Vol. 594 No. 2
1 Dr. Twomey asked the Tánaiste and Minister for Health and Children if the new doctor only medical card is a permanent feature of the GMS; the limitations which apply to the card; the additional resources she intends putting into primary care to ensure all new medical card and doctor only card patients will be able to avail of treatment under the GMS; and if she will make a statement on the matter. [32003/04]
The commitment to increase income guidelines to increase the number of persons on low incomes who are eligible for the medical card is contained in the health strategy. Families with children are a priority. In keeping with this commitment and the priorities for new health initiatives in 2005 both the income guidelines and the income allowances for children, in assessing eligibility for the medical card, will be increased in January 2005. The higher rate of increase in respect of the allowances for children is specifically aimed at assisting low income families with children in accessing primary care services. It is expected that in the region of 30,000 will benefit from this initiative.
The introduction of the doctor visit card provides free general practitioner services for individuals and families whose income will be up to 25% over the new medical card income guidelines. It is estimated that approximately 200,000 will become eligible for free GP services. Patients holding doctor visit cards will be or may seek to be assigned to particular doctors who hold general medical services contracts with local health boards. The new card is an entitlement to free general practitioner visits for those with otherwise limited category 2 eligibility. These new card holders are also eligible for the drugs payments scheme which provides that no person or family unit pays in excess of a current threshold of €78 per month, increasing to €85 per month from January 2005, for a range of approved prescribed drugs and medicines.
A sum of €60 million has been provided in the 2005 Estimates for these initiatives in primary care which will assist in overcoming barriers to accessing GP services for those on low incomes. This will also help remove poverty traps and disincentives to people taking up work or progressing to better paying work. An additional amount of €142 million is also being made available to meet the increased costs of the GMS. This represents an increase of 12%.
The Tánaiste did not deal with the core question. Is there a timescale on the doctor only medical cards? I fear patients could be worse off in the long term unless there is a timescale on them. They should be converted to full medical cards within a certain period. Patients will not benefit from the other services available with a full medical card. They could still end up paying €550 if they need to stay ten days in hospital and €1,000 per year if their medication costs more than €85 per month.
One subject that has not been broached in this discussion is the holders of discretionary medical cards who constitute a significant number with medical cards. What approach is the Minister taking to these cards? Discretionary medical cards are given to patients with a serious illness——
A question, please, Deputy.
I wish to explain this in case the Tánaiste does not fully understand it. A discretionary medical card is provided where the patient has a certain illness but is above the income threshold for a medical card. Will the Tánaiste ensure everybody who receives a discretionary medical card is given a full medical card rather than a doctor only card? The doctor only medical card might be used as a means of saving money by the health authorities. I hope the Tánaiste agrees every person with a discretionary medical card should have a full medical card.
The Tánaiste has not said what she will do in the primary care area to increase services for patients, especially now that an extra 250,000 will be included in the GMS scheme. In certain parts of north County Dublin which will be hugely affected by this change there is one general practitioner for every 2,500 patients. If certain areas become overloaded with extra medical cards, it could have a huge effect on the service.
The discretionary cards will remain full medical cards. There are 70,000 such cards in existence. Clearly, under the new unified system, there will be uniformity. There are varying gaps between regions. In some regions, by virtue of the discretion of the chief executive officer, a person might qualify while in another they might not. With a centralised system there will at least be consistency and uniformity.
It is not intended to convert the doctor only card into a full medical card. I strongly believe in the provision of graduated levels of services. I do not believe there should be one line where one gets everything and another where one gets nothing. This is a form of trying to give free doctor visits to the largest possible number on low incomes in order that they will not have to worry about taking a child to the doctor. Approximately 30% of those who visit doctors do not require follow up treatment and there is no prescription involved.
With regard to the primary care services, I am conscious of the huge gaps, not just in Dublin. However, in north Dublin there are huge gaps which we hope to address as part of our package for next year. There are many innovative proposals for providing GP services in the greater Dublin area, some of which involve collaboration with some of the insurers in the market. We need to examine all the proposals to ensure, for example, that a town such as Mulhuddart with 10,000 people is not left without a doctor, a pharmacy and basic facilities in the primary care area.
Does the Tánaiste——
Deputy, the six minutes for this question are concluded.
An important point was missed.
That may well be but there are only six minutes allotted. The Chair does not have a choice in the matter.
2 Ms McManus asked the Tánaiste and Minister for Health and Children if her attention has been drawn to the recent survey showing that death rates from cervical cancer here now exceed those of Britain and Northern Ireland and its finding that the lack of a national screening programme is the most plausible explanation; the steps she intends to take to ensure the early introduction of a national screening programme; and if she will make a statement on the matter. [31860/04]
I am aware of the study referred to by the Deputy concerning recent trends in cervical cancer in Britain and Ireland. The study shows that mortality from the disease in Ireland increased by 1.5% annually up to 2001. Data provided by the National Cancer Registry for the number of new cases of invasive cervical cancer for the years 1994 to 2000 show no statistically significant increase.
The number of smear tests carried out annually is approximately 230,000 and represents an increase of almost 20% in recent years. To meet this increased demand, additional cumulative funding of €11 million has been provided by my Department since 2002 to enhance the laboratory and colposcopy services. The funding has enabled the laboratories to employ additional personnel, purchase new equipment and introduce new technology, thereby increasing the volume of activity and improving turnaround times for results.
A pilot cervical screening programme commenced in October 2000 and is available to eligible women resident in Limerick, Clare and north Tipperary. Under the programme, cervical screening is being offered, free of charge, to approximately 74,000 women in the 25 to 60 years age group, at five year intervals.
The Health Board Executive, HeBE, commissioned an international expert in cervical screening to examine the feasibility and implications of a national roll-out of a cervical screening programme. The examination included an evaluation of the pilot programme, quality assurance, laboratory capacity and organisation and the establishment of national governance arrangements. The expert's report was submitted recently to my Department for consideration. We are now consulting with relevant professional representative and advocacy groups on the report as an essential input into the preparation of a detailed response to the recommendations. These groups are the Irish College of General Practitioners, An Bord Altranais, the Academy of Medical Laboratory Science, the Institute of Obstetricians and Gynaecologists of the RCPI, the Faculty of Pathology of the RCPI, the Women's Health Council and the Irish Cancer Society.
Additional information not given on the floor of the House
I am aware of the benefits of national population based screening programmes. Following the consultation process I have referred to, I will examine options for a national cervical screening programme. Any woman, irrespective of her age or residence, who has concerns about cervical cancer may contact her GP who, where appropriate, will refer her to the treatment services in her area. Appropriate treatment for women diagnosed with cervical cancer is available at major hospitals.
Does the Minister not accept that it is an abject failure of the Government that the screening programmes are either non-existent or totally under-developed, whether it is breast cancer screening or any other screening? In this instance, the screening programme promised but not delivered is one that saves lives. It is shameful that there has been an increase in the death rate from cervical cancer in this country of 1.5% per annum while in England the reduction has been 5% per annum and in Scotland 4% per annum. The overwhelming evidence is that this results from a universal population based screening programme. Will the Minister make it a priority of the Department to put this preventative measure in place in order that women's lives can be saved and that it does not mean that only women with money can be tested and screened? That is what is happening at present.
Will the Minister put in place a timeframe? She again referred to consultation. Wry smiles are brought to many people's faces when they hear this new Minister for Health and Children refer to consultation.
A question please, Deputy.
Would she not accept that the former Minister, Deputy Martin, used consultation as a cover for lack of action and that people are deeply cynical when they hear the word "consultation" being used in respect of the health service?
There is no doubt that I am a great fan of population-based programmes in respect of this and other areas. As regards consultation, a commitment was given to consult, and I do not think it is a bad idea to do so. In the earlier debate on the new HSE, which took place in a different forum, it emerged that most people are strong fans of a consultative process.
It dates back to 2000.
Yes. We put our first screening programme in place in 2000.
Deputy Noonan, as Minister at the time, was responsible for that.
The Tánaiste to continue, without interruption.
Deputy Noonan announced it in 1997 but, as with many other announcements, no resources were put in place in respect of it. We are spending a great deal of money on health care. We have trebled the figure in this regard in recent years. There is a number of priority areas and the evidence clearly suggests that where there is early intervention, great success follows. I refer here to many aspects of cancer care. I want to engage in discussions to see how the facilities can be rolled out. We also have a breast screening programme and although the age category is somewhat different, there are many similarities. We want to see how best we can roll the programme out, while recognising that we must be conscious of resource implications and ensure that it is done in the most cost-effective way.
Will the Minister indicate a timeframe for that?
I hope, if not by Easter then certainly by next summer, to have made decisions in respect of how to proceed in this area, in that of breast screening and also with regard to some male related cancers in respect of which there have been some good results.
Is the Minister going to change the breast cancer screening programme?
No. I want to identify how to proceed before we continue with the roll-out. For example, should we run two parallel screening programmes which would sometimes deal with the same group of women or is there another way to proceed? I want to do things in a way that is efficient from a cost point of view in order that we can proceed as quickly as possible.
Cost will determine how it operates and in the meantime people will die.
3 Mr. Gormley asked the Tánaiste and Minister for Health and Children the steps she intends to take to implement the recommendations of the latest report on MRSA; the likely costs of implementing this; and if she will make a statement on the matter. [32006/04]
MRSA is one of a number of antimicrobial resistant organisms of public health concern in the health care sector. The infection control sub-committee of SARI recently issued draft recommendations in respect of the control of MRSA. These recommendations update and are intended to replace earlier 1995 guidelines. I assume this is the document to which the Deputy refers. It has been issued by the experts for consultation and currently is only in draft form. The strategy, which was issued in 2001, contains a wide range of detailed recommendations to address this issue. Since this document was launched, approximately €16 million in funding has been made available to health boards to implement the strategy. Of this, in the region of €4.5 million has been allocated in the current year. Implementation of the strategy is ongoing.
A national committee comprised of a wide range of experts was established in 2002 to develop guidelines, protocols and strategies in respect of this matter. The National Disease Surveillance Centre collects data from hospitals on MRSA bacteria as part of the European antimicrobial resistance surveillance system. Ireland has the highest level of participation of any country involved in this system. In 2003, 477 cases were reported in Ireland. The NDSC has advised that the total number of cases notified for the first two quarters of 2004 was 274. It should be borne in mind that the number of laboratories notifying cases increased in 2004.
Hand hygiene is a key component in the control of MRSA. The SARI infection sub-committee has just released national guidelines for hand hygiene in health care settings. Chief executive officers at hospital and health board level have corporate responsibility for infection control.
My Department will await the final version of the recently issued draft guidelines which will then be evaluated. Costs arising in this context will be discussed at that stage. I want MRSA to be a priority issue for the new health information and quality authority when it becomes operational. Cleanliness and hygiene in hospitals are a concern I intend to address through the accident and emergency package of measures we are going to put in place next year.
I thank the Minister for her reply. Unfortunately, it was reminiscent of those provided in 1998 by the then Minister, Deputy Cowen, and in 2001 by her immediate predecessor, Deputy Martin, when I previously raised this issue. The first committee was established in 1993.
A question please, Deputy.
Does the Tánaiste agree that the situation has worsened since 1993 when the first committee was established? Does she also agree that antibiotics continue to be handed out like Smarties by general practitioners and others and that we have not dealt with this problem? Will she explain why, in Ireland, MRSA has been shrouded in secrecy? The Tánaiste may be aware of stories about people being identified as MRSA patients but this fact has not appeared on their death certificates. Why is it that only recently we were informed that deaths from MRSA are uncommon in Ireland? It emerged earlier today that the deaths of six patients at the Mater were linked to MRSA. Why is it that there is evidence that up to one in ten deaths in the UK are linked to MRSA, while we in this country have been told that such deaths here are uncommon? How many people in this country have died from MRSA? A league table is being introduced in Britain in respect of MRSA deaths. Would the Tánaiste favour the introduction of such a table here?
First, the reply I gave earlier was not the same as those previously received by the Deputy. The question may be the same but the reply is not.
I said it was reminiscent of those previously provided.
It is even different from that I provided to the Deputy on the previous occasion I answered questions on this matter.
League tables have their uses. However, I do not want a situation to develop where the more proactive hospitals will lose out because they are taking more precautions. We must be careful in respect of that matter.
I stated on the previous occasion that it is extraordinary that the main cause of MRSA is the failure of so many people in hospital environments to observe basic rules relating to hand hygiene and other forms of hygiene. If this matter involved the putting in place of high technology, we would probably have done so long ago or there would have been many calls for us take action in that regard. However, it involves something rather simple. I am extremely concerned about this matter.
I am informed by the medical advisers in my Department that people who contract MRSA mainly die because of the underlying causes connected to the original illness which led to their being in a hospital environment. I do not have statistics or figures at my disposal regarding the number of people who died purely as a result of MRSA. I am strongly advised that it is the underlying condition rather than MRSA which causes death.
I am not happy with the situation and we intend to give the new quality authority a strong role in respect of standards. Hygiene is one of the obvious standards. We need a standards body so that basic hygiene, both in terms of the activities of personnel and the cleanliness of buildings and their surroundings, is observed to the highest possible standard. As stated previously, we pay a great deal of money for these services and we need to ensure that we get what we pay for.
The Tánaiste stated that people are not dying from MRSA but that their deaths result from underlying causes. We know from what is happening in Britain, however, that this is not the case. Does the Tánaiste agree that we can only tackle this problem if we are honest about it and categorically state that people are dying in our hospitals because of MRSA? Does she further agree that, in addition to hygiene, the terrible conditions and overcrowding in our hospitals are fundamental causes of difficulties with MRSA?
We must proceed to the next question.
One of the recommendations in the report is that there should be less overcrowding in our hospitals. Does the Tánaiste agree that this should be the case? Will she promise the House that from now on she will insist that MRSA be listed as a cause of death? Will she do that much at least?
Basic hygiene is not related to numbers. The fact that a medical professional washes or fails to wash his or her hands has nothing to do with the number of people in a particular environment. Hygiene is a basic requirement. I would like to think that a heightened awareness campaign could be put in place in hospitals in respect of this matter. People must be aware, from the time they first enter a hospital, as to what they should or should not do. It would be a matter for medics and not for me to decide cause of death.
The Minister is——
That clearly must be done on the basis of medical advice. It cannot be done at political direction.
They want to hide it. The Minister is refusing to do it. She is washing her hands of the matter.
I do not believe they want to hide it.
4 Dr. Twomey asked the Tánaiste and Minister for Health and Children when the 25% increase for a private bed in a public hospital, as announced in the 2005 Estimates, will be implemented; her views on the effect this will have on the private health insurance market; and if she will make a statement on the matter. [32005/04]
The increased charge for a private bed in a public hospital will take effect from 1 January 2005. In the interests of equity, it is Government policy to gradually eliminate the effective subsidy for private stays in public hospital beds and relieve the taxpayer of the burden of carrying these costs. Even with this increase, the cost of providing services to private patients in the major hospitals will continue to exceed the income arising from the charges.
The cost of private health insurance to the subscriber in our community-rated market remains low by international standards. In addition, it continues to benefit from tax relief at the standard rate. Implementation of this increase will result in an increase of about 5% in health insurance premiums. I believe the impact if any on the numbers covered by private health insurance is likely to be marginal.
Some 50% of the population is covered by private health insurance. Those people will regard access to the health services as a form of double taxation. Does the Minister accept that private health insurance costs could increase by 10% next year, allowing for the extra charges on private beds? Will the Minister agree that health premiums will have increased by 40% in three years if these extra charges are carried through next year? Is she aware that low-income families, especially those with children, will suffer most from the increased cost and may well be forced to give up their private health insurance? Does she accept that average families with health insurance who require the full benefit of the drugs refund scheme could end up paying up to €3,000 a year or more? Under the drugs refund scheme, charges have increased from €53 in 2002 to €85 following this budget, an increase of 60% in the past three years.
There has been very little debate on the private health insurance market. The risk equalisation scheme was not activated under the last review. Does the Minister agree there is very little competition in the health insurance market? Many customers are fearful at the lack of availability of services in the acute hospital sector and feel obliged to take out private health insurance. The general population is being fleeced and 50% of those who have private health insurance are using facilities in public hospitals.
We have a mixed system and it has generally worked very well from the perspective of private insurers. The issue is one of equity. I would like to move to a situation where more of the private activity would be moved to a private environment so that public beds can be used for those in greatest need. I would love to see a situation emerge which would be neutral in terms of how public hospitals are paid for private and public patients, if one wants to use that language. Clearly there are great incentives when one type of bed earns more money than another type. We all know that the 80:20 ratio is not maintained, which is unsatisfactory.
There is increasing competition in the health insurance market. A new entrant recently announced its intention to provide cover and there is also a new entrant in the dental insurance market. I welcome all those developments. There is huge demand for the whole range of policies and products which these insurers offer. The way to keep the costs down is through greater competition. All over Europe, including in some of the countries that are held up as having a model health system, there is a raging debate about the cost of health care in many of the countries which traditionally funded their service from the public purse.
It is not unique to Ireland that health care is expensive because of new products, new technology and higher staff costs. These contribute to insurance and to more expensive health care costs. From the Government's perspective — this has been clear since 1999 — we want to move to a situation where the full economic cost of providing a private bed is charged to the private insurer.
Will the Minister inform the House of the full commercial cost of a private bed in a public hospital? She has increased charges by 25% but that would still be a long way off the full commercial cost of a private bed in a public hospital.
There is not a uniform cost as it varies from hospital to hospital and on the basis of the specialties. The teaching acute hospitals have a higher cost base than some of the smaller hospitals. I have some figures which I can make available to the Deputy. From an insurer's point of view, there is a range of fees for the use of these beds, which I can make available to the Deputy. The hospital is paid by the insurers for the use of beds. I understand there are three different categories of payment from insurers to the hospital. One of the issues that arises is in the context of ensuring that resources go to best performers. An element of the resource allocation rewards efficiency and effectiveness. In the future we will require a clearer breakdown of the costs of procedures.
Will the Minister be in a position to supply the information on the full costs?
I will supply the available figures to the Deputy.
5 Mr. S. Ryan asked the Tánaiste and Minister for Health and Children if she has satisfied herself that the Health (Nursing Homes) Act 1990 is being implemented in respect of inspections of private nursing homes; if the statutory requirement of two inspections per year is being met; the problems that are being identified in respect of the inspection of nursing homes; and if she will make a statement on the matter. [31859/04]
Under the Health (Nursing Homes) Act 1990, the inspection of private nursing homes is the responsibility of the health boards. Regulations made under that Act empower health boards to inspect private nursing homes. Having made inquiries of the health boards and the Eastern Regional Health Authority, I am satisfied that the nursing home regulations are being implemented. In the majority of health board areas the requirement of two inspections per year is being met. Health boards which are not meeting the requirement have advanced reasons for this, including the following: the two inspections may not have been carried out strictly within a 12-month period but would have been carried out shortly afterwards and the statutory requirement for six-monthly inspections was being met by environmental health officers. However, the requirement for twice-yearly inspections by the medical and nursing inspection teams was not being met in full in the case of all nursing homes. In many instances these nursing homes would be inspected more than twice a year arising from issues identified in routine inspections or where a change occurred relating to registration details.
An additional factor mentioned by one health board was an increase of 130% in the number of nursing homes established in its functional area over the past two years which has put extra pressure on the nursing home inspection team.
In the context of the health reform programme, added emphasis is being placed on the setting and monitoring of standards generally. It is also planned to extend the brief of the social services inspectorate to include residential services for older people and people with a disability and to establish it on a statutory basis. Building on the existing framework for inspections, my Department is satisfied that these additional measures give grounds for added public confidence in the effectiveness of the inspections regime.
Is it acceptable to the Minister of State that there are no inspections of the State's 500 public nursing homes caring for up to 10,000 residents? Is he satisfied that the range of inspections is sufficiently broad to provide information about the quality of life of the elderly residents? Will the Minister of State inform the House of the number of legal cases being processed by the health boards against private nursing homes? Are the health boards sufficiently rigorous in following up problems? There may not be alternative accommodation available if nursing homes are closed down by health boards.
The Deputy raised the matter of private nursing homes, not nursing homes directly administered by the State.
I asked the Minister of State a question and he should know the answer.
I will answer the Deputy but it is not the question he asked.
The Minister of State is wasting time. He should answer the question.
If the Deputy wishes to ask a question he should formulate the question and table it. He asked a question about private nursing homes and I answered it. On the question of nursing homes under State direction, the position is — I share the concern outlined by the Deputy in this regard — that it will be addressed in the quality legislation to be introduced early next year. The assumption is that the State conducts its business in accordance with proper practices. The inspection requirement is imposed on private nursing homes, as is referred to in the Deputy's question. The Deputy raised a very fair question and it will be addressed in the legislation on the quality issues and the establishment in the new year of the health information and quality authority.
Will the Minister of State respond to the important question on the number of legal cases the health boards are processing against private nursing homes for breach of regulations?
I will furnish the Deputy with the information if he requires it. The number of prosecutions taken did not arise in the Deputy's question in which he asked about inspections. I will, however, give him information on prosecutions. While I do not propose to comment on the merits of a particular case because it is still before the courts and must take its course, the difficulty which arose in the High Court in the case in question was jurisdictional in nature. The matter is still before the District Court.
Does the Minister of State accept, given the importance of the issue, that the inspectorate reports should be made publicly available or a mechanism established to bring them to the attention of the House or a committee thereof?
Yes, I agree. The issue can be addressed under health legislation currently in committee. Clearly, these matters should be brought to the attention of the Oireachtas under the new structures to be established under the legislation. At present, it is a matter for individual health boards to seek the information in question in the context of performing their duties.
