Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020: Second Stage

Minister for Health (Deputy Stephen Donnelly)

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

It is my pleasure to introduce the Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020 to the Dáil. Today marks another important step in working towards achieving the Sláintecare principle of universal access to care at low cost or no cost.

This Bill provides for two key measures that are central to achieving universal access to healthcare in a manner that is fair and affordable: a welcome increase to the gross income limits for medical card eligibility for persons aged 70 or older and the phased expansion of general practitioner care without charges to all children aged 12 years of age and under. We are all aware of the barriers that exist in the health system that prevent people from accessing the right care at the right time in the right place. The measures being debated here today will enable us to progress towards the achievement of the core message of Sláintecare, which I know is supported by all parties in this House. These measures will provide a significant benefit to cohorts at different ends of the life spectrum but who each have their own identifiable health needs. A range of measures have already been implemented to expand access to persons in receipt of medical cards and GP visit cards, which has resulted in almost 43% of the population having access to GP care without fees at this time. However, while these initiatives are welcome, this Government recognises the need to do more. That is why we have committed in the Programme for Government: Our Shared Future to implement new measures to expand access to GP care without fees and to wider health services. As Minister for Health I am delighted, therefore, to be bringing forward this legislation for debate today and affording it the priority that it deserves.

The first key measure provided for in this Bill is a welcome increase to the gross income limits for medical card eligibility for persons aged 70 or older. Expanding eligibility for medical cards to this cohort is an important initiative in ensuring better health and active ageing for older persons. As we seek to support older persons to live independently in their own homes and communities for as long as possible, we must put in place policies that enable them to access high-quality care close to their home, where feasible, to prevent unnecessary admission to hospital. This very measure is a key enabler to achieving this as it will increase the number of people who can access a wide range of services in the community at no cost or at very low cost. Health and healthy ageing are undoubtedly key determinants in the quality of life experienced by older persons. The Health in Ireland - Key Trends 2019 report identified that life expectancy in Ireland has increased by almost 2.5 years since 2007. It also highlights that each year the number of people aged 65 or over is increasing by about 20,000, a trend that is likely to continue. This is a positive and welcome development and reflects the decreasing mortality rates for major diseases. However, these factors also remind us that there are resultant implications for individuals living longer and for how we plan our health system to meet the needs of the inevitable increase in demand for health services. It is important that we put in place now the policies that will enable this older cohort to live well.

We know that the prevalence of frailty and chronic disease increases as people age. Therefore, having affordable access to a range of health services is key to both preventing and managing the impact of frailty and chronic illness. This is why this measure being debated here today is so important, especially when one considers that a significant number of people may benefit from its implementation. For many older persons, an immediate benefit of qualifying for a medical card is that they will be able to have affordable access to medicines. For example, we know that while persons aged 70 or over only account for 23% of all medical card holders, they account for over half of the spend on medications dispensed under the medical card scheme. Thus, expanding access to the medical card will ensure that a greater proportion of older persons will have affordable access to medicines, which is essential in managing chronic disease and enabling people to have better health and to live well.

Living well and healthy ageing not only benefit the individual, they are also important for society generally. Older persons are the fabric of our community. They undertake many important roles and their contribution is vital. This was borne out in a recent Trinity College Dublin study which utilised data from the Irish Longitudinal Study on Ageing, TILDA. That study identified that almost one-third of people over 70 are caregivers and that many are caring for their spouses. Additionally, it found that older people participate both economically and by volunteering in the community and they undertake caring responsibilities for relatives and grandchildren that enable others to participate in the workforce. This demonstrates the need to ensure that policy measures are implemented so that older people are supported in achieving healthy ageing so that they can contribute and continue to play an active part in their families and wider communities. The implementation of this measure will support this by giving access to health services at a time when their health needs are greater and undoubtedly more complex.

It is also important to highlight the sacrifices made by older persons in our society in response to Covid-19. I know that social distancing and cocooning - an awful word - were and remain very challenging for many older persons and have resulted in a rise in levels of loneliness and social isolation which have impacted on many people's well-being. Many people who have lived through this have shown incredible spirit and commitment. I acknowledge that today. It has not been an easy time for an awful lot of people. It is still not an easy time for an awful lot of people.

I turn now to the second key measure for which this Bill provides: the phased expansion of free GP care to primary school children. Deputies will be aware that the Programme for Government: Our Shared Future also includes a commitment to expanding to more children access to GP care without charges. It is an important deliverable in terms of Sláintecare and its implementation strategy, which commits to expanding eligibility for access to healthcare on a phased basis. Already since 2015 all children under six are automatically eligible for free GP care. Today's Bill provides a legislative framework to continue this path of universal expansion. It is a significant milestone and I am proud to be welcoming this beneficial public health measure.

There are many good reasons to provide universal access to GP care to children. Studies have shown that the identification of health issues at a younger age can mitigate or reduce the impact of ill health later in life and that the health and well-being of children is linked to the economic and social environment in which children are brought up. The measures being debated here today will, therefore, ensure that irrespective of the social and economic background of children, each child up to the age of 12 will have access to GP services without charge. We know that the cost of GP visits acts as a barrier to accessing care. The Growing Up in Ireland study, for example, showed that those who face out-of-pocket expenses to access GP care make significantly fewer GP visits and that children from high-income families are more likely to visit their GP. Therefore, there is a clear rationale for children having access to medical care in their own right, regardless of their parents' economic circumstances.

Providing this access will also bring great peace of mind to many parents who, perhaps, would previously have avoided attending a GP clinic due to unaffordability. Removing cost as a barrier will not only enable better utilisation of GP services but will also play a critical role in helping to address important health issues for children such as childhood obesity. As the vast majority of health needs of children can be met in the primary care sector, the GP is well placed to address early health issues arising, which helps to mitigate their impact in later life. It is estimated that the phased expansion of GP care without charges to children between six and 12 years of age will benefit approximately an additional 300,000 children.

Such positive large-scale reform of GP expansion will have inevitable costs attached with its implementation. These will depend on several factors, including the timing of the phases, the number of eligible children, the uptake and determination of fees payable to GPs and so forth. Furthermore, the implementation of this measure will require negotiation with GP representatives to address issues such as fees payable and the scope of services to be provided and, critically, whether there is capacity in the community and in general practice for it. I also recognise that such reform cannot happen overnight.

The initial stage of this phased expansion, therefore, will be first to all children aged between six and eight years so as not to overwhelm the health system. Specifically, the legislative framework provides a roadmap for the phased expansion to the following three age categories: phase 1 is to children who are aged under eight, that is, children who are six or seven years of age; phase 2 is to children aged under ten years, that is, children who are eight or nine years of age; and phase 3 is to children who are under the age of 13, that is, children who are ten, 11 or 12 years old. This approach will ensure that the expanded service can be introduced in a way that will meet the ongoing health needs of children and also be sustainable for general practice in the current Covid environment.

In that context, it is important to acknowledge the impact of Covid-19 on general practice. During this pandemic, GPs have remained at the heart of service delivery, demonstrating fantastic flexibility in adapting to new norms and taking pressure off the acute hospital system. This is unlikely to change as we move into the latter part of the year. In the likelihood of reduced hospital capacity for the forthcoming winter as a result of Covid, it is anticipated that a greater burden of care will fall on GPs to manage patients within the community wherever possible. In that regard and taking account of the forthcoming winter season, it is important that an expansion of GP care will not inhibit general practice from delivering appropriate care in the community for all patients. Thus, the implementation for the expansion will require careful consideration by officials in my Department and the HSE in consultation with GP representatives.

The purpose of the Bill is twofold, to provide the legislative framework for the further expansion of GP care and to increase the gross income limits for medical card eligibility for persons aged 70 and over. Before I outline the Bill's main provisions, I draw the House's attention to a miscellaneous provision included in the Bill, namely, an amendment to the Health Act 1970 that is provided for to take account of the new governance structures of the HSE.

Section 2 will amend the existing legislation relating to the gross income limits for medical card eligibility for persons aged 70 or over under the Health Act 1970. The amendment of section 45A of the Health Act 1970 will provide for an increase to the gross medical card income limits for persons aged 70 or over from €500 to €550 for a single person and from €900 to €1,050 for a couple.

Section 3 will provide a technical amendment to section 53C of the Health Act 1970 to replace the reference to "Director General of the Health Service Executive" with a reference to "chief executive officer of the Health Service Executive". The Health Service Executive (Governance) Act 2019 established a board and the chief executive officer governance structure for the HSE, replacing the directorate and director general structure. Part 3 of that Act amended reference to the "Director General" of the HSE, replacing this with reference to the "chief executive officer" of the HSE. This necessary technical amendment, therefore, will ensure that section 53C is consistent with the amendment approach previously provided for in the Health Service Executive (Governance) Act 2019.

Section 4 will amend the existing legislation under the Health Act 1970 that relates to the making available of a general practitioner medical and surgical service without charge to persons who are ordinarily resident in the State and under the age of six. The amendment of sections 58 and 58B of the Health Act 1970 expands the availability of these services to persons who are ordinarily resident in the State and have not attained the age of eight. This is the first age category being provided with eligibility for free GP care under the first phase of expansion.

Sections 5 and 6 will provide for the further making available of a general practitioner medical and surgical service without charges to persons who are ordinarily resident in the State and have not attained the ages of ten and 13 years, respectively. These are the second and third age categories being provided with eligibility for free GP care under the two remaining phases of expansion.

Section 7 will provide for the Short Title of the Act and for the introduction of both GP expansion and an increase to the gross medical card income threshold by commencement orders as required, with the consent of the Minister for Public Expenditure and Reform.

The measures provided for in the Bill are good news for all of us, for our children, parents and grandparents. I am confident they will significantly improve access to GP services and to a range of services for both older and younger people in our society. I commend the Bill to the House and look forward to hearing the views of Deputies.

Deputy David Cullinane

This is my first time, as the Sinn Féin spokesperson for health, to exchange with the Minister for Health. I wish him well. There are significant challenges in healthcare that we, collectively, have to deal with in the coming weeks, months and years.

We will support the Bill and have supported its quick passage through the Houses. Nevertheless, given the crisis in both primary and community care and acute care settings because of Covid-19, and the need to deal with Covid care, non-Covid care and what many are now calling the catch-up programme to deal with mis-care, we need rapidly to ramp up investment in our health services. I would have much preferred if the Minister had spelled out to us where that investment, that is, the additional investment in community care, primary care and acute care, will come from in the coming weeks and months.

I am not sure whether the Minister watched the "RTÉ Investigates" programme last night. It laid bare again the extent of the crisis in our health system and what front-line workers in all healthcare settings are facing, from supporting older people and acute hospitals to primary care, right across the board. It showed that because we did not invest in community and primary care to the extent we should have over the past decade, we have been left with an acute care system that simply cannot cope. Imagine if we had invested in the primary care infrastructure that we in Sinn Féin called for and if we had more GPs working for the HSE and better community infrastructure that could deal with diagnostics, for example. It would take a great deal of pressure off our acute systems.

The Bill is welcome insofar as it will extend GP cover to more sections of society. Some 150,000 children aged between six and 12 already have access to free GP care and the Bill will extend that service to about 300,000 further children, which we support. It will also provide for an increase to the gross medical card income limits for people aged over 70, which will benefit about 56,000 people.

What we now need to hear from the Minister is what will come next. One aspect of the programme for Government that puzzled me, and it is something the Government needs to clarify, is the several references to affordable care - not universal care but affordable care. We all know there is a big difference between universal healthcare and affordable healthcare. We were promised by the previous Government that it would implement what was in Sláintecare, that we would have a new dispensation in healthcare that would finally separate private from public healthcare, that people would be treated on the basis of need and that there would be a health service that was truly equal and accessible for all citizens. We do not have that, however, and we are a long way from it. One of the first steps I took when I became the health spokesperson for my party was to read Sláintecare again and the implementation reports. Any objective reading would suggest we are a long way from the targets that were set, and that was before Covid struck.

We are discussing expanded GP cover in this Bill so I will mention some of the measures that could have been in the legislation. For a long time my party has called for all cancer patients to have a medical card. I remember when we called for this in the past the previous Government argued that if it was done for cancer patients, it would have to be done for other patients. We want to see free GP care for everybody and we have a plan to do that over five years. However, a bit like what the Government is doing in incrementally rolling out free GP care to children who are under certain ages, we must start somewhere. A good start would have been those patients with cancer.

My mother passed away from cancer two years ago. I remember when she was first diagnosed the shock it was to her and the family. Every one of us knows people who have, unfortunately, developed cancer and the trauma that brings to families. The last thing they need to worry about is the additional medical costs. For all the heartache, trauma, care and treatment they must face, it is wrong that they must also worry about costs. The cost to the taxpayer of doing this is approximately €40 million. The Minister supported this when he was in the Opposition. It would mean 14,000 cancer patients would have access to medical treatment free of charge. It is one of the first things that should be done by this Minister and his Government in the expansion of GP care.

As we reflect on the commitments made in Sláintecare and seek to deliver a new healthcare system that addresses health on the basis of need rather than ability to pay, we must hear the Minister's plan as quickly as possible. What will the Minister for Health do to accelerate the implementation of commitments that his party signed up to along with my party and other parties in this Chamber?

I know we have a big challenge with the Covid-19 crisis. There are a number of big challenges that face the health service as we speak. We must deal with the ongoing Covid-19 crisis and people will need care if they contract the virus. We must prepare for a potential second wave or surge, which would put major stress on our healthcare system, which was unable to cope even before the virus struck. We had people waiting on hospital trolleys and waiting far too long for hospital treatment. People were waiting more than 15 months to see a hospital consultant. I could give the Minister a long list of specialties in this category in my constituency of Waterford, including orthopaedics, with people waiting two, three or four years simply to see a consultant. This was the reality before Covid-19 struck. We must still be able to deal with all the patients who must be treated if they contract the virus.

We must also deal with the existing non-Covid care that should happen anyway, and we have to catch up on missed care. There is absolutely no way this can be done with current capacity. Nevertheless, I do not see any plan from the Government to tell us where the additional capacity will come from. Where will we get the required beds, staff and diagnostics? Where is the plan? It is months since the election, although the Minister is only weeks in his job. Parties have had much time to reflect on what is needed. This is an urgent matter and if the Minister had seen last night's programme, he would know how urgent it is. Nevertheless, no plan has yet been published by the Government as to how it will inject serious capacity into the health service to ensure people do not die.

Cancer screening services, including bowel and breast cancer screening, must get up and running as soon as possible. If the Minister listened to the contributions to the Covid-19 committee some days ago, he would have heard the advocate groups crying out for help. They argue that if services are not rolled out quickly, there will be many missed diagnoses and people will die as a result. The Minister would accept that this is not scaremongering; it will be the reality if we do not inject serious capacity into the healthcare system.

I support the Bill and its intentions. Regardless of who became Minister for Health, we would have had this Bill before us. However, the Minister must come forward with a plan very quickly. Whatever about the cost, the Minister should agree that such a plan must come about. If we do not build modular units or capacity in community care very quickly, and if we do not get more beds into acute hospitals, we will have a crisis in healthcare in the State that we have never seen before. It is the reality facing us. We know it. People will die unnecessarily if we do not do the right thing. I want to see more urgency from the Minister and his Government. I want to see a plan very quickly.

There is no point in any of us slapping front-line workers on their backs, telling them how great they are, if we can see the significant stress they endure and the lack of the capacity in what they need to treat patients and keep people alive. We would not be doing our job in that case. We know what they will do, what they are capable of doing and what they have done in this crisis. We have our job to do, which is to ensure they can keep people safe and treat people. They will not be able to do that unless the Minister provides serious funding and capacity in the time ahead.

Deputy Violet-Anne Wynne

I commend the Government on bringing the Bill before the House to deal with a very important matter, the expansion of a scheme to include all children under 12 and provide them with free GP services, as well as the raising of income limits applying to people over 70. This is most welcome, especially for my constituents in Clare.

As the House is aware, we in Sinn Féin promised two free GP visits to each person in the country as part of our 2020 general election manifesto, with the long-term aim to provide universal healthcare free at the point of need and not based on an ability to pay. The Bill does not go that far or even to a point we would see as far enough, but I welcome that it is at least a step in the right direction.

The reality right across the country is that workers and families are struggling. These workers and families were undoubtedly struggling before Covid-19 but with the uncertainty brought by the health pandemic, they are in a state of financial despair. They are counting the cost of childcare and medical appointments and even preparing for costs arising in advance of the new school year, as well as many other household bills that loom over parents as they raise a family. The cost of attending a GP is quite often one of the most expensive of these bills and the need to attend is mostly unpredictable. As a mother of five children, I am very much aware of the unexpected cost of attending a GP when a child falls ill and how much an effect this can have. It is an average cost of €50 per visit just to be seen and heard by a GP, and this can often be the extraordinary cost that can push already struggling families over the edge. The Minister did not use the right word in this instance. Not being able to afford the cost of a GP visit for any child is an awful position for any parent.

There is also the raising of income limits for people over 70, which is a welcome announcement. Many older people in our society are often forgotten but seriously struggle with the costs of daily life. Most older people have worked their entire lives and contributed to the building of the country we live in today. I am happy to see this Bill will ensure that we, as a State, can give a little back to these people. They are the most vulnerable in our society, along with children, and it is our duty to ensure their most basic of healthcare needs are met.

It is estimated that this expansion of the criteria will benefit approximately 300,000 extra children and approximately 56,000 people over 70. I have no doubt the introduction of this access to healthcare will take some pressure off our hospitals, which is a crucial point. The reality is that early access to medical care if and when required can have a knock-on effect on people ending up in accident and emergency departments. This is an important matter for the people of the mid-west and particularly my constituents in County Clare.

The reality is that those who are fighting to keep bread on the table often have to pick and choose between bills. It is hoped that this legislation will ensure that their health will not be sacrificed for the payment of a bill.

According to the 2016 census, there are approximately 22,000 children in County Clare under the age of 13. Those, along with the 12,000 people, approximately, over the age of 70, will welcome the introduction of this Bill to the House.

The only hesitation I have about the Bill before us is the lack of a commitment to a timeframe. As I have said, while this Bill is welcome, I call on the Government to ensure that it is implemented as a priority as soon as possible. I also call on the Government to ensure that a clear, definitive timeframe is provided to ensure that this roll-out is completed as soon as possible but, at the very least, within the timeframe of this Dáil. The Minister should tell the people of Clare when it will be enacted because they want action now and not any more waffle. I call on the Government to address this matter and make a clear commitment to ensure that it is rolled out sooner rather than later.

Acting Chairman (Deputy Bernard J. Durkan)

I thank Deputy Wynne. I am sorry for not spotting her on the outer perimeter earlier. The problem is the long distance.

Deputy Brian Stanley

It sure is a long distance. For our part, Sinn Féin is committed to establishing a healthcare system that is free at the point of delivery and available when people need it. Despite the fact that we put more money per head of population into health services than any other European country, we still have a dysfunctional two-tier system. That is despite the best efforts of the front-line staff. Sinn Féin has a plan to move healthcare away from a system based on what is in one's bank balance or pocket towards a European national NHS-style system where all citizens are guaranteed a world-class service. We all know that this cannot be done overnight but we can make some simple changes to the current system that will make a major difference.

In our election manifesto in February, my party committed to two free GP visits per year for everyone who does not have a medical card and a full medical card entitlement for those who have cancer. We know that is not enough but these measures can be done in steps, and that is what we propose, as well as free GP care to all citizens over a five-year term.

In line with Sinn Féin proposals to move towards a one-tier system in healthcare, we welcome the steps taken in the legislation the Government has brought forward to provide GP care to all children under the age of 12 and to increase the income limits for those over the age of 70. Like the previous speaker, the only concern I would have is the timeframe for that. However, a major problem remains for all those who are working and do not qualify for a medical card. More than 1 million people in this State have no health cover whatsoever. They do not qualify for a medical card and they do not have private health insurance because, very simply, they cannot afford it. I want the Minister to address the case of a couple with two children under 16 years of age. They cannot get a medical card if their income is more than €342 a week. That is an incredibly low figure. A single person living alone loses the medical card if he or she has an income in excess of €184 per week, which is €19 less than what they would get on the dole. Even worse, those thresholds have not been raised since 2006. They need to be changed. I believe the Minister and I could agree on that. Low-paid workers should have medical card cover. The fact that a family of four on more than €342 per week does not have a statutory right to a medical card is a scandal, and we need to address it.

Parents with two children who are sick are choosing not to go to a GP because they cannot afford for both of them to go. I have come across that, as I am sure has the Minister. That is despite the fact that we spend €4,706 per head of population on healthcare, one third more than the average across the 35 OECD countries. That is according to the recent OECD figures. That €4,706 is far more than what many other European states that have a system that is free at the point of delivery spend. Of course, no system is free because people pay their taxes, including USC and PRSI, into it, but it is free at the point of delivery.

We have tolerated this for long enough. We have tolerated long waiting lists. We have tolerated a two-tier system. Now is the time to start putting those building blocks in place. We recognise that that has to be done in steps, but we want quick steps and long steps. We want to get there because it is the one mission on which every Member of this House says they are agreed. I have heard the Minister speak eloquently on it many times, and I hope he follows through on it now that he is in a powerful position.

We need to try to drive forward towards a national health system. We need greater North-South co-operation on health. Some excellent work has been done in that regard. People from the North get heart treatment in the South. People from the South get hip treatments in the North. We need to accelerate that because there are strengths and weaknesses in both systems. We need to strengthen those all-Ireland links, and Sinn Féin will not be found wanting in pushing for that. In the meantime, let us expand the entitlement to medical card cover. I welcome what is happening here in terms of the Bill, but let us address those families and workers I have mentioned. It is a scandal. The figures have not changed since 2006. Let us bring those low-paid workers and families into the medical card net. The thresholds have not changed in 14 years. We need to change it now. If the Minister could start doing that, it would be a great day's work.

Deputy Alan Kelly

I want sincerely to wish the Minister the best. I have done so in a private capacity but I want to do so publicly also. We need him to do well, so I ask him, please, to do as well as he physically can. He has inherited a very tough job but he was a spokesperson representing Fianna Fáil for a number of years. I sat with him for many hours in committees and in the Dáil and I heard him speak with great analysis. He studied his subject matters and often put forward solutions, some of which I agreed with and some of which I did not, but he put them forward with an analytic mind. He spoke often of his previous work as a consultant and brought that through in his analysis. I would like to see that coming through again. I respect that. However, there is a big difference between being in opposition and in government, and he will find that out very quickly.

I analysed many of the Minister's commitments, statements, and what he supports and does not support, some of which I agree with and some of which I do not, and I respectfully say to him that he needs to look at them also to see what is realisable, because he is on the record substantially with regard to many areas of health, and if he is not going to be able to deliver on them, he needs to tell us. Do not tell us in six months or a year. Tell us out straight. I will accept it, but he needs to manage the relationships with others also who have a feeling that he will be able to deliver with regard to their areas. It is important that the Minister sets expectations. I accept that the world has changed, although some of the commitments and commentary he made were with regard to Covid-19 but, by and large, I accept the world has changed. I accept that the position of the Minister for Health is a different one from what it was a few months ago, but the Minister put forward various policies and strategies and made commitments relating to resources. He needs to state his position on them now, what will happen during his term in office and his plan, because people are waiting.

I also want to say publicly that we need to see a visible Minister for Health. In fairness, the Minister has been reading into his Department brief and his portfolio over recent weeks, but we really need to see more of him. I had many a row, probably more so than most, with the previous Minister, Deputy Harris, but he was very visible. We need to see more visibility from the Minister. I was talking to some people over the weekend and they asked me to share that with the Minister.

In a situation like the Covid-19 pandemic, they want to hear from him as a stabilising voice who can allay their concerns.

We will support this Bill. I think everybody will do so. However, the Bill does not go far enough. We believe it should cover everyone under 18 years of age. We support the threshold changes. The three-phase structure leaves a bit to be desired. If the Minister was in opposition, he would ask for data to explain why it is being done this way. He would also question the value for money achieved by negotiating with GPs on three separate levels. As such, I need to ask him those questions. Here is a question the Opposition Deputy Stephen Donnelly might have asked the then Minister for Health. Why is this being introduced in three different phases? Are there value-for-money issues with the hop, skip and jump arrangement leading up to the age of 13? The Minister might answer those questions when he gets a chance.

Covid-19 is the biggest crisis this country has faced in 100 years or more. It is also a disrupter that creates the capacity to change the way we think and the way we do things. It creates opportunity. A window of opportunity is open to the Minister. It will not remain open for long and he needs to act to exploit the opportunity that exists. He has made very quick decisions, such as that relating to private hospitals, which, in my view, was the wrong one. Like my colleagues in this House, I have spent whole days talking about bed capacity. One can see how difficult it will be to pursue construction projects. I have no idea how we will create public bed capacity in the short term without nationalising at least one large hospital. The window of opportunity seems to have closed because of the decisions of this Government. I think that is wrong. We have an opportunity and the public is with us.

The public will not tolerate going back to a two-tier health system. Its tolerance for that was ended by Covid-19. The opportunity to make a change arose in the three or four months in which we had a single-tier health system for acute care. That was a missed opportunity which the Minister will regret. The overall bed capacity in our country needs to increase dramatically. We all know the studies. In the coming months and years I will pursue the Minister quite intensely on public bed capacity and his plans to deliver it. I want to know how he will do it. I do not have faith in this Government's initial moves to deliver that.

I despise the cycle of reliance on the National Treatment Purchase Fund, NTPF. Every year it encourages a dumbing down of the public health system. If we keep going to the private health system to bail us out, we will never sort out the public health system. Fianna Fáil Deputies are the biggest proponents of this approach. They always have been. The party's leader, An Taoiseach, has always supported it. That is not acceptable to me. Running to the NTPF every year is completely and utterly unacceptable. This matter needs to be dealt with.

I have several other questions for the Minister. I would like to know what he is going to do about the provision of drugs. We went around the houses quite a bit in discussing how this is dealt with. Our method of procuring various drugs is incoherent. Will the Minister honour what he said in opposition about changing that system? Change is very much needed. A lot of people out there are hopeful and want the Minister to honour what he said in opposition. We need a lot of structural changes and changes to the HSE. We need to ensure that more services are offered in the community and we need to reorganise community structures.

There is one pledge which the Minister will have to honour. At what point during this year will he end two-tier pay for new entrant consultants? I will say it straight: the Minister is out on a limb in respect of this matter. He has hitched his wagon to this promise very publicly, more so than anyone else. When will he deliver on it? He has said that solving this problem would unlock a range of other issues. I agree with the Minister to an extent, but I do not feel as strongly as he does. He has to deliver that this year. I do not think he has any choice. If he does not, he will certainly have failed to honour a pledge. The Minister has said that a lot of the issues with the health service emerged from that problem.

We are very dependent on bringing in doctors and nurses from outside of Ireland. I do not blame the Minister for that, but we need a plan. How are we going to plan to address this issue? I will work with the Minister on this issue.

I want to highlight several issues not related to Covid-19. The mortality rates relating to non-Covid-19 conditions are now higher than that relating to Covid-19. The resumption of service provision has left a lot to be desired. I refer to mental health services, community services, services delivered in the home and home help hours.

The issue relating to disability services is a real bugbear of mine. I will speak a little bit about that issue. People with disabilities are forgotten. I have spoken about adults with intellectual disabilities on two or three occasions in this House. The Minister of State, Deputy Rabbitte, replied to me earlier. She indicated that the Minister would bring a memo to the Cabinet next week. The Minister has the budget, by the way, because the Minister of State does not have delegated powers. These people are being left to rot. I have spoken to many of them throughout the country. I spent a couple of evenings talking to their families. Before half past seven this morning, I spoke to a family whose 29 year old son had been up most of the night because he has no routine. He no longer has the will to keep one.

Resources have been transferred from day services to residential services. As such, those who need day services are effectively being discriminated against. This cannot continue. They need some form of service, even if it is only available two or three days a week. Those people will be outside this House next Wednesday so the Minister can talk to them. This situation is intolerable, upsetting, wrong and immoral. It has to stop. Bringing a memo to the Government which states that there will be some form of service provision throughout Ireland in September will not wash. These people are at the end of their tether. I am pleading with the Minister to ensure the return of services. Just two days a week would be massive.

They have been locked inside their homes only going out for small occasions and they have no routine, no facilities, no stimulation and very little to look forward to. Every day is Groundhog Day. I have met with them and they are destroyed by what is happening. I keep raising this issue because I got so upset talking to them. This is way beyond politics and I am asking the Minister please to help them.

John Wall is an amazing human being whom I have got to know quite well over the past number of years. John is terminally ill and is fighting for medical cards for those who have been diagnosed terminally ill. I do not think there is a single person in this House who would oppose the entitlement of those people to a medical card. John's project, as I call it, has been brought to a certain stage and now we are waiting on the sign-off of the Comptroller and Auditor General. John is well at the moment, but as he says in his letter to the Minister of 21 July - I presume the Minister has received and read it; if not, I will text it to him now - he is begging him to push this issue forward and get it implemented. The Minister has dealt with John before. Some of the people John has been campaigning for are no longer with us and the amount of money involved is small. The previous Minister, Deputy Harris, brought the matter to a certain level and I am now asking the Minister to execute it. Again, this is not a political issue and the sums involved are very small. I ask the Minister to engage with John on the matter and to honour the undertaking of the previous Minister in this regard.

I attended Ruth Morrissey's funeral yesterday. Ruth was a national hero who was not only let down by the State but let down in a way that, for me, was unforgivable. She fought the State not once but twice. I know, because I had communications with Ruth and her family, what she wanted her legacy to be. It was not about getting an apology, because it was too late for that. She wanted the Civil Liability Act to be amended so that no more families would have to go through what she and others went through. Together with my colleagues, I am going to bring forward a Bill dealing with this matter in September. I will work with the Minister on it and I want to see it implemented. Ruth also wanted screening to be brought home. In addition, she wanted to ensure that women would never go through anything like she had gone through. We now have a situation where the tribunal is not sitting and two of the judges have gone off to other jobs. It is an adversarial tribunal. The Minister sat beside me in this House for years and he knows what these women went through. He saw the testimony of so many of them. A piece of work needs to be done to deal with this matter and it needs to be done very quickly.

Last week, I visited St. Gabriel's respite centre in Mungret in Limerick. It is a state-of-the art facility and the best one in Ireland for children with very severe disabilities. It cost €2.9 million to build and is supposed to provide a service for 100 families but it has been sitting idle for two years. It is an absolute scandal. I have never in my career seen a better, more purpose-built building. I am absolutely committed to raising this issue with the Minister. From a funding point of view, the money required is not huge and there are some economies to be made from funding it. A little over €1 million will fund it for 100 families every year. I implore the Minister to look at this issue because the St. Gabriel's facility is the example of what we should be providing for all such families throughout Ireland.

I believe we have a real issue in our acute system when it comes to transport provision. We have a fantastic ambulance service but it is not being ramped up. In the mid-west, which is my area, we have four hospitals all based off University Hospital Limerick and three other hospitals all at the same level, although in different tiers. Transport provision is always delaying how patients are being released from hospital for aftercare or to be taken out of a serious acute setting and into a step-down facility in the other hospitals. It is a ridiculous situation and it is one of a number of reasons that University Hospital Limerick has been left the way it is, because it cannot get people out to St. John's, Ennis and Nenagh hospitals. There is no way of doing it. We need intermediate vehicles and more ambulances. Sorting out that whole system should be a priority because it will unlock certain aspects of the issues with acute services.

Finally, I really implore the Minister to honour what he said he would do in regard to home help. The provision of home help hours is massively important. It keeps people in their homes, prevents them from ending up in nursing homes and, with a tiered-up provision, prevents them from ending up in acute settings. It actually makes economic sense as much as it makes health sense. The requirement here is considerable, not in money but in hours. However, the savings and the health benefits from keeping people in their homes are huge. I have 18 pages of notes I took of things the Minister has said on the record and he has said some serious things about this issue. Taking action on it is a quick win and it makes sense. We have always agreed on this issue and I ask the Minister to implement the necessary action now. I wish him well.

Deputy Róisín Shortall

At the outset, I congratulate the Minister formally on his appointment and wish him well in the job. He certainly has spent a good bit of time studying the area. From the Social Democrats point of view, we will fully support him if he is ambitious for the health service and if he delivers and makes progress on Sláintecare in a reasonable timescale. If not, we will criticise him. I hope it will be the former rather than the latter.

There are two issues I want to raise before dealing with the Bill. Yesterday, I got figures in regard to what is happening at our ports and airports with tourists coming into the country in the context of Covid. Shockingly, I was told that only 7% of people who arrive here are being followed up with a telephone call and only half of that number, 3.5%, are answering those calls. This is unbelievable when we consider the threat that is posed to the country, all the sacrifices people have made and the absolute priority of protecting people's health, ensuring schools can reopen and seeking to get the domestic economy up and running again. It was made quite clear to me by the Department of Justice and Equality that it is only doing this work on an interim basis and that it is the responsibility of the Department of Health to do it. The latter Department is waiting for the health authorities to take over. This is an absolutely urgent issue. Can the Minister tell me this afternoon, or come back with an answer tomorrow, when his Department will be in a position to ensure there is proper follow-up on these cases? It makes a mockery of all the hard work that has been undertaken over recent months if we are wide open and exposing the Irish people and the Irish economy to this level of threat.

The second point I want to mention concerns something that has just come to my attention. The Minister will be aware that €25 million in funding is threatened to be cut from disability services. His predecessor gave an absolute commitment, following meetings with the various organisations working in the area, that this funding would be reinstated. My understanding is that the Minister also gave a commitment, as did his party, that the €25 million provision will be reinstated. My information this afternoon, however, is that one of those organisations has been told by its local community health office, CHO, that the cut is going to be implemented. That cannot happen. We have been talking for some time about the huge pressure on the disability organisations in trying to provide services to people in very difficult circumstances, their fundraising capacity having been hugely reduced. They simply cannot sustain this level of cut and nor can the many vulnerable clients they serve. Will the Minister clarify for us, either this evening or tomorrow at the latest, that this cut will not go forward and that the funding will be reinstated?

The Social Democrats will not be opposing the Bill. However, it is very underwhelming as an initiative aimed at improving access to healthcare. It completely lacks ambition. In the context of the Sláintecare commitments to which the Minister's party and the other parties in Government signed up, the Bill is desperately disappointing. It falls far short of what they committed to achieving.

I refer to the issue of eligibility because that is what the Bill is about. I do not know how familiar the Minister is with the fact that Ireland is unusual in that access to healthcare is dealt with as a matter of eligibility rather than entitlement. This issue was teased out in some detail at the Committee on the Future of Healthcare. Access to healthcare is a matter of eligibility rather than entitlement and that is the difficulty. Various legal provisions set out the categories of people who are eligible for access to services, but they are only eligible if those services are actually provided. There is no legal entitlement to healthcare. There is a right of access to social protection and the various schemes thereunder, but there is no similar legal entitlement to healthcare. That is a fundamental problem in the context of how we provide services. It is one of the reasons for there being a postcode lottery when it comes to accessing services. Certain areas operate the schemes differently from other areas, depending on their funding and share of the healthcare budget, which varies significantly. The issue of eligibility and entitlement is at the heart of many of the problems relating to the lack of access to healthcare.

Eligibility for services is divided into those who have a medical card and those who do not. Those who do not have a medical card are required to pay the full cost of GP care and other primary and community care services, as well as a very significant portion of prescription charges and the cost of prescription medicines. The World Health Organization has called Ireland's approach to determine eligibility for publicly financed health services "unusually complex". It stated that it has led to notable gaps in coverage and inequalities in accessing essential health services. The heavy reliance on the private health insurance market mainly benefits wealthier people and has a negative impact on equity. That is at the heart of the problems in the health service. The lack of equity within the health service is a significant issue. If a person can afford to pay for private health insurance, access is quite good. If a person cannot afford health insurance, he or she may qualify for a medical card which may give eligibility to access services that are not really good enough, but those who are left in the middle must pay for everything.

Reference is made in the Sláintecare recommendations relating to universal health access to Ireland still being a far cry from the universal cover enjoyed in most other European countries. Ireland is very unusual in the context of such a large proportion of our population having to fork out for access to primary care. We are on our own in Europe in that regard. There is no other country in Europe in which such a large proportion of the population is charged the full rate to see a GP. It is unheard of. People in other countries would not tolerate it and there is no reason we should tolerate it here.

The Bill aims to introduce an extension of access to GP care for children in three phases. As Deputies are aware, and as the Minister frequently stated while in opposition, access is the key issue in the context of healthcare. Far too many people do not have access to primary care, which is the most basic level of healthcare. We know that cost is a significant barrier. It makes absolute sense to ensure wider access at primary care level. If cost continues to be a barrier to accessing GP care, we will undoubtedly end up with higher costs overall. We should be encouraging people to get their medical concerns and conditions addressed at the lowest level of complexity. That means people going to or bringing their children to a GP when issues first arise. That is what makes sense. That is how one ensures there is early intervention and early treatment of conditions and, as a result, heads off more serious conditions. If cost continues to be a barrier, people who have developing health conditions will inevitably end up with a more serious condition and may have to attend an accident and emergency department, see a consultant or be admitted to hospital.

As Members are aware, the health service is overly hospital-centric. Services are provided at the most expensive level rather than ensuring we have preventative medicine, early intervention and early access to care. We are doing the opposite of what we ought to be doing. Not only does that lead to poorer health outcomes, it is a much more expensive system. As the system is so hospital-centric, we are spending more than most other OECD countries - we are very much at the top level of health spend - but we are at the lower level in terms of access. That makes no sense whatsoever. That is why Sláintecare, our agreed plan, is about completely reversing the manner in which we provide care.

The Bill only takes baby steps. It falls far short of what is required and what was promised. Ireland remains the only European country that does not have universal coverage for primary care. Irish GP payments are the highest formal payments in Europe, with 60% of the population paying non-reimbursable fees of between €50 and €70 per GP visit. That is a significant amount of money, particularly for working and other families who, in the main, have no access to free GP care. Health spending in Ireland is approximately one fifth higher than the EU average, but public funding of health spending is only 73%, 6% lower than the EU average of 79%. Out-of-pocket payments for GP visits are far more significant in Ireland than in other EU states.

It is important to bear in mind the length of time for which the various parties, including that of the Minister, have been discussing universal healthcare. In 2001, the then national health strategy, entitled Quality and Fairness: A Health System for You, made universal coverage a guiding principle for the health service. The Minister's party leader, who is now the Taoiseach, was central to the primary care strategy discussed at that stage. Little or no progress has been made on it since. In 2011, the programme for Government referred to universal primary care which would remove fees for GP care. It stated that would be introduced within the term of that Government. In 2016, A Programme for a Partnership Government referred to extending in phases the introduction of free GP care to all young people under the age of 18. Very slow progress has been made in that regard. We have not got anywhere near that objective.

The recent programme for Government refers to extending free GP care to more children. That is really disappointing. On the one hand, it refers to accelerating the implementation of Sláintecare while, on the other, it mentions extending free GP care to more children. Even the Bill before us, which contains a phased measure, deals with children up to 13 years. It is fairly pathetic in the context of all of the commitments that were made. I say that it should be extended to the entire population. That is what Sláintecare is about.

On the programme for Government, it is important to bear in mind that earlier commitments never came to fruition in the lifetime of any of the previous Governments dating back to 2000. The level of ambition has regressed since 2011. Universal GP care is not just about providing better access to healthcare, it is also about raising the health status of the whole population. It is also about ensuring better quality of care and longer life free of disability or chronic illness. Further, it is about enhancing economic liberty. If Deputies want to use that argument about the economic impact of universal access to healthcare, we know that the high cost of healthcare is a significant factor in our loss of competitiveness, as are the high costs of housing and childcare.

There are also very significant GP supply issues that need to be addressed. I am not sure what the Minister is doing in that regard or what his plans are. There are 64.4 GPs per 100,000 people in Ireland, significantly lower than the EU average of 91 GPs per 100,000. In order to support universal healthcare policies, the Government must also support GPs. It is important to listen to what the data are telling us about GPs. We urgently need a new GP contract. The one in place is completely outdated and does not serve the objectives set out in Sláintecare. Nor does it help us in terms of the recruitment of GPs. People spend many years training to be GPs and provide healthcare services. We should not expect them to be businesspeople or to have capital behind them to set up private practices.

A great many of our qualifying GPs end up going abroad simply because they cannot work as GPs in this country. They are expected either to have the money to set up private practice or to go as an assistant to somebody else. That is not what they want. Various surveys in recent years show that they want to work as part of a multidisciplinary team. They do not want to be carrying the burden of running a private practice. Nor do they want to be without the benefit and support of a multidisciplinary team which is so essential for the provision of comprehensive healthcare. They also want better work-life balance. None of those things are available to people at the moment. Nor is a sufficient salary or guaranteed secure salary available to them. The previous Government promised to move to a system of salaried GPs. A lot of newly qualifying GPs would be very interested in being employed by the State for a decent salary. I cannot understand why the previous Government did not and this Government will not commit to progressing that.

I want to make a point about medical cards for the over 70s. The income limits are being increased to a small extent under this legislation. I have stated previously in the Dáil that the income limits for over 70s are based on gross income. They are extremely low for under 70s but at least there is provision for disregards for particularly high health or living expenses that can be offset against the income limits. In the case of over 70s, only gross income is taken into consideration, irrespective of what a person's outgoings are. It is a fundamental weakness in how we operate the income limits for over 70s. The Minister referred to high-quality care for people in this age category. There is not high-quality care available to people over 70 who desperately need home-care services. I do not know if the Minister is aware that at the moment there are some 6,000 people living at home in difficult circumstances with various medical conditions, who have met the difficult criteria in terms of qualifying for home care and who are on the waiting list for home care because insufficient funding is provided. That makes no sense. It is inevitable that many of them will end up having to go into nursing homes or hospitals.

There is a promise in the programme for Government - it was also made in the context of the budget - to reduce prescription charges. That was to be done by July but I have not heard anything more about it. Has the Minister any information on that? Is the promise going to be upheld? The bottom line is that Ireland lags far behind all of its European neighbours when it comes to access to healthcare, particularly primary healthcare. It makes no sense on any level. It is quite disappointing to see the baby steps that are being taken in this legislation. What is proposed falls far short of what was promised in Sláintecare. This is year three of Sláintecare. Access to free GP care was to be introduced across the population in the first five years of Sláintecare. We are many years behind the commitments that were made. Not only does this deny people access to basic healthcare and impact hugely on their quality of life, ensuring there is a lack of equity in how we provide healthcare; it also means that we are not getting value for money on the significant spend that we have relative to other countries. That needs to be addressed quickly.

Debate adjourned.

Dáil Éireann díospóireacht - Thursday, 23 Jul 2020