Dáil Éireann díospóireacht -
Thursday, 29 May 2014

Vol. 842 No. 3

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

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

Deputy Catherine Murphy

I will take up where I left off last night. For me, the three critical issues in this legislation are the capacity of general practitioners to take on the additional work, whether what is proposed will be at the expense of sick children and other people losing their medical cards, and whether additional infrastructure will be put in place. For example, in some locations public health nurses are not able to carry out routine developmental checks and other vital health checks which detect problems at an early stage because of the reduction in their number and the pressures on the service. Two years ago, €20 million was made available in the budget for the recruitment of additional speech and language therapists in locations that had been identified as being most under-represented. Not all of those positions have been filled. My constituency happened to be one of the worst areas in that a quarter of all vacant positions were in that area. That should not come as a surprise, given the demographics of Tallaght, west Wicklow and Kildare. It is critically important these posts are filled if we are to be able to provide services for people who have been identified as having needs, particularly children. While a child's need for speech and language therapy may be detected at an early stage, because they often have to wait up to two years for services, they start school without their needs having been met, at great cost in later life to the child.

The Minister of State needs to explain who will bear the cost of this. The Daily Mail recently published a five- or six-page article on a family who are constituents of mine and whose situation I have been raising for the past six or eight months. I also assisted them last year in putting together an appeal. If the Minister of State has not read it, I can forward a copy of it to him. This family, after succeeding in getting a medical card that was valid for three years, was told nine months later that it was up for review. The family, in which there are four children, is under incredible pressure. The youngest child will qualify for a medical card but the person in the household who needs it most, who is six years old and has cerebral palsy, will not. It is not only GP visits that are at issue in this situation; it is access to occupational and speech therapy, repairs to the child's wheelchair and so on. The child is also PEG-fed. That is just one example.

In some cases, the withdrawal of medical cards does not even make economic sense. I know of a man in his mid-thirties who is working and has two children and a mortgage. He needs a medical card because he has kidney failure. He told me that if he had to choose between paying for his medication to keep himself well or paying his mortgage he would choose to pay his mortgage. If this man does not get his medication he will end up on dialysis and will perhaps lose his job. While this will result in great cost, financially, to the State, the cost for that man will be greater. In another case, a mother had to give up her job in order to care for her baby who had to be fed through a tube. If the provision of this service is at the expense of such people, I would find it hard to support it. I want an assurance that this is not being provided at their expense.

General practitioners are of the view that patients who are well should not be used as ammunition to generate unnecessary health care activity when patients with higher needs are being routinely deprived of medical care. I believe it would be unethical of general practitioners to enable current Government policy, which is clearly aimed at political rather than health service gains. Although I understand that GPs are an interested group, it is important to listen to what they have to say. Some of what they are saying is very valid. I would not like to see a situation in which people have to make appointments and not see a GP for five or six days, thus putting pressure on acute hospital services. What would we be gaining? I have serious concerns about this legislation and look forward to hearing the Minister of State's response.

Deputy Richard Boyd Barrett

I will take up where Deputy Murphy left off. I am in favour of universal access to health care. The repeated emphasis in the Minister of State's introductory speech and the Government's setting out of its vision to develop the health service is on the need for universality in access to health care. The removal of user fees from any group is to be welcomed. I believe that user fees for health services are unacceptable, obnoxious and wasteful. There are a myriad of reasons why we need to remove them but, as has been said by Deputy Murphy and generally over the past while, the perfectly understandable perception is that we are giving free GP care to the under-sixes at the expense of other groups of chronically ill, disabled or elderly people with serious medical needs. The perception is that this is the quid pro quo. That is unacceptable. The Minister of State will say that this is not the case and that additional money is being provided.

We heard on Sean O'Rourke's show again this morning about the appalling and most impossible circumstances of families with severely disabled children who were being denied medical cards. It might have been related to the family to which Deputy Catherine Murphy referred. This week an elderly lady came to my clinic who could barely breathe. I could hear that she had an inability to breathe. She had a severe, chronic, permanent pulmonary condition and was wheezing constantly during our conversation. She informed me that her medical card had been withdrawn and that she had to reduce by half the medication she took, although she might literally collapse and die, of which she was fearful. She feared going up the stairs or going out for a walk. She could barely breathe, yet her medical card had been removed following a review. This is absolutely unacceptable.

Understandably, people ask how the Government could possibly endanger the lives, health and welfare of severely sick, disabled and elderly people, while at the same time giving free access to health care to children whose families may well have sufficient resources to pay for it. As a supporter of universal access to health care, I do not accept the setting off of one against the other and do not want to go down that road. It is absolutely understandable people are asking what the hell the Government is doing when they see medical cards being taken from chronically sick and disabled people. It is difficult not to conclude it is a political stunt.

I want to see universal access. We are not going to oppose this measure, but we are against the slashing of health budgets and what was referred to in euphemistic jargon, to cover over budgetary cuts, as "medical card probity". I love such phrases. In this case, probity means savage cuts affecting the disabled, the sick and the vulnerable. That is what probity turned out to be, as predicted by us when the measure was included in the budget. That is the current position.

The Government must do something to ensure the two sides are not set against each other. Young children should have access to whatever health care they need. I applaud and concur completely with the idea that we need to move towards preventive health care and what is proposed is a step in that direction. If we ensure children are healthy from a young age and give them the access to the health care they need, it will pay off and pay dividends further down the line, but this cannot be achieved where the policy is set against the literal endangerment of the lives of some of the most vulnerable, the ill, the elderly and disabled people. That is appalling and unacceptable.

Deputy Catherine Murphy's point is well worth underlining in the light of the example I gave of the lady who came to my clinic this week. Ultimately, there may be no savings, as the Deputy said. The lady who came to my clinic literally looked like she could collapse at any time. If she collapses, she will end up in an accident and emergency unit. This will cost more than it would if we were to give her the medication she needs by returning her medical card. What is occurring does not make sense and I seriously hope the Government will address that appalling set of circumstances.

Everybody deserves health care when he or she needs it. We need to allow for universal access that is free at the point of need. Nothing is free in this world; it is always paid for, but it is a question of whether we pay in a fair way through central taxation. This is linked with ability to pay and is thus fair and progressive. It is critical that people receive the health care they need when they need it.

Let me outline where I am critical of the particular model of universality in question. I have made the point on a number of occasions, including to the Minister, Deputy James Reilly, that linking universality with a plan to involve private health insurance companies is inappropriate. Putting the money into the pockets of private health insurance companies is sucking out resources that should be going into front-line services and contributing to the required staffing levels, health care, the recruitment of doctors and nurses, etc. I do not see why we need these companies or what value they add to the process. I have not heard any justification for their involvement in it.

The examples of Holland and the United States were raised by us on a number of occasions. I refer to the so-called Dutch model and the US model. As I pointed out on a number of occasions, the United States spends more, proportionately, on health than any other country, but 40% of that expenditure is on administration linked with private health insurance companies. It is utter waste. The money is spent on advertising, billing and all that unnecessary crap, including paying the massive and inflated salaries of the top executives in the health insurance companies. Why do we need them? We do not. Why are they involved? They should not be. They are profiting from health care and the health needs of ordinary people. It is all the same, whether the money spent in this way is sucked out of the pockets of citizens through inflated health insurance costs or the public purse. They are equally bad. It is money down the drain and a complete waste. What we need is a national health service and free access to health care at all levels, from the cradle to the grave, provided by a public health service funded through central taxation. This would remove all the waste and the middleman who is sucking out the money.

The Government needs to address the concerns of general practitioners. I am glad that there has been some agreement, but the case general practitioners made to us at the meeting in the Burlington was pretty scary. They were saying they were leaving; some had actually bought their tickets to go on the grounds that they were in an unsustainable position. Unless we get them on board, this will not work.

Deputy Denis Naughten

I welcome the opportunity to speak on this legislation and agree with its principle. The Minister of State, Deputy Alex White, probably has the most important job in the State at present in trying to develop the primary care sector. If he can achieve this, he will have done a service, probably for two generations to come, but it is a daunting task. The Bill is one small step in that direction.

Like previous speakers, I must ask who is paying for this. It is sad that every second person coming through my door or contacting my constituency office is doing so about a medical card. This morning at 8.15 a.m. a general practitioner in my constituency rang me to apologise for the number of patients he had been referring to my office about medical cards.

He explained to me the level of desperation he has in trying to deal with the volume of people coming in to him in situations where their medical card has been withdrawn and where he is trying to put the paperwork in place to justify the reinstatement of that medical card for people who are critically ill or have chronic diseases, and do not have the means to pay for their medication.

The whole idea behind discretionary medical cards is that they are there to address undue hardship. As the Acting Chairman will know, down through the years we have done that, particularly in the area covered by the Western Health Board, which was one of the most of the difficult health boards to get a medical card from. However, if one actually presented a clear case to the appeals officer at that time, a discretionary medical card was issued. That no longer applies. The hardship is now being caused when applying for or trying to renew a medical card, or trying to appeal a decision which was wrong in the first place. What I have found in recent months since the whole issue of probity came to the fore is that we are now denying medical cards to people who are legitimately entitled to them, black and white, and not just with the discretionary medical cards. I had a belief this practice was happening in the PCRS but it was only when I came across a recent case that I could actually prove it. I have e-mailed the details to Mr. Paddy Burke and I am still awaiting a response from him.

In this case, a 79 year old woman was informed at the end of April, on the renewal of her medical card by the PCRS, that she had lost her card because she was over the income threshold. Luckily, a relative who lives close by picked up the telephone and got through to the medical card section in Finglas. In fairness, the young woman at the other end of the telephone very politely went through the figures with her and it was realised that the Finglas section had made a mistake. The PCRS had calculated the woman's HSE widow's pension, which comes on a fortnightly basis as it does for every single HSE pensioner in the country, on a weekly basis. The PCRS staff member was very apologetic and said the PCRS had made a mistake and that the woman should not have had her medical card withdrawn. However, she then asked if the woman could submit an appeal and get her payslip from the Department of Social Protection along with the payslip from the HSE, and the PCRS would then rectify the matter. Of course, it takes three weeks for the data to go up on the computer systems in Finglas and it takes 15 working days to process the application that goes to Finglas. When nothing came back, I contacted Mr. Burke's office and pointed out that this woman would probably have to wait six weeks to get back a medical card to which she was entitled, in a situation where his staff made a mistake in regard to the calculation of her entitlement.

Her relative contacted me yesterday, irate, to tell me she had received another letter from Finglas informing her that the payslip did not state that the pension was paid fortnightly by the HSE, and that the PCRS wanted a letter from the HSE stating this. When that went in, the PCRS would reinstate her medical card. Therefore, she will have to wait another three weeks before the case is looked at again. It is just not good enough that a 79 year old woman who is legitimately entitled to a medical card has to go through these loops to get a card. If there was such concern that she had all of this money under the mattress, could someone in the PCRS not pick up the telephone and call the paymasters in the HSE to ask whether its pensions are paid weekly, fortnightly or monthly, and issue the card to the poor woman?

This is a renewal card. My understanding was that when it was a renewal, until a final decision was made on it, the person held onto that card. Of course, the decision to refuse was made on flawed mathematics and this woman has been denied her entitlement in the interim.

In another case I am currently dealing with, a man who is undergoing cancer treatment returned his renewal application and the PCRS wrote back to him looking for additional documentation. He sent back that documentation but when he went to his GP earlier this week, the GP said, "Tom, I am afraid your medical card is no longer valid". Again, it was my understanding that, pending any decision on the cards, people would retain their entitlement until a decision was made.

In another case I am dealing with, a young man with epilepsy has appealed a decision to the Ballyshannon office. Again, we are told that once an appeal is submitted, the medical card is reinstated temporarily until a decision is made. He had to go to one of the Dublin hospitals last week, and he was told he did not have a medical card and that he had no cover. He has to go back next week and he telephoned me yesterday in fear of what they are going to say to him when he goes back.

In another case, a young man who is just over 16 years of age has been informed that if he does not respond within 21 days of the date of the letter regarding his application, the case will be closed. The real sting in the tail is that the letter to him states that a new medical card-GP visit card application form will have to be submitted with up-to-date documentation. If anything puts the fear of God in people, particularly sick people, it is having to fill out the form, gather up all the documentation and get it resubmitted to Finglas again, when it should be there on file in the first place.

The reason this young man cannot send back the documentation is that he needs to have his parents' medical card reference number in order to have the application processed. The difficulty is that the PCRS has his parents' medical card suspended and they must wait for another six weeks before they will get a decision on that before he can respond. In the meantime, he will be told that, because it is outside the 21 days, he will have to go through the whole rigmarole again.

We deal with the Department of Social Protection on a regular basis, and the target is that documentation has to be sent back within 21 days. It could be 22, 25, or 30 days, depending on the time it takes to get the documentation from the different agencies involved. However, I have yet to have a case where the Department of Social Protection came back to me to say it was rejecting an application because it was outside the 21 days, although if it an application is six or 12 months late it might legitimately dismiss it. The idea with the medical cards is to break people down and to create as much hardship as possible so they will abandon their application. The policy is to try to force people to throw in the towel, to surrender, to put up the white flag. That is what probity is about within the PCRS at the moment.

I have another example in regard to documentation that was sent by e-mail from my office on 8 April last. On 14 May, the PCRS wrote back to the family looking for the same information. The family came to me wondering had I sent on the information, and I had the record that I had sent it. Nonetheless, I sent it on again to the PCRS, enclosing the original documentation, and still no decision has yet been made.

We are told with great fanfare that the troika has left the country and we are back to our own devices. Yet, we find that the processing of these applications has been sent to Germany. Naturally, someone in another jurisdiction will look at the black and white situation regarding the rules of the medical cards, and say that a person is not entitled to a medical card based on the rules.

Of course, as the Minister of State knows, based on the rules, nobody is entitled to a medical card in this country. The income limit for a single person is €184, and the social welfare rate is higher than that, so nobody is entitled to a medical card, if one looks at the rules that are set down there in black and white, because the rules have not been updated. The Minister of State should not look confused about that, because it would really scare me if he did not know the income limit for a medical card.

I spoke to a postman at the weekend who told me that he dreads going out with the medical card review letters. The fact that older people are living in fear of getting that letter from Finglas telling them that their medical card is under review, even if they have only had it for a couple of months, is one of the reasons the Government got such a bashing during the recent elections. It is the threat of the withdrawal of that card that causes the fear. People who have lost their medical cards and cannot afford their medication are visiting GPs such as the one with whom I spoke this morning to ask them what tablets they really need to take and what medication they can put on the long finger, because they cannot afford to buy all of it.

Another issue with which the Minister of State can deal very quickly is the lack of understanding of what is and is not covered by the medical card. People are coming to me who are afraid of having to pay for an outpatient appointment - which, of course, does not have to be paid for regardless of whether the person has a medical card. These are people who, based on the comments of Ministers, are legitimately and legally entitled to a medical card but who are denied that at the moment. Each of those cases involves a person who is entitled to a medical card pending a final decision or who is entitled to a medical card based on the figures he or she has submitted but who has not got it. I am not talking about discretionary medical cards. These are people who are entitled to medical cards, but they are being denied them.

The other issue on which I wish to focus is that of children over the age of six who have a profound disability or illness. As the Minister of State knows, we have spoken about children with life-limiting conditions. I put a proposal to him that we create a national fund of about €8 million that could support home care for those children. These are children in palliative care situations who will never have the opportunity to vote for the Minister of State or for me because they will never see their 18th birthday. Some of those children are stuck in very expensive paediatric beds in hospitals in this city, costing approximately €150,000 per year. We cannot find the €24,000 or €25,000 that the Jack and Jill Foundation needs to keep them in their own homes or that the LauraLynn children's hospice needs to care for them in the hospice service, yet we have a fund of about €8 million that is spread across the country in respect of the various primary care units. If we could pool that nationally, it would be an effective budget. We are not talking about new or additional money to provide very valuable care for these children. We are talking about using the existing money more efficiently to deliver a service for some of the most vulnerable children in this country. I hope that in his response, the Minister of State can update me on the progress he has made on this issue, which has been on his desk for more than 12 months.

My next point relates to the Our Children's Health campaign. I met the people involved in that campaign earlier this week. The Minister of State knows their objective is to try to ensure there is an automatic entitlement to a medical card for children diagnosed with a serious illness or a congenital condition. We are giving automatic entitlement to every child under the age of six, yet we are told that we cannot legally grant automatic entitlement to people with particular conditions, which is, of course, wrong. This tripe is being given out to these parents who have seen what has gone on. There is a lack of understanding of the hurt caused to a parent when they get a letter asking them to prove that someone with a genetic disability such as Down's syndrome still has the condition. It is really hurtful to get a letter like that and it really drags any family down.

If we are talking about giving every fit and able child and every child with a disability under the age of six a medical card, we should review matters regarding sick children over the age of six. There is nothing worse than having a child with a long-term illness that requires parents to go in and out of hospital. They have enough on their plate in trying to meet hospital appointments without having to go through the rigmarole about which I spoke earlier. It hurts me when these parents come to me and I have to help them jump through the hoops to try to prove their entitlement to a medical card. Two of those parents met me this morning to speak about genetic illnesses. It is just not right that they have to go through the yard manure about which I spoke earlier. We wrote into law through the Health (Amendment) Act 1996 a provision giving women who had contracted hepatitis C from contaminated blood, due to a monumental mistake by agents of the State, a legal entitlement to a medical card based on a medical condition and regardless of means, so it is possible to do it. We are talking about a small handful of children and I will tell the Minister of State why it is just a small handful. There are about 56,000 discretionary medical cards in this country, and we are talking about the withdrawal of roughly 2,000 of those per year due to probity measures. The sort of money we are talking about is around €2 million, based on the average cost of a medical card. Of those who have discretionary medical cards, perhaps about 50% - probably fewer - are in respect of children, so we are talking about a very small cohort of children who would not automatically be entitled to a medical card or who would be entitled to a discretionary medical card once they have gone through all the hoops. Enshrining this entitlement in law would mean they would not have go through these hoops any more and would get a medical card by right. The Minister of State can set down in a statutory instrument exactly what those conditions are. He knows the implications of it, including financial implications.

If we are considering introducing an entitlement for under-sixes, surely we should be looking at this for what is a saving to the Exchequer of about €2 million per annum. That is the sort of money we are talking about. It makes such a difference to those families. I will press this on Committee and Report Stages and I hope the Minister of State will examine it. I know he is one of the exceptions in the Government. When I met the families this week, I told them he is a Minister who thinks and listens to what goes on in this House. I know he will take this away and consider it. I hope that by the time this legislation is passed, he will still be dealing with it - or, possibly, he will be in a more senior position to deal with it.

Deputy Finian McGrath

He could be leader yet.

Deputy Denis Naughten

I ask the Minister of State to look at this and not to put it on the long finger. I will be tabling an amendment. The provision is there and the precedent has been set. There is conditionality in respect of the hepatitis C issue, and in this case the condition could be that the person is under the age of 18. Parents should not have to go through the yard manure about which I have just spoken. I urge the Minister of State to deal with this mess.

People who are legitimately entitled to medical cards are not getting them because the PCRS believes the only way it can make savings is to deny people who are legally entitled to medical cards.

Deputy Finian McGrath

I am grateful for the opportunity to contribute to the debate. The Bill is relevant in the current climate, particularly in the context of the issue of discretionary medical cards and the horrific problems faced by sick and disabled children who are being hounded about their medical cards. Medical need must be the top priority, on which there can be no fudge. I call on the Government, in particular the Ministers for Health and Children and Youth Affairs, to act on this matter. It is a question of priorities and values. A society or state that does not look after the sick, the elderly or the disabled is going nowhere, but, above all, it is one without a heart. Let us deal, first, with the issue of sick children; second, look after the disabled; and, third, look after senior citizens. When we have dealt with these priorities, the Government can move on with its broader vision and reform plans and address the professionalism required in the health service. Anybody who says the opposite in this debate is not serious about providing a top class, quality health service, which is the objective of most Members. I agree with much of Deputy Denis Naughten's contribution. A consensus is emerging that we must provide a quality health service with universal access, which is professional, caring, humane and built on compassion. However, there is also the reality that it must be paid for.

The legislation provides for free GP care for children aged under six years who are ordinarily resident in the State. The HSE will provide a choice of GPs for this purpose in so far as it is practicable to do so. Nobody disagrees with that principle; therefore, I welcome the legislation. A total of 240,000 new children will have access to this service. Before that happens, the Minister must consider the position of the minority of children who are very ill. They must be prioritised. The Government also has to put into practice all the talk uttered by its members about the rights of children, the children's rights referendum and putting children first. We must ask ourselves whether we are doing this. We are not putting sick children first and enough is not being done for children with an intellectual or a physical disability or children who grow up in families in crisis or who come from disadvantaged backgrounds. These issues need to be addressed in this legislation which deals with the health and future of children.

I am annoyed when I consider the priorities that are sometimes accepted by the House. A classic example was yesterday's meeting of the Joint Committee on Justice, Defence and Equality, of which I am a member. We wanted a few clear answers on the issue of Garda whistleblowers and the Guerin report, but we could not get them. A number of inquiries are due to be held, some of which will cost approximately €2 million. This morning I was contacted by a group of parents from Darndale in my constituency who use an excellent preschool service that looks after 260 children and employs 100 staff. It is a beautiful example of a playschool that adopts best practice in dealing with vulnerable children and it works. I have been on site and met the children, parents and staff. However, they face a budgetary shortfall of €200,000. I raised the issue with the former Minister for Children and Youth Affairs, Deputy Frances Fitzgerald, and the newly appointed Minister, Deputy Charles Flanagan. There seems to be money available for many other projects, but sometimes when it comes to children's issues, they are parked and we have to kick and scream and jump up and down about them. Again, it is a question of priorities and values.

We need to support children with disabilities. Six months ago the Committee of Public Accounts investigated the disability sector in the context of the high wages being paid and the squandering of money. While that debate was ongoing, disability service providers were coming under pressure because of cutbacks of between 3% and 5%, but this was ignored. We need to face up to this issue.

In budget 2014, €37 million was allocated to cover the cost of accessing free GP care under this legislation, which equates to €154 per each child who gains eligibility. The legislation also amends the existing legislation on appeals concerning eligibility for GP services. The programme for Government, in the extract dealing with primary care, states:

Universal primary care will remove fees for GP care and will be introduced within this Government's term of office.

The legislative basis for Universal Primary Care will be established under a Universal Primary Care Act.

Universal Primary Care will be introduced in phases so additional doctors, nurses and other primary care professionals can be recruited.

It is essential when introducing such changes that this be done in phases. The programme for Government also states:

Access to primary care without fees will be extended in the first year to claimants of free drugs under the Long-Term Illness Scheme at a cost of €17 million...

Access to care without fees will be extended to all in the final phase.

Many of us support this philosophy in providing a quality health service. I stress, at the same time, that we must pay for it, which will mean additional costs and, therefore, increases in taxation. However, most realistic, sensible people say privately that if they were guaranteed a good quality health service, they would not mind paying an extra few bob for it.

Fine Gael has looked to Holland and elsewhere for examples of best practice. However, the Government should examine universal health care systems that work in other countries such as Cuba. I have visited that country and its health service is amazing. The GP service is excellent when one considers Cuba is a poorer country than Ireland and being hammered by the United States through a trade embargo and sanctions. It is disgraceful that a small country such as Cuba is being hammered by the United States. They are located within kilometres of each other and people should sit down and resolve the issues involved, particularly when Cubans have a good quality primary health care system which we all could emulate. We have to be open and creative. Every society has its faults and extreme right-wing people will give out about Cuba, but that is their problem. The country has a quality health service that works and we should not be afraid to look at it.

The Government states it wants to plan a quality health service with universal access based on equality and medical need. Those of us who support that principle want to see this happen. However, on occasion the Government parties are not prepared to stand up for it. The cuts to child benefit were an attack on children. Meanwhile prescription charges for medical card holders increased to €2.50 per item, while the rate of stamp duty on pension schemes for senior citizens increased to 0.75%.

In addition, 35,000 medical cards were taken out of the system. Another disaster was the cut of the bereavement grant of €800. Maternity benefit was cut to €230 per week, which will cost mothers €832 this year. We must examine these issues as well if we are considering an overall health strategy and plan. It is important that we deal with these issues in the legislation.

We talk about costs and GPs' private fees. The data on GP private fees are not routinely collected, but sources say that an informal check found that the fees in urban areas were approximately €50 to €55 and that they were slightly lower in rural areas. In 2009 an Economic and Social Research Institute, ESRI, research paper by Samantha Smith stated that private charges for GP visits ranged from €40 to €60 and that the charges varied according to GP and could be hard to predict in advance. The Competition Authority has highlighted the rising cost of doctor visits and its impact, stating that the cost of visiting a GP had risen rapidly in recent years, significantly outpacing the general rate of inflation in the economy. It said there were indications that a substantial number of private patients were delaying GP visits due to cost factors and shopping around for cheaper consultation fees. That is something we must examine. We met such people on the doorsteps during the local election campaign, people who said they were afraid to pay the extra few bob to go to the GP. They were outside the threshold.

Health must be a priority. I missed the earlier part of the debate but I understand the issue with the GPs has been resolved. Is that correct?

Deputy Alex White

We have a basis for resolving it. We have agreed a basis for talking.

Deputy Finian McGrath

I welcome that. I had intended to raise their case because we have talked to the GPs and understand their situation. It is very difficult. We do not wish to lose high-quality people so we must ensure they are supported. We understand the costs they have in terms of administration and so forth. When I visit my GP, his clinic sometimes resembles the very busy clinic of a backbench Deputy. With so many people there is stress, and the staff are under pressure too.

Under this scheme, approximately 240,000 children - that is, 57% of children under six - will gain entitlement to free GP care that they did not have previously. A total of 420,000 children aged five years and younger will be eligible under this scheme. Within that number, 181,000 - 43% - will retain the eligibility they currently have for GP care under a medical card or GP card. These figures reflect the number of children aged under six in the last census in 2011, which is 420,745. However, we will have to be prepared, because the Central Statistics Office, CSO, has projected that by 2014 the population of this age group will have increased to between 441,907 and 443,133, which suggests there will be a little over 20,000 more children aged under six years in the State than the figures quoted. We must be constantly vigilant about the numbers because we have a rapidly growing population. This is also having an impact in our primary schools, particularly on the junior infant classes.

I mentioned the high cost of GP visits. Currently, GPs earn income by way of fees from their private patients, which are approximately 60% of the population, and providing services to public patients under the GMS scheme, which covers medical cards, GP visit cards and other free-at-the-point-of-use services such as immunisation and screening. The IMO has argued that the GMS scheme is designed to protect the poorest and most vulnerable in society and that it believes the integrity of the scheme is lost in this proposal. This was said in a debate that was held earlier. The Society of St. Vincent de Paul was also worried and said we must target people on low incomes and people with particular needs. That fits into the points I made earlier. We must ensure that the poorer and weaker sections of society are not forgotten in this broader debate.

Another issue arose recently. I do not know if the Minister saw "The Saturday Night Show" with Brendan O'Connor which featured Declan Coyle and his family. His son Alex, whose medical card has been axed by the HSE, was brought into the studio. He requires a cocktail of syringes, feeding pumps, nappies and medication. All of his issues were related to us. We cannot allow situations such as these to arise. It should be about medical need, the rights of the children, protecting their health and supporting their families.

Overall, I welcome the legislation. I will always support reforms that are sensible and I will always support a health service that is based on equality and respect for the citizens of this State. If we are serious about building a new republic, and there is cross-party consensus on this, people must accept that changes must be made. We cannot return to the ways of the past. We can use this opportunity of reorganising the country and the public finances to start afresh. Many other countries have done that in the past. There is no reason we cannot start to build from the mess of the banking crisis of the last number of years, the evolution of the international financial crisis and the rampant greed that was in our society for many years. We can all learn and make a start. We can start through small measures such as this legislative measure. That is one part of it, but we must also be very realistic and sensible. If every person in this State pays their few bob and their tax for the health service, they are entitled to a health service.

Equally, there is the issue of those who work in the public service and the health service. The vast majority are doing a fantastic job, sometimes against the odds. However, we must ensure that standards and professionalism are always maintained, and there have been many cases in which families have been let down. All of us must constantly up our game. That is what public service is about. It is amazing that we are losing many good nurses and medical personnel. They train and go to college here - we spend millions on them every year - but then leave within two or three years. We must stop that brain drain, particularly in the medical services. Those young people are the future of the health service.

Legislation such as this can assist young children, but it can also kick-start the fulfilment of a broader vision of a health service that looks after its patients and makes top-quality health care the priority.

Minister of State at the Department of Health (Deputy Alex White)

I thank the Deputies for their contributions on this Second Stage debate. The contributions were extremely thoughtful, not just on what is provided for in the Bill but also on the broader issue of medical cards, the awarding of medical cards and the allocation of resources generally. It has been a very good debate.

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 in the Future Health strategy framework. It has been decided to commence the roll-out of a universal GP service by providing all children under the age of six years with access to a GP service without fees. I emphasise, as Deputy McGrath and others fairly acknowledged, that this is just the first phase of a comprehensive project. Additional earmarked funding of €37 million was provided in budget 2014 to fund this first phase.

It has been made very clear that this measure is not being funded on foot of savings implemented elsewhere in the health system. There are good reasons to provide universal access to GP care in view of the health needs of this particular age cohort. The early identification of health issues at a young age can mitigate or reduce the impact of ill health later in life. I am aware that Deputies have raised concerns regarding medical cards awarded on foot of the exercise of its discretion by the HSE. I will return to that issue before I conclude.

The legislation's key features are the entitlement for all children aged five years and younger to a GP service without fees, the removal of the need for children aged five and under to have a medical card or GP visit card under the GMS scheme to qualify for the GP service, and a provision whereby the HSE may enter a contract with GPs for the provision of the GP service to children. The Bill further provides that the Minister may set the rate of fees payable to GPs for the service.

As I stated on Second Stage yesterday, I was pleased to announce the conclusion of a framework agreement with the Irish Medical Organisation. The framework agreement sets out a process for engagement on the whole GMS GP contract and other publicly funded contracts involving GPs. The agreement has been reached following a series of discussions with the IMO by the HSE and the Department, led by myself. 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 for medical practitioners and within the context of the provisions of the primary legislation to 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.

I welcome the support expressed by Deputies in the House for the further strengthening of primary care services generally in Ireland. I acknowledge that endorsement has also been given by most if not all speakers to the introduction of universal access to the health system in place of the existing two-tier health system as soon as possible. Contrary to the concerns raised, for example, by Deputy Billy Kelleher, it is not expected that the Bill will have a dramatic impact on the capacity of the GP service in Ireland. We have done some modelling work on the impact which shows there will be some. It is an issue I look forward to discussing with the representatives of GPs in the course of our engagement on the new contract we now need.

There has been a suggestion that the approach of discretion worked well in the past. While I acknowledge this, it is a fact that significant regional variations in the issuing of discretionary cards arose. For example, 24 cards per 1,000 persons were issued in Cork while four cards per 1,000 persons were issued in Meath. In the view of the ombudsman, the different treatment of persons depending on geographical location is improperly discriminatory, an undesirable administrative practice and contrary to fair or sound administration. I reject the suggestion that the number of discretionary medical cards was increased by 800 cards in April for what a Deputy described as "election purposes". The HSE has never ceased awarding medical cards through the exercise of discretion in accordance with the framework set out in the health legislation.

Notwithstanding the foregoing, the Government is very aware of public concern about medical cards. The Cabinet sub-committee on health met this morning and decided to develop the policy framework governing eligibility in a manner which also takes account of medical conditions. The HSE will establish an expert panel to examine the range of conditions that should be brought into consideration. The process will include the development of a new legislative framework as necessary. In light of the decision, the HSE's director general will now suspend reviews of medical cards where discretion has been exercised to take account of medical circumstances. The Department of Health has also been mandated to develop a policy paper on the further roll-out of GP care free at the point of access in the context of the move to universal health insurance. The Minister for Health will present a memorandum for Government setting out the next steps in this regard.

To return to the Bill, as all children aged five years and under will be covered by the new GP service under the Bill, children who have not yet attained the age of six will be removed from the existing GP service under the medical card scheme. It is important to be crystal clear that children aged under six who are currently entitled to a medical card will continue to qualify for a medical card and their entitlement to other health services, including prescription drugs, will not be affected. The Bill provides a framework whereby the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained GP for the provision of general practitioner services to all children aged five years and younger. The Minister for Health may, by regulation, with the consent of the Minister for Public Expenditure and Reform, fix the rate of fees and allowances to be paid to GPs for services provided under these contracts. The relevant section requires that the Minister in making a regulation for this purpose must engage in consultations and it prescribes the role of the Minister and HSE, the nature and manner of the consultations and the considerations to which the Minster must have regard in making regulations.

The new framework agreement we have reached with the IMO will govern the basis of our engagement, consultation and negotiations with the representatives of GPs so that they are integrally involved in the planning, roll-out and necessary contractual arrangements needed to underpin this new service. I look forward to that real and meaningful engagement, as sought by the IMO, on all aspects of the contract.

I thank Deputies for their contributions on the proposed legislation and commend the Bill to the House.

Question put and agreed to.