary to make root and branch changes to our health system. We have a dual health system. A patient who has money will receive a service and one without money will not. This is unfair.

As a first step we should increase the income threshold for eligibility for medical cards. The current income limits are so low that a husband and wife lose eligibility if their income exceeds £135 per week. A couple with an income of £140 per week cannot afford private medical care. A husband and wife with two qualifying children do not qualify for a medical card if their gross income exceeds £168 per week and a single person will not qualify for a medical card if his or her gross income exceeds £93.50 per week. How many people could exist on a weekly income of less than £93.50? This is absurd. It was never intended that this should happen. Only the very poor qualify for the general medical service.

The Government should more than double income limits to bring 450,000 more people into the medical card scheme. The Minister for Finance, in his December budget, should set a limit of £10,200 per annum for a single person under 66 years; a limit of £16,820 per annum for a married couple under 66 years; and a limit of £19,720 per annum for a married couple with two children. This would place eligibility levels on a par with tax exemption levels when adjusted in the budget.

Given the existing income restrictions, is it any wonder there is such pressure on the secondary care hospital system? At present, 31% of the population is covered by a medical card at an average cost of £291 per year, a total of £337 million. To increase this by 450,000 people to 1.6 million people or just over 40%, which is an increase on the present figure of 31% of the population, would cost an estimated £130 million gross. The existing agreements between the IMO and the Department of Health and Children, allows for up to 40% of the population to be covered. This proposal is in line with the agreements with the Irish Medical Organisation. There will not be any need for any further negotiations. It could be introduced by the Government simply by making a political decision.

While the total cost would be somewhere around £130 million, the net cost would be much less because those not currently covered by the GMS system, can claim a refund in excess of monthly expenditure of £42 for medicines and all medical expenses in excess of £100 for an individual, or £200 for a family per year against income tax. A disproportionate number of those to whom extended cover would apply, will be young and therefore, less likely to impose a full cost on the Exchequer. Furthermore, the gross cost to the Exchequer would be reduced as fewer people would present at hospitals and there would be a saving in secondary care costs. Even this should only be an interim measure. There is a good case for going much further and for transferring from secondary care to primary care, more of the resources to tackle the health needs of the population.

Poor people suffer more and die younger. According to the ESRI research for Irish men aged 55 to 64, higher professionals have a death rate of 13 per 100,000. For the semi-skilled groups, this rose to 22 per 100,000 and to 32 per 100,000 for the unskilled manual groups, that is, the mortality rate was almost three times higher among the lower income groups than the professional groups. Access to general practitioners and medicines in primary care, together with access to hospitals when needed, would help reduce the number of deaths among poorer persons. In addition, pharmacists should be encouraged to become more directly involved in primary care, through medicine profiling of patients and minor injury treatment.

Some estimates suggest that more than 50% of people do not take medicines correctly. Hospital doctors and general practitioners are often under pressure and patients do not always revisit the doctor if they have an initial bad reaction to medication. They simply stop taking the medicine or do not take the correct dosage. Often minor changes in the drug usage or advice on medication and use of, for example, alcohol or tobacco at the same time, can assist. Pharmacists who play an active role in hospitals giving advice on patient needs could play a more active role in giving advice on medication to those who do not need hospitalisation.

The report of the Inspector of Mental Hospitals for 1999 was published earlier this month. I commend the inspector for the excellent work he is doing in the area and for bringing the report for last year forward in this year. Not many years ago, we had to wait three or four years for the report of the Inspector of Mental Hospitals which was totally irrelevant by the time it was published because conditions had changed in the preceding years. The general view of the report is that the treatment of those in need of psychiatric care in the State falls short of a standard deserved by people who are mentally ill and in deep crisis. It is a disgrace that this situation prevails.

In his report the inspector castigated the level of service provided for those who are in mental hospitals. For example, the inspector has drawn attention to areas of concern in the quality of service provided. These include the substandard nature of some long-stay accommodation. He also pointed out that too many locations where the standard of furnishing and decor in which patients spent their lives was unsatisfactory. These long-stay institutions are in a bad state of repair and are symbolic of a different era. All pre-1900 constructed psychiatric hospitals should be closed immediately.

There should be rationalisation of the system of keeping long-term patients who are severely disturbed in hospital with people who have a mental disability but who are not ill and with aged patients who should be at a geriatric hospital and not in a mental institution. There are approximately 300 patients, who have a mental disability and who are not ill, in in-patient care. I am excluding here, St. Joseph's unit in St. Ita's Hospital. This is an unacceptable situation. The inspector took a very serious view of this derogation of appropriate care delivery to all patient groups, to the mentally retarded, the severely mentally ill and the elderly in hospitals.

The inspector pointed out that clinical review of long-stay patients on a regular systematic basis is essential. It is particularly important that the rehabilitation of long-stay patients is not neglected. In the case of elderly people, the physical disabilities of their age rather than any major psychiatric impairment was their main problem.

The Government should introduce a policy of de-designation from psychiatric services and the establishment of a high quality service for older people, to deal with their physical ailments. This has long been advocated by the inspector of mental hospitals who pointed out that no progress was made in this issue in 1999. This should not be tolerated. It is not acceptable that there is concern regarding documentary matters on patient care issues such as case note entries, recording reasons for seclusion, the reason for extending temporary patient reception orders or the reason why patients are not given their own clothes shortly after admission. These matters have again been raised in the report. It is not acceptable that there is a poor level of communication with relatives, as was pointed out or that there is an absence of complaint procedures and mechanisms in some services. The absence of public display of patients' rights under the Mental Treatment Act, 1945, is not acceptable. The Minister must immediately ensure that this is corrected.

The inspectorate has always been committed to moving away from the traditional mental health care delivery system, which was dominated by the doctor-nurse model, while at the same time, realising that the nursing profession will continue to provide the bulk of 24 hour treatment and care for the mentally ill. Perhaps the Minister will respond at the end of the debate to the view of the inspector that there is much evidence that other skills such as those of psychologists, social workers and occupational therapists are a necessary component of the delivery of the mental health services. Without them, adequate treatment and management in the broader sense, is more difficult. The absence or shortage of such professionals in many Irish mental health services represents a serious diminishing of service quality. What measures are being introduced to ensure that multi-disciplinary teams are available as recommended by the inspectorate?

The inspector points out that it has been known for a long time that persons suffering from psychiatric illness have higher mortality and poorer life expectation than the general population. It is of great concern that there were 37 deaths in in-patient care in 1999, 14 by suicide. Surely, this level of suicide in our mental institutions is totally unacceptable. The Minister must immediately initiate an examination of why there is such a high level of suicide while people are in the care of State institutions. The 1998 report pointed to concern about prescribing of medication and the widespread prevalence of simultaneous prescribing of a large number of drugs. The inspector felt that a more organised approach to prescribing drugs was required in many services. The necessity of frequent reviews of patients' medication, particularly of long-stay patients, was again stressed this year in the inspector's report, as was the fact that medical prescriptions should be carefully written and signed. This is a very important issue and it is a scandal that such a laissez-faire approach is taken to the prescribing of drugs for long-stay patients.

We must have a root and branch examination and change the way we deliver our mental health services. Since the foundation of the State, and not just during the term of the Minister, the mental health services have been neglected and under-funded. The provision of these services should be put at least on a par with the provision of the general health services, both in hospital and community care. There rightly has been criticism of waiting lists, but it would be a huge move for the mental health services even to reach the level of the general medical service.

There is overwhelming evidence that psychiatric services concentrating on rapid response in the community setting are superior to the more conventional services. A community early intervention service should be introduced to provide a rapid response service for patients with severe mental illness. The service should see patients in their houses and other appropriate settings, including in general practices, community based day centres or relatively rarely in hospitals. An early intervention system should be multidisciplinary and include senior psychiatrists, psychiatric nurses, social workers, psychologists, occupational therapists and an administrator. The overall philosophy should be to try to treat all mental disorders outside of hospitals in the first instance, with particular emphasis on joint working with other agencies, home treatment when necessary and a collaborative approach to care which involves the patient as an active participant in all treatment decisions. There should be an aftercare service for patients discharged from hospital following treatment for psychiatric illness. The introduction of a community early intervention service should be carefully planned with particular emphasis on manpower planning.

The substandard nature of long-stay accommodation is unacceptable. The institutions are in a bad state of repair and symbolic of a different era. All psychiatric institutions constructed pre-1900 should be closed and replaced by modern, purpose built hostels for long-stay patients. Facilities should be created in general hospitals for all acute admissions. Modern special secure facilities should be made available for the relatively small number of long-term, severely disturbed patients. These changes should address the issue of younger patients, functional psychotic patients and patients with intellectual disabilities sharing the same ward, as at present.

Negative attitudes and the stigma of psychiatric illness need to be addressed. The low level of awareness among the general public of all areas of the service limits the accessing of those in need of the service. A public awareness campaign through the media should be introduced on all aspects of mental illness and positive mental health issues.

The Joint Committee on Health and Children accepted the genetic and neurological evidence that attention deficit disorder and attention deficit hyperactivity disorder have a biological basis. There is severe under recognition and under diag nosis of attention deficit disorder and attention deficit hyperactivity disorder in Ireland by health and educational professionals. Funding should be made available for a national prevalence survey of ADD. Extensive diagnostic ADD centres should be located in different regions and services for children and adults should be made available by the health boards as recommended by the report presented to the Joint Committee on Health and Children.

In the first half of the 1960s an average of 64 people per annum died by suicide. The average for 1997-9, inclusive, was 462. We should recognise the urgency of introducing clear, systematic programmes aimed at the prevention of suicide and suicidal behaviour. A strategic plan should be put in place to implement the recommendations in the report of the national task force on suicide which was published in January 1998. There are several Departments responsible for this and a procedure to co-ordinate the introduction should be introduced. Last year, 439 people died by suicide, 90 of whom were female. This is almost equivalent to two jumbo jets crashing with the loss of all passengers. We can think what the outcry would be if two Aer Lingus jumbo jets went down with the loss of all lives. A strategic plan is an urgent necessity, with time limits to ensure the full recommendations of the national task force on suicide are introduced.

Mr. M. Kitt

I welcome the Bill and congratulate the Minister of State on bringing in legislation which will provide competition in the health insurance market. The Minister also stated very clearly that it will strengthen the basis on which solidarity between generations operates through community rating. This is a very important issue because we know of people who have wanted to enter the health insurance market but were not too keen to provide a community rating which has been a feature of the VHI since its establishment.

I also note the Minister says the legislation includes provision allowing insurers discretion to apply late entry premium loading in specified circumstances. Now that we have more competition, which is very good, I hope people will get a fair deal and that those who may not have joined VHI in their younger days will be allowed a fairer deal at a later stage.

The amount of hospital development and building is unique which is most important in terms of having a balance of health services in the different regions. I listened to a person on "Marian Finucane" this morning describing the situation for people from the west who have to travel to Dublin, for example, for cancer treatment. One man described it very well when he said it is the difference between living in Rathgar or Rossaveel. Treatment might be available around the corner in Rathgar but it involves significant travelling for those from Rossaveel who perhaps have to go for cancer treatment a few days a week. Hopefully this will change now that we have more hospital development.

I was delighted to be in Galway last Monday when the Minister for the Marine and Natural Resources, Deputy Fahey, laid the foundation stone for phase 2 of the extension to University College Hospital at a cost of £70 million. It will ensure a revolution in the health service in the west as we will have cancer treatment and cardiac surgery for the first time. These services were neglected by successive Governments and it is good these developments are in place. There will obviously be implications for private health insurance companies when the new services are in place. We already have VHI and BUPA and new companies may enter the health insurance market. I have been a strong supporter of companies such as VHI and BUPA. Cost increases have been sought in recent years and the Minister for Health and Children had to intervene to prevent the most recent VHI premium increase being granted. I am aware that considerations such as the possible effect on inflation were involved in that. It is very discouraging for people who have been with these companies for years to be faced with such increases.

Some of these companies do not cater for the people who require services, nor are some of the services which are required provided. I have referred to the issue of orthodontic treatment on many occasions. There is a very long list for orthodontic treatment in the Western Health Board region. Many people cannot avail of the treatment because they do not meet the guidelines laid down. Health insurance companies should ensure that this treatment would be included within their own services.

There is a very strong case to be made for neurosurgical services in the western region. Such a unit is not included in phase 2 of the hospital development in Galway and I hope to see it included in phase 3, irrespective of whether it has been provided for in the national development plan. A very good opportunity exists for the development of such a unit in view of the fund raising which is ongoing in Galway. As it stands, people with brain injuries must travel to Cork or Dublin. This cannot be allowed to continue; we are all aware of the necessity to treat brain injuries quickly but that option is not currently available to people in the western region.

The waiting list initiative is to be welcomed. I am a former member of the Western Health Board which made a very strong case to the Minister for such an initiative. The board has received a very positive response in terms of funding. I hope funding will be provided on an ongoing basis as hospitals and health board chief executive officers need to know what funding will be available to them at different times of the year.

Given the number of nursing homes throughout the country, it is very important that health boards would continue to get contract beds in nursing homes. VHI, BUPA and other insurance companies have a role to play in this regard. Nursing home costs are increasing. A subvention was introduced seven years ago in 1993 and the rates have not been increased since. It is high time that nursing home subventions were increased. Many people who do not have health insurance cover find it difficult to pay increased nursing home costs.

Tuam Cancer Care Organisation was founded specifically to help people who did not have health insurance cover. For more than ten years, many families from Tuam and the surrounding areas have availed of the "bed in the grove" service in the Bon Secours Hospital. Sadly, the Bon Secours sisters have announced their intention to close their hospital in Tuam but we are trying our best to see whether that can be deferred. I debated the issue with the Minister of State last night.

The Tuam Cancer Care Organisation has received money from local people, as a result of which it can provide a homely environment for cancer patients close to family and friends. This helps to alleviate a very difficult situation for many people who may be financially or physically stressed. I commend such groups for becoming involved in this area, although in an ideal world such care should be provided through the health services.

Deputy Neville spoke about suicide, an issue which must be examined. He also referred to psychiatric hospitals. The number of patients in such hospitals is falling rapidly. There were formerly more than 1,000 patients in the hospital in Ballinasloe but the number has fallen to 300. Many patients are moving out into the community and that creates new challenges for the construction of new buildings and the movement of staff from major hospitals into the communities in which patients live. While this is a very positive development, resources are required to ease the transition.

I welcome the element of competition to which the Minister referred and the re-examination of the community rating situation. I would also welcome the introduction of increased competition in the health insurance market in order that people may be able to avail of such insurance at less expensive rates. Competition will help companies to keep costs down and provide good services for people.

Mr. Perry

I welcome the opportunity to speak on this Bill which will contribute to the development of more competitive and innovative private health care at a time when the burden of public funding on the health care system is becoming unsustainable. It is very important that we clear the way for fundamental reform of the health care system. This Bill will help to deliver that much needed reform.

The Bill is the first part of a two phase process, the second stage of which will involve the conversion of the VHI into a semi-State body with a full commercial mandate, paving the way for full privatisation at some stage in the future. There is a risk of people cherry-picking business and that should be avoided.

Insurance schemes covering out-patient, GP and dental services will be removed from the scope of the legislation. The core changes proposed by the Bill relate to the alteration of the health insurance contract. Health insurance subscribers face staggering premia depending on the subscribers' age and the length of their insurance contract.

The Bill seeks the introduction of a lifetime community rating which will allow insurers to add a late entry surcharge for people over the age of 35 who purchase private health insurance for the first time. As identified in recent market research, there is a demand for a greater choice in the health insurance market.

It is important to look at the barriers that prevent new insurers entering the market. Consumers have seen the value of meaningful competition in many sectors, most recently in banking, telecommunications and air travel. It is important to have open competition in the health insurance area. I note from press clippings that BUPA is opposed to the proposal requiring it to give £20 million over three years to its competitor, the VHI, which is highly profitable.

We saw recently where Esat developed on the back of Eircom's infrastructure. I am not familiar with the charges but it made millions on the massive development of Eircom. The company was eventually floated and sold. New entrants to the market should not be penalised. The case is comparable to that of a new supermarket coming into a town and the existing large supermarket feeling obliged to subsidise the new entrant. Perhaps I am missing something but I would like to have the matter of the charge placed on BUPA clarified. It begs questions from the point of view of free competition and prevents meaningful competition. Why is it necessary? How is it justified? Is it EU law? Consumers want competition which is the life blood of any trade. You cannot have competition and an open market and, at the same time, ask your competitor to pay a charge.

The VHI plans to introduce age related products under the Health Insurance Bill but we must look at community rated primary care products and GP cover. As regards State aid, apart from the question why taxpayers' money should be put into the private medical market, it is a further means of distorting the market, favouring the dominant player. These proposals will not help to develop competition nor will they benefit the consumer. There should be four or five insurers in the market but they have not come in because of the barriers to competition. There are 31,000 people on the waiting list and perhaps they should be asked for their views on the matter. We have a two tier system – those who can afford to pay consultants and those on the waiting list. The benefits that accrue from PRSI payments are very small. PRSI accounts for 20% of a wage, taking the employer's and employee's contribution into consideration. Deputy O'Keeffe said £15 billion extra has been put into this area but the test is how it has been spent.

The Health Insurance Act provided, in the interest of the common good, for the regulation of the business of private health insurance. The Act required health insurance undertakings to operate in accordance with community rating. There is provision under the Act for minimum benefit where undertakings cannot provide less than a specified level of cover. It also provides for risk equalisation – undertakings to share community risks. In a well heeled economy there are people who can afford to pay a premium of £1,200 and additional sums for members of their family. However, I am concerned about those who cannot afford VHI or BUPA premiums, the 31,000 people on the waiting list. They must be not be overlooked.

I know of a case where a lady was waiting for an appointment for Beaumont Hospital. The scanning facilities were not available and the secretary could only give an appointment for months in advance but the consultant's private secretary could make one within two weeks. I have nothing but the height of praise for Sligo General Hospital. It does outstanding work. The doctors and general managers there are quite efficient. However, every hospital should be judged according to how it deals with private and public health care. Public health is a major issue and I would relate it to a business. I look on someone who comes into my constituency office in the same way as I would a customer and give everyone an equal service. There is no regard for the fact that people who visit their GP under the medical card system can be quite ill and in need of hospital services urgently.

We are funeral directors and a few months ago the son of an elderly lady came to see us. She had been discharged from Sligo General Hospital and was waiting to be called to Dublin for a scan. Unfortunately, the lady died and her son was aggrieved that she did not have the scan before she died. He did everything he could to have his mother brought to Dublin but that did not happen.

The Bill provides that the VHI and other health insurers are to be allowed to charge higher premiums to people who are over 35 when they first take out insurance. It also modifies the principle of community rating. The loading on first time insurers over 35 will be laid down by regulation. It is important to clarify what this regulation will be. Those who take out health insurance before reaching the age of 35 will not be subject to any age related loading for basic health cover.

It costs businesses £280 to pay a salary of £200 to an employee. Employees are seeking a minimum wage of £4.40 net. It is regrettable that so much money is being paid to the State in PAYE and PRSI for which the employees receive nothing in return in terms of benefits. They have as a consequence no option but to join a private health insurance scheme such as that operated by some businesses. What we have, therefore, is a double-barrel system. Employees should be able to opt for a form of health insurance. From their point of view, employers are paying for cover which is never availed of as employees are obliged to take out private health insurance with either the VHI or BUPA.

The question of entitlement to a medical card has been raised. It is outrageous that the cut-off point is so low. It currently stands at £19,000. No regard is had to the position of children attending third level who come from a large family and whose parents are operating on a shoestring budget. Should they require medical attention it will cost them £20 to visit a doctor. Their parents also have to meet the cost of accommodation. Because of the costs involved, students should be entitled to a medical card in their own right.

There is a need for reform. We are talking about one of the biggest budgets in the State. The Minister of State mentioned that there are 31,000 on the waiting list. The actual figure is considerably higher. Many patients are frustrated and have lost faith in the system. The orthodontic service is a joke. Children identified as being in need of such treatment at the age of ten may not receive it until they reach of age of 15.

On a recent visit to a private nursing home I was informed that it did not maintain waiting lists because of the numbers seeking such accommodation. There should be a nursing care facility or unit within each community. In the latter years of their lives elderly persons are placed in accommodation 25 miles from their homes. Without a subvention they find it almost impossible to secure accommodation in a private nursing home closer to home.

Those issues are somewhat removed from the Bill which deals mainly with private health insurance. It is important that there is regulation and a concession is granted to those who join a private health insurance scheme at the age of 65 whereby the loading on the premium payable is not excessive. Within a few years the VHI, like Eircom, will offer shares for sale. It is unfair, therefore, that new entrants to the market are being penalised by having to make payments to the VHI which can cherry pick the market. There is a need for competition. The VHI can increase its rates when it suits. Two years ago it was not making a profit; today it is making a huge profit. Why? The answer is not that consultants have dropped their prices, but that the VHI has increased its premiums. It has a monopoly. Those with a medical card do not have a choice. People are forfeiting a holiday in order to take out insurance cover with the VHI. The ideal situation for the Government is for each of the 31,000 patients on the waiting list to take out such cover. It is wrong that patients have to wait due to the fact that they are not members of a private health insurance scheme. There should be a comparable State scheme under which patients would receive the same level of attention that members of the VHI or BUPA receive from consultants. Members of the VHI who are guaranteed appointments within a week rarely come to my clinic. The people who come to see me are those waiting indefinitely for a hip replacement or cataract operation.

Because of the enormous pressure exerted on public wards there has been a move towards day wards with little time for convalescence. Elderly patients are often sent home early to be cared for by a health nurse, a service that is both inadequate and over-stretched There is one health nurse in the Ballymoate region alone to provide follow-up treatment. This is an area at which the Minister must look. In the United Kingdom the very young and the elderly receive regular visits from health visitors on leaving hospital. This is the time at which tragedies can happen.

I am delighted to have the opportunity to speak on the Bill which deals with the well-heeled in society. In the area of public health care the problem is not money, but benchmarking the dedication and quality of service provided by consultants who are being paid handsomely by the State for their work in public wards. It is important that those who have the wherewithal to pay for a private consultation receive the same level of treatment and within the same time span.

Mr. U. Burke

I welcome the opportunity to contribute to the Bill. It is regrettable that an ideal opportunity has been lost to restructure and introduce meaningful reforms to the health service to ensure better use is made of the enormous sum of taxpayer's money invested. A sum of £15 billion has been expended during the lifetime of the Government. In spite of this, there is chaos. The Minister of State and all those involved in the Department must realise that there is something radically wrong with the service. We are near the bottom of the league table in Europe. The introduction of this Bill could have provided an ideal opportunity to restructure and refocus the health services.

The Bill introduces competition into the health services, which is welcome in as far it goes. However, that is not a priority with the public. They know that those who hold health insurance are a minority. It is good to have health insurance. Those of us who are covered in that way are aware of the safeguard we have.

The VHI has been a wonderful asset and benefit to many individuals and families. There were no difficulties in dealing with it. If a person had a need in terms of consultant's fees, etc., an up-front payment was made and if a person was entitled to cover for charges, payment was made without question. That alleviated many hardships and concerns in families who were unfortunately visited by serious illness.

The arrival of BUPA has introduced competition. However, given that the VHI was first involved in this area, it is important that newcomers are not allowed to cherry-pick. The Bill provides for the loading of certain categories of cover. We must be careful about this, especially if parallels are drawn with the loadings that occur in other areas of insurance. It is the thin end of the wedge of more serious developments where people covered by private insurance could be loaded for any number of reasons, as is now the case with motor insurance. I hope we do not allow loading to become an integral part of the cover people may obtain in the future.

A health service which will deal fairly with those in need of medical care and treatment is important. Real competition will occur only when the consultants can be convinced to enter meaningful dialogue with all partners involved in the delivery of the service. We could be easily critical of the consultants and the part they have played in the premium increases paid by many people. The Minister and the Department must have the determination to tackle the problems faced by consultants and to address the issue of the huge charges passed on to the consumer, the scale of which appear to be protected by the consultants. If these issues are not addressed we will, unfortunately, continue to have a two tier system.

Public representatives have been told repeatedly that those who have the ability to pay, be it through insurance or otherwise, will be treated almost immediately while others must depend on the public health services and wait for treatment. Tragically, those on waiting lists often die. There is no equality in the health services. According to the Minister, there are 31,000 people on the waiting lists. The numbers are probably far higher. It is an indictment that there is something seriously wrong, which must be tackled.

To where does one look for the reasons the health service is not working? Does one look to the Minister and the Department, to the health boards, who deliver the service at local level, or to within, to the structures in the hospitals? None of these aspects can be isolated. An overall plan is required, but neither the Government nor the Minster have one. The services are in chaos. How can they be rescued?

It is of little value to say there are vested interest groups protecting their areas. I do not accept that as a reason for the chaos. The health boards were established at a time when the demand on the health services was not great and when patients' anticipation of cover was not as demanding as it is today. Can we restructure the health boards?

Rather than address these questions we have task forces, committees and reports. As a member of a health board I find that at every meeting I attend we are over burdened with reports from various groups, all of them involved in a roundabout way with the health services. However, they have very little input into the delivery of service to the patients, the people who are suffering.

While we have lost an opportunity with this Bill, I call on the Minister to immediately address the problems in the health services in a comprehensive manner. That would include the health boards. Administration within the health boards is top heavy and increasing because many of us demand greater access to, and an extension of, existing services. That is natural at a time when greater funding is available from the Exchequer.

How can this be reconciled with increasing waiting lists? We all know that in our health board areas additional funding was provided for the waiting lists initiative programmes, yet I do not see any positive response. Nothing has changed. Where has the funding gone? Has it been squandered on administration, other task forces or new reports? It is difficult for a Minister to know where to start. Something needs to be done across the health services.

One would imagine that in the current economic climate a greater number of people would be entitled to medical cards. However, the opposite is the case. Fewer people in the Western Health Board area have a medical card now compared to five or ten years ago. That should not be the case. Many people asked the Minister to ensure cancer patients were given medical cards. I am a member of the Western Health Board and at its last meeting I suggested that we should try to do something in this regard. However, I was told that while such patients would not be excluded on the basis of income, the primary factor must be medical need. The people receiving treatment for cancer and their families are worried about how to pay for such treatment, particularly if they are not lucky enough to be included in an insurance scheme. I ask the Minister to make free medical services and treatment available to the increasing number of people who suffer from cancer.

Initiatives should be introduced to eliminate waiting lists. I want to bring to the Minister's attention the situation in relation to orthodontic treatment in the west. It has been impossible to appoint an orthodontist in the Western Health Board area in the past ten years. If a person was appointed, he or she stayed only a short time. This resulted in a huge backlog of orthodontic treatments. Because there is no orthodontic specialist in the Western Health Board area, the health board is encouraging people to go to private specialists and it will pay the bill. Another alternative is to find adequate treatment in Northern Ireland which is readily accessible and cheaper, despite the distance involved in travelling. That is a damning indictment of a strangled system.

The school dental service no longer exists or is piecemeal and patchy. Can the Minister call that a service? This is in spite of the fact that a former Taoiseach welcomed an initiative to give everyone a toothbrush which would encourage them to pay more attention to dental hygiene. It is unbelievable that the Minister, the Department and the health boards misunderstand what is happening.

Simple treatments, such as cataract operations and hip replacements, which mean a lot to many people in our ageing population because it will give them reasonable comfort in their old age, are being denied to them. I recall trying six different hospitals in late November or early December last year for a person who had been waiting a year and a half for a hip replacement. The person's family decided to provide the money necessary for the operation. I tried Croom hospital, Cappagh Hospital, University College Hospital Galway and every other hospital with a proficiency in hip replacements. However, despite the fact we have a two tier system, not one of the hospitals could carry out the operation prior to February of this year. The person, who was in intolerable pain, had to suffer for an additional four months. Yet the Minister will outline the great things he and the Government have done for the health service. That is a sham.

I was told 18 months ago that a decision was pending in the Department about the acquisition by the Western Health Board of Portiuncula Hospital in Ballinasloe because the Franciscan Sisters had decided not to continue the excellent service they had provided since the hospital was established. Every month since then I have inquired of the chief executive officer of the health board about the matter. Will the Minister tell me what is holding up the acquisition? The delay is causing concern among the staff and the population in the area who have relied on a service in Portiuncula Hospital over the years. If this delay continues, people will become suspicious and their confidence in the hospital will be eroded. I do not want that to happen. It has provided an excellent service over the years in my constituency, not only as a maternity hospital but also in other specialities, such as coronary, medical and surgical care.

Last night we discussed the closure of the Bon Secours Hospital in Tuam. The response of the Minister of State was a disaster. This facility could be adequately reconstructed for the services needed in the area, but the Minister of State said that was not possible.

Ms Hanafin

It is a private hospital and the religious order has chosen to close it.

Mr. U. Burke

It will now be moved to a greenfield site. Will the Minister of State indicate to the Western Health Board and its chief executive officer when the Department will give its final permission for the Western Health Board to acquire Portiuncula Hospital? This is a matter of urgency.

Mr. Callely

I am happy to participate in this debate on the Health Insurance (Amendment) Bill, 2000. Private health insurance plays an important role in the provision of hospital services to a large proportion of the population. This Bill is, therefore, important. I understand the key change in the Bill relates to the definition of health insurance contracts which form the basis for any insurance arrangements offered by insurers. The principal change in the Bill will be removing from the existing definition the scope with which insurance plans are solely concerned, namely, ancillary health services such as out-patient and general practitioner services. The proposed removal of ancillary health services from the regulatory framework has been carefully considered by the Minister in the context of facilitating the development of insurance cover in this area. I therefore welcome the Bill.

I take this opportunity to congratulate my good friend and colleague, the Minister of State, Deputy Hanafin, on her appointment to the Department. This is my first opportunity to speak on a Bill which the Minister of State has presented to the House.

I listened with interest to the debate on this issue. For a considerable period of time I have been involved, in one form or another, with the health services. It is interesting to note that a number of speakers seemed to point the finger at the Minister, the Government or the Department for the failure of a person to get an appointment with a consultant, a hospital bed or whatever.

A particular interest of mine is an area which is now referred to as intellectual disability. Prior to this Government coming into office, successive Governments had failed in that area. It is interesting to note people from all parties contributing to this debate and referring to mental handicap and other disabilities – physical, sensory and so on – yet when they were in a position to do something about this area, they failed. I am pleased to say that since this Government came into office, £127 million has been spent on issues relating to intellectual disability. It is the intent of the Government to deal with all other major issues relevant to those with a disability. That is a tremendous record of achievement and one that should be acknowledged in the House.

As late as this month we had interesting despatches from the Department in relation to the whole focus and change in the speciality areas of autism. I want to record my congratulations to the Irish Society for Autism and in particular to Nuala and Pat Matthews who have done Trojan work on the development of much needed services. Specific projects currently in the Department are worthy of approval and the sooner the society can get sanction, the sooner the service will be in place. I encourage the Department to look favourably on the society's submission because it has a tremendous proven track record. I want to refer to an area where I am aware the society is experiencing some difficulty and that is the bureaucratic system it has to go through to avail of funding.

Mr. M. Higgins

Hear, hear.

Mr. Callely

I am delighted to hear Deputy Higgins support me on this issue. When the society wants to make a purchase, on many occasions it has to go through the local health board and the Department. That can take many weeks and months and, in the meantime, some other group may come along and, for want of a better description, pull the mat from under the Department. A fund should be available to the Department whereby groups which present a worthy project can be quickly given clearance to go ahead.

The other issue that has been discussed is that of medical cards. The previous speaker indicated that fewer people in his area have medical cards now than was the case heretofore. It is tremendous that fewer people require medical cards. Rather than bemoan that fact we should acknowledge that because of the current economic climate, people have more money in their pockets and therefore they do not qualify for a medical card. They do not qualify because when this Government came into office it decided to double the income limits for those who qualify for a medical card, in particular the group over 70 years of age. We should be careful about what we say in the House. Are we saying that there are fewer people with medical cards who are experiencing difficulty and hardship or are we saying that because of the current economic climate, they have more money in their pockets and that is the reason they do not qualify for a medical card?

Mr. M. Higgins

They are in a poverty trap.

Mr. Callely

Deputy Higgins had the opportunity to sit at Cabinet and increase medical card guidelines but, unfortunately, that did not happen. The medical card guidelines have been greatly increased and a new sector has been introduced – the age group from 70 to 79. These are welcome developments and it is important that we record them in the House.

We should acknowledge that an extra 55,000 people have received hospital services in the past two years. That is a tremendous record. To put a figure on what we are talking about, my understanding is that the day to day spending on health services is in excess of £3.5 million. That is a tremendous expenditure.

Mr. M. Higgins

It is less of a percentage of GNP than it was in the 1980s.

Mr. Callely

I disagree with the Deputy.

Mr. M. Higgins

Less of a percentage.

Mr. Callely

That is revenue but on the capital side there has been a £2 billion allocation for the period 1999 to 2006. If Deputy Higgins wants to make comparisons, I am happy to inform him that that expenditure is treble the expenditure of the previous seven years during some of which time he was in office. If we want to examine expenditure and what is happening in the health services, I would be happy to debate what has happened in recent times with anyone in this House. Give credit where credit is due.

We must now look at funding the health providers and the agencies on their ability to deliver services. I acknowledge the change that has occurred with regard to the greater proportion of the population in the Dublin region, which has a population of 1.4 million, in terms of the statutory services, namely, the decision to put in place a new Eastern Regional Health Authority with three boards under the new authority.

Mr. M. Higgins

In response to the total chaos that existed.

Mr. Callely

I have the utmost regard and admiration for those who worked in the Eastern Health Board—

Mr. M. Higgins

We know that.

Mr. Callely

—in the provision and delivery of services.

Mr. M. Higgins

We all do.

Mr. Callely

I disagree with Deputy Higgins's remark about chaos.

Mr. M. Higgins

Total chaos.

Mr. Callely

The Eastern Regional Health Authority is privileged to have as its chief executive officer the eminent Mr. Donal O'Shea and his management team. I congratulate Mr. O'Shea on the handle he has taken on the delivery of health services in that region. I congratulate him and his management team on their success to date and wish them and the chief executive officers and management teams of the area boards continued success.

A tremendous amount of good work has been undertaken, some of it by the Department, the Minister and, more importantly, the Government. The Eastern Regional Health Authority has moved on a number of important issues to which previous speakers referred, including bed capacity, waiting lists, A&E services, services for intellectual disability and so on. The authority has an innovative ten point action plan to tackle waiting lists for admission to hospitals in its region based on agreed principles of equity, quality of service and accountability. I am honoured to be chairman of that authority, which has made tremendous strides in that area.

We decided our approach to tackling the number on waiting lists should be grounded on a number of principles. They include that the ERHA would ensure that access to health care would be based on need for services rather than ability to pay or geographic location; that the authority would safeguard equity of access and maintain the agreed proportion of public and private patients treated; that it would actively pursue initiatives to reduce waiting times for those requiring services; that patients have a right to accurate information about their likely date of hospital admission; that GPs must be given full and relevant information on waiting times so that they can best assist their patients to choose a consultant or hospital, which is an important issue; that the authority will assure evaluation of the outcome of procedures and treatment; that structured arrangements must be in place in each acute hospital to ensure that the organisation and management of elective procedures and waiting lists and waiting times operate efficiently and effectively; that ongoing validation of waiting lists should be a key feature of waiting list management systems and that the new authority must co-ordinate action on waiting lists and intervene to offer patients an option to obtain treatment in other centres where they could not get earlier treatment in the hospitals they attend. Those principles were put forward following a wealth of intelligence gathering and contributions by personnel involved in the delivery of health services who recognise that following such principles presents a way forward to overcome some of the difficulties experienced in the delivery of health services.

We also asked each hospital in the region to urgently validate its waiting lists to ensure a process is put in place in each hospital to provide appropriate treatment for patients within a minimum waiting period. Hospitals that are in a position to carry out additional work have been asked to provide the ERHA with details and costs of additional procedures they could carry out. I congratulate Mr. O'Shea on shaking the can in this regard. He asked those in charge of one hospital why they had a six month waiting list for procedures, whether ENT, cardiovascular or hip replacements. When he went to another hospital and learned from those in charge that they did not have a waiting list for procedures, he informed them he would buy those procedures to reduce the waiting list for them in the other hospital. He has managed to get an additional number of procedures carried out in that manner.

I am amused that some speakers seemed to point the finger at the Minister or the Department for a person failing to get a hospital bed. One Deputy indicated that he tried to make telephone contact with the consultant and hospital manager concerned. Surely we are not saying the Minister is responsible for the procedures performed and the administration, admittance and well-being of hospital patients or of people who attend a GP, public health nurse or health centre. If that is the area for which the Minister responsible, let the House say that. We have highly paid chief executive officers of hospitals. I was concerned at the amount of media coverage the post of the former chief executive officer in Tallaght Hospital received and I have no regrets about him no longer holding that position. If my memory serves me right, that man argued for and eventually got a salary of £135,000 a year, and that was three or four years ago. That man had a management team and I presume not one of his managers was on a salary much less than half or no less than a quarter of his salary. I presume his management team was made up of eight to 12 personnel and each had a manager in each of their departments and each of their managers had a supervisor. If we want to talk about who is managing what, let us start pointing the finger at those concerned.

Tremendous strides have been made in identifying the problems in the delivery of health services in the Eastern Regional Health Authority. Negotiations to address those problems have taken place under the auspices of the chief executive officer of that authority and hospitals in the region have agreed to carry out additional procedures and, in some instances, such procedures have been carried out.

The authority has asked hospitals to examine the potential for day surgery and an increased use of existing theatre capacity on an after hours basis or when existing clinical staff have booked annual leave. It is a disgrace that people are on waiting lists for procedures while some hospital theatres may not be open on a particular day in the week.

The Eastern Regional Health Authority is doing tremendous work. It has identified the areas in which it can improve A&E services. Much of the difficulties experienced by the authority are not due to a lack of funding from the Department but to a shortage of personnel due to the current buoyant economic climate. The authority cannot recruit the required personnel and I am not talking about medically qualified people.

The authority has developed units for the elderly. In one such unit in my constituency 30 beds are empty because the authority is unable to recruit the necessary personnel, whether they be nursing, medical, domestic, administration or clerical. Blockages are created in acute hospitals due to beds being occupied by the elderly. We should examine why such a high level of nursing personnel are required to staff nursing homes. Surely another level of care attendant could be established which would reduce the criteria for nursing personnel in nursing homes. Surely we could have another level of care attendant in place which would help reduce the nursing criteria.

I congratulate the Minister on his cardiovascular and cancer strategies, on addressing the issue of youth homelessness and care of the elderly as well his other innovative strategies. I also congratulate a relative of mine on his recent retirement – Paddy Murphy of the Irish Heart Foundation, who did tremendous work in the health area.

Mr. Boylan

This debate is probably one of the most important we will have in the short length of time remaining for this Government. If we can bring some sense to the huge problems in this area we will have done some good and the contributions so far have been quite good.

We are not facing up to the problem here. We are like a man putting four new tyres on a car when the engine is banjaxed and needs a complete overhaul. That is what the health service needs – it is like an old car that works on a stop and go basis. Health care is like a lottery in that one may be lucky when going to hospital and see a consultant or surgeon.

This Bill deals with the area of insurance and I encourage everyone to have health insurance cover, which is vitally important if health breaks down in a family. That can be very costly and may even push people into bankruptcy. I might not agree with all of Deputy Callely's points, but this is a worry about which people are very conscious. The cost of health insurance is prohibitive. If we do not realise that we are not living in the real world. There are people with large incomes for whom it is not a difficulty; the premium is deducted at source and is not noticed, but the majority of people are moving into what Deputy Michael D. Higgins rightly termed the poverty trap. They are caught between the cost of private health insurance and the non-availability of medical cards. For that reason, I welcome the statement from our health spokesperson, Deputy Gay Mitchell, that when Fine Gael returns to Government in the next few months cover under health cards will be available to a wider range of people on higher incomes. That is very important, as many families are worried by this. I am aware of families who have opted out of VHI because they cannot afford it. They do not quality for medical cards and they are in dread of experiencing poor health, which can happen in any household.

Something must be radically wrong when one considers the amount of money needed to provide a very poor and inadequate health service for a country of three and a half million people. Something is wrong when one considers the astronomical premia for VHI. I welcome competition in this market, though whether different terms or a level playing pitch should be available to them is an issue with which I do not have time to deal today. I live in a Border constituency and if one is referred to a hospital in the North for treatment, one's VHI does not cover that treatment. That may surprise some people, but it is a fact. If a person takes ill in Northern Ireland one is covered for treatment, but if one is referred there by a consultant one's VHI cover does not apply. This must be addressed if we are serious about cross-Border health care and co-operation.

If there are services available in Northern Ireland that are not readily available here, people should be able to avail of them and vice versa. People from the North should have the same freedom to attend Cavan, Monaghan or Drogheda hospitals. As has been said, it is cheaper to get orthodontic treatment in the North than it is here. Doctors are advising people with children on waiting lists who have orthodontic problems – and such problems occur particularly among girls in the developing years – to take those children to the North, where they can be treated immediately. It is less costly but it is not covered. However, in the Republic it costs from £1,500 to £2,000 to have braces fitted. That is an astronomical figure, but I cannot query it as it seems to be the standard rate. The same procedure can be carried out in the North for £150 to £200. Obviously, something is radically wrong with charges and health costs here.

I encourage everyone to have some form of health cover if they can, whether it is private or a medical card, though the latter must be expanded to deal with the widening gap in this area. Deputy Callely said it is great that fewer people have medical cards, but fewer people are qualifying. While incomes have gone up to take people out of the medical card threshold, those people cannot afford the cost of private insurance. If a prominent Government backbencher is not aware of that problem, is the Minister of State aware of it? Is she aware of the concerns of parents in this regard?

What is the problem in the health care area? I have no doubt it is administration. We have excellent consultants and nurses. In my experience they are wonderful, but it is well nigh impossible to see them. Why are people given appointments for 10 a.m. in the morning and not seen until 4 p.m. that evening? That is a regular occurrence. I do not blame the consultant; I blame the administration. I do not expect a person to be seen the moment he or she arrives at the hospital, an hour is acceptable, but the situation I outlined is not unknown. I recently spoke to a person who spent three months in hospital before being discharged and given an appointment for 10 a.m. on a certain date. The day before his appointment he checked and was told to come in at 10 a.m., but he had not been seen by 4 p.m. and went home without being seen. As he said, he did not mind as he was back to full health, but he was concerned by the number of patients in the waiting room – mothers with small children, elderly people and people who were quite ill. Nobody seemed to be going anywhere. Occasionally a nurse would come out to apologise and say the staff were coming to them, but nobody seemed to be moving. Everyone seemed to be brought in at the same time – 10 a.m. – yet by 4 p.m. very few of them had been seen. That is an administration problem that needs to be addressed. It is unacceptable. If the health service were a private business, the receiver would have been sent in long ago. I do not blame the doctors, consultants, surgeons or nurses because they have a job to do. Doctors see their patients in their surgeries and they cannot be aware of what is happening in their waiting rooms.

The delays result from the way the system is run. The system of health boards is outmoded and is a cumbersome method of administering health. There is nothing but complaints and that is not just in one health board but nationwide. It is a nightmare if patients are referred to Dublin from my region, as happens occasionally.

Cavan General Hospital was supposed to be a regional general hospital. People campaigned for it and contributed generously to it. Services were to be available there which would be on a par with any of the Dublin hospitals, but it is not happening. They are not available. A neighbour with a minor ailment who lived within two miles of Cavan General Hospital was sent to Monaghan Hospital 30 miles away. This man is elderly and his wife is an elderly woman who does not drive. She depends on her neighbours to drive her to Monaghan to see her husband. Had he been in care in Cavan General Hospital, she could have afforded a taxi to take her to the hospital occasionally or her neighbours would have driven her to and from the hospital because it was a short distance. Instead, her husband is 30 miles away. Having lived together for 50 years the State has finally separated them. It is outrageous and unacceptable.

Another story that states the position in a nutshell is that of a nice old lady who fell in her garden and sprained her hand. Her husband drove her to the hospital where she waited for hours. She said to me afterwards that there were about ten people to take her name and address and not one to put a bandage on her hand. She summed up the health service. We are snowed under with administration, applications and forms but, when one goes to the coalface, one cannot get the service. It is time there was a radical overhaul of the health boards. They are cumbersome and bogged down with bureaucracy, such as members' expenses and all that nonsense, and people cannot get the reasonable service they seek.

An issue relating to Cavan General Hospital has surfaced which has caused great annoyance, which I said I would raise in the Dáil and on which a public meeting will be held in Cavan town on Monday. It concerns the mammography machine. It was recommended for the hospital and was put in place in 1997 with a special room prepared for it. Three years later, we have been told that the mammography machine will be transferred to Drogheda and that a mammography service will not be available in Cavan General Hospital.

Every day I come to this city I listen to the radio and hear Marian Finucane's show or another of those marvellous programmes where people can ring in and talk to someone who will listen to them. I heard a programme on Tuesday on the issue of cancer, cancer care and the early diagnosis of cancer. I heard a senior consultant say to Marian Finucane that, with the mammography machine, a cancer the size of a pinhead can be detected and early treatment can be given which will guarantee a cure. Early diagnosis is important and he encouraged women not to be afraid and have the test done. Something that was new to me was that breast cancer is an ailment which can also afflict men. The machine can make an early diagnosis of the problem and people should be screened every two years.

Despite the generous contributions of people through the Friends of Cavan General Hospital towards the cost of this machine, it will now be transferred to Drogheda and the women and men of Cavan who wish to avail of this service can travel there. I have no objection to Drogheda Hospital and I know the machine is needed there to service that area. However, if the women of Cavan, north Leitrim and Fermanagh are expected to travel to Drogheda, why can the people of Louth not travel to Cavan? Why must it be all one-way traffic? I have given a pledge in the Anglo-Celt and I have committed my party leader, on our return to Government, to have that mammography machine returned to where it belongs and put in place for the service of the people of Cavan.

It is unacceptable and people are outraged and it is only an indication of what is happening in rural Ireland. The Minister must take the blame for the services provided by the Government. Deputy Callely asked if the Minister were expected to be responsible for the everyday operation of hospitals and admissions. He is not expected to do that, but he is expected to be responsible for policy and he alone is responsible for it. If the system does not work, he must take the blame. The Minister, Deputy Martin, has been in office for a number of months. It was expected after the previous Minister that there would be a new breath of life and new developments in health care and there has not been. The system has failed and I am sorry to say that and that the Minister of State's officials must listen to that. However, if we do not speak the truth, we will not achieve change and deliver a health service to the people. For a small nation of 3.5 million people, we are making a heavy job of providing a reasonable health care service.

There were references to the various afflictions of small children, and to babies born with autism. Autism is a terrible and shocking problem. Nothing was done in the past and we were all guilty because we did not know how to address the problem. I know parents who, in desperation, campaigned and raised funds to bring their children to a clinic in Boston where some success was attained. It is an especially difficult problem. I hope as a result of the recent court case a positive development in the care of children with autism will occur and that we will realise the terrible difficulty young parents have with a child suffering from this ailment. We can have success and bring about improvements. There is the problem of diagnosis and consultants having different opinions but I have been told that, if there is an early diagnosis and the child is worked with from as early an age as three – it is often seven or eight before the problem is realised and much damage will have been done by then – it can have an effect. This has been indicated in various areas of mild mental illness.

More can be done. There is the problem of both parents having to work to provide an income and children being left in care. In such circumstances the condition may not be diagnosed in time because the carers have so many children to care for. There is the further possibility of the parents being too tired in the evening to notice. Some would say they should rear their families but I do not accept that. That was fine when the mother stayed at home but that scene has changed. I draw attention to these problems in the area of mild mental handicap. Much can be done if conditions are addressed at an early stage. Great progress could be made which would not only bring relief to parents but give such children an opportunity to have a meaningful life.

There are many similar areas which need to be addressed. I have raised the issue of a mammography machine and I hope the Minister of State has taken note of it and that she will ask the health board why this insult has been heaped on the people of my county and region. Perhaps we would have a positive answer from her before Monday night regarding this machine being left where it belongs to provide a service. If the Minister of State were to do that, it will have been worth my while standing up in the House this afternoon. Other issues will be raised by other Deputies. These issues are not unique to my area. This is a national problem and a national policy is required to address it.

Debate adjourned.