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Dáil Éireann díospóireacht -
Wednesday, 8 Dec 2021

Vol. 1015 No. 5

Health Insurance (Amendment) Bill 2021: Second Stage (Resumed)

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

I will pick up a the point in the report where I left off yesterday:

The letter was submitted to a multi-disciplinary meeting of 4th March 2008. However, there are no minutes of this meeting and it is not clear how this letter was received. Two days later on 6th March 2008, psychiatrist (1) wrote to Brandon's GP referencing this meeting, emphasising again the concerns raised by staff in relation to Brandon's behaviour, "An emergency case review was held with nursing staff and care staff from "Abbeyside" ward together with the director of nursing (1) and myself on 4th March 2008. Staff are very concerned in relation to Brandon's increased sexualised behaviour towards residents".

There is no evidence to suggest that as a result of the staff letter to the meeting that any significant changes occurred for staff on the ground.

On 30th June 2008 a seven point plan was developed to mitigate the risks Brandon presented. This plan included an alarm on Brandon's door to be activated in the afternoon and at night. It also included 1:1 supervision of Brandon and the implementation of a new day programme. In spite of this plan, however, Brandon continued to behave in a sexualised way. His annual review on 19th August 2008 referred to four service users in particular who were described as his "preferred target group". The annual review record also went on to say, "He is escorted by a staff member throughout the day but when other clients need attention/assistance or there is a serious incident, Brandon takes advantage within seconds to assault clients". This review statement echoes the opportunistic nature of Brandon's behaviour referred to in the staff letter of 26th February 2008 and underscores just how difficult it was for staff to safeguard those in their care...

6.8 Communication with families

Throughout the period under review eighteen known victims of Brandon's sexual assaults have been identified. There is no evidence that any of the families of these residents were informed at the time of these assaults. Although there was a note on resident 2's file suggesting open disclosure had been conducted with his family, the family have subsequently told the NIRP that they had never been told that their son was sexually assaulted by Brandon.

The need to tell families about Brandon's behaviour appeared to be a regular theme in many of the records reviewed by the NIRP. For example a risk assessment and management plan dated 31st August 2004 stated: "if Brandon was sexually inappropriate the family of the person affected were to be informed".

The importance of open disclosure to families was emphasised by the external opinions provided by psychiatrist (3) and the forensic psychologist. On 27th April 2011 psychiatrist (3) wrote ''The fact that relatives of his known victims have not been informed of the episodes of abuse could be interpreted as collusion or complicity if the situation were ever the subject of an investigation. Therefore, it would be advisable to consider informing the next of kin and also advising them of the steps put in place to ensure no further abuse occurs".

On 16th November 2011 the forensic psychologist advised "...A clear plan would have to be devised as to how to address on-going behaviours and any harm caused by past be behaviours. This should lead to the development of a policy regarding the circumstances in which to inform families in the future". In spite of these recommendations from senior clinical experts a decision was made not to take the advice of these experts and family members were not informed until after the Look Back Review reported in 2018...

Section 6.10. Reports to An Garda Síochána (AGS)

The CHO have reported to the NIRP four occasions of contact between Stillwater services and An Garda Síochána (AGS) in relation to Brandon. The first record is dated 9th June 2011 which documented that nurse manager (1) met with a Garda sergeant in the local station and informed him of the sexual assaults carried out by Brandon on service users in Stillwater. The Garda Sergeant undertook to discuss the issue with senior Gardaí however, the NIRP found no evidence of any follow up on this report. On 9th September 2019 the NIRP wrote to An Garda Síochána seeking clarification on this point.

The second occasion occurred in March 2017. This is an undocumented recollection by service manager (2) which was described in a letter dated 13th July 2020 from the CHO to the NIRP:

"(service manager (2)), has provided the following commentary.

Comment: "I do not have any documentary evidence of this meeting. I do not have the exact date of this meeting. I met with Garda 2 when she was on site at Stillwater Complex attending there as Garda Liaison. I informed her that there was a look back review being completed by an independent team into alleged historical abuse of a sexual nature within the centre. She asked whether there was anything she needed to do at that time. I informed her that a copy of the final report would be given to the Gardaí. No notes were taken by her or me as I was just informing her of the review."

The third report to An Garda Síochána took place on 8th December 2018 when service manager (2) met with the Garda liaison to Stillwater services and briefed her on the outcome of the Look Back Review (2018). A copy of the report was given to the Garda liaison officer who advised that she would be escalating this information to senior Gardaí.

The fourth occasion, on 24th April 2019 representatives from the CHO met with An Garda Síochána. An Garda Síochána confirmed to them that they are completing an investigation regarding Brandon.

An Garda Síochána replied to the NIRP in a letter dated 26th February 2020:

"There is currently an on-going Garda investigation into allegations of abuse of patients at Stillwater... and also into the alleged withholding of information on the sexual abuse patients by staff employed by the HSE. It is expected that a file in these matters will be submitted in the coming weeks which will in turn be forwarded to the Director of Public Prosecutions for direction..... as this is on on-going investigation An Garda Síochána are unable to comment any further at this point". ...

6.14 HIQA

The Health Information and Quality Authority (HIQA) was established under the Health Act 2007. HIQA is an independent authority established to regulate health and social care services in Ireland. For most of the period of this review HIQA did not have a remit of legal authority to inspect disability services in Ireland. This legislative requirement began in November 2013. While the NIRP believe Brandon continued to pose a threat to residents living in Stillwater services until his move to a nursing home in 2016 all of the recorded incidents of inappropriate behaviour by Brandon towards others took place in Stillwater services prior to 2011. This timeframe preceded HIQA's legal authority to inspect residential centres for people with a disability.

Stillwater services were first inspected by HIQA in July 2014. This inspection identified both moderate and major non-compliances in 7 of the 10 standards inspected. Following this inspection service submitted an action plan in October 2014 detailing how they planned to address these deficits.

The next HIQA inspection was carried out in March 2016 which examined 7 out of 18 standards. This inspection identified major non-compliances in all 7 standards. This inspection identified "significant risks to the safety and welfare of the residents in the centre". Additionally, they identified "serious failings in the governance and management of Stillwater services", citing failures to report and investigate allegations of abuse "Inspectors identified several allegations of abuse that hod not been appropriately reported to management or when reported, had not been properly investigated in accordance with national safeguarding policies or procedures". It is not clear from the HIQA report what "allegations of abuse" HIQA are referring to, or if these are in an way related to Brandon's behaviour. However, during the NIRP's meeting with the two staff members, (see paragraph 6.6, pg. 31) one staff member alleged that they had met with a HIQA inspector and gave her details of the abuse of residents by Brandon in Stillwater including specific names of victims. HIQA corroborated this information in a letter to the NIRP dated 10th January 2020, they stated:

"Unsolicited information of concern was received from a staff member of the service in February 2016 raising concerns about safeguarding. The initial regulatory action was to carry out an inspection shortly after receipt of the information".

The March inspection also found no evidence that the required "provider led six monthly audits" or "annual reviews" were being carried out and no arrangements were in place to support and develop staff. Following this inspection the CHO commissioned a team of external managers from the quality improvement and risk management team to review the service. They also changed the structure of Stillwater services from one designated centre to five smaller designated centres. One additional 'Person in Charge' was appointed, bringing the total amount of 'Persons in Charge' to two in order to oversee five designated centres. On the 9th May 2016 Brandon moved from Stillwater services to a nursing home.

On this Bill, if the privatisation of services continues, we will not get to a point where we will be able to deal with a situation like this. I know this case relates to disability services but the logical conclusion of privatisation is that it will move from hospital services to disability services. That is why we have this problem.

This is a positive Bill. It is probably not the most exciting work we will do in Dáil Éireann this week but it is very important, particularly from a consumer point of view.

The Health Insurance (Amendment) Bill is somewhat akin to the Finance Bill or the Social Welfare Bill. It arrives in November or December each year. The measures in it are designed to support risk equalisation and sustain community rating in our health insurance market so that older people, whom the Minister of State, Deputy Butler, represents very well, and those with long-term illnesses can avail of the same health insurance cover as everyone else and are not discriminated against in favour of younger, healthier people in society.

The most crucial part of this Bill is its provision for the reduction in stamp duty levies on advanced health insurance contracts, which will decrease from 2021 to €406, representing a decrease of €43. Non-advanced health insurance contracts will decrease from 2021 to €122, a saving of €35. As a result of lower claims activity due to the past 18 months of Covid-19 and restricted use of hospital services, a surplus has built up in the risk equalisation fund. Consequently, the Minister of State and the Departments of Health and Finance are looking at the reduction in stamp duty to ensure health insurance contracts will benefit from that from 1 April 2022. That is good overall. It puts money back in people's pockets and ensures those who are most vulnerable continue to get the same level of public health insurance without having to dig deeper into their pockets.

The principle of risk equalisation is part of global insurance. We have had it for many years. It works quite well in health insurance. However, if I may go on a slight tangent, risk equalisation has become an absolute stinker in the area of flood cover. They are two different realms but it is all the world of insurance. The principle of risk equalisation might make a hell of a lot of sense when it applies to health when there might be an older person and a younger person or a person who is perfectly fit and healthy versus someone who has underlying illnesses. It makes sense in public health and the provision of private health cover but it does not make sense in the realm of flooding.

If we take any field or townland, the topography varies very much. There could be undulating land, hills, drumlins or parts near water drainage or even at sea level. In County Clare, 5,000 or 6,000 households struggle annually to get flood cover on their home insurance policies because of the risk equalisation principle. Every year, I have to write a letter on behalf of some of my neighbours. Using Dáil headed paper, I state that it is my belief, in all the years I have lived beside the persons in question, their houses have never flooded and, thus, I implore their insurance company to provide them with flood cover on their policy. I can rattle off the text because I write this letter maybe 50 or 60 times a year. It is insane. The insurance industry accepts a letter on Dáil headed paper that the person living in No. 95 does not experience flooding. Risk equalisation is bonkers. The home of the person who is denied flood cover year after year is about 60 ft above the maximum level of the River Shannon. That has to change too.

Risk equalisation is working very well as far as VHI and health insurance are concerned, and we are glad people will be reimbursed stamp duty, but it really does not work as far as flood cover is concerned.

I welcome the opportunity to speak. In Ireland our health insurance is supposed to be community rated. The Health Insurance Acts prohibit risk rating, the reason being to ensure people will, in theory, pay the same price regardless of their age or health status. The health insurance market in Ireland is worth over €2.5 billion and 2.31 million people are covered, which represents 46% of the population.

Section 8 of the Bill provides for a reduction in the stamp duty levies on policies from 1 April 2022. The current levels of duty are €52 per child and €157 per adult for non-advanced contracts and €150 per child and €449 per adult for advanced contracts. It is proposed to reduce these amounts to €41 per child and €120 per adult for non-advanced contracts and €135 per child and €406 per adult for advanced contracts. It is noted that stamp duties are levied on insurance companies rather than consumers and, therefore, it is up to insurance companies to decide whether to pass on any reductions to customers. It is important that every Member of the House make the point that it is imperative that the insurance companies pass on this reduction to consumers. If we were discussing an increase, there would be no question that the increase would be passed on to the consumer.

During the pandemic, the cover provided by private health insurance has been drastically reduced. While I acknowledge refunds were given to members, these did not cover the true reduction in services experienced. In effect, the private hospitals were not available for many treatments. The reductions in stamp duties must be passed on to the consumer.

The insurance companies have been increasing premiums each year. Health insurance is still too expensive. Why does more than half the population not have private health insurance? In my constituency office in Dundalk I deal with a large number of queries from constituents who have had issues with their health Insurance provider. One of the issues that consistently crops up is that of not having cover for a particular treatment or hospital. Much of the time, exclusions are buried among pages of small print.

Has anybody looked at the number of different policies available lately? There are literally hundreds of different policies to choose from. This is only confusing the consumer. Why do we need so many different policies? Surely there can be a more simplified system. Many policies have more hidden exclusions buried in the small print. If we want to make health cover more accessible, we need a simpler and more transparent system. I have read through a number of policies lately and to be honest this area is a minefield.

My colleague, Deputy Naughten, has previously raised an issue in relation to model 2 hospitals and the fact that a particular insurance provider decided it would not provide cover in these hospitals. He rightly pointed out that we cannot have a situation where these insurance companies can decide not to provide cover. Hospitals such as the Louth County Hospital provide an excellent service for local people. They take great pressure away from the larger hospitals and to have a scenario where particular insurance companies simply cannot provide cover is wrong. Insurance companies that decide not to provide cover for model 2 hospitals must be called to account. They are undermining the health system. We must support our local hospitals such as the Louth County Hospital rather than exclude them from private health cover. The bottom line is that health cover should be available for every model 2 hospital in the country. Will the Minister of State comment on this matter and provide the House with an update on any discussions the Department has had on it?

If we are to encourage more people to take on private health insurance, the system needs to be more transparent and easier to navigate. We have three insurance providers, yet we have literally hundreds of different policies available. Reading through the small print of many of these polices, one finds too many exclusions. This needs to change.

The cost of health cover also needs to be reduced as it is too expensive. Why is health cover in Ireland among the most expensive in Europe? I ask the Minister for Health to examine the issue of certain providers excluding model 2 hospitals from cover. This practice needs to stop and the providers need to address it.

I call on the insurance companies to pass on the reduction to stamp duties directly to their customers. As I said, if there was an increase, the insurance providers would pass it on immediately.

I am pleased to speak briefly on this very important issue. This Bill seeks to provide a risk equalisation mechanism for ongoing sustainability of the private health insurance market, while maintaining health insurance policies at an affordable price. It will also provide for a reduction in stamp duty levies on advanced health insurance contracts, which will decrease from 2021 to €406. That is a decrease of €43. Non-advanced contracts will decrease from 2021 to €122, which is a decrease of €35. This is a welcome but belated action. It is partial recognition that prices for health insurance are simply astronomical and out of the reach of many people, especially those with chronic or long-term health conditions or large families.

I note section 4 of the Bill amends section 7F of the principal Act to deal with the benchmark for "reasonable profit". This section is being amended for the purposes of assessing whether an insurer has been overcompensated by the scheme. That is one of the key issues of this entire debate which we must address. What exactly is it that determines a reasonable profit and how far may a health insurance go in settling costs? Clearly, it is the case that in this area, just as with motor vehicle or business insurance, we have a sector that is not always as transparent or open to public scrutiny as it should be. We have all seen how insurers have responded to Covid and, indeed, the forced closure of small and medium enterprises, SMEs, and local traders. It took High Court action to challenge the insurance sector to make good on policies people had paid into for a long time. That should not have happened. I raised this issue in the House on behalf of businesses. Insurers should have been fairer and more reasonable.

Some years ago, the European Commission informed Insurance Ireland, the association of Irish insurers, of its preliminary view that the association breached EU antitrust rules by restricting competition in the Irish motor vehicle insurance market. Many people have the sense that there is a similar level of market restriction with health insurance.

The Government's position is our community-rated health insurance market means the cost of health insurance is shared across all members of the market and that in general, with certain exemptions, everyone can buy the same policy at the same price and insurers cannot alter their prices based on an individual's current or potential health status. This is a regulatory version of wishful thinking. In the consultation conducted by the Health Insurance Authority in January, found that:

It is widely recognised that in a community rated market without a robust [risk equalisation scheme] RES, insurers with lower risk profiles will tend to be more profitable, all else being equal. As a result, in the absence of a robust RES, insurers will be incentivised to do the following:

- Design products so that they are not attractive to older and less healthy customers ... [which, as we know is called risk selection]; and

- Segment their customer base by age / health status so that older and less healthy people pay more for insurance (market segmentation).

We need to ensure insurers are not allowed engage in such practices and that all people who want it can afford a different level of comprehensive health insurance. It is a matter of ensuring fairness for everybody and that everybody who needs and wants health insurance can avail of it in a fair and just manner.

As no other Deputies are offering, I invite the Minister of State to respond.

I thank the Deputies who indicated their support for the Bill. I also thank the Deputies who spoke in the debate today and yesterday for their contributions. I will only speak and comment on issues related to the Bill.

As was discussed in yesterday's debate, a large number of people hold health insurance. For some, this is a choice while others, unfortunately, may view it as a necessity. The Government is committed to improving public health services under the Sláintecare programme.

As access to these services improves and the public's confidence in public health services increases, it may be that we see a change in the numbers that hold health insurance. In addition to providing support to community rating, the amendments to the risk equalisation scheme have regard to the sustainability of the market and the need for fair and open competition. Importantly, they also ensure that there will not be overcompensation of any insurer from the scheme, as required under the EU framework for state aid. The Bill allows us to maintain our support for the core principle of community rating, which is long-established and well-supported Government policy for the health insurance market. The Bill will ensure that we can continue to provide the necessary support to ensure that the costs of health insurance are shared across the insured population.

Various issues were raised over the past day or two. My officials have said that they will take a look at the issue of restricted membership undertaken, which was raised by Deputy O'Reilly. Many Deputies spoke about the number of people who have health insurance in this country, which stands at 46% of the population. It is important to put on the record that while a large number of people hold private health insurance, and this Bill provides support for them, to also draw Deputies' attention to the number of people who are able to access public healthcare without having to pay. As of 1 November 2021, 1,563,184 people in Ireland hold medical cards. This represents 31.2% of the population. Some 525,813 people hold GP visit cards, which is 10.5% of the population. In total, these cards cover just shy of 42% of the population. This represents massive funding for public healthcare in Ireland.

Many Deputies also referred to Sláintecare. The Sláintecare Implementation Strategy and Action Plan 2021-2023 was approved by the Government in May. The six-month progress report published last month indicated that of the 112 deliverables, 109 were on track or progressing with minor challenges. I expect the progress to continue at pace in 2022, supported by the allocation in budget 2022 of €21 billion, the biggest ever investment in Ireland's health and social care service, to deliver Sláintecare. I also want to touch on the roll-out of the vaccine because it epitomises what Sláintecare is all about. Some 8.2 million doses, free at the point of entry with access to all, have been rolled out. I take this opportunity to encourage anyone who is entitled to a third vaccine, or a booster shot, to take it up.

Deputy Shortall mentioned the benchmark of reasonable profit. In 2016, the benchmark of reasonable profit was set at a 4.4% return on sales following a benchmarking exercise among European insurers with a similar profile to the net beneficiary of the Irish risk equalisation scheme, which is VHI Healthcare. An overcompensation test is conducted for every three-year period to make sure that the net beneficiary of the scheme does not make more than the reasonable profit figure. A new benchmarking exercise was conducted among Irish and European health insurers and the Health Insurance Authority recommended the 6% figure, which is at the low end of the recommended range. The 6% return on sales figures will only apply to the net beneficiary of the scheme, which for the foreseeable future will be VHI Healthcare. While VHI Healthcare operates on a mutual basis and all profits are reinvested in the company's products and services for the benefit of its customers, it is conceivable that a company which operates on a for-profit basis would become a net beneficiary in the future. To provide for that circumstance, it is necessary to review the benchmark to make sure that it is appropriate and to provide that an insurer with a worse risk profile than its competitors is not being further disadvantaged by keeping its profits below a competitive figure.

I will also touch on the role of private health insurance in Sláintecare. Removing private care from public hospitals remains an incremental and progressive long-term objective of Sláintecare. This process is aligned with other reforms being progressed under Sláintecare allowing more time to put in place the necessary improvement in capacity and care models. One of the recommendations and milestones yet to be achieved is the implementation of the Sláintecare public-only consultant contract. Negotiations on this contract are currently ongoing. The programme for Government contains a commitment in respect of the finalisation of this contract and the introduction of related legislation to support public-only work in public hospitals. The impact of implementing the removal of private care will happen progressively. Anyone with health insurance can continue to receive private care in public hospitals for the foreseeable future. After that, anybody with private health insurance will still be able to receive private care in private hospitals. I was asked last night by Deputy Kenny if I believed in Sláintecare; I absolutely do. I quote from it every day when I am talking about my brief on older people and mental health. It is about providing the right care, at the right place, at the right time and as close to home as possible.

There was a lot of talk last night about waiting lists. The Department of Health, the HSE and the National Treatment Purchase Fund, NTPF, are focusing on improving access to elective care in order to reduce waiting times for patients. These plans include increased use of private hospitals, funding weekend and evening work in public hospitals, funding see and treat services where minor procedures are provided at the same time as outpatient consultations, providing virtual clinics and increasing capacity in the public hospital system. Under the NTPF, 122,000 outpatient appointments were approved by the end of October this year. Some 47,474 appointments were arranged and 26,730 patients have been seen at an outpatient clinic. The health budget for 2022 provided an additional allocation of €250 million, comprised of €200 million to the HSE and €50 million to the NTPF, in respect of work to reduce hospital and community waiting lists. The €250 million will be used to fund additional activity in the public and private sectors. The €50 million in additional funding provided to the NTPF brings the total allocation for 2022 to €150 million. As a consequence, a budget of €350 million will be available to support vital initiatives to improve access to acute hospitals and community health services.

One of the issues that has been raised with me on many occasions since I came into post is the length of the primary care psychology waiting list for young people. Unfortunately, when I was appointed last year, more than 5,000 over-12s were already awaiting supports. I received €4 million this year, for the period September to December, to try to put a targeted approach to waiting lists in place. All the community healthcare organisations were able to get consultants to work some overtime, hire locums and use both the public and private sectors to do so. We will meet a target of 20% of those on that waiting list, which means 1,000 children will be seen over four months. We have much more to do, but it is at least a start. I hope to secure more funding in the new year to keep that initiative going. I commend the Bill to the House.

Question put and agreed to.
Sitting suspended at 3.39 p.m. and resumed at 4 p.m.
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