Health (General Practitioner Service) Bill 2014: Second Stage (Resumed)

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

I understand Deputies Seán Kyne and Patrick O'Donovan are sharing time.

I welcome the news that the legal difficulties in arriving at a contract have been resolved between the Irish Medical Organisation and the Department of Health. This is certainly something that general practitioners raised with many Deputies during recent months, both individually and collectively at a meeting that I attended at the Ardilaun Hotel in Galway. I welcome that the difficulties that arose can be resolved.

The medical card issue has arisen during the course of the local and European elections and, indeed, over the last six months in particular. There is a lack of discussion and reasoned debate on the cost of the medical system and how the system can be substantially funded. There is also a lack of honesty about the figures. There are nearly 2 million medical and GP cards in circulation at present, covering 43% of the population. Unfortunately, on a case-by-case basis, medical cards have been withdrawn incorrectly and wrongly, which is very much to be regretted. Many constituents with medical conditions deserving of medical cards are without them because of the financial focus of the legislation. I am particularly talking about cases in which there are family members with Down's syndrome, autism or other conditions whereby the person would have had a discretionary medical card for a number of years, but because of the financial threshold or due to the centralisation of the system in Dublin, that card was suddenly withdrawn. This is of grave concern. I know of parents who lost a medical card for their daughter who has Down's syndrome. Their view was that we can impose whatever tax we want, be it income tax, property tax or water tax, but the medical card was for their daughter because she was different, because she was special and because she would always have that condition, and, therefore, she was deserving of a medical card in her own right. That was the premise of their argument and it is something that is very difficult to disagree with. That whole area needs to be looked at in any further review of the legislation, and if new legislation needs to be brought in, so be it. This needs to be considered.

I also expressed disappointment regarding the medical card plan for those who are covered by the long-term illness scheme. I accept that this was legislatively difficult to do but it was something that was committed to, and I am sorry it has not been brought to fruition.

The Health (General Practitioner Service) Bill 2014 is to provide a legislative framework for the provision of free GP care for all children under the age of six. This is the first step in the phased introduction of universal free GP care. Overall, 420,000 children will have free GP care, and the 181,000 who already have a GP card or medical card will be joined by a further 240,000 who will gain entitlement under this Bill.

The number of GP visits made is related to price, and research shows that free GP access results in more frequent visits to the GP. However, common sense dictates that the sooner illnesses are treated, the lower the long-term cost both to the patient and to the health system. Budget 2014 set aside €37 million to meet the costs of this new policy from an overall health budget of €13.66 billion in 2014. While over 40% of the population have a medical card, I would agree that children are a priority health group. However, thankfully, the vast majority of children do not require ongoing GP care and attention. At the same time, there are many adults with long-term or chronic illnesses who benefit from free GP care. Ireland is the only EU country that does not offer universal primary care cover, and most OECD countries have free or heavily subsidised primary health care.

The IMO, the Society of St. Vincent de Paul and others have criticised the new direction of introducing free GP care for those under six, because they believe it moves away from the current general medical scheme, GMS, objective of assisting the most vulnerable and the less well-off in obtaining primary medical care. However, the GMS will continue to exist. Currently, those with medical cards are very often better able to access primary care than many of those on middle incomes due to the costs involved.

It is important to highlight that GPs have contributed to stabilising and repairing the economy. GPs have experienced a reduction in fees paid under the GMS. In 2008, GPs received €353 per patient per year. In 2012, that figure was reduced to €243 per patient, and a further reduction was implemented in July 2013. However, the overall amount paid by the Government to GPs under the GMS remained at €450 million. This is due to the fact that an extra 600,000 people have become eligible for medical or GP visit cards. The GMS system has been maintained largely due to the co-operation of GPs and the health service. It is important to recognise that the economic crisis simply meant that the GMS could not have been funded at the pre-crisis level.

The news regarding the agreement reached today is very welcome. This is something that has been discussed with doctors over a long period of time. There was much concern about this move, including the fact that GPs were unable to negotiate their own contracts and certain aspects of the original draft contract, so it is certainly very welcome and positive news that this change has taken place. I hope they can go into these negotiations and sign the contract. Obviously, this legislation will allow that contract to come into being and allow the delivery of a key component of universal health care for our under-sixes.

I would like to reiterate the point regarding those who suffer from conditions such as Down's syndrome or autism. There is a very serious anomaly with regard to what we as a Government have been doing in withdrawing medical cards from these children on financial grounds while at the same time introducing legislation to give medical cards to children under six with no regard to their parents' finances. This anomaly needs to be addressed. The Minister of State said that it is not possible under the existing legislation. Fortunately, those children who had medical cards up to now had them under existing legislation. They had them by discretion, by default or based on community welfare officers knowing the real details and getting to know the people, the cases and the fact that these children had particular conditions. It is important that we re-examine that. We have been at fault in respect of what we have done in certain cases such as this. It is very difficult to stand up here and support a model such as this, although I fully support it, while at the same time trying to defend the removal of medical cards from children with autism or Down's syndrome based on their parents' income. There is a dichotomy between what we are doing and what we are planning to do. I hope that the Minister of State will be able to look at that area and, if it does not fall under the 1970 Health Act, to introduce new legislation to allow for different criteria and a different type of medical card based on existing conditions such as those I have outlined. I certainly hope, and I think it has been suggested by the Minister of State and the Taoiseach, that this can be looked at very soon. I hope it can be introduced because there is a need and a demand. We have lost touch with those families who have suffered from the withdrawal of medical cards in those cases.

I note that the acceptance of a scheme such as this by GPs is hugely important. They play a huge role in our health care system. It is a health care system about which there is very little complaint, or probably none. We know there are many complaints about different areas of the health sector, but the GP sector is not one of those. I hope they can sign up to this contract as soon as possible now that the IMO and the Department of Health have successfully negotiated their deal and that we can see this legislation enacted and rolled out to provide free GP care for the under-sixes as committed to in the programme for Government. I look forward to that. Additional finance may be needed, but that is a decision for the Minister, as the deal today stipulated that there cannot be any negotiation of fees element in the contract.

The next speaker is Deputy Catherine Murphy, who is sharing time with Deputy Boyd Barrett.

In principle, I support the idea of universal health care as a positive element in society, but I feel that inadequate consideration has been given to the practical consequences. The incremental measure will lead to a decline in the quality of health care for many people. I look at the practical side of this. If one is going to deliver a measure such as this, one needs to do it in co-operation with those who will deliver the service. When we talk about free GP care, I look at some of the most basic care, such as that provided by the public health nurse to new infants in development checks. Some of these have been dispensed with, because there is inadequate cover with regard to that side of things. It shows how threadbare our primary health care service really is. We run the risk of making GPs into bureaucrats and of having very long delays for people who require an immediate visit to a GP but who will have to make appointments days in advance, as is the case in some parts of the UK.

I would have liked to have seen an impact analysis in advance of this legislation so that we could have some understanding of how it will pan out. I would like to see the service provided to children under six, but I would have thought that if one was looking at the pecking order of need, one would have looked first at those who are sick or who have disabilities - the cohort of people who would have had an expectation of medical cards. I think the Government had set this out as their expectation for the roll-out. I do not know why this criterion or intention was changed.

We are certainly turning doctors into bureaucrats. I have ongoing dialogue with the local GPs in my area, who are constantly going to and fro. We are asking them to fill out forms for discretionary medical cards, which is time they should be using to deal with the health needs of people who turn up at their practices rather than administrative needs of the HSE. I know the IMO is a vested interest, but it is also quite expert in this area. It is extraordinarily critical of this Bill and has pointed out that if introduced, it would certainly lead to an increased workload in clinics and a need for additional resources. Has this point been considered? At the very least, it should be considered. If it is not valid, I will accept it, but there may be some validity in what the IMO is saying and, at the very least, it needs thorough consideration.

The point has been made by GPs that it is not enough to simply introduce free health care for those under six. What we need is a preventative health care plan for each child. An interesting fact I have come across, as I am sure most other Deputies have, is that when a child receives an early diagnosis, very often he or she ends up on a very long list even for fairly minor procedures such as a tonsillectomy. I was told that the waiting list in Tallaght is two years and that one might be better off advising people to go back to the GP and see if another hospital can accommodate them.

Debate adjourned.