Health (General Practitioner Service) Bill 2014: Second Stage

I move: "That the Bill be now read a Second Time."

It is my pleasure to introduce the Bill, which will provide for a general practitioner, GP, service to be made available without fees to all children aged five years and younger. The key features of the Bill are the provision of an entitlement for all children aged five years and younger to a GP service without fees; the removal of the need for children aged five years and younger to have a medical card or GP visit card under the GMS scheme to qualify for a GP service; and a provision that the HSE may enter a contract with GPs for the provision of this GP service to children and that the Minister may set the rate of fees payable to GPs for this service.

I am also pleased to inform the House of the conclusion today of a framework agreement with the Irish Medical Organisation, IMO, which sets out a process for engagement concerning the general medical services, GMS, general practitioner, GP, contract and other publicly funded contracts involving general practitioners. This agreement has been reached following a series of discussions with the IMO and involving the Health Service Executive, HSE, and the Department of Health, led by me. The process got under way following my invitation to the IMO at its annual conference on 26 April to enter "talks about talks." I am pleased that these talks have culminated in the drawing up of the agreement. The framework agreement sets out an agreed process for engagement on all aspects of the GMS contract with GPs, with due regard to the IMO's role as a representative body of medical practitioners and within the context of the provisions of the primary legislation that will underpin the introduction of GP care free at the point of access. I look forward to a meaningful engagement with the IMO on the GP contract.

The Government is committed to introducing, on a phased basis, a universal GP service without fees for the entire population within its term of office, as set out in the programme for Government and the Future Health strategy framework. As announced in the budget, it has been decided to commence the roll-out of a universal GP service by providing all children under six years with access to a GP service without fees. Additional earmarked funding of €37 million was provided in budget 2014 to fund the first phase. It is not funded on foot of savings implemented elsewhere in the health system. The 2013 report of the expert advisory group on the early years strategy recommended providing access to GP care without fees for all children in this age group.

There are good reasons to provide universal access to GP care in view of the health needs of that age cohort. The early identification of health issues at a younger age can mitigate or reduce the impact of ill-health later in life. We should bear this in mind, given that the Growing Up in Ireland survey has reported that almost one in four children in Ireland is either overweight or obese and the likelihood that this will lead to significant health issues later in life. When the first phase is in place, approximately half of the population will be covered by a GP service without fees at the point of use. The Government is in the process of examining the next phases of extending the universal GP service.

Deputies will be aware that our current arrangement of health care provision can be traced back to the mid-19th century with the 1851 Poor Relief (Ireland) Act when limited services were provided for those who were unable to pay for them. Frankly, this is astounding. It is an anachronistic and inappropriate basis for a 21st century health system and far from any comparable modern health system of any other European country. It underpins the importance of moving towards a health system based on universality of access. The concept of eligibility has been somewhat amended by legislation, most recently in 1991 and 2005. However, the fundamental principle of means testing access to health services was retained by the Oireachtas on both occasions. One result has been that the means-based legislative framework has produced a very complicated eligibility system which must take account of a person's "overall financial situation" as stated in the 1970 Act. This system is very likely to confuse and almost certainly makes it impossible for a person to know whether he or she qualifies for a medical card. It is clear from the real concerns raised by members of the public that there are difficulties for some persons with permanent conditions in obtaining access to health services under the medical card scheme. This is a problem that we must address. It is being treated as a matter of priority by the Government and we are actively examining the issues involved and working towards a solution.

I have stated previously that I believe we must move towards a health system based on universality of access which must be sustainably funded to enable the provision of services to meet health needs. I recognise that a move from a means-based eligibility system to a universal system of health coverage is difficult and that many anomalies arise. Members and others are perfectly entitled in the course of the debate to point to these anomalies and contradictions as they see them. We must try as best we can to address these issues in a sensitive and pragmatic fashion. However, the Government's commitment is to fundamentally reform the health system in the way we have proposed. In that context, I wish to hear more from our critics about any alternative approach they may have to the organising of health care coverage in Ireland, apart from maintaining the existing system.

It has been suggested, although perhaps not in this House, that people should be eligible for a medical card on the basis of their having a particular medical condition. On the face of it, it is manifestly right that if one has an illness, one should be able to access the health service. This is, of course, at the heart of the reform we are seeking to bring about and I passionately believe it is something we, as legislators, should strive together to deliver. However, in seeking to supplement our current inadequate means-based system with an illness-based approach, there is a risk that we could cause unintended consequences. As legislators, we should examine and consider these risks when considering possible or potential changes we might have in mind. Personally, I would not advocate an illness-based eligibility system as a long-term solution. It would result in the health service inadvertently only treating people with certain conditions, while excluding others with other conditions from care. We are in the process of reorientating the health system from one that only treats sick people to one that keeps people well. That is one reason I believe a universal system is the best option.

However, these major reforms take time. We should consider and explore how best the existing eligibility system can be adjusted to ensure people who are on low incomes or who have permanent or terminal conditions can obtain timely access to the health system. There is a good case for saying the existing eligibility system has become over-complex, resulting in people focusing on the assessment process rather than the provision of services. We should not lose sight of the fact that an ill person should be able to receive primary health services in his or her own area. At the same time, we must remain steadfast and committed to implementing the most radical reform of the system in the history of the State and developing a universal system that treats all according to their health needs, not their means.

The purpose of the Bill is to provide for a general practitioner service to be made available without fees to all children aged five years and younger. The Bill provides that the HSE shall make available a general practitioner service without fees to all children aged five years and younger. It also provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services for all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six month period following commencement of the section. Such a contract shall specify the services to be provided by the GP.

The Minister for Health may, by regulations and with the consent of the Minister for Public Expenditure and Reform, fix the rates of fees and allowances to be paid to GPs for services provided under these contracts. The section stipulates that the Minister, in making a regulation for this purpose, must engage in consultations. It prescribes the role of the Minister and HSE, the nature and manner of the consultations and the considerations to which the Minister must have regard in making regulations. Where the rates fixed by regulations under the section are varied in subsequent regulations, a GP who does not wish to continue providing services may terminate his or her contract by giving the HSE three months notice.

As all children aged under six years will be covered by the new GP service under the Bill, it removes children who have not yet attained the age of six years from the existing GP service under the medical card scheme. However, it is important to be very clear that children aged under six will continue to qualify for medical cards and their entitlements to other health services such as prescription drugs will not be affected in any way.

Among the other provisions in the Bill are amendments to the existing legislation relating to appeals under the Health Act 1970. The Bill provides for the current HSE appeals process to be extended to decisions on the operation of the new GP service for all children aged five years and younger and also provides for the director general of the HSE to appoint persons to carry out appeals. It clarifies that where the person carrying out an appeal is an employee of the HSE, that person shall hold a grade senior to the original decision maker. The existing provision in the Act that the Minister may make regulations in respect of the appeals process is restated without change.

The Bill also amends the existing "ordinarily resident" framework in the Health Act 1970 to reflect changes made in section 2 and extends the framework to include the new GP service for all children aged five years and younger.

Before I explain the main provisions of the Bill, I advise the House that the heads of the Bill were forwarded to the Joint Committee on Health and Children for a pre-legislative scrutiny process. Unfortunately, this was somewhat delayed as operational protocols for pre-legislative scrutiny were not available at the time. As a result, the Bill was published by the Government before the committee had had an opportunity to discuss the proposals. However, I look forward to detailed discussions with Deputies on Committee Stage of the Bill.

Section 2 amends the existing legislation relating to appeals under the Health Act 1970. It provides for the extension of the current HSE appeals process to decisions on the operation of the new GP service for all children aged five years and younger and also for the director general of the HSE to appoint persons to carry out appeals. It clarifies that, where the person carrying out an appeal is an employee of the HSE, that person shall hold a grade senior to the original decision maker. The existing provision in the Act that the Minister may make regulations in respect of the appeals process is restated without change.

Section 3 amends the existing "ordinarily resident" framework in the Health Act 1970 to reflect changes made in section 2 and extends the framework to include the new GP service for all children aged five years and under. Section 4 removes children who have not yet attained the age of six years from the existing GP service under the medical card scheme as provided for in section 58 of the Health Act 1970. They will be covered by the new service under section 58B. As I mentioned above, it is important to be clear that children aged under six will continue to qualify for medical cards, and their entitlements to other health services, such as prescription drugs, will not be affected in any way.

Section 5 provides for the insertion of sections 58B and 58C into the Health Act 1970. Section 58B provides that the HSE shall make available a general practitioner service without fees to all children aged five years and under. It provides that a parent or guardian of a child seeking access to this service should provide to the HSE such evidence as it considers necessary to demonstrate entitlement to the service, and where such evidence is not provided the HSE may treat the child as if he or she is not entitled to the service. Where possible, the HSE will offer a choice of GP to those accessing this service.

Section 58C provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and under. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six-month period following commencement of the section. The contract shall specify the services to be provided by the GP. The Minister for Health may by regulation and with the consent of the Minister for Public Expenditure and Reform fix the rates of fees and allowances to be paid to GPs for services provided under these contracts. The section requires that the Minister, in making a regulation for this purpose, engage in consultation. Further, it prescribes the role of the Minister and HSE, the nature and manner of the consultations and the considerations to which the Minister must have regard in making regulations. Where the rates fixed by regulation under this section are varied under subsequent regulations, a GP who does not wish to continue providing services may terminate his or her contract by giving the HSE three months' notice.

Section 6 is a technical amendment necessary to enable the seamless implementation of section 2. It extends the existing eligibility appeals process to the new GP service for all children aged five years and under. Section 7 states the Short Title of the Act, provides for the collective citation of this and prior Health Acts as the Health Acts 1947 to 2014 and includes a standard provision relating to commencement of the provisions of the Bill.

In conclusion, the main purpose of the Health (General Practitioner Service) Bill 2014 is to amend the Health Act 1970 to provide for a general practitioner service to be made available without fees to all children aged five years and under. The Bill also provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six-month period following commencement of the section. I commend the Bill to the House and look forward to hearing the views of Deputies.

When one reads the Bill, there is little with which one would have major concerns regarding the aspiration to make free GP care available to children under six and the broadening out of that over a period of time to ensure that there is universal access to primary care over the next number of years. That is the stated purpose of the Government. As most people acknowledge, all the various reports suggest that unhindered access to primary care advances the health of the nation. International standards and comparisons highlight that. There are other fundamental issues at stake, however. The Minister talks about universality, which is something we welcome. The issue with it is that it must be funded and sustainable.

We ration health in this country every day of the week because we have a defined amount of money with which to provide health services. Decisions are made day in, day out in the rationing of health. Universality funded by resources that were not taken from elsewhere would be fine but, whether the Minister of State accepts it or not, when one has a defined envelope of money for health service provision and wants to roll out universality of primary care access for under sixes, the money must come from somewhere else. After analysing the accounts, the HSE service plan and last year's budget, the only possible conclusion is that the money is coming from those who need medical care immediately. These are people whose lives have been afflicted by grave illness, physical and intellectual disability and aging. The decision of the Government to launch a vicious attack on those who most need the support of the State in their time of difficulty is almost morally bankrupt. I mean that. It is not just Deputy Ó Caoláin or me saying that; it has been said on all sides of the House over the last number of months. It was said emphatically last Friday at polling stations throughout the country. People want fairness in our health system. When one is rationing health services on foot of the limited amount of money one has to spend and making decisions on who gets services, what one is doing is taking from one to give to the other. That is what is happening here.

To say the under-six provision does not impact on the budget available for discretionary medical cards is not credible. It was stated in last year's Budget Statement that there would be a probity exercise in relation to medical cards to assess the eligibility or otherwise of recipients. That was a coded, polite way of describing the withdrawal of medical cards. It was stated in the HSE service plans for the previous year that there would be a reduction in the number of discretionary medical cards. It is a stated policy of the Government that it will reduce the number of discretionary medical cards. Efforts have been made in the House consistently by the Minister of State and his ministerial colleagues in the Department of Health as well as by the Tánaiste and Taoiseach to assert that there has been no change when it has been stated categorically that there will be a reduction in discretionary medical cards, about which the Minister of State said there was "no such entity". That is as clear as anything.

What is clearest of all is that the Irish people last Friday expressed many views on the Government's policies. The thing they were crystal clear about was their desire for fairness. They want those who need a medical card - those who are dying, have a lifelong, life-limiting illness, are battling cancer or are children with profound challenges - to be looked after first. That is what they said to me. I am sure the Minister of State picked it up also. There is something inherently fair in the Irish people. To announce a grand plan of universality for under-sixes does not camouflage what is happening to those over six. Medical cards are being taken from people at the end of their lives, people with cancer, children with Down's syndrome, men with motor neuron disease, people with multiple sclerosis. That is what has happened here. We have said it time and again, while the Minister of State has asked time and again what my view is on universality. I have said time and again that while I have no difficulty with the concept of universality, it cannot be put before those who most need the support of the State. That is what is happening as we speak today.

A very interesting figure was published with regard to discretionary medical cards, which was that almost 800 were granted in April 2014.

I welcome the allocation of every discretionary medical card. Every one was deserved and, most importantly, was needed. It is interesting that the elections were in May.

We were told there was no change in policy. I welcome the fact that the office of the Minister of State often helped me in pursuing a discretionary medical card, an application, a review or an appeal but the point is that we were told there is no interference. All of a sudden, a plethora of cards were granted in the month of April. I find it interesting to say the least. There were 800 such cards. There was a change in policy and then there was an acceptance that the policy was causing grave anxiety. I am not sure whether the concern was the anxiety of the people or of the candidates meeting people. One way or another, there was an acceptance by this Government, the Taoiseach, the Tánaiste and others that what was happening for the past two years was wrong and unfair.

We are waiting for the Minister of State to come forward with proposals to address the issue. The discretionary system was working fairly well. People say there was disparities between various counties. That is the case and we can argue some counties were overly generous or that some counties were not understanding enough in granting medical cards. I am not sure which it is but discretion is critically important. Over the past number of months, the Minister of State has said that discretion is a grey area and that there are difficulties with it. Discretion is used every day of the week by agents of the State. Children are assessed for special needs assistants and for the number of hours they need. It is discretion when a professional makes a judgment that a child needs two hours, four hours or six hours per week. A public health nurse uses her valued public professional judgment and her discretion that someone needs four, six or seven hours of home help. We do not need a legislative blade that cuts off people from something when they need it most. We need humanity and fairness in the system.

The Minister of State said that granting medical cards on the grounds of illness is a difficulty but I must remind him that it was the stated policy of the Government to grant medical cards on grounds of illness. The first tranche of free GP care was to be for those on the long-term illness scheme. It was a stated policy and I do not see anything wrong with that. I would welcome the Government reversing from where it is, until the nation's finances improve, to grant medical cards to those who need them most first, and as time goes on and as we can expand the economy, we can fund a broader roll-out. Putting it the other way around is morally bankrupt and something I have grave concerns about. These concerns have been expressed in this Chamber and through many organisations that have consistently been saying, for the past two years or more, that a particular issue was causing great concern.

I raised the issue of the withdrawal of discretionary medical cards in January 2013 in the Chamber during Leaders' Questions. A woman who has had a double mastectomy had her discretionary medical card withdrawn. It has been appealed and reviewed but, unfortunately, the woman does not have the medical card. We have raised the issue of children with the most challenging disabilities whose medical cards have been taken from them. All of the families with these major challenges in their lives do not want anything else for themselves. They just want this for their children and are willing to pay for GP care for themselves and for other children. They are quite happy to do so but they want medical cards for their children.

Deputies in this House are on reasonably good salaries and I suspect every Member can afford to pay a GP. However, if something tragic hits a family, we would like to think the State would come in to give some support. Every family thinks the same way. That is why free GP care for children under six years being put ahead of addressing the problem of discretionary medical cards for those who need them most must be addressed quickly. Between now and the debate on Committee Stage, there should be some way of addressing this through the legislative process. Otherwise, the Minister of State should announce the considerations of the Government with regard to addressing the shortcomings exposed over the past two years because of the change in how discretionary medical cards are awarded. That should be done quickly not to satisfy me, but to address the misery and the hardship it causes in our communities.

It affects people but it does not affect all people. It was an issue raised at every second door I went to. There is inherently and innately something fair in the Irish people. If they think they are getting a free GP care cards for themselves or for children under six years when they can afford to go to a GP while a neighbour's child is being denied a medical card, they find it distasteful. Week in, week out, every community is involved in fund-raising efforts at community level, parish level or school level to help a child. That is happening in our communities throughout the country and it is beautiful to watch. People get together and rally around to help someone who needs help. At the very least, the State should be willing to do the same. In that context, will the Minister of State revisit and reverse the policy quickly? It should be done in the context of this legislation.

Reference has been made by the Minister of State and others to the fact that the provisions in the Bill date to the 1970s or the 1950s. The Minister of State says that we must change legislation but that is the purpose of this Chamber. It is within our gift to change legislation and it is within the gift of the Minister of State to propose to the Government to change legislation. The Government can then present it to this House. It is not a major obstacle to change the legislation. In fact, that is the purpose of the debate today. The idea that the Health Act 1970 is a statute that cannot be changed is not the case.

That is what we are doing.

It can be changed, as can the criteria of how we address discretion. Discretion is used by many other arms of the State every day of the week. We provide professionals with the powers to make decisions on a discretionary basis. We do not have legislation to decide how many home help hours someone gets because we trust the public health nurse and her valued judgment to award so many hours within the resources available.

That is discretion. It happens all the time and nobody questions it. We assess children for the provision of resource teaching hours by taking the word of a professional. That is their opinion. This is what we need to do in the case of discretionary medical cards. We need to allow people to make a professional, value judgment, unhindered by the policies pursued in the past two years in the context of a stated policy to reduce the number of discretionary medical cards. This policy of the Government to reduce the number of discretionary medical cards exists is written.

The Minister of State said he was meeting the IMO and others to discuss the contract in respect of children under six years of age. For a long time we have been talking about making primary care the focus in the delivery of health services in the years ahead. Unfortunately, we have spent a long time just talking about this and primary care teams, but we need to get to a position where we fund primary care services. The difficulty we have, as a result of policy, property bubbles and everything else that happened in recent years is that we have a fixation on massive primary care centres which have huge debts hanging over them. That is a concern. We have some fine primary care centres, but they have been holed below the water line financially. Many of them are in huge trouble. However, this should not stop us from trying to build critical mass in primary care services. Even with defined budgets, we must start to look at a way towards setting out a clear path. There must be a transfer of money from the acute hospital sector to primary care services over a period to build capacity. We talk about shifting the provision of chronic illness and disease treatment from the acute hospital to the primary care setting, but this must be resourced. General practitioners have pointed out that this will impact on their ability to treat patients and that is my concern. General practitioners are well able to advocate for themselves. They are professional and competent and have good organisations such as the National Association of General Practitioners and the IMO which act on their behalf.

The key point is that if we increase demand in the system because of the contract for children under six years, this will have consequences. One consequence will be that GPs will not be able to treat those people we want them to treat, including patients suffering from a chronic illness and disease, in the primary care setting. We have a defined number of people who are capable, competent and willing to do this work, but if they are obligated under a contract to provide services for children under six years, there is a serious concern that others will suffer. The people and general practitioners are concerned by this. My concern is that people with COPD, who have diabetes and suffer from other chronic illnesses will no longer be able to have a 45 minute or one hour consultation and that they will drift back to the acute hospital setting. This does not make sound economic sense because the acute hospital setting is the most expensive in delivering health care services. Primary care services must be funded, resourced and expanded.

The Deputy is talking my language. I agree with him.

Another source of concern is that many general practitioners are leaving the country. We must examine and address the reasons they are leaving. Is it purely for remunerative reasons or is it because there are no clear career paths or defined advancement opportunities in their profession? We must address these issues quickly because we are haemorrhaging GPs at an alarming rate. This is a First World country which has a good education system in providing for professional competence in the health sector. I am not particularly happy that people are moving abroad and that we must go to Third World countries to take their best trained to fill the vacuum left because our GPs have moved somewhere else. This is morally wrong. We are enticing and inducing doctors to come here from countries that need these professionals. Some of them come to gain experience and for the remuneration, but it is almost a policy that our doctors go to other First World countries and that we must then scour the third world to find the best and bring them here to fill the vacuum. This is questionable, to say the least. I do not blame the Minister of State for this policy, but we need to resource primary care services. We must make the system attractive for young, professional GPs and other allied health professionals to stay here. A remunerative package is critical, but there must also be clear defined pathways for their professional development. We must move quickly to do this. I have attended a number of meetings organised by the National Association of General Practitioners, spoken to many young GPs and received a plethora of e-mails from them telling me that they are on their way out of the country. This is alarming for many reasons but, most importantly, in the delivery of health care services.

Perhaps the Minister of State might deal with the issue of the Competition Authority in summing up or on Committee Stage. We tabled an amendment to the Companies Act in this context. When the Act was introduced, I supported it. However, I do not believe it was envisaged that the Competition Authority would block the State's ability to have discussions with a service provider; rather, the proposal was made to stop the development of monopolies and price fixing. That was its primary purpose. In a case where an agency or group of people provide services for the State there should not be an inherent block in their being able to discuss with the State how best to provide these services. This issue should be examined. It is welcome that the Minister of State is in discussions on the issue.

A framework agreement being published today addresses the issue. There is agreement with the IMO on the process. We hope to resolve that matter today.

That is welcome. I have pages of information highlighting many cases which have been highlighted for me in the past two years and more to do with discretionary medical cards. The details of these cases have been forwarded to the Taoiseach and the Minister of State's office. The policy on discretionary medical cards must be addressed and I hope it will be. There is a window of opportunity before Committee Stage to do this. I believe the Bill will now be taken on Committee Stage a week later than originally intended and hope something will be done between now and then to address the issue.

On health services in general, we cannot take one area in isolation. The Department has a defined amount of money to spend each year and must prioritise and make choices. I accept this, but some of the choices made and priorities set should be revisited. Dealing with the issue of discretionary medical cards is an obvious priority. The Department also needs to refocus the funding streams from the acute hospital setting to the primary care setting. If it makes economic sense to treat patients in the primary care setting, it should be a priority for the Department which has a certain amount of money to spend to transfer the spending from the acute hospital setting to the primary care setting. We have all bought into the primary care strategy published some years ago, but we need to look at it again to determine how we can deliver primary care more quickly and with more determination.

We have spent more time in this House talking about where the Minister should locate primary care centres than about the primary care system in general. This is an issue I have not yet got to the bottom of and it is another day's work.

I do not ever expect to get to the bottom of how they define the locations for primary care centres given that I have tried and failed. However, we live in hope on that issue.

Some interesting figures have come out on waiting times. We now have a major concern that waiting times are creeping up rapidly and the numbers of people waiting are also creeping up. The number of people who have been waiting for a year or more to be seen as outpatients has increased from 4,000 at the end of last year to more than 14,700. The outpatients figure is quite alarming even though the Minister, Deputy Reilly, has said on numerous occasions that it is not a major issue of concern - I do not mean by this that he is not concerned about it. He said it would be easily resolved because approximately 250,000 outpatients a month are seen. However, the figure is now moving rapidly in the wrong direction and that area needs to be looked at quickly.

While the Minister of State talks about the successes and I try to make proposals from time to time that might be considered, I would be failing in my duty as an Opposition spokesperson if I did not also highlight the failings. The area of waiting lists needs to be looked at very quickly or else there will be grave difficulty very soon with regard to the numbers of people waiting for outpatient, inpatient or consultant appointments. That is happening as we speak. When we consider the acute hospital budget overrun for the first three months of this year, the Government will find itself with a major problem at the tail end of the year and that needs to be addressed.

I will not oppose the Bill on Second Stage. I have grave reservations because it prioritises healthy and wealthy children over those who need the service more than ever. That has been happening for the past two years. I believe the budget ring-fenced €37 million for GP-visit cards for those aged five and under. However, when one builds a fence one can keep people out with the fence or keep people in. The ring-fencing of the €37 million has taken €37 million away from those who need it more at present. I hope I will be able to support the Bill on Report and Final Stages because the Government will have added the measures, with which I will try to assist it, on Committee Stage to ensure that people who need the support of the State because they are exceptionally ill or dying will get it first and foremost. We need to introduce an element of fairness, humanity and compassion into the system of how we assess people for the provision of medical care.

The debate on this Bill is timely because the cutting of discretionary medical cards was undoubtedly one of the key issues in the local and European Parliament elections and in the two by-elections just concluded. This issue was presented at door after door to canvassers across the political spectrum.

The effective removal of discretion as a category of medical card has had a devastating impact on many families, especially those with seriously ill or disabled children. During the final week of the last Dáil sitting before the elections Sinn Féin tabled a Private Members' motion calling on the Government to reverse the cuts to discretionary medical cards imposed in the Health Service Executive 2014 service plan. Now, with an even stronger mandate from the people, we make that call again here in this debate.

The Government must ensure that the HSE treats with due respect, consideration and compassion all applicants for medical cards, taking fully into consideration not only incomes but the burdens imposed by medical conditions, illnesses and disabilities. It should consult with all Oireachtas Members, and not on a selective party political basis, on the effects of the cuts on citizens. It should extend free general practitioner care to all on a programmed, timetabled and transparent basis and in such a manner that, at the least, no one entitled to a full medical card under the current rules will lose any of the services provided under the card in the context of a free-GP-care-for-all system. It should clearly set out in legislation entitlements to health care and, in line with the recommendation of the Convention on the Constitution, provide for an amendment to the Constitution to recognise the right to health care. I urge the Minister of State to note that and act on it.

This is not about tweaking the current system, or providing a kinder voice on the telephone or a more nicely worded letter. This is about ensuring that those most in need receive the health care they require and when they require it. The State is failing to do that at present.

As I have stated repeatedly in this House and outside it, we need to set our aim higher and work towards universal health care, including primary care, delivered free at the point of delivery. It must be based on medical need not on ability to pay or geographic location and it must be funded on the basis of fair and reformed general taxation.

The principle of universality is fundamental, a view I believe we share. It is the best guarantee - the only guarantee - that no one is denied the medical care they need. It is deeply regrettable that the Government has undermined the principle of universality in two important ways. First, it has set in train a system of privatised universal health insurance as the way to fund and organise health care. This is to be based on competing private for-profit health insurance companies. We do not know what the so-called basic basket of care will be, which immediately begs the question as to what is covered by the term universal? What type of care or types of conditions may be excluded?

Second, the Government has undermined the principle of universality by its treatment of medical card patients. On the one hand it brings forward this Bill to provide free GP care to children aged five and under. On the other hand it has cut discretionary medical cards and last year it enacted two Bills designed to remove medical-card coverage from more people over 70 years of age. These are real and stark contradictions.

We have moved from having in place universal medical-card coverage for over-70s under the previous Fianna Fáil-led Government to that Government’s attempt to end universal over-70s coverage altogether. This was followed by huge protests by older people leading to a partial U-turn with provision for the over-70s being made subject to a higher income limit. Under the present Government, that income limit was lowered once in budget 2013 and was lowered again in budget 2014.

At that time the Minister for Public Expenditure and Reform, Deputy Howlin, defended the taking of discretionary medical cards from children with disabilities by asking if it was right that such children from wealthy families should have them.

Simultaneously, however, the Government signalled its intent to provide GP cards for all children aged five and under regardless of income or wealth and as provided for in the Bill before us. Since then I have inquired on many occasions where the consistency is to be found in these policies, if one can refer to them as policies at all. A Fine Gael-Labour Party Government which states that it is committed to the provision of GP care for all at the point of delivery is actually moving in the opposite direction. Discretionary medical cards are being cut back even for some of our most needy citizens, young and old. I know some of those people personally and I have given voice to their specific needs.

Under the Health (Alteration of Criteria for Eligibility) (No. 2) Act 2013, more people over 70 years of age lost their cards and fewer will qualify when they reach the age of 70. Prior to 2008, people over 70 received medical cards without a means test. When the then Fianna Fáil-led Government decided to end that entitlement, the current Minister for Health, Deputy Reilly, who was then the Fine Gael health spokesperson, described this move as a "vicious attack" and a "savage assault on the elderly". Then came the Fianna Fáil-led Government’s climb-down - to which I have already referred - in the face of mass protest by older people. The 2008 legislation set the income limit for over-70s medical card qualification at €700 per week for a single person and at €1,400 for a couple. What did Deputy Reilly, then in opposition, say in response? Here in this Chamber he stated it was a "desperate climb-down" that represented nothing but a "tinkering with income limits" and was "nowhere near good enough". In budget 2013 the income limit for medical card qualification for those aged over 70 was reduced from €700 to €600 per week for a single person and from €1,400 to €1,200 per week for a couple. The income limits were cut again last year, this time to €500 per week for a single person and by a whopping €300 to €900 per week for a couple. When this was announced, Age Action Ireland stated, "It is contradictory to be removing means-tested cards from a section of society which has high medical needs, in a budget which is rolling out free GP care for children and heralding it as the roll out of its universal primary care plans."

That brings us to the point we have reached today with this Bill. At the very time when the callous cuts to discretionary medical cards affecting some of the most seriously ill and disabled children are coming to light, we have been presented with this legislation. Quite naturally, this is prompting people to ask why is the Government giving with one hand and taking away with the other - and, most pertinently, taking from those who are most in need and giving to those who are possibly least in need. Citizens are understandably asking where the fairness lies in giving automatic entitlement to free GP access to a healthy child of four but denying it to his or her very ill or disabled sister or brother. Where is the fairness in giving free GP care to a disabled child from birth and taking it away on his or her sixth birthday? These are the anomalies and inequities that are built into a system which does not offer universality of access on the basis of medical need alone and regardless of income, age or - in view of where I live on this fair island - geographical location. The Government will argue that it cannot roll out universal free GP access in one go. That is fair enough. We support universality and, in that context and as I have informed the Minister previously, we will not oppose this Bill and are prepared to regard it as a first step. Where, however, is the timetable and the programme to roll out universal free GP care in a progressive and transparent manner? It is not contained in the Bill. That sounds all sorts of alarms for me.

How will the Bill be implemented? It is clear that the Irish Medical Organisation, IMO, has set its face against this legislation and the proposed new GP contract. That is what I have heard to date. The chairperson of the IMO's GP committee has stated:

This legislation has nothing to do with GP visit cards for children. It is nothing less than a unilateral attempt to replace the long-standing GMS Contract with a new, draconian contract which will destroy the very fabric of the GP service in Ireland and there are very serious concerns as to the future viability of the service.

The individual in question is well known to the two Ministers who are now in situ. The IMO has also pointed out that the proposed contract would penalise whistleblowers with the clause - I ask the Minister and Minister of State to note this - which states that those under contract "shall not do anything to prejudice the name or reputation of the HSE". I note that the Minister of State, Deputy White, has said that the Government is prepared to negotiate all aspects of a new contract with the exception of that relating to fees. This clause should certainly be top of the list for deletion from the contract as now drafted.

That would not be a Sinn Féin deletion, would it?

I welcome the Minister. I am sorry he cannot remain for the remainder of the debate.

The Minister of State has also indicated that competition law precludes him from negotiating in respect of fees.

I wonder if the Deputy might allow me to make a brief interruption in order that I might point out that in my initial contribution I indicated that I have concluded with the IMO a framework agreement to provide for a process of engagement with it on the entire contractual issue. I am merely trying to be of assistance to the Deputy and I am not trying to challenge him. The framework agreement to which I refer was only announced at lunchtime and I referred to it at the beginning of my contribution. Good progress has been made with regard to the relationship between the State bodies and the IMO in the context of negotiations.

I am conscious of what has been happening. Perhaps the Minister, Deputy Reilly, distracted the Minister of State; he may have missed it when I noted that he has indicated that the Government is prepared to negotiate on all aspects of the new contract, with the exception of that which relates to fees.

The framework agreement goes beyond all of those issues. That is why I am trying to help the Deputy.

Is the Minister of State indicating that this includes fees?

The framework agreement will deal with all of those issues.

Again, I am commending to the Minister of State - nothing that I have said changes this - that he should address several issues. At the top of the list is the need to address the section 31 clause, for want of a better description. I can only speak in terms that I have long known and, sadly, been affected by myself.

The Minister of State will certainly understand it from his previous role in life before coming to the House. Again, I put it to the Minister of State that the reference in the contract to "shall not do anything to prejudice the name or reputation of the HSE" is an outrageous insertion.

The Minister of State can clarify the matter in his response at the end of Second Stage, but he has stated that he is precluded from negotiating on fees by competition law. That is what the Minister of State has said on the public record. If that were to be revisited or changed I would welcome it, as would the Irish Medical Organisation, I have no doubt. If there were such obstacles to the process, a full and inclusive engagement would be problematic and such an engagement would of itself, I suggest, cast doubt on the operability of this legislation, because the general practitioners' willingness to function with and to embrace what is being provided for would render the whole exercise decidedly difficult in delivery terms.

The Government may insist on proceeding with the Bill, and, as I have indicated already, we will not oppose it. However, as I have pointed out to the Minister of State, it is flawed, it lacks clarity and, importantly - I emphasise this point to the Minister of State - it lacks a timetable for the roll-out of universal free GP care as a first step to universal access to health care for all. This timetable is critical to my and my colleagues' support. We have no wish to see an indefinite disparity between those who are being provided for under this legislation and those who will clearly be excluded. It is very important that the continuum of what is being provided for in the legislation is signalled at the earliest stage possible.

This Bill comes at a time when the Government is actually exacerbating inequality of access to GP care. The Government is now clearly mired in controversy with general practitioners, the announcement of today's engagement excepted.

It is an agreement.

It is an agreement to engage, not an agreement of finality and closure on the issues. Anyway, I wish the exercise success; let us make no mistake about it. There is no other way but to sit down and hammer out the issues, and I welcome the development today as the essential first step.

We also need to take into account the legitimate concerns of GPs regarding the under-resourcing of primary care. I have no doubt that this will also be a factor to be addressed. This was made clear in an IMO presentation to the Joint Committee on Health and Children only yesterday. The organisation stated that the workload of GPs had increased while resources have been cut. The number of patients with a medical card and GP visit card has increased by 500,000 in the past six years while resources have been cut by €160 million. The Government spends only 2% of total health expenditure, public and private, on general practice - I expect the Minister of State is fully conversant with the statistics - compared to 9% north of the Border in the Six Counties and in Britain. Practices are struggling. I accept that this is factually the situation not only in the circumstances of GPs that I know and those I have met personally but in many practices throughout the State which are struggling financially and in terms of capacity. This is neither a tolerable nor sustainable position for the future.

Simply put, the Government must go back to the drawing board with this Bill. In any and all of the points I have made I am keen to see in-built within the legislation a commitment to a timetabled roll-out of universal access and, initially, to free GP care across the board. This is essential for wider public buy-in to what the Bill provides for. As I have said, I will not reserve my position. As I have indicated from the outset, my intention and my colleagues' intention is to support its passage. I hope the Minister of State will be able to allay my fears in respect of the Government's follow-on intent.

Deputies Pringle and Clare Daly are sharing time, with 15 minutes each.

There is something a little sick about a situation whereby we are in the House discussing a proposition to allow GP cards for children under six years against the backdrop of all of our offices being inundated with parents of children who happen to be slightly older than six years, perhaps teenagers, who are victims of the most appalling illnesses or disabilities. However, because of their age and because of the Government's changes to the discretionary medical card system, they are being denied the medical assistance they so desperately require.

When the issue was raised during Leaders' Questions yesterday, the Minister for Finance, Deputy Noonan, sort of laughed it off and asked whether the Deputies on this side of the House wanted everyone to have a medical card, as if this were some sort of outrageous proposition to put forward. In reality, the idea of universal health care for all citizens as a right based on medical need or necessity is something we should be fighting for, and it should be funded through a progressive taxation system, rather than a discretionary scheme which discriminates against people because of their financial means.

I wish to put on record my support for the parents who launched the Our Children's Health petition and campaign yesterday. They are demanding amendments to the Health Act 1970 such that all children, rather than only those under six years, particularly those who have been diagnosed with a serious illness or congenital condition, would be entitled not only to a GP visit card but to a full medical card based on medical need. This issue needed to be addressed urgently. In some ways the Government's proposition on this issue has been viewed as something of a stunt against the backdrop of the situation that many seriously ill children are in.

I offer one example of a child in my area who happens to be seven years of age. This child has had several operations since her birth. She was diagnosed with infantile scoliosis. The family have had a medical card since 2009, although both parents were working - they continue to do so - and they were around about the threshold. Last year the medical card was taken away from the family at a time when the child's health was deteriorating and when her consultant recommended that she needed a back brace and other medical assistance. The family applied for a medical card for the child but it was refused because of their income. Basically, as well as coping with the child's illness, they have spent the past year trying to deal with that. This has been completely and utterly demoralising for them. In an e-mail to me the father said - I find it heartbreaking - that if he gave up work the system would look after his family healthwise, but perhaps, by working, he was doing undue harm to his daughter in being unable to provide for her medical needs, a terrible thing for a parent to have to say.

We must address urgently the question of access to general practitioner, GP, care for all citizens, but other Deputies have highlighted that there have been considerable difficulties with the scheme from the beginning. There has been a kickback from the GP organisations. The Minister of State mentioned that the Government had sorted out the issue with them, but we will see. It has been ongoing for months, yet people will only start to debate it at the eleventh hour. How could the medical profession which one imagines is only concerned with looking after patients, building practices and doing a good job be driven into organising large public meetings and major e-mail campaigns and hounding politicians for months to be heard? There is something wrong somewhere along the line. I hope the heads of the agreement will sort out the problem, but many issues need to be addressed.

Like us all, the Minister of State will have received correspondence from a number of GPs, one of whom I will address. When this GP's assistant left the practice, the GP decided to emigrate because the stress of the job was too much. The practice could find no one to fill the vacancy, which is not uncommon. One of the factors that pushed the GP into deciding to emigrate was the idea of a GP contract for under six year olds. The doctor who had operated as a qualified GP for four years stated the Department's proposition had forced her into emigrating. She highlighted a number of issues with the original contract, which I hope will be sorted out in the Minister of State's talks. Under the scheme as proposed, she would have been asked to do work that had been scientifically discredited, for example, screening and measuring well children. She would have been asked to tick boxes and waste time on bureaucracy instead of dealing with sick patients. It gave no indication of how much GPs would be paid. How could any business operate like this? It created layers of extra supervision when GPs should only be engaged in looking after their patients. GPs were gagged in criticising the HSE. The GP concerned cited many other issues as an affront to GPs' professionalism. She concluded her correspondence by saying she was leaving the country to work in a system under which the state respected its full-time workers and that general practice, the one part of the health service that had been managing to function, albeit under strain, was being put into free fall by this measure.

The Government must fight an uphill battle in its talks with GPs who have overwhelmingly rejected the proposals made. If they are to give their agreement, I can only imagine that the current proposals stand the original scheme on its head. I hope these issues will be addressed, but bringing the scheme into being on top of the dysfunctional medical card system creates the wrong emphasis and is a poor way of doing business. This morning I received what could only be described as an hysterical telephone call from an upset wife, whose husband had been in hospital for the past month with Alzheimer's disease. She was facing the prospect of their medical card not being extended at the end of this month because allegedly they had not submitted enough information. When we rang to find out what financial information was being asked of this older citizen, it turned out to be copies of her house insurance and mortgage protection policies, her car log book showing travel expenses which she had never claimed in the first place and a GP's report which she had already submitted. The woman concerned who was dealing with a sick husband in hospital was told that, unless this information was submitted, her issues would not be addressed.

During the Private Members' time debate on medical cards I asked whether the system's dysfunction related to some extent to the fact that the reviews had been given to a German company, Arvato, to be conducted. It has been alleged that one reason there have been so many reviews since 2003 is that a private company's IT department performed a roll-over on a computer because of a backlog in 2012, which resulted in everyone, including people with no entitlement, receiving a medical card. Now the system is in free fall and trying to reclaim some of these medical cards. Innocent people who deserve their medical cards are being caught in the crossfire. When I raised in the House the issue of Arvato being involved in reviews, the HSE issued statements to the effect that that was not the case and that Arvato was only involved in data capture, whatever that phenomenon is supposed to be. That is not the case. I contend that Arvato is involved in the review of medical cards and either the Minister of State is not being told or he is not telling us.

The medical card centre in Finglas is staffed by a mixture of directly employed HSE workers and agency staff. The system is in complete mayhem. These agency staff who have been employed as a result of the public sector recruitment embargo and legislative changes which mean that they cannot be discriminated against in their pay are costing significantly more. Not only must they be paid the same amount as directly employed workers but the agency must also be given a cut of the profits. There are more than 100 workers in that category. The Arvato staff who have handled reviews received one day's training from existing staff, some of whom came from the HSE, while others had been seconded from the likes of the Central Statistics Office. I am sure they are good workers, but statistics and medical card reviews are entirely different. The people concerned did not receive training. When someone becomes a community welfare officer, he or she is given three to four week training, must sign the Official Secrets and Data Protection Acts and receive Garda clearance before ever being allowed to look at, for example, a rent allowance claim. No such checks are made in the much more sensitive matter of medical cards. Staff who have worked in the centre have put it to me that Garda clearance is not even sought until the person is made permanent, which might happen after four years.

The company lacks training in and an understanding of how the system works. This is the only explanation for the bizarre decisions being imposed on citizens. Let us be clear - these decisions mean the difference between people being able to manage in their lives and having the stuffing knocked out of them when they are at their most vulnerable, namely, when a loved one is sick, a child has a severe disability, etc. Unless the Government addresses these issues, it will be judged on the basis of callousness, over which no previous Government has stood. Lauding proposals to, for example, provide free GP care for all under six year olds as some sort of stunt is not sufficient. If the Government is serious about looking after the needs of children, it must move urgently for those whose ill health requires intervention now, regardless of their age. It should then get its act together and introduce universal health care.

I welcome the opportunity to contribute to the debate. I give the Bill a guarded welcome, as the provision of universal health care rather than universal health insurance is something towards which the Government should strive. There has been a great deal of debate. Despite developments in the past year and a half in terms of the provision of medical cards, the bombshell only seemed to hit the Government when its members canvassed during the local elections and they realised that this was a serious issue for many across the country. We have seen some of the publicity generated in this regard. This shows the value of raising concerns in the House, even though they fell on deaf ears.

The problems with the medical card system, the removal of discretionary medical cards and the withdrawal of medical cards from seriously ill children and children with life-limiting disabilities have been raised in the House continuously in the past year and a half, yet the Government has not listened. It was only when its members started knocking on doors that they realised the extent of the anger over the issue. If the Government took note of what happens in this House it might not have received such a shock in recent weeks in realising the importance of these issues. When we see families with children aged under and over six years who are in dire need of their medical cards having them withdrawn and having to go through hoops to have them restored, it is an indication that the system does not care about them and that it is about saving money, as the Government laid out in the budget.

I have asked the Health Service Executive to consider that some people applying for medical cards for their children know that they exceed the income limit but they are applying for them on the basis of medical need. However, the Primary Care Reimbursement Service, PCRS, will go through the process of assessing their income, requesting additional information and delaying the decision on whether there is a medical need by forcing people to produce additional financial information when they know from the outset that they will not qualify and must get the application assessed on medical hardship grounds.

If the Minister intends to change the system and make it more responsive, I believe it could be done easily. When an application is received, rather than starting with assessment of means, it should be assessed on medical grounds initially to ensure that if somebody has a medical need they do not need to go through a means test and the card can be awarded. The problem with that system is that it is going on the premise that the PCRS wants to award the card. The problem is that applications are being dealt with in such a way that people are prevented from getting their entitlements. I believe that is being done because a certain number of people will not use the appeal or review systems and will not have the heart or the ability to battle the system to achieve that to which they are entitled.

In recent months the PCRS appears to have learned from the Department of Social Protection in terms of the way it deals with medical cards. When applications are submitted for medical cards now, the PCRS gives a commitment that they will be dealt with within 15 working days. They are not actually registered on the system for nine or ten days after they are received; the 15 working days does not start until they are registered on the system. I have dealt with many cases in which it was acknowledged to my office that an application had been received by the PCRS, but two weeks later it still had not been registered on the system as having been received. When we raise it with the PCRS we are told it has not received the application. When I state that we have an e-mail confirming receipt of the application, the response is that it has not been registered on the system. It is about delay and preventing people from getting fully through the system and receiving their medical cards.

Regarding the Bill, I welcome the Minister's indication that a framework agreement has been reached with the Irish Medical Organisation on the detail of the talks, but there are a number of issues in the proposed contract that must be highlighted. Other speakers highlighted the gagging clause whereby a general practitioner will not be able to say anything that brings the HSE into disrepute. That must be removed immediately, because it is madness. GPs must be able to talk about the way the health service is operating, bring information to the fore and ensure we can identify changes that must take place.

Also included in the framework agreement is the idea of health checks and regular health monitoring of the population, which I understand has been in the United Kingdom contracts for a number of years but which is being examined with a view to removing it from the contracts because it has not been shown that it is of any real value or that it works.

There is no doubt that the provision of free GP care to children under the age of six will lead to extra visits to GPs. The Growing Up in Ireland report estimates that there will be an increase of 0.6 visits per child if they receive free medical treatment and GP visits, but that has been overstated. I become concerned when I hear the IMO stating that medical card patients visit the doctor much more frequently than private patients. The reason for that is that people with medical cards generally are less well off or ill and therefore they need to visit the doctor more frequently. The number of extra visits may not be as high as has been indicated by some of the medical organisations, but there is no doubt that visits will increase.

I had three children under the age of five, and during those years we felt that we were visiting the doctor at every turn. There are many families waiting for that measure to be implemented so that they can rest assured that if their children need to visit the doctor they can afford to take them. As children reach the age of six or seven, the frequency with which they visit the doctor declines significantly because they are not as prone to chest, throat or ear infections.

Another concern about the legislation is that access to medical cards may be restricted for children under the age of six. The Minister denied this in his contribution, but the evidence within the medical card system makes a lie of that. I hope it does not happen, but I believe the medical card system will use the fact that children under six have free GP visits to restrict access to medical cards for those children. That is being rolled out, but I believe we will be here in a year's time raising incidents of children who are covered by the legislation being unable to access medical cards. That they get free GP visits will be used against them and their families to restrict their access to medical cards. I hope that will not happen but I believe it will happen because all the evidence shows that the way medical cards are being dealt with currently will be used to restrict access by children who are ill to the additional supports and care they need.

There has been talk - the Minister mentioned it and it will probably be dealt with in the talks under the framework agreement - of some limitation on the number of visits a child under six will be entitled to under this system. I hope that does not rear its head again, because it will make a mockery of the entire system. Probity reviews were brought in this year. Will similar probity reviews be carried out under forthcoming budgets to limit the number of visits children under six can make to their GP under this scheme?

Another aspect of the legislation that concerns me is the idea that to qualify under the scheme one must be ordinarily resident in the State for at least one year. I have a lot of experience of dealing with habitual residence conditions within the area of social protection. It is a system that is used to restrict access and make sure that people who have a genuine need for payments cannot get them. People are being refused without any regard to the conditions for qualification. What people need to be able to show that they qualify under this residency condition is laid out, but the Department of Social Protection ignores them and refuses people in the hope that a number of them will not continue to fight through the system.

Debate adjourned.