Dáil Éireann díospóireacht -
Thursday, 16 Apr 2015

Vol. 874 No. 2

Health (General Practitioner Service) Bill 2015: Second Stage (Resumed)

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

Deputy Colm Keaveney

In December 2011, a briefing note was sent from the office of the then Minister of State with responsibility for the implementation of GP care. It details the sequencing of the introduction of the free GP scheme as originally intended. This was early in the lifetime of the Government and before electoral concerns came to the fore for the parties in government. The memorandum states that free GP care is to be phased in over the term of the Government.and that this would take place in four phases, after which everyone would be entitled to free GP care. The note goes on to argue that it would take four phases to allow for the financing of the initiative and the recruitment of more GPs and practice nurses. The first two phases were chosen on the basis that the numbers were known and were small enough and manageable.

Each of the phases is set out in the programme for Government and they are as follows:

Phase 1

The first phase will involve providing free GP care to claimants under the Long Term Illness Scheme.

Phase 2

The second phase will see free GP care extended to claimants on the High-Tech Drugs Scheme.

Phase 3

The third phase will involve extending subsidised GP care to everyone. There are a number of possible scenarios for this and these are being looked at. In particular, we would hope to use this phase to focus on preventative care, particularly for people with chronic health conditions.

Phase 4

The fourth phase will involve extending free GP care to all.

The note goes on to provide some points of clarification and states:

- Please note, only those people who qualify for the Long Term Illness Scheme and who are current claimants will benefit in the first year. This amounts to about 56,000 people. One of the main beneficiaries in the first year will be people with diabetes.

- The reform is scheduled for commencement around early Summer 2012, although this is subject to change. The reform will require legislation and there are a number of logistical elements that have yet to be worked out.

Almost three years have passed and the Government parties' original plan for rolling out the scheme has failed.

The briefing note to which I refer went on to provide further clarification on how the scheme would operate, including information on the medical conditions that would be covered in phase 1. They include: mental handicap; mental illness; diabetes; haemophilia; cerebral palsy; epilepsy; cystic fibrosis; multiple sclerosis; spina bifida; muscular dystrophy; acute leukaemia; and conditions arising from use of Thalidomide. As can plainly be seen, the original intention behind this worthy scheme which Fianna Fáil supports was to roll it out by prioritising on the basis of need and leaving those of us who are generally healthy until last. Sadly, and in response to increasing electoral imperatives, the Government lost the will to roll out the scheme in a fair and just manner. Instead, it decided to prioritise the rolling out of the scheme on the basis of where the greatest electoral gain might be achieved. This resulted in the announcement in recent days of an agreement with one of the GP representative bodies to extend free GP cards to those under six years of age. This will provide free GP care for all children under six years, while children who are seven or eight years of age and suffering from long-term illnesses will be denied such care. I genuinely see universal GP care as potentially being a great step forward in the area of public health and want it to be implemented. However, I cannot understand why the Government proceeded to introduce it in the way I have outlined.

Many of those who are in dire need of care and languishing on waiting lists are questioning the Government's policy in this area. The scheme should have been rolled out in the way that was originally intended, namely, with those in greatest medical need being prioritised. Legal concerns have been cited as an explanation as to why the Government decided to proceed in the way to which I refer. However, that explanation is insufficient. What does a parliament do? The answer is that it creates laws. If there are legal concerns about or impediments to the roll-out of long-term illness cards, the place to take action and solve any problem is in these Houses. Shortly after sending the briefing note from which I have quoted, the Minister of State concerned felt compelled to step down from her position on a matter of principle in another area of public health policy. Once she was gone, the political will to implement policy on long-term illness cards in a fair and just manner was lost.

The Bill before the House involves the extension of the scheme to those over 70 years who currently do not qualify for long-term illness cards. Approximately 36,000 will gain from this measure. I welcome this aspect of the Bill and look forward to supporting it, as we should provide for some ease of comfort and security for senior citizens. The Government no doubt hopes the Bill will buy it some forgiveness from the elderly for the series of attacks to which it has subjected them during its term of office to date. Deputies opposite should be aware that elderly people will not forget and that they are not prone to forgive. Only two years ago, the Government brought forward legislation to take medical cards from the over 70s.

Deputy Leo Varadkar

The party of which the Deputy is a member did that when it was still in government and before we took office. Of course, he was still in the Labour Party at the time.

Deputy Colm Keaveney

I would be grateful if the Minister------

Acting Chairman (Deputy Joe O'Reilly)

The Minister should not interrupt.

Deputy Colm Keaveney

Was the Minister a member of the Progressive Democrats?

Deputy Leo Varadkar

No.

Deputy Colm Keaveney

Is he going to join Renua Ireland?

Deputy Leo Varadkar

No.

Deputy Colm Keaveney

Over two years ago the Government brought forward legislation to take medical cards away from those over 70 years of age. In the spring of that year-----

Deputy Leo Varadkar

This is-----

Deputy Colm Keaveney

We can all change.

Deputy James Bannon

We all remember the former Minister of State, Mr. John Moloney, and his actions in respect of the elderly.

Deputy Colm Keaveney

In the spring of the year in question cards were taken from over 20,000 elderly people and a couple of months later a further 35,000 were taken. During Leaders' Questions last week the great Deputy James Bannon laughed when it was announced that children were being placed in psychiatric wards.

Deputy James Bannon

We know too much about the Deputy and his way of operating.

Deputy Colm Keaveney

I know too much about the Deputy.

Acting Chairman (Deputy Joe O'Reilly)

The speaker should be allowed to continue, without interruption. In addition, he should not seek to be as provocative as he has been up to now.

Deputy Colm Keaveney

Deputy James Bannon should wait for the crumbs to fall from somebody else's table.

The dramatic cut in the number of medical cards to which I refer was accompanied by hikes in prescription charges, the abolition of the telephone allowance, an increase in DIRT on savings, changes to the household package and the scrapping on the bereavement grant. A sense of security is essential for all of us. It is particularly essential for the elderly because they have a right and an entitlement to some comfort at their stage of life. The Bill will certainly provide some security in terms of their access to medical care. However, the cuts to which I have referred, particularly the abolition of the telephone allowance, have done much to undermine their sense of security. Many elderly persons were reliant on the telephone allowance to pay for their land lines and the security alarms attached to them. This might mean nothing to Deputy James Bannon, but it means a great deal to senior citizens, particularly those in County Longford.

Deputy James Bannon

The Deputy is all over the shop.

Deputy Colm Keaveney

If older people got into difficulty in their homes, previously they could have alerted others to their need for assistance by pressing a panic button. I accept that this is a "smirking" issue for Deputy James Bannon, but it is not for senior citizens throughout the country. The abolition of the allowance removed the security blanket which having an alarm offered to many elderly individuals. Like County Longford, my constituency is largely rural and many people live in isolation. The removal of the security blanket to which I refer has forced some of my constituents to move from rural areas into urban settings. Those who did not move are living with a sense of unease and discomfort as a result of the threat they perceive. Is this the kind of society those opposite want to create?

I will not be opposing the Bill. As a slight and insufficient measure to reverse the attacks the Government has made on senior citizens, it has some merit. However, it is debatable whether it has such merit in terms of being a move towards the roll-out of universal free GP care. It is a shame that the Government parties lost the political will to implement the policy it set down in 2011. Those suffering from long-term illnesses, including children as young as six years, are not going to be covered. Those to whom I refer have been told to go to the end of the queue and wait until the parties in government are done with their attempts to win re-election.

Deputy Jack Wall

I wish to share time with Deputy James Bannon.

Acting Chairman (Deputy Joe O'Reilly)

That is agreed.

Deputy Jack Wall

It gives me great pleasure to support the Bill which provides for a universal GP service for everyone over the age of 70 years. This is a significant and important step on the road towards free GP care for the entire population. The Bill will also provide a much-needed boost for pensioners because, regardless of their income or means, all persons over the age of 70 years will have access to free GP services. In addition, it provides that dependants, including spouses and partners under 70 years of age, will have access to GP services free of charge in circumstances where the existing income qualifying criteria are met.

When introducing the Bill, the Minister of State indicated that general or family practices were often viewed as being at the core of the primary care system. I support her view. The confidence patients build up in those who work in their local practices helps to alleviate a great deal of the fear and dread which senior citizens and others have when faced with medical problems.

The new arrangements will allow greater confidence in the relationship between the GP and the patient. The young couples who will be bringing their children under the age of six years to their GPs will be commencing a lifetime of medical care with that doctor or primary care centre. It is a question of building confidence over a period of time.

I had to deal with a sad family incident recently. It was gratifying to see the level of confidence my family had in our own GP, who had been caring for my family for many years. His support for my family during that sad occasion had to be seen to be believed. The same could be said for the consultants who treated Anne. That confidence meant that we could approach them and ask them questions. We could be assured that they were giving us accurate information. That type of relationship offers me an assurance about the service's ability to improve.

Young couples need to have the confidence that they can develop a strong relationship with their GPs as their children grow towards adulthood. This Bill will foster that confidence. The two age groups provided for in this and the previous Bills are only the first steps, and I hope that during the lifetime of the next Government similar GP services will be made available to everyone. In this way we will ensure that people need not fear to attend their GPs with illnesses or other problems and thereby improve the general health of the country.

In his opening statement, the Minister for Health referred to persons with permanent conditions who are finding it difficult under the current medical card scheme to gain admission to hospitals. All of us have encountered problems of this nature through our constituency clinics. The people who are admitted to hospital will attest to receiving a wonderful service from the commencement of treatment onwards. They are more than satisfied with the system. The big problem is the waiting list. I hope the Minister will investigate that problem.

The previous speaker referred to a number of issues. In a perfect world these issues would have been dealt with but his own party created the problems that mean we are not living in a perfect world. Unfortunate decisions had to be made but we are taking another step towards rectifying the problems created after 2008 by wild decisions of the previous Government. Signs of progress can be seen throughout the country. I readily admit that the progress is not fast enough but we are at least ensuring that the progress we make will make a difference. There is no doubt that the decision by the Minister, Deputy Varadkar, and the Minister of State at the Department of Health, Deputy Kathleen Lynch, to provide free GP care for those under six years or over 70 years is a step in the right direction. I hope further efforts will be made during the lifetime of this Government to address problems in respect of hospital waiting lists. I commend the Minister and the Minister of State on their efforts thus far to address the many problems created by the previous Government. There is understandable criticism about expenditure on health services but that is not the fault of the Minister or the Minister of State, who are trying to rectify the problems created for them. I believe the HSE, working with representative bodies of medical professionals and the Department of Health, will improve to the point where it matches the best in Europe.

Deputy James Bannon

It is regrettable that Deputy Keaveney is no longer in the Chamber because I have a list of quotes by him consisting of criticisms of Fianna Fáil's health policies dating from the period when he was on this side of the House. Rather than rehearse the quotes in his absence, I will leave them for another day.

I warmly welcome this Bill, which commences the second phase of the introduction of a universal GP service in Ireland, as set out in the programme for Government. The first phase of this process was the Health (General Practitioner Service) Act 2014, which provides free GP care for children aged under six years. The Health (General Practitioner Service) Bill 2015 now seeks to make GP care free at the point of use for all persons aged 70 years and over. At present, nearly half of the population have access to medical or GP visit cards. Eligibility in the majority of cases has been determined by a means test. As a result of eligibility criteria, 36,000 people over the age of 70 were not entitled to a free GP visit card. Thanks to the actions of this Government and the Minister for Health, everybody aged 70 years or older will have free access to a local GP.

When it comes to GP care, we are one of the few OECD countries with GP fees. In a majority of OECD countries, primary care is either free or heavily subsidised for most of the population. Furthermore, Ireland is the only EU health system that does not offer universal coverage of primary care. We must also bear in mind that cost is a barrier to someone deciding whether to attend a local GP. The former Minister of State at the Department of Health, and now Minister for Communications, Energy and Natural Resources, Deputy Alex White, was absolutely correct when he stated: "The evidence is clear that people delay or avoid visiting their GP where a fee is required. Removing this cost barrier will ensure citizens will be far more likely to address medical problems". Removing the cost barrier for 36,000 older people means that older people need no longer delay visiting their GP, thereby enjoying better health while at the same time ensuring health care services will not incur higher costs as a result of a delayed diagnosis. Therefore there is a significant benefit from improved GP access in terms of health and well-being.

Nothing will change for any person over 70 years of age who is already entitled to medical cards or GP visit cards. They will continue to receive all of their medical entitlements as normal. Attempts by the Opposition to distort this are nothing but cheap politics, although nothing Fianna Fáil or Sinn Féin does surprises me anymore. Throughout this debate I have spoken about the importance of access to GP care and removing the barriers to services.

This is particularly important in regard to the Midland Regional Hospital Mullingar and the HSE's promised commitment to 90 new nursing posts. While the appointment of a second palliative care consultant in early March was very welcome, I have been made aware of concerns at the hospital that the HSE may row back on its plan to create these badly needed nursing posts. When I visited the hospital last Saturday, I was told that the accident and emergency and maternity wards are understaffed. The staff had hoped that the announcement of the new nursing posts would improve the situation in the hospital, yet we are still awaiting confirmation of that news. Without doubt, this is one of the busiest and best performing hospitals in the country, taking patients from Roscommon, Cavan, Longford, Westmeath and the wider region. Any row-back on the plan to provide 90 new nursing posts would have a serious effect on staff and morale at the hospital. Indeed, it would go against the key reforms and progress the Government is trying to make in the health sector.

The concerns that have arisen due to the level of overcrowding and pressure on beds in the Midland Regional Hospital Mullingar provide an opportunity for St. Joseph's care centre in Longford to reduce the problem. St. Joseph's care centre is a fine example of an excellent care facility that could be more fully utilised. I wrote to the Minister and spoke to him on this issue. The standard of care and the quality of staff are excellent. All of the centre's facilities have been purposely built towards care. The facility already has a GP out of hours service, a physiotherapy service and a radiology department that is connected to the national IT service. If this facility was to become a step-down clinic, it would undoubtedly free up acute beds in the Midland Regional Hospital Mullingar. I have spoken to the Minister about this and hope he is positive on this proposal. I thank him for that and hope he can come up with a solution.

To conclude, the Government is upholding its commitment towards establishing a universal GP service for the entire population in line with the programme for Government, but we also need to uphold our short-term commitments and to ensure that the HSE does not row back on its pledge to the Midland Regional Hospital Mullingar. Economic recklessness in the past has neglected vital health infrastructure and Longford-Westmeath patients suffered as a result.

Deputy Richard Boyd Barrett

One would not oppose this Bill in so far as it proposes to extend free GP care to those over 70, as this is something that will benefit that age cohort. The Bill is welcome in that regard. However, this small step serves to highlight the spectacular failure of the Government to honour the promises and commitments it gave to the people in the run-in to the last general election. The Bill fails also to honour the rhetoric that was screamed from podiums at the demonstrations that took place against the moves by the last Fianna Fáil-led Government to remove medical cards from the elderly. Fine Gael and the Labour Party joined in the chorus of opposition denouncing those moves by Fianna Fáil, who it seems has now suffered a conversion on the road to Damascus. I have heard its spokesmen here espousing universal health care and complaining the Government has not gone far enough. That is a bit rich coming from Fianna Fáil since it was the party that started the attack on universal provision for one cohort, the elderly, during its last reign in government. Its hypocrisy is apparent.

Given that the Labour Party and Fine Gael joined in the justified chorus of indignation when Fianna Fáil launched that attack, this Bill falls far short of restoring the situation in terms of health cover for the elderly and far short of the trumpeting of universality it promised in terms of a universal health insurance system and free GP care for everybody. The programme for Government suggested that free GP care would have to be phased in, but this Bill also runs counter to the priorities the Government set to provide free GP care first of all to those with the greatest medical need, particularly to those with chronic or long-term illness.

The provision seems fairly arbitrary and random and does not make much sense, notwithstanding that it is a good provision for those who will benefit from it. The problem with isolating particular groups or cohorts and ensuring a free GP care service for them is that this results in injustices, unfairness and anomalies around the edges of the groups. For example, what has the Government got against those aged from 65 to 69 years? They have retired, their income has fallen, but they do not get free GP care. This is a cohort which quite often has greater medical needs, but has been hit by other cuts inflicted by the Government, including to an income that will fall on retirement. They also have lost out on household benefit packages and telephone allowances. Many of these people are also living in areas where property prices are high and will be victims of the property tax. Often, people on very low incomes must fork out huge amounts in property tax. This tax bears no relation to their income or ability to pay. Arguably, this cohort needs free GP care just as much as others, but do not get it. This is the type of injustice that can arise. Similarly, a child of six or seven may have a particular need for free GP care, but does not get it.

This debate offers the opportunity to highlight this failure to deliver on the great rhetoric the Government trumpeted pre the election regarding how it would introduce universality in terms of GP care and health care generally. Instead, we are getting piecemeal, random, small incremental changes, some of which do not make sense in terms of priorities. Added to this is the whole debacle regarding discretionary medical cards that the Government rowed back on and the change in income limits for medical cards, which have removed medical cards from many of the elderly.

It is something and it is better than nothing but it is far short of what was promised nor does it not make a whole lot of sense in terms of priorities. Even where those who benefit from getting the free GP care that will result from this legislation - they will then be referred to surgery or to hospital - do not have a full medical card they will still face the problem of the costs they may have to bear such as hospital charges and consultant fees. Very likely they will also face very long waiting list times because of the assault - not just under this Government and the previous Government - of cuts to the health budget, the significant number of beds that have been closed, the chronic under-staffing and under-resourcing of the health service generally. Even where such persons get free GP care and are then referred, they still face all the problems in the rest of the health service. What this highlights is really the failure of the Government to deliver on the vision of universality and the failure to sort out the mess that is our health service which the Government promised four years ago. That failure to deliver on the promises and aspirations flows fundamentally from the fact that the Government does not have a plan. In so far as it has tried to deliver on those promises, its whole vision is based on a flawed model of a mixture of a public and private system. It has not recognised that the only way to sort our health service is to move away from this mixture of public and private which does not work, is dysfunctional, unfair, inherently about a two-tier system that creates injustices and anomalies, and to grasp the nettle of the need for a national health service. That is the only way we will resolve this system. However, the Minister's determination, which one can only describe as an ideological determination, is based on his belief that private health insurance companies or the private sector has some useful role to play in health, when it does not have such a role. There is no evidence anywhere in the world that relying on the private sector is helpful in terms of delivering a universal health service in a cost-efficient way. In fact, all the evidence points in the opposite direction. The most notable example of course, being the United States which spends more per capita than any other country in the world on health but about 40% of that expenditure goes into the pockets and the profits of the private health insurance industry, the private sector generally, into unnecessary costs and administration, billing, advertising, all the waste that goes along with a system where the private for-profit sector is involved in trying to deliver something that should be a universal right for all citizens, namely, health care. It is that failure, that ideological blindness and blinkered attitude of this Government, that is at the back of its failure to deliver on all the promises.

For many people, when they heard the rhetoric of universality prior to the election, what they imagined was precisely a sort of national health service model but they did not really hear the word "insurance". The two things directly contradict each other because the universality and a single-tier system go out the window once private for-profit insurance interests or private for-profit health companies or hospitals or whatever it is, are in the mix, because they are in it for the money and not to provide a service to people.

I will not oppose this Bill but it is a very pale shadow of what the Government promised. It raises as many questions as it answers in terms of the prioritising of health care services to those who need it but the biggest question it raises is whether this Government really has a plan to sort out the mess that is the health service, in order to deliver the universal system, the health care to which every citizen is entitled on the basis of need. Has the Government a vision and a plan? More than four years into this Government's term, it is absolutely clear that it does not. The Minister has more or less admitted this, with universal health insurance being put on hold. All the talk of the Dutch model has disappeared now because any serious examination of the Dutch model shows very serious problems associated with the cost of health care. This has all gone out the window and we are left not knowing where we are going but we are left with very serious problems in our health service that this Bill will not address in any serious way, notwithstanding the fact that some people may gain some benefit from it.

Acting Chairman (Deputy Joe O'Reilly)

Deputy McLoughlin is sharing time with Deputy Seán Kenny.

Deputy Tony McLoughlin

I welcome the opportunity to speak on this long awaited Bill which will, among other technical provisions, allow the Irish State to provide free GP care to the most vulnerable age groups in our society, namely every single child in the State who is aged under six years and those persons over the age of 70 years. The Bill represents the first steps by the Government to introduce a free universal GP service for our citizens, which I warmly welcome.

This proposed service for the under sixes will be combined with a similar service being offered to people over the age of 70. From this summer, the Bill will cater for more than 250,000 people who would usually have to pay to see their GPs. It will cost the State over €67 million to provide this service. However, this figure will actually help to bring down costs in the health budget, which must be welcomed.

The commencement of this new GP service will make a real difference to the lives of the youngest and the oldest in our society and for the families who care for them. I believe that this agreement is a major step forward in improving access to and the quality and affordability of health care in Ireland. It will mean real savings for pensioners and for the families of young children but, as the Minister, Deputy Varadkar has stated, it is about much more than that. These two initiatives are part of the Government's wider plan to enhance the primary care system in this country, while also achieving real savings in the health budget. Removing the cost barrier and allowing all children and elderly people free access to a GP means earlier diagnosis which is more beneficial for families and patients alike. This service will also make our health service more economical in the long term as it will keep more people out of our hospitals, thus reducing the pressure on beds. It will oversee the beginning of the process of pumping money back into the general practice system once again. This is an important aspect which has resulted in the support for the Bill from the IMO.

This new enhanced GP service covers all children under six and people over 70, including those who already have medical cards. However, along with providing a free GP service, it will also include age-based preventative medical checks focusing on the health and well-being of the patient and the prevention of disease before it occurs.

The proposed new system also includes an agreed cycle of care for asthma patients, in which GPs will carry out annual reviews of a patient's symptoms in order to gauge the development of the disorder.

Approximately 50,000 people with a medical card or a GP visit card are expected to further benefit from the type 2 diabetes care plan, under which those who hold a medical card or a GP-only card will be entitled to two visits a year to their GP. That means that they will have their condition managed by the GP who knows them personally, rather than in a hospital clinic, which is preferable to the patient in most cases.

GPs play a crucial role. They act as a gateway to the entire health system. The patient-centred GP approach guides the patient through the referral process and into the health care system. It is widely considered that a well developed system of primary care has beneficial effects on the health care system as a whole. The Bill ultimately seeks to improve the role of the GP. It is important to note that, even when the national economy was in a healthy position, a universal, patient-oriented GP service such as has been initiated in the Bill was never considered important enough for consideration by previous Governments. The fact that it is being introduced now, as we emerge from one of the most difficult economic crises in our history, shows the Government's commitment to reforming the health service and improving the quality of care provided for patients.

I am fully supportive of the proposed legislation. As legislators, w must stand up for the most vulnerable in society. Therefore, I have no hesitation in supporting the Bill and call on Members on all sides of the House to put party principles aside and support it. It has taken a great deal of time and effort to get it onto the floor of the House. I commend the Minister for Health, Deputy Leo Varadkar; the representatives of the GPs who have agreed to the proposals and officials at the Department of Health for the work put into the Bill to get it this far. I look forward to its speedy implementation.

Deputy Seán Kenny

I warmly welcome the fact that free GP care will be available for children under the age of six years and people over the age of 70 from the end of June this year. This is a major step forward that will deliver huge savings for families and pensioners and help to promote health and well-being throughout the population. People over 70 years who currently have to pay to see their GP will now be able to access the free service. This is the latest phase in the overall plan to provide free GP care for all citizens. The Government is making progress with plans to roll out free GP care to children under six years. The reason these two groups of citizens are having free GP care services extended to them first is the youngest and oldest members of society have the greatest need for health care services. It is intended that the legislation will be put in place this year and for the service to be introduced alongside the free GP service for children under the age of six years. Free GP care is a fulfilment of the Government's commitment to the introduction of a universal GP service for the entire population on a phased basis. I am pleased to see it is being implemented gradually.

From this summer, up to 300,000 children and senior citizens who currently have to pay to see their GP will no longer have to do so. That is a big step forward in how people across the country, particularly the youngest in society, avail of health care services. Some 240,000 children will be able to benefit from this new development when it takes effect. That will mean real savings for pensioners and families, but it is about much more than this. The new enhanced service covers all children aged under six years, including those who have medical cards already. They will benefit from the management of asthma in general practice and preventive wellness checks. Adults of all ages will benefit from the new diabetes programme, meaning that they will have their condition managed by the GP who knows them, rather than in a hospital clinic.

Under the new arrangements, an additional 240,000 children under six years will benefit from free GP care at the point of service. All children under six years will benefit from the new enhanced service under the proposed GP contract which will involve age-based preventive checks focused on health and well-being and the prevention of disease. These assessments will be carried out when a child is aged two years and again at age five, in accordance with the agreed protocol. The contract will also include an agreed cycle of care for children diagnosed with asthma, in which GPs will carry out an annual review of each child where the doctor has diagnosed asthma.

The extension of free GP care at the point of service to everyone aged 70 years and over who does not currently qualify for this benefit will take effect at the same time as the under-six service. This service will benefit approximately 36,000 new patients and be provided under the existing contractual arrangements for this age cohort.

The negotiations with the Irish Medical Organisation, IMO, have also resulted in an agreement on the introduction of a diabetes cycle of care. This will enable patients with a medical card or a GP visit card who have type 2 diabetes to avail of two annual visits to their GP practice for a structured review of their condition. This service will begin in quarter 4 of this year. This initiative will help to integrate care across the continuum of care, improve clinical outcomes for patients and reduce complications often experienced by people with this condition.

Making health care more affordable has long been an objective of the Labour Party in government and underlines its commitment to enhancing primary health care. I thank the Minister for Health, Deputy Leo Varadkar, and the Minister of State at the Department of Health with responsibility for primary care, Deputy Kathleen Lynch, for their tenacity in pursuing this project, despite the many barriers they faced along the way. It is certainly fitting that a Labour Party Minister is delivering such a meaningful project, in line with our policy of supporting families and ensuring they share in the economic recovery that is now clearly under way. I warmly commend this legislation to the House.

Deputy Arthur Spring

I thank the Whip's office for giving me an opportunity to speak to the Bill. I am very much in favour of advancing anything to do with general practitioners. As I come from a household in which my mother was a nurse and my father, a GP, I understand the role played by the GP in society. I am very much of the opinion that in an advanced society people should have access to medical care.

One of the cohorts of people who need access to medical care more than anyone else is the elderly owing to the ailments that go with age. I welcome the provisions included in the Bill for the over-70s. A basic GP service should ensure people will feel free to go to a doctor and seek peace of mind that their ailments can be treated accordingly and that they can be sent in the right direction if there is something wrong. This also gives us an opportunity to welcome the provision of GP cards for children under six years of age. The Minister for Health, Deputy Leo Varadkar, is present in the House. The previous Minister, Deputy James Reilly, was also an advocate of free GP care. Members of both Government parties espouse a policy of universal health care, which is a long-held belief within the Labour Party and Fine Gael has endorsed the same ideology. The intention is to introduce the system incrementally.

I had the privilege of living in Sweden at one stage. The capacity to access medical care there spurred my belief in the ideology of social democracy. A cap was placed on the amount any single individual would pay - the Swedish krona equivalent of approximately €100. People made a small contribution over the course of five to eight visits to their doctor, after which it was considered the medical condition warranted access to medical care on a continuous basis and they did not have to pay any more once the cap had been reached. The premise is that when a person pays a little towards the cost, he or she takes ownership of the process and also demands more of the service. However, people only access the system when they need it. The amount of money involved was not particularly onerous.

I have spoken to people about how medical practice in Ireland has changed in the past 20 years. There is a perception that sometimes people with medical cards routinely abuse the system of access to GPs and medical facilities.

There needs to be honesty and clarity but the abuse of the system needs to be eradicated. We have limited services and need to provide them in a way that is meaningful for the individual and for the GP whose time is needed by a wide cohort of people, particularly in areas that are geographically challenged. Some GPs say that medical practices are becoming unviable in areas where the State subsidy is not enough. I am sure the Minister is aware of this. I have met with individual GPs, with their new organisation and the IMO. We need to safeguard access to primary care in rural constituencies. In future areas of a 25 or 30 mile radius may not have GPs. That is daunting for citizens in those areas and for GPs who want to retire but feel they need to stay as long as possible to provide the services to these people.

I admire many aspects of this Bill, particularly the access to primary health care for people over the age of 70 and that their dependants can get a GP medical card. The financial parameters are quite generous, set at an income of €700 per week for a single person and for a married or cohabiting couple, or civil partners, the dependant over the age of 70 will qualify if their combined income does not exceed €1,400 per week.

I would like to see more compulsion for GP cards for children under the age of six. If in areas where GPs can have a monopoly of services they do not opt in it will cause people a great deal of hardship because they need access to a GP personally and will not want to take their kids to another place. As a father of two young children I can see the need for this. There is nothing more frightening for parents who are financially strapped than to need to access medical services for sick children. The generation having children now is the hardest hit by the economic downturn, being in negative equity and making mortgage repayments. Some live in apartments and aspire to progress to houses in the natural way for families. This is a way of giving them and their children a break.

This Bill, however, concerns people aged over 70. It is a step in the right direction. The Government will try to encompass all of society in the system over time. The role of GPs in society cannot be underestimated. The easiest way to get elected to Dáil Éireann is to be a GP. There are not too many people who give out about the medical profession because they need it when they are sick. There is nothing more salient to people’s being than their health. I admire the profession greatly for the services it provides. It is well remunerated but we must admire it. This is a good Bill. It represents an advance and I hope we can make further progress in this area.

Deputy Denis Naughten

I welcome the opportunity to speak on this Bill and I thank the Minister for Health for being present for the debate. I want to declare an interest because I have two children under the age of six who may potentially avail of the medical card. I spoke about one last year, as he was coming up to five years of age in September and I asked would he get the card. It is coming close to the wire.

When the Minister is responding I would like him to clarify what will happen in rural areas, of which there are many in the west, where there is a single GP practice that decides not to go into this scheme? It is even very hard to get GPs when one retires in these areas. The suggestion has been made that the patient can move to another GP but if that GP is 40 or 50 miles away that is not much good to the family or the community. How do we address that problem in isolated rural communities? In my new constituency of Roscommon-Galway, just over 8,000 children will be able to avail of these medical cards, which is welcome for those families. What happens to the six year old who has a chronic ongoing condition, which imposes a significant financial burden on the family? Initially we were told this would be phased in for children, that it would start with those under the age of six and progress to include those in primary school and on up to the age of 18. In the revised programme for Government, however, it is being provided to those over the age of 70, who have in excess of €36,400 per annum, plus potentially another €36,000 in the bank. Is this a good use of limited funds, to spend an additional €12 million in providing a free GP card for some of the most affluent individuals in this State, ahead of children aged between six and eight who have chronic ongoing illnesses which place a huge financial burden on their families? That is wrong. Compare that with a family with two children, one of whom is sick, who earn half of the €700 a week threshold applied to the people aged over 70. If it earns over €350 a week it is over the income limit for a medical card. That family will sweat blood and tears to try to get a medical card to have free access to a GP.

A woman came into my clinic on Monday morning who has recently been diagnosed with cancer. I sympathised with her, not because of her diagnosis, which is a huge burden that she and her family must deal with but because of the horrendous experience she will have with the Primary Care Reimbursement Service, PCRS, based in Finglas, to be granted a medical card. Sadly, her family is over the income threshold for a medical card. She will get a medical card at the end of this protracted process, three to five months down the road, but she has started chemotherapy and will be quite sick in the next couple of weeks. The last thing she needs is letter after letter coming from Finglas asking her to justify her request for a medical card because she happens to be on chemotherapy and receiving treatment. That is wrong. Most individuals in that situation would throw in the towel. They are too sick to have to deal with this on an ongoing basis, having to send back information, then be told there is something else missing, that their payslips are outside the three month limit and that they have not provided clarity that they are sick and no longer in work and may have a reduced income.

They have an additional cost not only of having to deal with the loss in income, but also of having to travel. That is because we have developed centres of excellence, particularly for cancer, but for all other services as well. If a person does not drive and is unfortunate enough to live in County Roscommon, it will cost €150 to get to see a consultant in Galway. Such a person cannot use public transport, so they must pay a minimum of €150 for a taxi from any part of County Roscommon to Galway city to see a consultant and receive medical treatment.

In theory, the medical card section is supposed to take that into account. I have been reassured on numerous occasions that the cost of transport to medical appointments is taken into account, but I have yet to see any evidence of it. I will cite an example of a recent case I dealt with. It concerned a young woman who attends her GP 20 times per annum. She is also attending an endocrinologist in Galway monthly, and a gastroenterologist annually in Ballinasloe. She also attends for audiology appointments six times a year in Galway, and the gynaecology department in Ballinasloe three times a month. In addition, she is attending a fertility clinic in Galway every eight weeks and is forking out €285 a time for that. She is also attending a migraine clinic in Ballinasloe quarterly and is receiving monthly bereavement counselling. She is also attending the breast clinic in Galway ten times a year, as well as awaiting a neurology appointment and one other appointment.

That woman cannot access public transport and does not drive. Her husband has to take time off work so that she can attend those appointments. Based on that, she has been given an allowance for health expenses of the princely sum of €11.54 a week. The allowance for prescribed medicines and appliances is €33.23 a week, which is the drug payment cap of €144 per month. She is also getting an allowance for hospital charges of €14.42 a week, which is the hospital cap of €750 a year.

In that case, absolutely no recognition is being given to the cost of attending those appointments or the cost of her husband having to take time off work so she can attend them. Even though we have sent detailed information to the HSE's medical card section in Finglas, it says that the original decision stands. We have also gone to the appeals office, yet it is giving the woman no hearing whatsoever because the rules, as set out, give no recognition for additional costs associated with transport.

Apart from that particular case I can give the Minister numerous other examples. I know of an individual living in Galway city who is being treated in St. Vincent's Hospital, Dublin. They get an allowance of €11.54 per week for health expenses and €33.23 per week for prescribed medicines and appliances. I also know of another patient in Galway city who is being treated in Galway University Hospital with exactly the same allowances. Can the Minister justify how that woman living in my constituency, who has to travel to the four ends of the country to attend appointments, should receive the same allowance as someone in Galway city who is receiving care there? What about someone in Galway city who has to travel across the country to get treatment at St. Vincent's Hospital in Dublin? Where is the equality in that?

Time and time again, I have been told by the HSE's medical card section that it recognises geographical considerations when people must travel to appointments. That is not happening, however, and people are being discriminated against geographically as regards medical cards. That is based on the fact that they happen to live in a rural area and can no longer access social welfare support to pay for the cost of a taxi to Galway city. Social welfare will not entertain that cost whatsoever. Consultants are not prepared to leave Galway city and carry out appointments in local hospitals, which would save such costs. The hospitals say it is not their problem how people get to appointments. They have no funds for that, so it is up to people to get there.

Is it any wonder that people are missing hospital appointments or struggling to cope with the costs of diagnosing chronic conditions, including cancer, when all these additional costs are not being recognised? One person might live in Galway city and can therefore access cancer treatment nearby via public transport, while another person might live in Arigna and has to pay over €200 for a taxi to Galway city, but it makes no difference as far as the HSE's medical card section is concerned. That is wrong and it should not happen. We were told that it was not happening, but I have the documentary evidence that it is occurring daily. That system needs to be changed without delay because people are being wrongly discriminated against based on where they live.

I want to ask the Minister about figures for the over-70s. Speaking in the Seanad last November, the Minister said that about 10,000 people over the age of 70 would get GP cards. In the briefing we got on this Bill, however, a figure of 36,000 was mentioned. Can the Minister explain the change that has taken place since his speech in the Seanad last November when he said an additional 10,000 GP cards would be issued? Now he says that 36,000 such cards will be issued. Does the Minister have any idea of exactly how many cards will be issued?

There is a welcome provision in the Bill for a new cohort of people who move in with a grandmother. If someone is a qualifying dependant who is not married to the person over 70, but is living with them, they can apply for a medical card based on having an income of less than €700 per week. This seems to be a new provision that has been included, and it is probably welcome because it will encourage young people who are not eligible under the existing medical card scheme to move in with a grandmother. They will thus become a dependant of their grandmother and on foot of that will be eligible for a medical card based on the higher threshold of €700. It will encourage people to move in with their grandparents, but what sort of a handle has the Minister put on the figures involved?

I would like the Minister to clarify the income threshold for a medical card. There is provision in this legislation for the over-70s medical card whereby the income threshold can be increased in line with inflation. Yet for the standard medical card the income threshold for a single person is €184 per week, which is less than the basic social welfare rate of €188. Anyone earning the social welfare rate who is trying to go out to work will be denied a medical card, but if they sign on for the jobseeker's allowance they will get a medical card, even though they have the same income. If a person is slightly over the social welfare income, they will not get a card at all. That is because the income thresholds have not kept in line with inflation or even with social welfare increases over the years.

Surely it is an anomaly within the system whereby we are discriminating against those who want to work but cannot hold onto their medical card. They cannot keep the medical card because when they go over the income threshold the card is withdrawn. It is a barrier for people who try to get off the live register and work. That issue needs to be examined urgently.

One other issue I want to raise concerns the same section in the Bill. There is a provision in it where compensation payments under the hepatitis C tribunal and the Residential Institutions Redress Board are disregarded for the means assessment. That is very welcome but there is another small cohort of people of whom the HSE and child care services have been grossly negligent as regards protecting children under the age of 18. After their 18th birthdays the HSE has paid out significant amounts of money in compensation because of the gross neglect, yet they are being penalised in the means assessment as regards both the medical card and social welfare. There is no recognition of that in the legislation.

Debate adjourned.