Amendments Nos. 1 and 2 are out of order because of a potential charge on the Exchequer.
Health (Amendment) (No. 2) Bill 2010: Committee and Remaining Stages
SECTION 1
Amendments Nos. 1 and 2 not moved.
Question proposed: "That section 1 stand part of the Bill."
I thank the Minister for her replies to the various queries raised on this section earlier. Will the Minister clarify a matter on the administrative side? The Minister appears to be suggesting that the system is already set up to capture a significant amount of data and that there will be no difficulty incorporating these new expenses and costs into this data system. Will the Minister clarify if this is the case?
I refer to cases involving long-term illness cards. The Minister indicated anyone with a long-term illness card will be exempt. Will the Minister comment on the position of cases of palliative care and whether they would qualify as one of the exceptions? I assume people with cancer would be covered if they have a long-term illness card but not otherwise. Will the Minister clarify this? Some confusion has arisen of late with regard to the position of people suffering from cancer and medical cards. There have been situations in which many such people had access to medical cards but that appears to be changing at the moment.
The Bill gives the Minister powers to introduce extra charges. It is effectively a carte blanche to introduce extra charges. The Minister referred to the range of criteria she would use to do so. This can work either way. The Minister can exempt people who have a particular medical condition or disability or the medical needs of persons of that class. Will the Minister indicate what lines 46 and 47 mean exactly? They refer to one of the criteria the Minister may use.
The Minister can also use the criteria of medical needs and the financial burden on the persons who avail themselves of services under subsection (1), which is rather wide. It seems to give the Minister wide powers to increase charges arbitrarily and to exclude certain groups. Will the Minister address how she intends to proceed in this regard? How does the Minister envisage this working within the Department and what actions does she intend to take? What data would be collected to inform that decision and other decisions under subsection (4) and what criteria apply in such cases? Some of the criteria are straightforward such as the consumer price index but others are rather wide. I call on the Minister to address these issues.
I have similar questions. Who will arbitrate on the individuals who wish to make a case if they are included or excluded and if the charge does not apply to them? Who will decide on this? Will it be such a person's medical doctor, a community welfare officer or a doctor at the Department's expense? How does the current system of payment operate and how will it incorporate the new charges in a seamless way without additional charges or staff costs? When the HSE tried to apply the PPARS system, it could not accommodate all the various grades, types and rates of payment for people. What sort of refinement of the system will allow this to be imposed seamlessly and to accommodate increases in future? How will that operate?
All community pharmacy contractors have a contract with the HSE which involves their being paid. In the case of the GMS, general medical services scheme, they are paid a particular fee for the first 20 items prescribed and a different fee thereafter. The payments systems are linked by computers and technology. The HSE has good data in respect of each person, what he or she gets each month and what he or she pays for. Patients pay for these as they do under the drugs payment scheme. The system will have to be adapted as it was last year when we changed the payment regime. I accept there may be a cost involved in adapting the system to deduct the 50 cent per item prescribed.
I refer to the question of whether this legislation would involve additional administrative staff and the answer is "No". By centralising the administration of medical cards we are reducing the work load in that area and taking many personnel out of the application and administrative processes, in line with what most people want, and applying them to other areas where they are required. Significant savings will come from this.
I refer to Senator Fitzgerald's comments concerning the basis on which I will make decisions. I have considered sympathetically several categories I would have preferred to exclude from the charge. However, it was not possible in every case. For example, one cannot define palliative care in such a way as to make it easy to determine when someone has a medical card for drugs for palliative care. I refer to the powers in page 5 of the legislation. I envisage asylum seekers who live on €19 per week will be excluded. The idea was to give the powers without referring to them in the primary legislation, which would be extraordinarily difficult and complex in cases involving palliative care, asylum seekers, those suffering from thalidomide and other cases where I would take a sympathetic view. Earlier, I referred to the areas covered by long-term illness cards. In particular, issues were raised about diabetics. Currently, diabetics have a long-term illness card. No Minister with responsibility for health has added anything to long-term illness cards since the 1970s. Anomalies exist and the long-term illness card together with the review of eligibility legislation for entitlement to health and social care services are being urgently reviewed in the Department. I will bring proposals to the Government later this year because we must have clarity in law about the entitlements of different groups of people. The groups covered by a long-term illness card are excluded.
I was asked about the basis on which I would increase the charge. I am introducing it at a modest level. Almost every country in western Europe, as well as Australia and the United States, provides for co-payment. I visited New Zealand recently and there is co-payment both in respect of the doctor's fee and the drugs payment for every single person who uses health services. This has been contradicted by somebody who is supposed to be a health analyst, but she is incorrect. I accept some do not agree with this proposal, but a small co-payment for prescription items is not unreasonable in the current environment. We probably would not do this if there were no financial constraints, but there are. Therefore, we must examine every possibility to maintain the level of funding for health services. Given that there is evidence to suggest a small charge changes prescribing behaviour, I hope this will affect usage behaviour, particularly where antibiotics are concerned. It will be open to the Minister under the provisions of the legislation to alter the charge or the categories excluded from it by way of regulation.
On Second Stage I mentioned the proposals IMO representatives had made regarding cost savings and the range of activities they considered could be engaged in to address prescribing and usage behaviour. They were of the view that these proposals offered a better alternative to opting for a prescription charge. Did the Minister make progress with them on the proposals made? Does she believe other categories of patients should be exempt such as asylum seekers, thalidomide and polio victims and those in receipt of palliative care, not only methadone users and children in care? Why did not she not provide exemptions for these groups in the legislation?
It is impossible to define in legislation what palliative care means and to identify it with the medical card. That is why there is a need for specific regulations because these are complex and difficult issues.
With regard to the IMO proposals, essentially, we need doctors to prescribe differently. The clinical care pathways being rolled out by Dr. Barry White will include prescribing protocols. In addition, the reference pricing and generic drug substitution I will introduce later this year will mean we will be closer to the position in the United Kingdom than we are. In the United Kingdom 63% of the medicines prescribed are generic; in Ireland the equivalent figures are 18% under the medical card scheme and 12% under the drugs payment scheme. Reference pricing and generic drug substitution will greatly increase the volume of generic drugs dispensed. That is an effective way to do it. The IMO suggestions would have involved the investment of money to make this happen. In the current climate we do not have additional resources to apply. It is best done, therefore, by way of protocols laid down by the lead clinicians, including those involved in primary care, and through reference pricing and generic drug substitution.
To achieve savings, we have to examine every aspect of the pharmacy chain, including producers, distributors, whom we addressed last year, and the community pharmacy sector, as well as examining this modest prescription charge. In his report Mr. Colm McCarthy said it should be €5 per prescription, which would have been substantially more severe. Instead of raising €24 million per year, we would have raised more than €90 million on the basis of 16 million prescriptions. The proposed levy is modest in comparison with what was recommended in the review of public expenditure.
Does the Minister have any reservations about the charge in the context of the deterrent effect of such charges on people who are most vulnerable from a financial and illness point of view? Is she concerned that we may end up spending more on the health budget because people will not look after themselves in the way they should and that they will end up in crisis? I acknowledge patients with diabetes are excluded, but we have mentioned other illnesses.
An bord snip nua made many recommendations and I take the Minister's point that Mr. Colm McCarthy recommended a more punitive prescription charge, but it would have been disgraceful if we had gone down that route because it would have had an enormous impact on individuals who had recently lost their jobs, the elderly and social welfare recipients on limited incomes. Mr. McCarthy recommended that €55 million be saved through transport scheme efficiencies among CIE companies and suggested that by merging various agencies such as Enterprise Ireland, FÁS and the IDA €87 million in savings could be generated. The Government, therefore, had choices in raising the sum of €24 million it proposes to generate under this legislation. It made the choice to target this group on medical cards with a prescription charge. With regard to decision-making, did the Minister have any reservations about targeting this group and the impact it could have from a health perspective?
If we compare this jurisdiction with Northern Ireland, we have similar demographics, a similar cultural experience and a shared history. In Northern Ireland the number of items per prescription is 1.7 whereas it is 3.7 here. If we compare two populations on the same island with similar demographics, doctors here prescribe much more than their counterparts in Northern Ireland. Any Minister for Health and Children would have to be concerned about this.
I seriously examined the evidence and the literature and it is mixed. One can make as many strong arguments against doing this as one can in favour of it, but it will be an experience for us to see what the measure will do for prescribing practice. International evidence suggests essential medicines are still prescribed and consumed. According to one statistic, half of those who need blood pressure tablets are not on them and half of those on them should not be on them. That is a poor use of a limited resource. We need to do much more with patients, which is why the clinical pathways being rolled out by the lead clinicians in dealing with diabetes, coronary care and neurology will be of benefit. They will put in place appropriate protocols for prescribing and appropriate reviews of medications, all of which have a part to play.
In the United States insurance companies entered into agreements with Merck, Sharp & Dhome which meant it was in the interests of the pharmaceutical company to make sure medicines were prescribed and that it was in the interests of the insurer to make sure they were prescribed to the right people and both were able to achieve savings in working together. These measures are being implemented by health financiers all over the world because the cost of medications is increasing. The increase in Ireland has been greater than in any other OECD country, at 12.5% annually for the past six years. We must, therefore, consider every measure to contain the cost, while recognising that this measure must be kept under review because it is new.
If there were no financial pressures, we would probably not do this. It was by no means the first item on my agenda, which was why I addressed the distribution and wholesale margin last year, the retail payments and the payments to manufacturers. We are doing this as a contribution to saving money and I hope it will make all of us think about the medication we are using and, in particular, encourage doctors to discuss with their patients whether they need a prescription just because they have visited their doctor. The evidence suggests that many patients feel let down if they do not get a prescription. We have become a little obsessed with drugs always being necessary to help the recovery process and in many instances they are unnecessary, certainly as far as prescribed medication is concerned.
We must keep this legislation under review and watch its impact on a constant basis. We must hear about its impact from the professionals and analyse its impact in terms of prescribing practice. That will be done by me and my officials and, no doubt, by the HSE. We will be able to get data quite early because it is one area where we have fantastic data, due to the manner in which we pay for medication. The HSE can literally tell what each person with a medical card is on per month. As Senator Feeney said, the average payment will be approximately €2.50 per month. Even in the current constrained environment in which many families operate, it is not an undue burden. Senator Callely asked about people who have their pints and back horses. I do not know if he suggested that we should not take a prescription charge because of that.
We must consider all the options to achieve good prescribing practice and to reduce the unsustainable and growing cost of medication in the health system.
The Minister mentioned that half the people who are on hypertensive medication should not be on it. I agree with her. What was very common during my time in active nursing was what was called "white coat syndrome", whereby if one went to the doctor and one's blood pressure was taken immediately, the blood pressure was bound to be high as the nature of the visit to the doctor caused it to happen. If people who are on medication had frequent check-ups in the primary care setting by utilising the public health nurse system more effectively, it would give rise to a review of people's medication. A series of estimations of blood pressure taken over a series of days would allow that. If there is a track that shows blood pressure within relatively normal limits, is that down to the fact that the patient is being visited by a public health nurse specialist or to the fact that they are on medication? If the blood pressure is down, should they try to only have the medication every second day? There is scope, therefore, for examining best practice with regard to how people are monitored.
It is also widely acknowledged that if people make lifestyle changes, their need for medication reduces. In the case of somebody who is overweight and suffering from hypertension, for example, reducing the weight could reduce the blood pressure as well. There is also diet, exercise, reducing salt intake and so forth, all of which is well known. The issue is trying to tailor the medication needs of individuals. If there is a primary care team operating effectively and people on medication are regularly checked by public health nurses, it would be a far better system because, in fact, people's need for medication would reduce. The fact that people would be able to make changes and perhaps stop taking medication is a positive thing, rather than a visit to the doctor resulting in somebody having to continue or increase their medication. That is a far more depressing scenario than somebody telling them there is no need for it because they have made a number of changes in their lives.
The moratorium in the recruitment of public health nurses and the fact that 120 posts are not filled are having a major impact on how people are treated. There is scope within the system to make the savings other than through imposing a charge on prescriptions.
The Minister made the point I intended to make. On Second Stage, I pointed out that, based on the figures the Minister gave us this morning relating to families, the cost works out at roughly €2.50 on average per month, per family. Even if it was €2.50 per week per family, it is still a very small charge. If Senator Fitzgerald really believes people will do without medicine because they cannot afford €2.50 per month, those people obviously fall into a net where other moneys and supports are put in place for them. I do not accept the Senator's point that people's health will fail as a result of a 50 cent per item charge.
We are losing sight of the ethos and value in this legislation, particularly with regard to the generic content and what the Minister said this morning about where she wants this to lead and what she intends to do in September. There are people who will not object to paying 50 cent per item. Many old people might be glad to pay it. They will see it as their way of contributing towards something they are glad to have. Everybody knows the income level for the medical card. The Minister said this morning there are 1.66 million people with a full medical card; I forget how many have doctor-only cards. People will understand what the Minister is trying to do and there will not be objection to the 50 cent charge.
Other points were made this morning and I hope the Minister takes them on board. I am glad to hear Senator Prendergast's contribution. Let us see what we can do with this to move the issue forward in the best interests of patients. Continuing prescriptions should be reviewed. Where there are continuing monthly prescriptions, including for medication such as painkillers, one will have cases such as the one I mentioned where 600 or 700 Panadol tablets were found in the house when the old person died.
Looking for revenue from those on the GMS is hitting the worst off. That is the point. Some people will pay the €10, and it might well be the elderly who will be hit most frequently. The elderly often have a very complex range of medication. I do not know if the Minister has the figures but it is not unusual for elderly people to be on a great deal of complex medication into older age and towards the end of their lives. In that context a charge of 5% of their income is not to be spoken of as if it would have no impact, particularly at a time when there are such financial pressures on people. I am not inventing this information. Eamon Timmins of Age Action, who has much experience working directly with elderly people, has said it will create hardship for sick people. He said patients do not decide what medication they take and the change would punish them for the decision of doctors.
The Minister made a very important point about the education of the patient. There is much educating to be done with regard to the demands of people for medication and the pressure experienced by doctors to prescribe. Obviously, however, the behaviour change must come from doctors as well, not just from the patients. This legislation, however, targets the patient and the medical card holder for the behaviour of doctors who prescribe.
The Minister said she will review this and that the data will come in quite quickly, as the system is set up to collate that type of data. I ask her to bring a review of what happens with this to the House. She comes here regularly to discuss the health service so perhaps she might give an indication of when she might be able to do that. We should be given that information. Also, what plans does the Minister have to inform the House if she decides to exclude other groups, as she has the authority to do under this Bill?
I supported the Bill on Second Stage, not because I am in favour of a charge for prescriptions but because when the an bord snip nua report was published, I was appalled at the figure of €5 proposed. The position taken by the Minister in the legislation is not unreasonable from that point of view and is a major improvement following the shock we got at that stage. I take on board the point made by Senator Fitzgerald and others that this measure might cause hardship and that is my only reservation about it. I am not sure whether the Minister can make regulations in a later part of the section we are discussing to vary the position on the basis of a financial burden or hardship being imposed. The answer is to review the measure and come back to us with the results. Also, there should be an appeals mechanism which I understand may already be in place for those experiencing hardship and poverty. Senator Feeney has made the point that there are other support structures in place that could be made available to help those who will find themselves in difficulty because of this measure.
I have stated many times in the House that there is overuse and abuse of medications, not in the sense of people shooting up but misuse. I have argued with the Minister many times about the money being wasted. Often the things people get for nothing are regarded as having no value. I realise that is the speech made by my grandmother, but there is an element of it in this instance. The perfect solution would be for the Minister to hold the charge and have an appeals structure in place. As Senator Fitzgerald said, the last thing we want is people to damage their health for the sake of 50 cent but on the other hand the Minister questions whether people would damage their health for the lack of 50 cent. A balance can be achieved in that respect.
At the weekend I spoke about aspects of the matter to somebody who works in a hospital. I was cited the example of someone living 40 or 50 miles from Dublin who had genuinely lost their child's medication. The person concerned telephoned to get a repeat prescription. It took much effort to find it and the person concerned insisted that it be sent by taxi, even though they had a car. That is the other side of the story. I am not using this story to undermine the valid arguments made by my colleagues on this side of the House but to support my position that there is a number of people who take the health service for granted and do not recognise that it is taxpayers' money. It is our money and the way it is spent is important. It is important that it is spent properly.
My point to the Minister is that it is not unreasonable to have a charge. Neither is it unreasonable to respond to the point made by Senator Fitzgerald that there be a review of the charge and that there be in place a fail-safe mechanism to ensure nobody's health will be compromised in a manner not contemplated by the legislation and certainly not by the Minister. This is a tricky one because it is about striking a balance. I would like to say I am opposed to the Bill on principle because it imposes a charge, but I find that to be an unreasonable position in terms of where we are. Rather than aiming to eliminate the charge, I hope people will be better off in the future and better able to cope with it. I, therefore, support the section.
The things that receive attention in the health service are the things that go wrong, but I am happy to say many things are going right. Among them is the decision to allow nurses to prescribe. Although we do not yet have definitive research, the findings from other countries and the anecdotal evidence here suggest nurses are much more conservative in prescribing. They put much more thought into it than, say, doctors who are busy in general practice.
We must do much more to educate patients. I recently opened a new primary care centre in Leopardstown. That team undertakes some fantastic pioneering projects, as do many other primary care teams, one of which is on the management of diabetes and another on smoking cessation. They have told me that those who stick to the smoking cessation programme — I accept many drop out after the first or second week of what I believe is a ten week programme — have a 70% success rate if they come to the centre every week to participate in what is effectively counselling. That is a fantastic result. It is amazing how one to one contact and group therapy has a huge impact on the way we behave.
Equally, many diabetics — I know this from experience in my wider family — sometimes feel they are fine and do not need to take their medication. It is estimated that 45% of medication is not used appropriately and that 20% of people do not use it. It is clear that this does not make sense from a cost and health outcome perspective.
A medicines usage review is under way, involving pharmacists and 16 primary care teams, for which the training was done in May. The pilot scheme is being run in the months of June, July and August and we will know the outcome in the autumn. Some pioneering work was done last year in Cork with 500 chronic illness patients and the results showed that medications some patients were on conflicted with others and that there was over-prescribing and overuse of certain medications. Data are important, but we must find a way, whether it is through using the public health nurse, the general practitioner, the pharmacist or a combination of all three working together as part of a primary care team, to talk to and educate patients on the use of medicines because the rate of prescribing of medications is high here in comparison with other countries. As I said, nearly twice as many medications per prescription are prescribed here than in the North. There appears to be no reason for this. We have a long way to go, therefore, in dealing with the issue.
On the fail-safe mechanism referred to by Senator O'Toole, that is the reason the Minister will have the power to make regulations to exclude categories of patients. If a case is made to me — a case is often made to me about mental health patients — and there is evidence to support it that patients are not taking their medication, I will not stand over this. That is the reason I have introduced the modest sum of 50 cent.
When this measure was placed before the Government and the wider political system around the time of the budget when it received more attention, the one comment most people made to me was: why is the charge so low? It is low because we are starting something new. We are moving into unknown territory; it is pioneering work, and we want to keep the matter under constant review. I will report back to the Seanad, the Dáil and the Joint Committee on Health and Children on the regulations made.
Regarding the person who lost medication and looked for a taxi to bring a repeat prescription, I know Senator O'Toole said that was the exception, but when something is free, people sometimes adopt an attitude that is not appropriate. I am told by some doctors that patients often ask them to prescribe a particular medication in case they need it. We do not need to prescribe medication in case people need it. We want to make sure everybody obtains the appropriate medication, that he or she takes it and is educated on how to use it. We do not want to spend money unnecessarily at a time when many services are under pressure. There has been a rise in the cost of drugs in Ireland, notwithstanding the changes made last year. We have reduced the cost base by approximately €250 million, but because the level of prescribing is increasing we are not seeing the reductions we should be seeing, nor will we. This is about halting the rise in rather than reducing the overall cost.
The amendments were ruled out of order on cost grounds. Senator Fitzgerald is opposing the section which effectively gives the Minister the power to implement this modest charge which, as I said, will be kept under constant review. I repeat what I said. The international evidence is mixed, although I accept arguments can be made both ways. Our experience in Ireland seems to be very different, particularly in terms of the numbers of items prescribed, from that in other jurisdictions. We have a relatively young population, yet the rate of prescribing seems to be increasing at a level that is unjustifiable in terms of cost, the number of items prescribed and the number of new prescriptions. There has been an increase of 4 additional million items in a short period and 15 million items in a five-year period.
I will make a final point. The health data for life expectancy and illnesses show clearly that those who are least well off financially, those dependent on social welfare and those with medical cards, make up the most vulnerable group which this legislation is targeting. The Minister states the evidence is mixed. I refer to the international evidence on the impact of a prescription levy; it indicates that it places a financial burden on the poorest in the community and that any charge has a negative effect on the health of that population group. That is my concern about the Bill. While it is the case that the Minister will come back with the data, the evidence on those most likely to be affected by the charge may be hidden and difficult to access, which means this group will become more vulnerable and monitoring will be difficult. For these reasons, I oppose the section. It would have been fairer and more socially cohesive to introduce reference pricing. There should have been a greater attack on the pharmaceutical companies before the Minister decided to go after this group. She had a wide choice available to her and the Government as to where savings could be made. I regret that she has decided it should be this group who will provide the revenue saving of €24 million because the levy has the potential to have a serious impact on their health and that of their families. I refer to the international evidence which supports that position.
I again clarify that no old person will pay 5% of his or her income; the maximum percentage such a person will pay is 1.25%. The maximum amount to be paid will be €2.50 a week, if they have more than 20 prescription items a week. The charge is capped at a sum of €10 a month or €2.50 a week. As the old-age pension is slightly more than €200 a week, this amounts to a figure of 1.25%.
The international evidence is mixed. There have also been significant reductions in the pharmaceutical sector. As a result of the contract agreed with it three years ago, Ireland was placed in the group of countries with a cheaper basket of prices with countries such as Spain. We had been in the group of countries with the most expensive basket. That, together with the reduction of 39% this year in the cost of off-patent products, is leading to us saving a couple of hundred million euro. In addition, we have reduced the margin in the retail pharmacy sector from 50% to 20% under the drug payment scheme. We have changed the manner in which we pay for items prescribed under the medical card scheme and reduced distribution costs from 17.6% to 10%. We are, therefore, doing a lot and the next step in the process is the introduction of reference pricing and generic drug substitution. We have completed Mr. Mark Moran's work. He chaired a group of experts from my Department and the HSE. They have completed their task promptly and it is an excellent piece of work. The legislation is now ready to make this happen as quickly as possible in 2011.
Question put.
The Committee divided: Tá, 29; Níl, 17.
Tá
- Boyle, Dan.
- Brady, Martin.
- Butler, Larry.
- Callely, Ivor.
- Carroll, James.
- Carty, John.
- Cassidy, Donie.
- Corrigan, Maria.
- Daly, Mark.
- Dearey, Mark.
- Ellis, John.
- Feeney, Geraldine.
- Glynn, Camillus.
- Hanafin, John.
- Keaveney, Cecilia.
- Leyden, Terry.
- McDonald, Lisa.
- Mooney, Paschal.
- Ó Brolcháin, Niall.
- Ó Domhnaill, Brian.
- Ó Murchú, Labhrás.
- O’Brien, Francis.
- O’Malley, Fiona.
- O’Sullivan, Ned.
- O’Toole, Joe.
- Ormonde, Ann.
- Walsh, Jim.
- White, Mary M.
- Wilson, Diarmuid.
Níl
- Bacik, Ivana.
- Bradford, Paul.
- Burke, Paddy.
- Buttimer, Jerry.
- Coffey, Paudie.
- Coghlan, Paul.
- Cummins, Maurice.
- Donohoe, Paschal.
- Fitzgerald, Frances.
- Mullen, Rónán.
- Norris, David.
- O’Reilly, Joe.
- Phelan, John Paul.
- Prendergast, Phil.
- Ross, Shane.
- Ryan, Brendan.
- White, Alex.
Tellers: Tá, Senators Niall Ó Brolcháin and Diarmuid Wilson; Níl, Senators Maurice Cummins and Phil Prendergast.
Question declared carried.
SECTION 2
Question proposed: "That section 2 stand part of the Bill."
Can the Minister outline the date for this Act coming into operation?
The intention is to bring this Act into operation as quickly as possible. However, it is the intention of the HSE GMS payments division to have discussions with the IPU. Subject to any time constraints that may be involved in administration, it will be done as quickly as possible. I hope this will be by 1 September. The intention was for this to happen earlier in the year but unfortunately banking and other legislation took precedence in the Office of the Attorney General. The legislation has been somewhat delayed. Subsequent to the passing of the legislation, my officials will enter into discussions with the HSE and representatives of the pharmacy profession as soon as possible.
Will the content of these discussions concern the administration of the scheme? In that respect, the Minister mentioned the need for some adaptation to the computer system in operation at present. How extensive are the required changes? Can the Minister provide any information on this?
The system is being adapted all the time. It was adapted last year when we changed the level of payments. I do not believe the change needed is substantial. It is relatively straightforward and should not delay matters. We would like to have discussions between the contractors, namely the retail pharmacists, and the HSE.
In my earlier contribution, I mentioned connectivity and modern technology. Can the Minister indicate whether the HSE, the regional offices, pharmacies and wholesalers have connectivity in respect of software and their computer systems? As for the Minister's comments on the timeframe for implementation, can she indicate to Members the timeline that will be required to conclude the discussions between the HSE and the pharmacies to facilitate implementation?
I do not believe there is any connectivity between the wholesalers and the HSE because the latter's contract is with the retail pharmacists, rather than with the wholesalers. There is connectivity in respect of the retail pharmacists because that is how they are paid. As all data with regard to GMS and drug payment scheme patients are transmitted from the pharmacies to the HSE for payment; they are connected.
As the intention is to start this process on 1 September, the adaptation of the payment system should be possible within that timeframe. Clearly, when legislation of this kind is enacted that results in a change; it is normal practice for discussions to take place. However, I do not envisage that such discussions should delay implementation of the charge. The sector already is aware of the charge, which has been flagged since last year's budget. It was a Government decision related to the budget and consequently there were no surprises. Moreover, the legislation was made available to the Irish Pharmacy Union on its publication last week and clearly, the HSE also has been kept informed of developments regarding the legislation.
When does the Minister expect to be in a position to have a meaningful assessment of how much this measure is liberating into the coffers and helping her case? Does she envisage it will take six months or a year or what kind of timeframe?
Clearly, if it becomes operable on 1 September, it will raise €2 million per month from then onwards.
During my contribution, I also mentioned the safety net that might be in place, apart from the two exemptions to which the Minister referred, to ensure continuity in people's ability to obtain their required medication. I mentioned people who may have a particular habit, such as a packet of cigarettes, a bottle or a pound on the horses. I refer to the case of people with restricted incomes, who qualify for a medical card and who are on required medication but who, on foot of increased local authority rents, waste charges, dietary or clothing requirements or whatever are the personal issues, are not in a position to pay the required charges. Is there a safety mechanism for such people to continue to receive required medications?
As for patients, I mentioned earlier on Committee Stage that at present, the HSE is involved in 100 medication usage reviews involving 16 primary care teams nationwide, as well as the local pharmacists. Its purpose is to acquire good data on the use of medication. It is known that 45% of medication prescribed and dispensed is not appropriately used and 20% of people do not take their medication at all. It is clear that none of this makes sense from either the patient safety and outcomes perspective or the cost perspective. In future, health care professionals, including pharmacists, doctors and nurses will engage more fully with patients on the significance of medication usage.
On the question of exemptions, I have provided for children in care, as well as for those who are on methadone. In addition, there is provision in the legislation that is about to be passed for the Minister to make regulations excluding other categories of people from being obliged to pay the charge. This will be based on the evidence as it emerges. Clearly, anyone with a long-term illness card, which includes all diabetics, will not be obliged to pay the charge. This also is true in respect of mental health patients under the age of 16 and a whole category of others that I read out previously. There are approximately 20 different categories of patients to whom this charge will not apply.
However, everyone will be expected to pay the charge when he or she presents his or her prescription to a pharmacy. Senator Feeney made the point, which I now reiterate, that it is unlikely there will be much evidence of people failing to receive their medication for the lack of paying 50 cent. I acknowledge that such charges were abolished last April in Northern Ireland and do not apply in Wales. However, in virtually every other country throughout Western Europe, as well as in Australia, New Zealand and North America, there is co-payment, even for very poor people, in respect of prescription charges or doctors' visits or both. This is new territory for Ireland and the Department will keep this charge under constant review. I gave a commitment to report back to this House and to the Oireachtas joint committee on any significant issues that may arise in the context of implementation of this charge. Were any category of citizens not taking their medication because the charge was prohibitive, clearly that would be something that any Minister for Health and Children would be obliged to take on board.
If the scheme seeks to influence demand and patterns of prescription in the GMS, does she envisage a reduction in the amount saved other than the aforementioned €2 million per month? I refer to the intention to dictate prescribing practices or perhaps generic substitutions.
I thank the Minister for her response. My concern is that some people believe that Members do not know what happens in the real world, where people may experience rent increases, have particular dietary requirements or face unprecedented waste charges or other such demands on their restricted incomes. A small number of people may be affected. I acknowledge the Minister has made the point that this is a relatively small charge but nevertheless, it constitutes yet another charge. Moreover, I am aware of the applications regarding people with diabetes, long-term illness and so forth. My suggestion to the Minister is that rather than waiting for something to happen, a memorandum should be issued to community welfare officers. While community welfare officers are rigorous in their application of the rules, perhaps the Minister would see fit to put a safety net in place should anyone need it. This would not be abused. I do not expect the Minister to respond to this point now but simply ask her to consider the suggestion.
In response to Senator Prendergast's point, if fewer items are prescribed even more money will be saved because we will not be obliged to pay for the medication and it will not merely be a question of saving 50 cent. As we would not be obliged to pay for the medication in the first place, clearly, the savings would be greater. I assure the Senator that very few items, if any, are prescribed that cost 50 cent or less. Perhaps my officials might indicate whether any such medications exist but I am not aware of them and at the kind of prices I see, the cost is far from 50 cent. Clearly, were fewer items prescribed because of this measure and were better prescribing practices to be enforced, then even more money would be saved.
Although Senator Callely did not expect me to respond to his last comment, I make the point that I have thought carefully about this legislation. The recommendation in the McCarthy report was to impose a charge of €5 per prescription. The community welfare system in Ireland is very good because it is flexible to the needs of individuals in circumstances that can never be predicted to be enacted in law. Therefore, the community welfare officers respond to needs on a daily and weekly basis. I recently heard of a case of what could be broadly regarded as a woman who was connected with a very well-off person but whose circumstances were such that she required assistance for a temporary period, which was greatly appreciated. There must be a flexible system so that citizens can have access to the essentials, such as medication, food or whatever. This is the reason this system is in place. Although the officers in the community welfare system are attached to the Department of Health and Children, they are moving to the welfare system. This is long overdue because it constitutes genuine welfare support at ground level.
Question put and declared carried.
Title agreed to.
Bill reported without amendment.
Question put: "That the Bill be received for final consideration."
The Seanad divided: Tá, 29; Níl, 19.
Tá
- Boyle, Dan.
- Brady, Martin.
- Butler, Larry.
- Callely, Ivor.
- Carroll, James.
- Carty, John.
- Cassidy, Donie.
- Corrigan, Maria.
- Daly, Mark.
- Dearey, Mark.
- Ellis, John.
- Feeney, Geraldine.
- Glynn, Camillus.
- Hanafin, John.
- Keaveney, Cecilia.
- Leyden, Terry.
- Mooney, Paschal.
- Ó Brolcháin, Niall.
- Ó Domhnaill, Brian.
- Ó Murchú, Labhrás.
- O’Brien, Francis.
- O’Malley, Fiona.
- O’Sullivan, Ned.
- O’Toole, Joe.
- Ormonde, Ann.
- Quinn, Feargal.
- Walsh, Jim.
- White, Mary M.
- Wilson, Diarmuid.
Níl
- Bacik, Ivana.
- Bradford, Paul.
- Burke, Paddy.
- Buttimer, Jerry.
- Coffey, Paudie.
- Coghlan, Paul.
- Cummins, Maurice.
- Donohoe, Paschal.
- Fitzgerald, Frances.
- Healy Eames, Fidelma.
- McFadden, Nicky.
- Mullen, Rónán.
- Norris, David.
- O’Reilly, Joe.
- Phelan, John Paul.
- Prendergast, Phil.
- Ross, Shane.
- Ryan, Brendan.
- White, Alex.
Tellers: Tá, Senators Niall Ó Brolcháin and Diarmuid Wilson; Níl, Senators Maurice Cummins and Phil Prendergast.
Question declared carried.
Question put: "That the Bill do now pass."
The Seanad divided: Tá, 29; Níl, 19.
Tá
- Boyle, Dan.
- Brady, Martin.
- Butler, Larry.
- Callely, Ivor.
- Carroll, James.
- Carty, John.
- Cassidy, Donie.
- Corrigan, Maria.
- Daly, Mark.
- Dearey, Mark.
- Ellis, John.
- Feeney, Geraldine.
- Glynn, Camillus.
- Hanafin, John.
- Keaveney, Cecilia.
- Leyden, Terry.
- Mooney, Paschal.
- Ó Brolcháin, Niall.
- Ó Domhnaill, Brian.
- Ó Murchú, Labhrás.
- O’Brien, Francis.
- O’Malley, Fiona.
- O’Sullivan, Ned.
- O’Toole, Joe.
- Ormonde, Ann.
- Quinn, Feargal.
- Walsh, Jim.
- White, Mary M.
- Wilson, Diarmuid.
Níl
- Bacik, Ivana.
- Bradford, Paul.
- Burke, Paddy.
- Buttimer, Jerry.
- Coffey, Paudie.
- Coghlan, Paul.
- Cummins, Maurice.
- Donohoe, Paschal.
- Fitzgerald, Frances.
- Healy Eames, Fidelma.
- McFadden, Nicky.
- Mullen, Rónán.
- Norris, David.
- O’Reilly, Joe.
- Phelan, John Paul.
- Prendergast, Phil.
- Ross, Shane.
- Ryan, Brendan.
- White, Alex.
Tellers: Tá, Senators Niall Ó Brolcháin and Diarmuid Wilson; Níl, Senators Maurice Cummins and Phil Prendergast.
Question declared carried.
Sitting suspended at 4.30 p.m. and resumed at 5 p.m.