Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Tuesday, 20 Feb 2007

Vol. 631 No. 6

Priority Questions.

Cancer Screening Programme.

Liam Twomey


84 Dr. Twomey asked the Minister for Health and Children her views on a national cervical cancer screening programme; the role a cervical cancer vaccine may play; and if she will make a statement on the matter. [6488/07]

The roll-out of a national cervical screening programme is the most efficient population approach to preventing and controlling cervical cancer. It is my objective to have such a programme rolled out, beginning late this year, based on an affordable model. For that purpose, on 1 January this year, I established a national cancer screening service which amalgamates BreastCheck and the Irish cervical screening programme. The total allocation to the new service is €33 million, a 71% increase on the 2006 allocation to the services. It includes additional revenue funding of €5 million to commence roll-out of the cervical screening programme and €8 million to commence roll-out of BreastCheck. Significant preparatory work is well under way in respect of the roll-out of cervical screening, involving the introduction of new and improved cervical tests, improved quality assurance training and the preparation of a national population register.

In parallel with the roll-out of cervical screening and as is the case in other jurisdictions, we are examining the potential role of vaccination against human papilloma virus. One vaccine, Gardasil, has been shown to be effective against four types of this virus, including two that cause 70% of cervical cancers. However, there would remain at least 30% of women whose cervical cancer would not be prevented by the vaccine. The national immunisation advisory committee has been asked to advise on its potential use.

The Minister has stated the vaccine, Gardasil, would protect approximately 70% of patients from cervical cancer and that the other 30% could be protected by a national cervical cancer screening programme. When added together, those figures show that under the Government 100% of women are not being protected because a national screening programme in not in place and the vaccine, Gardasil, is not to be made available to women with medical cards. A pilot scheme for cervical cancer screening has been in operation for six years but, on the other hand, the Minister is referring the vital question with regard to Gardasil to be considered by another committee. This weekend there will be a big row about whether the anthem "God Save the Queen" should be sung in Croke Park but at least the Brits have had a cervical cancer screening programme in place for the past 40 years, while we are talking about something that the Minister is considering doing or is referring to a committee to be discussed. It is becoming a national joke that we have not yet sorted out a national cervical cancer screening programme. A pilot scheme is ridiculous in a sense.

Patients are waiting significant lengths of time. Current expenditure on a screening programme that is not working is approximately €10 million to €12 million. For the same sum of money we could have a proper programme. The Minister should show a clear commitment and move forward. A national cervical cancer screening programme needs to be undertaken urgently. The vaccine, Gardasil, could then be added to the programme for those women most at risk. There has been screening for cervical cancer for 40 years and it can be organised logistically. It amazes me that the Minister has failed to implement the programme. I am also amazed at her replies. In so far as cervical cancer screening is concerned, a total of 100% of Irish women are being let down by the Government because of its failure to take this issue seriously.

It is true that there has been cervical cancer screening in other jurisdictions for some considerable time, including the United Kingdom and Canada, where it was introduced in the 1960s. I acknowledge that we are way behind in many areas. However, we have in place a co-ordinated programme for the roll-out of both BreastCheck and a cervical cancer screening programme on a sustainable basis. The vaccine has not been rolled out in either the United Kingdom or Canada. Everybody is examining the most effective way of rolling it out. It would not be appropriate to simply provide for it on the medical card. Any immunisation programme would have to be targeted at the whole population to be effective. Some countries have decided what course they will take — I understand the Canadians are considering a programme aimed at nine year old children while others are considering beginning with 11 year old children. We have asked the national expert group, which advises on immunisation programmes, first, whether we should do it and, second, how we should do it. The most effective way to do it would be on a whole-population basis among the age group to be targeted, probably utilising the schools.

To take as an example BreastCheck, a national screening programme, of the women contacted, 70% come forward for screening and 30% do not. The most effective way to implement screening programmes is to seek the most appropriate way to reach the whole population. If we decide to introduce a vaccine for nine, ten or 11 year old girls, we should do this through a school programme.

The cervical screening programme will begin later this year and the screening group has been put in place. In addition to a roll-out of the screening programme, we must also deal with cytology facilities, which, as the Deputy knows, are inadequate. Due to these inadequacies, a number of smears had to be sent abroad recently so that results were expedited and not delayed. The HSE is currently working with hospitals to improve cytology facilities so smear tests give accurate results. As a general practitioner, the Deputy will know there have been hundreds of thousands of opportunistic smears. The results have been questionable and in one case it was necessary to close down a screening clinic given the dubious results.

Huge action is being taken. As I said, later this year we will have both the screening programme and, I hope, a decision with regard to the vaccine.

Huge action is not being taken. Rather, no action is being taken. The issue to which the Minister refers in regard to the workload of cytology clinics has been known for years. Another point on screening is that non-attendance decreases dramatically on second and subsequent calls for attendance at any screening programme, whether it is BreastCheck or cervical screening. The problem is there is no nationwide screening programme for anything. The Minister has let everybody down with regard to screening. That is the point we need to make. The Minister is doing nothing.

As the Deputy is aware, no country has eliminated cervical cancer.

At least they tried.

Screening plays a major part, as it does with other cancers. We are currently rolling out BreastCheck and in April it will be rolled out to the rest of the country. Clearly, rolling it out on a population basis cannot be done overnight. Particular issues arise with regard to lower socio-economic groups, which is why the issues of education and awareness, and the huge efforts being made in that regard, as well as the provision of mobile facilities to try to bring screening closer to the population, are so important.

With regard to cervical screening specifically, a pilot project has been in operation in the mid-west for several years. We have learned from that experience and this will inform the manner in which the new screening board, established on 1 January last, will later this year begin the roll-out of a national programme for 25 to 60 year olds.

Industrial Relations.

Liz McManus


85 Ms McManus asked the Minister for Health and Children, in view of the decision by the INO and PNA to pursue industrial action to have their grievances addressed, the action she will take to address these concerns and ensure that essential services are not disrupted; and if she will make a statement on the matter. [6500/07]

The background to the planned industrial action by the Irish Nurses Organisation and Psychiatric Nurses Association is that they will not take part in the current benchmarking process which is reviewing the pay of public servants and is due to report in the second half of 2007. The INO and PNA have so far declined to sign up to the new national partnership agreement, Towards 2016. Both unions have lodged eight cost-increasing claims related to pay increases and a reduction in working hours. The additional cost of these claims would be almost €1 billion per annum. The unions are also seeking retrospection estimated to cost in excess of €500 million.

In November of last year the Labour Court recommended that the pay claims be processed through benchmarking. On the claim for reduced working hours, the court recommended that the parties should jointly explore the possibility of initiating an appropriate process aimed at achieving major reorganisation of working arrangements and practices within the health service generally. While health service employers have accepted this recommendation, the unions have stated they neither accept nor reject the recommendation.

Following the publication of the Labour Court recommendation on the union's claims, I wrote to both unions and arranged for exploratory discussions to be held between all the parties concerned on 19 January last. While I understand the discussions provided clarity as to the respective positions of the parties, the meeting adjourned without agreement on the way forward. It remains the Government's view that benchmarking is the appropriate mechanism to resolve the pay issues. Management is readily available to enter into discussions on an appropriate process aimed at achieving major reorganisation of working arrangements and practices within the health service generally, within the context of the Labour Court recommendation and the prevailing national agreements. I urge the leadership of the INO and PNA to give further consideration to the recommendation of the Labour Court and to make the case on behalf of their members, as other nursing unions have done, before the benchmarking body.

The INO and PNA served three weeks notice of industrial action on 2 February. This notice states that there will be a nationwide work to rule and series of work stoppages across health employments. Health service employers have been endeavouring to agree contingency arrangements to ensure maintenance of essential services during the planned industrial action. However, the INO and PNA have not stated the format, location and timing of the work stoppages. The failure to provide this information is a very serious matter. The HSE requires this information to ensure that services and patients are not put at risk. I ask the leadership of the INO and PNA to urgently reconsider their position.

I thank the Minister for her reply, although it does not bring us very far. The Minister will recognise the health service is still in crisis. Only today we received notification from Beaumont Hospital that the much-vaunted accident and emergency strategy simply is not working. At one point this morning there were 52 people waiting on trolleys and chairs in the accident and emergency department at the hospital, which is the highest figure ever.

Does the Minister accept that, where nurses are working in these conditions, she needs to take note that the almost 100% response to the ballot carried out by the Irish Nurses Organisation and the Psychiatric Nurses Association was for industrial action, and that this is such an overwhelming vote her reply is an inadequate response? Is the Minister stating this matter can only be progressed through the benchmarking process? It seems a more imaginative approach is needed if we are not to see many difficulties being created in the health service by people who, as everybody recognises, do tremendous work, often in stressful conditions. Nurses do not lightly take industrial action, yet in this case they have overwhelmingly decided to take industrial action.

What is the precise approach the Minister is taking? Is it only through benchmarking or is the Government considering alternative means that may lead to some resolution to this very serious situation?

As the Deputy is aware, there is labour relations machinery in the State through which the eight claims in this matter were progressed. The Labour Court recommended that nurses pursue certain matters through the benchmarking process, in particular the issue with regard to the approximately 1,000 nurses in the mental health area, where those reporting to them receive about €3,000 per annum more than the nurses. The Government recently negotiated a national pay agreement with hundreds of thousands of trade unionists, who have accepted the agreement, which gives a 10% pay increase over the next 27 months. Some nurses, including those represented by SIPTU, have accepted this agreement. It is not just an issue with regard to nurses but one of public pay policy.

The Deputy may be aware that, as I stated at the Joint Committee on Health and Children last week, major work practice changes are needed in the health system. In particular, we need staff working more closely together as part of a team at primary care level. We need longer working days from certain health care professionals, particularly those involved in diagnostics, so that patients can get the service they require, on a non-emergency basis, for longer and after 5 p.m. In that regard, I have suggested — I am not the author of the suggestion, which comes from the Irish Congress of Trade Unions — it would be worthwhile to establish a process whereby we could bring various stakeholders in the health system together to find whether we could develop innovative solutions with regard to the work practice issues, such as the kind of model we devised in the 1980s with regard to the economy. That is worthy of consideration. I would like to think the INO and the PNA would consider pursuing, for example the issue of a 35-hour week, through that process.

The health care system has substantial numbers of nurses working in it, 12.2 nurses per 1,000 patients, whereas in France the figure is 7.5 and 8.5 throughout the European Union. With regard to the issue of a 35-hour week, as I have said to the nurses' organisation, if we can, with the same number of nurses, cover in 35 hours what is currently covered in 39, there will not be an issue. However, if a reduction to a 35-hour week were to require the employment of 4,000 more nurses, there would be an issue. What is required is an innovative process in which some of these matters can be explored, for example, different ways of working or a better skills mix. We could develop many innovative processes for better working practices in the health system if we could establish a forum in which these issues could be pursued. I hope a forum can be established in this case. The issues relating to nurses can be explored in that context.

I think the Minister would acknowledge that the nurses have been very open to the idea of changes in practice with regard to health reform. However, the problem relates to the lack of engagement by the Minister, the Department and the HSE. The Minister talks about a forum and an innovative process, but when will that forum be established? What will be its terms of reference and how speedily will the process begin? If the Minister has faith in it, why is she talking about it in such broad terms when a head of steam which will have a major impact on the delivery of health services, particularly at acute hospital level, is building up?

There seems to be almost lethargy about the way the Minister is talking. It seems to be almost an abstract view that it might be a good idea to develop a new approach. Is this the approach? Has the Minister talked to the nurses about a timeframe, terms of reference, how it will be done etc? Does she recognise that child care workers who are being paid more than nurses answer to nurses? This imbalance is unique and I am not aware of anything similar happening in any other sector. While such difficulties require an innovative approach, they also need a coherent and realistic approach. Exactly what approach does the Minister suggest?

We have a process for dealing with relative pay claims, the benchmarking process, and this is the approach suggested by the Labour Court with regard to the issue raised by the Deputy. There are 1,000 nurses working in the mental health service in which those reporting to them are paid approximately €3,000 more than them. The reason for this is that their work is extraordinarily difficult and it is very difficult to get people to work in the area. I accept there is an issue when the person to whom these workers report is paid less than them. The Labour Court recommended after adjudication that this should be considered in the context of benchmarking. I understand the nurses organisations want any increase extended to every nurse, not just those working in that environment.

The innovative approach I suggest will not work if all the stakeholders are not involved. By all the stakeholders I mean those that represent the key professions that work in the health system, including radiographers, physiotherapists, occupational therapists, junior hospital doctors and so on. We cannot resolve in isolation the issues that affect nurses and the new working arrangements we want to see without it being done as part of an overall arrangement with other key professionals.

I repeat: we have processes and want them to be used. Public pay is determined in the context of the social partnership agreement, not in any other process. Changes in work practices that could involve a shorter working week could be pursued through an innovative approach through a process or forum. Others are exploring this option. It is not a matter for me, as I do not represent the workers involved. However, my door is open, as is that of the Government, to any process agreed by the various stakeholders to look at devising innovative work practices within the health system.

Hospital Services.

Arthur Morgan


86 Mr. Morgan asked the Minister for Health and Children if she has received a copy of the report on Our Lady of Lourdes Hospital, Drogheda which was drawn up by the joint department of medicine for the Louth hospitals and presented to the Health Service Executive in December 2006; the discussions she had with the HSE on this report; and if she will make a statement on the matter. [6545/07]

I take it that the Deputy is referring to a discussion document prepared by the joint department of medicine at Our Lady of Lourdes Hospital, Drogheda and Louth County Hospital in advance of a meeting between the joint department and the National Hospitals Office. I have seen a copy of the document and I am advised that it is the subject of ongoing discussions between the National Hospitals Office and the joint department. It outlines an increase in volume and complexity of medical activity at both Drogheda and Dundalk hospitals and notes the concerns of the joint department for patients and staff arising from this increase in workload. It includes an endorsement of the Teamwork report, Improving Safety and Achieving Better Standards. In line with the recommendations of the report, the HSE is developing a single medical clinical network for the whole of the north-east region, including County Louth.

I am afraid it involves much more than what is covered in the Minister's reply. Is she aware the report states patients cannot access routine basic care requirements such as food, water and washing facilities? Is she aware it further states patients get better despite the service, rather than as a result of the care they receive and that large numbers are managed in a site not fit for the purpose by persons not trained for the purpose? It also states it is a testament to the staff that no fatalities have resulted to date with medical patients. That is the import of the report.

Is the Minister not ashamed of conditions in hospitals such as this? Is she shamed by the content of the report? What is she doing about it? I have already asked what discussions she has had on the report. She mentioned the Teamwork report. Is she aware that under that report, it is proposed that medical facilities from Louth County Hospital be transferred to Our Lady of Lourdes Hospital, Drogheda, thereby compounding the problems there? When the medical facility transfers to Our Lady of Lourdes Hospital, the accident and emergency unit will automatically follow. Is the Minister aware the intensive care unit will also transfer, compounding the problems in the Drogheda hospital where outpatients spill into the accident and emergency area? Accident and emergency patients have had to be housed in the maternity unit which is already at breaking point. The facilities in Drogheda are getting worse.

I would appreciate it if the Minister would address a serious issue I raised under Standing Order 31 last week. It concerns the Minister's view on these matters and on whether she should remain in her position. I raised the issue of her resignation and do so again today in a calm and measured manner. As long as these conditions persist in our hospitals, the Minister should consider her position carefully.

There is nothing new in the Deputy's call for my resignation, as he calls for it frequently on the radio station in the north east.

This is only the second time.

I have visited both hospitals and seen at first hand the wonderful way in which the joint surgical department works. Essentially, day surgery is performed in Dundalk and more complex surgery in Drogheda. The system works well and the volume of surgical procedures in both hospitals has increased substantially as a result. The new road network makes the joint working process more acceptable than perhaps it would have been in a different era when the distance to be travelled was greater.

With regard to the report from the physicians of both hospitals, they suggest a similar process be put in place for medicine, that they should have a joint department of medicine — in effect, the two hospitals would work as one. Currently we might have patients on trolleys in Drogheda, while there are vacant beds in Dundalk. This makes no sense. If we can get hospitals such as those in Dundalk and Drogheda to work closely together, it makes more sense from patients' point of view.

As the Deputy is aware, there are significant deficiencies in the north east where we have five hospitals for a population of 350,000. The hospital admission rate in the area is 5.9 per 1,000. In the United Kingdom the rate is approximately 1.7 per 1,000. Half of all surgical cases and 30% of medical cases from the area are referred to Dublin. Therefore, there is a crying need for a state-of-the-art regional hospital and that will happen. That welcome decision has been made and endorsed by the Government. In the meantime, unlike other facilities and although we have made a decision to proceed with a new hospital, we must invest in the existing hospital infrastructure. We need a new accident and emergency department in Drogheda. This year over €6 million will be provided from the capital programme towards this year. We need other investment in personnel and staff in the region in order to provide services between now and the time we will have the new hospital in place.

It is not the case that nothing is happening. Much is happening. Above all else, we must take on board the reports commissioned and the advice of the training bodies on patient safety and accreditation. Dr. Eilís McGovern has been appointed by the HSE to oversee implementation of medium-term changes in the north east. The HSE and I have given an assurance that nothing will change until something better is put in its place. That is what is currently under way, and I expect the support of the Deputy and everyone else. Change is never easy, but patient safety must come first. We must use resources in County Louth as effectively as possible for the benefit of all patients.

I would love if we adopted the principle that nothing should change until better facilities have been put in place. However, the opposite experience has obtained and I ask the Minister to examine that position. There should be a public inquiry into what is going on, such is the current state of crisis. Half of the cases in Louth are coming to Dublin for major operations because there are no facilities in the north east for them. I welcome the proposed regional hospital, but when one has hospitals in Monaghan, Louth and Navan closing and pouring their patients into an already overcrowded facility at Our Lady of Lourdes in Drogheda, there is not much chance.

I will give a brief example. The paediatric protocol was implemented in Louth on 10 April 2005, meaning that no children could be treated in the accident and emergency department of Louth County Hospital. They too are now having to be admitted to it and then transferred to Our Lady of Lourdes, joining an already excessive queue for basic treatment. Someone must examine what is going on because I have no doubt that in future, when there is some scrutiny of this carry-on, we will be told that the authorities did not realise the seriousness of the situation. I put the Minister on notice that we are absolutely at crisis point and that it is unacceptable. I call on the Government to act once and for all. It is already too late, but it should nevertheless address the situation.

We are doing so, and for as long as I have been in the Oireachtas — 30 years this summer — hospitals in the north east have been a major political issue. Every time that we were about to get around to doing something imaginative, it was suddenly reversed, one of the reasons behind current problems. The consultant cardiothoracic surgeon appointed, Ms McGovern, is well respected nationally and internationally. She is the appropriate person to oversee implementation of a programme of reform in the region, in particular ensuring that patient safety is foremost in the minds of everyone involved in the change process under way. That is happening, as the Deputy knows.

Things are still getting worse.

He will also be aware that it is the most reviewed region in the country. There have been several reports, one of them being Teamwork.

Matters have not improved.

We have had several reviews and at last things are improving because decisions that should have been made years ago are being taken, particularly the decision to have a state-of-the-art hospital, something lacking in the region. That is why so many patients have to come to the Dublin area.

The situation is worsening.

People generally want to stay in their own region if the facilities are there and that is what will happen.

Health Insurance.

Liam Twomey


87 Dr. Twomey asked the Minister for Health and Children her views on the recent Competition Authority report on competition in the private health insurance market; and if she will make a statement on the matter. [6489/07]

I welcome the publication of the Competition Authority's report on competition in the health insurance market and the Health Insurance Authority's companion report published last Friday.

The Competition Authority report makes 16 recommendations. Several are of a very technical nature and require further consideration by the Department and the Health Insurance Authority. Many of the recommendations that require action on my part will be included in the VHI Bill, which I hope to have published before Easter. I fully accept the recommendations designed to increase consumer awareness and to make it easier for consumers to switch from one insurance provider to another.

I have repeatedly restated the Government's commitment to maintaining community rating in the market and to promoting greater competition. I also want to ensure that the regulatory framework does not place unnecessary obstacles in the way of companies seeking to enter the market. For that reason, I have appointed a market review group to examine the rate of return to be earned in the market and associated issues as quickly as possible. When I receive its report before the end of March, I expect to bring proposals to the Government based on its recommendations and those of the Competition Authority and the Health Insurance Authority.

Essentially, nothing will change until publication of another report at the end of March.

It is important that we ask those who pay private health insurance premia. What will their situation be when the Minister receives the report at the end of March and they face the next general election? VHI, without risk equalisation payments, will increase its premia by between 5% and 10%. The Minister's co-location plan to build private hospitals and move private beds out of public hospitals could add another 5% to 10% to premia. Medical inflation adds between 10% and 15% to premia. Does the Minister agree that VHI premia alone could mean increases of anywhere between 20% and 35% for its 1.5 million customers on top of normal market variations over the next five or six months?

Does she further agree that if VHI has to increase its reserves to the levels held by other insurance providers that could add another 5% or 10% to premia? I would like her to tell me this, since VHI is a semi-State organisation. The CEO has increased premia by 12.5% in each of the past two years. He has made public statements on some of the figures that I am using here to the effect that premia have risen as a result of Government policy and medical inflation. Why has VHI not yet announced how much premia will increase by next year? Has that been subject to political influence because of the approaching general election and because the Government has made such a mess of the private health insurance market that the customer and patients with private health insurance are to be hammered?

The Minister was very unclear regarding the co-location plan and what the Competition Authority and her own group intend. We cannot distinguish fact from rumour, for example, whether VHI is to be broken up. The Minister has said nothing about whether serious plans exist to split the services that VHI provides. The market is incredibly muddled and those getting the rawest deal are private patients. What happened with BUPA was anticipated and has caused untold worry for its customers. What is happening now will do the same for Quinn Direct and VHI private patients. They will be hammered by the cost of premia, since the Government has lost direction and does not know what it is doing regarding the private health insurance market. The Minister should explain to us her exact plans to keep premia down.

I find Deputy Twomey's intervention extraordinary because when BUPA announced that it was to pull out, he stated on the airwaves that the risk equalisation was far too severe.

That is not what I said. I asked the Minister what could be done about risk equalisation. I too can throw out glib statements, for example, that the Minister did not give a hoot about matters. She knew for a year and a half what was going on, but did nothing about it.

I did a great deal about it. For example, I fought a very successful court case and won. The way the Deputy is going on, one would think that we had lost it.

It is the private patients who are losing.

For the first time, I have secured a Government decision to put VHI on a commercial footing. The tragedy is that it was not done in 1996, when we legislated for risk equalisation, since it is among the reasons that we do not have a level playing field. VHI does not have to meet its competitors' solvency requirements, a major issue for the latter. The Deputy knows that it is being pursued by the European Union. The regulatory body requires 40% of premium income to be put aside as a reserve, while in the EU generally the figure is 23% or 25%. Our requirements are far too severe and very conservative.

The group that I recently established, led by Mr. Colm Barrington, is specifically tasked with taking on board what BUPA and Vivas have said, namely, that one cannot make a fair return on capital in the Irish market. Its members have enormous experience of insurance and investment and will report by the end of March.

In the meantime, there are real issues to address. We have an exemption under Irish law whereby one can enter the market and provide health insurance for three years without making any risk equalisation payments. That issue must be addressed, and I intend doing so, but there are also other questions. For example, many people do not yet realise that one can switch from one insurance company to another without any penalty. I still find that there is great ignorance among consumers in that regard.

Among the suggestions in the two reports that I have mentioned is that renewal notices be issued up to a month in advance. I believe that the period for car insurance is 15 days and that has had a major impact. At least people then have a chance to shop around. The HIA has recommended that up to a month's notice be given and renewal notices should probably include reference to the fact that one can switch insurers without any penalty.

On the future of VHI, the Government has decided to commercialise the organisation and it is important that this is done as quickly as possible. The Deputy acknowledged on a previous occasion that it could not happen overnight because of the solvency issues. I have not spoken to VHI about price increases, nor would I interfere with its board or executives. I therefore resent very much any suggestion that, because there is an upcoming election, the VHI has been asked to act inappropriately. I would not stand over any Minister being involved in practices of this kind. It would be totally dishonest and the board of the VHI would be reckless if it were to agree to such a request, if put to it.

Considering the board of the VHI made so many comments during 2006 on the impact of risk equalisation and competition, or the lack thereof, in the Irish private health insurance market, does the Minister not believe it should indicate its planned increases in premiums? It is usually at this time of the year that we are told what they are to be. Given that the board has been saying all along that risk equalisation, medical inflation, the collocation plan and a range of other factors, such as the reserves, have an impact on the cost of premiums, and that 2 million people will be affected next year, would it not be more appropriate for it to make comments on the increases? Some aspects of this matter are outside the Minister's control but quite a few of the health insurance cost drivers are well within her control. In some respects, she has contributed to the costs. Might it not be prudent for the board of the VHI to indicate its planned increases?

On the supply of private facilities or consultants, in most insurance markets companies like to see more suppliers of products and services because this drives innovation and drives down prices. The health insurance industry in Ireland is unique, perhaps because there has mainly been one company, apart from the providers of the ESB and Garda medical schemes, offering insurance in the market since 1957. The view was taken that the fewer the number of private hospitals, the better, but neither I nor patients accept this. Deputy Twomey knows as well as I do that the huge shortages are such that many patients must wait some considerable time for access to a consultant. The private system has not filled the gap, as it would do in other countries.

We need 1,500 more consultants so everybody can gain access to one quickly. If somebody tried to suggest to me that we should limit the stock of private hospitals to keep down the price of medical insurance, I would reply that it would also delay patients' treatment. This is not a solution to any problem.

Collocation has been proposed for a very good reason. The beds involved are ring-fenced for private patients in public hospitals and are funded and staffed by the taxpayer. Everybody should have access to these beds. Equity of access is central to our new contract of employment for consultants. Access to facilities funded by the taxpayer should be on the basis of equity and one group of patients should not be privileged over another. This is why nine hospitals are so interested in collocation.

Collocation provides an on-the-site response. The taxpayer obtains money from the lease or sale of the land in question rather than having it used as a carpark. The public system can procure, if it wishes, services from the private provider, or the private provider can procure services from the public provider. Thus, both sides work in a co-ordinated way, as is the case at St. Vincent's Hospital. This system is preferable to having one in which a plethora of small private hospitals emerge, which are not connected to the public hospital system. If the two are connected, a better service is afforded to patients and we get better bang for our buck.

Community rating and competition are fundamental to my policy and that of the Government. If there is no competition, there can be no innovation or good value. Rather, there would just be a monopoly supplier of services in the market. Obviously there cannot be community rating without risk equalisation because, if one company has all the younger premium holders and another has all the older ones, they could not compete on a level playing field.

I recently met a couple in their 60s who returned to Ireland after having lived in the United Kingdom. They stated that, because of their health condition, their insurance in the United Kingdom cost £12,000. Their health insurance in Ireland, involving one of the better plans, costs in the region of €2,200. That shows the difference. There is no doubt that, without community rating, insurance cover in Ireland would be held by approximately 10% to 12% of the population and certainly not the 54% who hold it at present. Community rating is central to Government policy.

I have a few points to make.

If the Minister can make statements——

There are other questions to be answered. We have already spent seven minutes on the question and cannot allow any more time.

She throws out statements as if she has no connection with this matter.

We must proceed to Question No. 88.

The fact is that Government policy made the small hospitals spring up around the country. It was when former Minister, Charlie McCreevy——

We have spent double the time allowed on the question.

——dropped the barrier in respect of beds.

The Chair has called Question No. 88.

Health Services.

Catherine Murphy


88 Ms C. Murphy asked the Minister for Health and Children if, in consultation with service providers, she will carry out an evaluation of the impact the levying of charges on those in residential care has had on persons with intellectual and physical disabilities whose care is partially funded through their social welfare payments; and if she will make a statement on the matter. [6340/07]

The Health (Charges for In-Patient Services) Regulations 2005 have provided for two different classes of persons on whom charges may be levied. These regulations were signed by the Minister for Finance and the Minister for Health and Children on 14 January 2005.

Class 1 refers to people in receipt of inpatient services on premises where nursing care is provided on a 24-hour basis on those premises. In this case, a weekly charge of €120, or the weekly income of that person less €35, whichever is the lesser, can be levied.

Class 2 refers to people in receipt of inpatient services on premises where nursing care is not provided on a 24-hour basis on those premises. In this case, a weekly charge of €90, or the weekly income of that person less €55 or 60% of the weekly income of that person, whichever is the lesser, can be levied.

These regulations provide for the maximum charge to be levied on either class of person. The HSE issued revised guidelines for the implementation of the charges in July 2006. No further distinctions are made in terms of the classes of persons to which charges apply and I do not have plans to introduce any.

The HSE has the power to reduce or waive a charge on the grounds of "undue hardship". Under section 1(b) of the Health (Amendment) Act 2005, the HSE can examine a person’s overall financial circumstances in view of his or her reasonable expenditure regarding himself or herself or his or her dependants, if any.

I welcome the recent decision by my colleague, the Minister for Social and Family Affairs, to grant the full disability allowance to all persons in institutional residential care who, prior to this decision, were not eligible for this allowance. The net impact of granting the full disability allowance, in the context of long-stay charges, is that the individuals will continue to receive the same level of service as before but will have increased income which they will be able to retain for their personal use.

I heard many of the Minister of State's points during the reply to an Adjournment debate and am aware of the charge that is levied. I was essentially seeking an evaluation of the impact of the charge on patients. Having read the explanatory memorandum to the Health (Amendment) Act 2005, I note it focuses very much on old age pensioners. Was it envisaged, when the legislation was being drawn up, that those with physical and intellectual disabilities would be subject to the charges? What consideration was given to differentiating between those living in capital-assisted houses with a house parent and the others? Those in the former category are not subject to the charges. Many individuals living in residential institutions, who aspire to live in capital-assisted houses but have not had the opportunity, are doing the same sheltered work as those living in capital-assisted houses, yet there is a very significant difference in the income they are allowed to retain.

Was the legal opinion proffered during the drafting of the Bill that one could not apply the charges to elderly people if they were not applied equally to everybody else in residential institutions? The difficulty is that there is a class of persons whom nobody expected would have to pay a price for the introduction of the legislation.

Much fundraising is done by parents and friends to keep residential institutions functioning and many of these people are elderly. I have met pensioners who are making contributions from their pensions towards the cost of keeping their children in institutions.

I call for an evaluation of the impact of the charges on people in institutions for whom small treats such as being able to choose their own clothes and shoes or going to the pictures are being put in jeopardy. The charges are also impacting on family members with limited means who may wish to take their relatives out of institutions. I do not think the charges are in the interest of patients.

While there is no intention at present to re-evaluate the policy, the charges will be kept under review for any anomalies that may arise. The decision by the Minister for Social and Family Affairs to pay the full disability allowance, which means that residents of institutions have more money to spend, should be welcomed by everybody.

Given the amounts charged in administrative fees, the institutions are going to end up with more money but is there any benefit to the residents of institutions from these charges? It seems they were simply seen as a soft target. The Government is legally compliant in that it imposes a charge irrespective of whether a patient is elderly or has an intellectual or physical disability but many of the people to whom I refer are not in a position to fight back and their parents and families often do not fight because they do not want to upset the institutions. This is a mean charge on a vulnerable group of people.