Health (General Practitioner Service) Bill 2014: Second Stage

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

It is my pleasure to introduce the Bill, which will provide for a general practitioner, GP, service to be made available without fees to all children aged five years and younger. The key features of the Bill are as follows: it provides an entitlement for all children aged five years and younger to a GP service without fees; it removes the need for children aged five years and younger to have a medical card or a GP visit card under the general medical services, GMS, in order to qualify for a GP service; it will remove the need for many families with children aged five years and younger to be forced into a situation where they need to consider whether the child is sick enough to justify paying for a visit to the GP; it provides that the HSE may enter a contract with GPs for the provision of this GP service to children; and it provides that the Minister may set the rates of fees payable to GPs for this service.

The Government is committed to introducing, on a phased basis, a universal GP service without fees for the entire population. At present, just over 40% of the population can access a publicly-funded GP service. The balance of the population, almost 2.5 million people, must pay the market rate for a GP consultation, which is currently in the region of €55 per visit.

A number of consequences arise from this. It deters some necessary medical care because it is generally recognised as unreasonable to expect an individual to make a good decision on what is necessary and unnecessary care. Given the complexity of health issues and modern health treatments, an individual does not have the expertise to make a fully informed decision. That is why the ability to attend a GP is so important as a gateway to accessing care in the health system. The current situation also works against the objective of increasing and enhancing the role of primary care and preventive care. It is difficult for a person to justify spending money today on a GP visit for an issue that may or may not become serious at some point in the future. Finally, the current situation impedes the reorientation of our health system from a hospital focus to a primary and community care focus, which is an objective we all share. When this first phase is in place, approximately one half of the population will be covered by a GP service without fees at the point of use.

As announced in the budget, the Government has decided to commence the roll-out of a universal GP service for the entire population by providing all children under the age of six years with access to a GP service. It is important to be clear that nothing will change for families who currently have, or are eligible for, medical cards, including those with children under the age of six. They will continue to receive all of their medical card entitlements as normal. There will be no change for them. They will not be affected in any way.

The 2013 report of the expert advisory group on the early years strategy recommended providing access to GP care without fees to all children in this age group. There are good reasons to provide universal access to GP care in view of the health needs of the cohort aged under six years. The identification of health issues at an earlier age can mitigate or reduce the impact of ill-health later in life. For example, the Growing Up in Ireland survey reported that almost one in four children in Ireland are either overweight or obese, which is likely to lead to significant health issues later in life.

We must move towards a health system based on universality of access, which must be sustainably funded to enable the provision of services to meet health needs.

It is important that we view this Bill as a stepping stone to universal GP service. I wish to see the rapid roll-out in successive phases of more GP coverage, and I would not be as supportive of this legislation if the under-sixes scheme were an end in itself. This Bill is a stepping stone. It is the first phase, not an end in itself. If we believe, as I do, that our society should progress to a universal GP service, I ask Senators to support this Bill as the first step towards achieving a universal service.

The policy objective is to have the entire population covered by a State-funded GP service. A universal GP service is a vital building block of universal health insurance and the reform and restructuring of our health service. A universal GP service will also complement the existing universal hospital system. The Government's clear aim is to achieve this objective by 2016.

I now turn to the substantive provisions of the Bill. The primary purpose of the Bill is to provide for a general practitioner service to be made available without fees to all children aged five years and younger. The Bill provides that the HSE shall make available a general practitioner service without fees to all such children. It also provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and younger, and the contract will specify the services to be provided by the GP. The Minister for Health may, by regulations and with the consent of the Minister for Public Expenditure and Reform, fix the rates of fees and allowances to be paid to GPs for services provided under these contracts.

Section 2 amends the existing legislation relating to appeals under the Health Act 1970. It provides for the extension of the current HSE appeals process to decisions on the operation of the new GP service for all children aged five years and younger and also for the director general of the HSE to appoint persons to carry out appeals. It clarifies that where the person carrying out an appeal is an employee of the HSE, that person shall hold a grade senior to the original decision maker. The existing provision in the Act that the Minister may make regulations in respect of the appeals process is restated without change.

Section 3 amends the existing "ordinarily resident" framework in the Health Act 1970 to reflect changes made in section 2. It also extends the "ordinarily resident" framework to include the new GP service for all children aged five years and under.

Section 4 removes children who have not yet attained the age of six years from the existing GP service under the medical card scheme as provided for in section 58 of the Health Act 1970. They will be covered by the new service under section 58B. As I mentioned earlier, it is important to be clear that nothing will change for families who currently have, or are eligible for, medical cards, including those with children under the age of six. They will continue to receive all of their medical card entitlements as normal.

Section 5 is the heart of the Bill. It provides for the insertion of sections 58B and 58C into the Health Act 1970. Section 58B provides that the HSE shall make available a general practitioner service without fees to all children aged five years and younger. It provides that a parent or guardian of a child seeking access to this service should provide to the HSE such evidence as it considers necessary to demonstrate entitlement to the service and where such evidence is not provided the HSE may treat the child as if he or she is not entitled to the service. Where possible, the HSE will offer a choice of GP to those accessing this service.

Section 58C provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six month period following commencement of the section. The contract shall specify the services to be provided by the GP.

In addition, the Minister for Health may by regulation, and with the consent of the Minister for Public Expenditure and Reform, fix the rates of fees and allowances to be paid to GPs for services provided under these contracts. The section requires that the Minister, in making a regulation for this purpose, shall engage in consultation. Further, it prescribes the role of the Minister and the HSE, the nature and manner of the consultations and the considerations to which the Minister must have regard in making regulations, including having regard to agreements entered into with the representatives of GPs relating to the conduct of such consultations.

Senators may be aware of the framework agreement with the Irish Medical Organisation, IMO, which I signed on 4 June. This agreement sets out a process of engagement on all aspects of the GMS contract with GPs, with due regard to the IMO's representative role and within the context of legislation underpinning the introduction of GP care free at the point of access. That engagement with the IMO has begun with regard to the draft contract for the provision of services to all children aged five and younger. Under the framework agreement, the IMO can fully represent its members in respect of discussions around all aspects of this draft contract, including fees, and in respect of the GMS contract. Where the rates fixed by regulation under this section are varied under subsequent regulations, a GP who does not wish to continue providing services may terminate his or her contract by giving the HSE three months notice.

Section 6 is a technical amendment to the nursing homes support scheme to put beyond doubt that assets which are transferred after an application for the scheme is made also come within the definition of "transferred assets". The purpose of the amendment is to prevent a situation arising where an applicant could transfer assets immediately after an application for State support is made on the basis of an argument that such asset transfer is not definitively captured by the definition of transferred assets in Schedule 1 of the 2009 Act. The nursing homes support scheme is predicated on the principle that applicants must contribute according to their means. The existing Act provides that assets transferred within the five years prior to applying for the scheme are taken into account in the financial assessment. The provision does not affect a person's right to sell assets for full market value. Rather, it is intended to prevent people from depriving themselves of assets for the purposes of the financial assessment. If a participant in the scheme were to transfer assets immediately after an application for State support is made, or at any point subsequent to that, the existing definition means that it may be possible that the asset could be excluded from a financial review. Therefore, it is essential that there is no ambiguity in this regard, and this amendment seeks to address that.

Section 7 is a technical amendment that will change the election year for the Opticians Board from 2014 to 2015 and provide that the subsequent election years will be 2019 and each fifth successive year after 2019. The purpose of this amendment is to have the practical effect of removing the requirement to hold elections to the Opticians Board this year, a matter of months before the board is due to be subsumed into the Health and Social Care Professionals Council. This is in accordance with the Government's programme of rationalisation of State agencies. The drafting of the Bill to rationalise the Opticians Board into the council is currently being finalised,. It is intended that the regulation of the professions of optometrist and dispensing optician will be transferred to the amended Health and Social Care Professionals Act 2005 by the end of this year or early next year.

Section 8 is a necessary technical amendment to enable the seamless implementation of section 2. It extends the existing eligibility appeals process to the new GP service for all children aged five years and younger.

Section 9 states the Short Title of the Act, provides for the collective citation of this and prior health Acts as the Health Acts 1947 to 2014 and includes a standard provision relating to commencement of the provisions of the Bill.

In conclusion, the main purpose of the Health (General Practitioner Service) Bill 2014 is to amend the Health Act 1970 to provide for a general practitioner service to be made available without fees to all children aged five years and younger. I look forward to hearing the views of Senators and I hope that they and people in general will support this landmark first step to universal GP service for the entire population of the State.

I commend the Bill to the House.

I welcome the Minister. I wish him luck later this week in terms of the personal political deliberations.

I welcome this Bill. While there was much discourse over the last number of months about the Bill, I and my colleagues had a serious problem with it against the backdrop of the medical cards debacle. It is a noble cause to try to engage in early intervention, which this Bill will achieve, in terms of creating the necessary engagement with the health service from the earliest stage, so we all have histories, and in terms of trying to help families who are to the pin of their collars. Those aims are noble and we certainly support them.

The medical cards debacle was highly regrettable. We had a taste of it ourselves when we were in government in respect of the over-70s. However, it went on for some time and that is regrettable.

In fairness, the Minister of State has acknowledged that it is regrettable that Members on all sides in both Houses have been obliged to place on record the anecdotal evidence being made available to them in their clinics. Members have been outlining the distress being caused to families, individuals, children with Down's syndrome, those with serious illnesses, etc., for some time. However, it took a major political development, namely, the loss of hundreds of local authority seats by various parties in the recent elections, before someone decided it was time to take action. My general criticism of the political process is that in many ways we live in a dictatorship disguised as a democracy. A couple of people run the whole show. It is a closed shop with one or two senior civil servants involved. Those who run the show ignore, as a matter of form, their own backbenchers and the Parliament as a whole. I have often stated that the Parliament is actually subservient to the Government of the day. It should be the case that the Cabinet of the day - regardless of its political hue - should be subservient and responsible to the Parliament. In practice and regardless of who is in power, this sadly does not happen. We all face a challenge in this regard going forward.

We are within the so-called three-week period when 15,000 or so discretionary medical cards and GP visit cards are due to be returned. I have seen some evidence that they are being returned, which is a hugely welcome development. I hope all of those affected will have their cards returned to them as quickly as possible, because that is what is required. That said, the Bill before us is to be welcomed. I do not doubt the Minister of State's personal commitment but I am not so sure the Government has gone about what it is doing in the correct manner. In essence, it made an announcement, is proceeding with its work and is only now knuckling down to what might prove to be difficult negotiations with the IMO. I welcome the conclusion of the framework agreement. As with Europe and the United States, the authorities here had no one to speak to on behalf of GPs. Thankfully, some progress is now being made in this regard. In the context of any adjustment of competition law, Fianna Fáil is committed to allow for the appropriate consultations to take place on a collective basis.

We must exercise caution during the negotiation phase. We can all criticise various aspects of the health service. I refer not to the individuals who work within it but rather to its general management and organisation. One area in respect of which I believe we can all pretty much agree the health service is working well is the provision of primary care by GPs. We must be cognisant of the need to avoid, if possible, messing up in this area.

It is easy for politicians and members of the public to state that consultants make a fortune. While a salary of €109,000 or more per year seems huge to me, I am conscious of serious competition from abroad. I read a newspaper article in recent days which stated that consultants in Ireland are among the highest paid in the world. I am not so sure, particularly when one considers that 250 posts throughout the country are vacant and there is no queue of people seeking to fill them. I am not trying to focus too much on money, but we are not attracting the relevant people. It appears that young doctors who have completed their GP training are attracted to Canada and Australia. I do not know whether it is actually the case, but it seems that annual salaries of €250,000 are on offer, pretty much the norm and achievable in these locations. If it is a choice between entering a new set-up and flogging their bodies for a salary in order to try to build up a list of clients, or travelling abroad to avail of opportunities such as these, then I can understand the attraction.

From a consultant's perspective, one can understand why people might leave the country if it is a case of earning hundreds of thousands per year as opposed to €109,000. I met a retired orthopaedic surgeon who originally trained in Canada. He informed me that good interns and senior registrars worth their salt who are seeking to become consultants are worth between $700,000 and $900,000 per year. I consider that amount of money to be obscene, but if that is what we are up against, then we have a problem. We will be obliged to devise some innovative ways of dealing with the disparity that exists in this regard and in respect of GPs. We must certainly be cognisant of the disparity in salaries in the context of the overall aspiration of having free GP care for everybody. If we have an expectation that people who have studied for 11 years or more are going to provide their services for what I might consider to be either the average industrial wage or an appropriate wage, we are going to be disappointed.

The principles behind what the Government is doing are all fine and the benefits are many. However, there is a need for it to be extremely careful in the negotiation phase and in what it might seek to do in upsetting what is generally a good system. We all agree with the aspiration to make the system better but we must ensure that we get it right. In the current climate, it is difficult to approve of the payment of large amounts of money. However, we must not throw the baby out with the bathwater.

I hope no one will interpret what I am about to say as being racist. We are extremely lucky that people of other nationalities are prepared to come here to work. I understand that 15 years ago the number of non-consultant hospital doctors from abroad working here stood at 5%. That figure is now heading in the direction of 25%. There are a number of factors at play in this regard. It is great to have those doctors here, but we must ask whether we are exporting expertise on one hand and then importing it on the other. Is that an appropriate way to proceed? I recall Senator Crown explaining on a previous occasion that all 20 senior oncologists in this country had trained at the top six institutes in the United States. There is not a hospital or state in the US that would not give anything to have that type of expertise available to it. Will we be able to say the same thing 20 years from now, or will we have exported our best and brightest?

I would appreciate it if the Minister of State would take the couple of points I have made on board. There are issues we may raise on Committee Stage, but we will be supporting the legislation.

The services available at accident and emergency departments can be abused on occasion. When free GP care for those under six years of age becomes available, we must appeal to the public to be responsible when it comes to the use of the service. There cannot be a scenario in which a person with a headache goes to the accident and emergency unit; he or she must go to his or her GP. Some private health insurance companies offer a system whereby they have nurses on call and their customers can ring them to seek medical advice. When one has one's first child, every time he or she belches one wants to know what is going on. Perhaps a similar telephone service might be provided in respect of those under six years of age in order that their parents might obtain advice as to whether they need to bring their child to see a GP or whether they should proceed directly to accident and emergency. It might be useful to consider introducing such a service.

The Minister of State has my best wishes in the contest due to take place later in the week. I am conscious of the fact that he began his political career in this House and it would be great to have a party leader with whom I shared these benches.

I commend the Bill to the House.

I welcome the Minister of State and join my colleague in wishing him well during the next seven days. It is important to place on record the figures relating to medical cards. I have consistently stated - I will continue to say it - that since we entered office in 2011, the number of medical cards in circulation has increased by over 217,000, from 1.73 million to 1.951 million. The Bill before the House deals with a particular group of individuals, namely, those under six years of age. Many members of the medical profession have stated that they do not understand why people who have very good incomes should receive free GP services for their children. However, there are many individuals who are caught in the middle in this regard. I refer to those who are working, who do not earn large incomes and who do not have the benefit of a medical card. People with two, three, four or five children are caught within the tax net while not receiving the support they require. I have encountered families that have had a bad run of luck whereby two or three of their children may have become ill at the same time, and that has proven to be expensive for them.

It is in this case that the legislation will be of benefit, which is important. It is also important to realise we have worked out the net cost of this provision. There are already quite a few children under six who benefit from medical cards in any case. Approximately 60% of children do not have free medical services provided to them. We are talking about including them in the equation to ensure they will have access to adequate health care.

I am not disagreeing in any way with the Bill but believe we have changed slightly in respect of prescriptions through the imposition of a nominal charge. We did so because there was a problem with people getting a lot of medication and not necessarily using it. I wonder whether we shall be asking in the House in a few years whether there should be a nominal charge for going to the general practitioner.

We reviewed a large number of medical card holders and the outcome was that four in 100 were to be removed from the scheme because they did not fulfil all the criteria. The other 96% still had to go through the process. The big problem general practitioners have raised with me at a number of meetings, both as groups and individuals, concerns the amount of administration and paperwork they are now doing. It is consuming a considerable amount of time. The time general practitioners have to devote to examining health issues has been greatly reduced as a result. I am concerned that there could be circumstances in which people will go to their general practitioner with the slightest cough. I was talking to an individual recently who overheard a medical card holder in a shop stating she had taken her child to a general practitioner and got a prescription and medication. She was asked how the medication worked but she replied that her child was fine and that she did not bother giving it to him. However, this required a general practitioner visit, the issuing of a prescription and the collection of that prescription, thus incurring a huge cost. The lady went through the process for reassurance rather than anything else but it was interesting to note how the cost arose. It is in this context that I am making my point.

Overall, I welcome the Bill. It represents a good move. There will be a benefit for working, taxpaying families on a very tight budget. If they have a bad run of luck, they will have difficulty in gaining access to the medical services they require. That is what this Bill is addressing. I welcome the decision by the Minister to bring forward this legislation.

Let me touch on section 6. I have been considering this issue in a different context, namely in regard to the transfer of assets under the nursing home scheme. As the Minister knows, I have been very involved in this matter for over ten years. I have been examining the matter from a legal perspective over the past six months. It relates to the qualifying criteria that apply when somebody has assets. Strangely, if somebody becomes unwell, different criteria apply. I am open to correction and am not asking the Minister for an answer today. I will probably be reverting to him on it. There is a cut-off point of three years in regard to the contribution to nursing home care. If one has a gradually worsening illness, such as MS, and ends up in a nursing home because one needs a full-time carer, there is no upper limit on the number of years for which one must contribute. The problem this is causing for a family on my books is that, on the basis of an income assessment, the contribution will have to be made ad infinitum until the patient passes away. This is causing great difficulty for the family because the income now being generated from their asset, a farm, is not sufficient to support the family who have taken over the running of it. This is unfair. I have a question over the constitutionality of it.

We are now amending the section. I see where the Department is coming from. It is a technical amendment requiring the transfer of assets afterwards. However, it is the current legislation that I am concerned about. There is a discrepancy causing difficulties. A very small number of families are affected but extreme difficulty is caused for them. There is a cost to the State because nursing home costs are working out at roughly €50,000 per annum per patient. Where there is income, there has to be an appropriate contribution, obviously, but in some cases the contribution required is excessive and makes it difficult for families who are trying to run and generate an income from the family business or farm. This is just one of the problems that has arisen.

Overall, I welcome the Bill. I hope general practitioners will be brought on board in regard to the implementation of this service. We need to be conscious of the amount of administrative work, however.

Let me touch on what was said by Senator MacSharry, who has raised some important points. I do not agree with the report in The Irish Times and the comments of the OECD on the consultant issue. There is a strange set of circumstances regarding the interpretation of consultants' salaries here.

That is not what the Senator said on radio when he was talking to the consultants the other day. I did not hear him raise that point.

The point I am making is that when we are looking at consultants' salaries, we look at the gross figures. When we consider the salary compared to that in England, we should note there is a primary salary initially and that one is paid for any additional work taken on. The starting salary of a consultant in England might be £80,000 but additional sums are added, which brings the figure way above that in Ireland. There are no English qualified consultants applying for jobs here.

Is this relevant to the Bill?

The Minister is welcome to the House, as always. I very much welcome this Bill. I will try to restrict my comments to the Bill and its intention, which is to provide GP cards to all children aged five years and younger without fees. I acknowledge there are many competing demands in our health services but I will not play one off against the other.

What we learned from the medical card crisis, or whatever term different parties give it, is that each story gave us an insight into the ensuing distress for individuals and families. I do not stand over any of the withdrawals or the lottery-type system but believe that what occurred very much shows how we need a health system that is transparent and based on rights. That is what we are trying to do today.

Giving free GP cards to all children under six is the first step in taking a rights-based approach to health care. Article 24 of the UN Convention on the Rights of the Child states the child has the right to the enjoyment of the highest attainable standard of health possible and to have access to health and medical services. In giving free GP cards, we are proceeding in line with General Comment No. 15 of the Committee on the Rights of the Child, which calls for universal coverage of quality primary health services. The World Health Organization has identified that the aim of universal health coverage is to ensure that everyone can use the health services they need without risk of financial ruin or impoverishment.

GP care is often the first point of contact with our health system. Illness is not a planned activity and families can find they have one, two or even three unexpected doctor visits in one month. It is not something any of us can plan. The cost of visits to the GP along with prescription charges and other associated costs can be significant and very often move families dangerously close to the at-risk of poverty threshold or even push them beyond it. With so many pressures on family finances, a small health concern may be postponed until it becomes a significant health issue. A report on medical card entitlement highlighted that parents, particularly mothers, neglect their own health because of the expense and related costs of GP visits. When it came to spending decisions, children were their priority.

GP care is the cornerstone of a successful health service as highlighted in the Children's Rights Alliance report card in 2014. It is the first point of contact with the health system and we must ensure that it is resourced, effective and making the connections. We have seen in the study on growing up in Ireland how important access to GP care is. My concern is that where a child gets access to GP care, he or she may still have to wait a long time before seeing a consultant. We have certainly seen that those living in more socially disadvantaged areas are less likely to go to a consultant or obtain further treatment. While I welcome this move, I wonder if it will show up other areas of stress in our health system.

We must note the cumulative impact of six tough budgets which have pushed many parents to their limits. We must give hope to families and communities. The survey last week by Pfizer - the health index - found that 69% of people are still finding it difficult to make ends meet while 81% did not see that their current level of disposable income would improve during the year. The majority of those surveyed were very welcoming of the new free GP card.

I have a question about equality of access. We must ensure that all children benefit, especially those who are less likely to link in with the same GP on a regular basis. This was raised in the Children's Rights Alliance report card, which set out the example of Traveller or Roma children as well as children who live in direct provision accommodation. We must ensure we do not just link into our child benefit register or PPS numbers as those systems exclude many of these groups of children. I want to be clear that the Bill is for all children in Ireland irrespective of their status and that the habitual residence condition will not apply.

I welcome the Bill. While I realise the pressures that are on the health service, this is a rights-based approach and a welcome first step towards universal health care. I support the Bill.

I welcome the Minister to the Chamber. I welcome the Bill as the legislative basis for a new universal GP service. I point out that €37 million has been provided in the 2014 budget to fund this initiative, which is a funding provision over and above that which already exists within the system. To say the funding is being diverted from existing services is not just factually incorrect but politically dishonest. I have heard the argument used all too frequently and, I am afraid, all too effectively during the recent elections. When the legislation is implemented, 240,000 children who must currently pay to see a GP will have access to free GP care. Almost half the population will have access to free GP care, which is the first step in the provision of free GP care to the entire population. This is also a key step towards the provision of universal health insurance. I ask the Minister what the next step is.

It has been asked why high earners who can well afford to provide for their own children's GP care should be included in this. This is the argument about universality versus means testing. When one puts a means test in place, one must decide where to set the threshold. It comes back to what Senator van Turnhout spoke about and the question of whether we go down the utilitarian route of the greatest good for the greatest number or the rights-based route. My preference and that of the Government is for a rights-based approach to health service provision.

I attended several meetings of GPs in the south of Ireland over the last number of months. The GPs outlined vocally their concerns and spoke not so much about the provision of free GP care for the under-sixes, but in general terms about the new GP contract, which was drawn up under a previous Minister. Whoever drew up the contract certainly gave GPs plenty of scope for concern. Certainly, they made well-targeted criticisms of it. The situation has not been helped by the fact that it was thought that the ruling of the Competition Authority precluded GPs' representatives from entering into strategic negotiations with the Minister and the Department. The Minister referred to the June agreement with the IMO and he might say a few more words on that in his response to the debate.

Our ability to deliver a universal health insurance system has been questioned by many commentators in politics and the media. It has been said that it cannot be done at all, that nothing has happened and that the political will is not there. The Netherlands has a system which is something like the one we are purporting to introduce here. It took almost 20 years to introduce it there. The Dutch model is based on numerous health care providers and insurers competing for resources and it appears to offer best value for money and the best health outcomes. There is high patient involvement, which is key, as well as very low political interference. The latter is very important and something we could perhaps do with in this country. One of the main criticisms of the system involves its cost. Studies have shown that a high level of expenditure does not always equate with good health outcomes. What is more important than the amount of money spent on health services is the organisation and political culture in which health or any other services are being delivered. That is the best guarantor of good health outcomes. In preparing for the debate, I was amused to read one report which referred to politicians involving themselves in the provision of health care as well-meaning amateurs who ultimately undermine the very system they purport to support. We have a bit to learn in this country in that regard.

At one of the meetings I attended in the south with GPs, a politician who shall remain nameless stood up and said he had received 26 representations on health issues that very day. That struck me as more than most GPs in the room had received. There must be something very wrong with a system where people feel the first port of call for health care delivery is a politician rather than a medic. The diagnosis not the remedy is the awful two-tier system we have. There is competition for resources and access to health is not always determined by medical need but often by one's ability to pay. I am glad to support the Minister's efforts to reform health services radically and get rid of the awful two-tier system the results of which we see in our clinics all the time. I am glad the legislation is before us today and that the first step is being taken in the radical transformation - not simply reform - of the health service. I look forward to continuing to support the Minister's efforts.

I call on Senator Barrett. Does the Senator wish to share time?

I think Senator Crown is known to have thoughts on these matters.

Do we not have time to make individual contributions?

Yes. The Senator has time later on in the session.

I welcome the Minister of State and wish him the best of luck in the next week and in his subsequent career. I do not welcome the Bill. It harkens back to the era of bribing people with their own money. It was reported in the Irish Examiner last Thursday that the Department of Health has a reported overrun of €158 million. Why on earth are Ministers in that Department extending eligibility when they cannot fund what they have? That has been a persistent criticism of the IMF. I note that the Minister of State does not state how much it will cost or the number of people involved. This could very well repeat the mistake made the last time we had one of these measures, which was the extension of medical cards to everybody over 70 which was a massive cost overrun.

I believe in targeting and that those who have should put money into the fund so the have-nots will benefit. We cannot entertain the delusion that one can subsidise everybody although we did so by borrowing vast amounts of money abroad. Redistribution in society means that some people pay in - I think they should be those in the top half of the community - and some people benefit. First of all, those who benefit should be those right down at the worst level of poverty. We should gradually work on them. Extending benefits to the entire population in a country that is bankrupt is bizarre. It is bribing people with their own money. To the economist in me, this brings us right back to what got this country into trouble - people making irresponsible political promises. I apply this to the tax cuts I have heard mentioned in some discussions.

Everybody accepts that there should be a redistribution from the haves to the have-nots. This is what the medical card system set out to do. As the Minister of State said, it is currently benefiting the 40% of people who are worst off. In respect of extending it to 100%, I wish to draw attention to the EU Survey on Income and Living

Conditions, EU-SILC, study of poverty among children which used an index involving 12 items such as a separate bed, their own books, food and drinks for friends when they call over, their own money, a family holiday in Ireland or abroad, a day out with the family, a bank or post office account, shops close to home. The study found that 69.5% of children reported not having to go without any of those items. Why did we not use the DEIS model which deals with deprivation in schools? It caters for 167,000 out of 888,000 children in primary and secondary schools. Barnardos estimated recently that 9.9% of children are in consistent poverty. The DEIS number is 19%. The EU-SILC survey has a figure of about 30%. Nobody has 100%. We are fooling ourselves in this House if we think we can subsidise 100% of the population on the basis that somehow 100% of children in this country are in poverty.

I also note that there are other solutions to this. I see that VHI offers a 15% discount for children and students that expires in October. The fourth child and subsequent children are free on those plans. We must be serious about income distribution in this country. It does mean taking from some people to give to other people. One cannot give something to everybody except through the kind of foreign borrowing we have engaged in. Bribing the electorate with their own money or borrowed money should be left in the past. There is no evidence to support subsidising 100% of children in any of the research on child poverty that I have researched in preparation for today.

The GP service is the part that actually works. It does not keep people on trolleys and does not seem to have waiting lists. I believe the Government wishes to abolish the HSE. It should have tackled the problems in hospitals but it is now interfering with the bit that does work. A total of 60% or 70% of the population pays €55 to visit a GP. We would all love to shunt the bill on to somebody but that is make-believe land. There is no magic wand that will pay that bill. Why are we distorting the part of the health system that actually works and not reforming situations involving people on waiting lists and people on trolleys?

This was a misguided political promise. I do not think it has any benefits at all. We were doing it at the time. We were taking away medical cards from people who were in genuine need. Given the precedent of the mistake that was made with the over-70s, we should not have continued with this. I ask the Minister of State to redistribute resources towards the really needy in society and not people who do not satisfy any of the research criteria as to what constitutes poverty. Pretending we are all poor and that, therefore, we will have a huge redistribution policy towards everybody is an illusion. It is part of the reforms that we should have introduced in this House when we all came up here three years ago and part of the response to when a country goes bankrupt. To persist with the free money from Brussels and free gifts for everybody when we know the current state of Exchequer - we are borrowing €8 billion per year - is wrong. Choosing the richest 40% and 50% of the population as the group to benefit from a measure like this is doubly wrong.

I welcome the Minister of State to the House and I welcome the Bill. The Bill, as other Senators have alluded to, has caused considerable angst among the medical community prior to the agreement with the IMO, which I commend. From recent polls, it is clear that 80% of the public are behind the proposal. This Bill is the starting point for a new universal GP service. This first step will give an entitlement to a GP service without fees to all children aged under six. It is the first step in the Government's ongoing commitment to ultimately bring about a universal GP service without fees within its term of office and as set out in the programme for Government. It is one on which we need to deliver.

Many people have concerns around the introduction of this. Some of these have played out in the newspapers over the past year. One of my main sources of concern is that many GPs, including many of my friends, are leaving the country. It is not just GPs who are leaving. Consultants and junior doctors are also leaving. We need to urgently figure out why these people are leaving the country in a way that goes beyond anecdotal evidence and then address those factors. Is the reason financial? I think it is. Is it supply-based? Is it because of career path concerns or other reasons? Obviously, people reach decisions for a variety of reasons. It is not just GPs who are leaving. I would be very interested in hearing the Minister of State's comments because it is something that affects many of my friends and acquaintances. One matter that is of grave concern to me involved the sister of a friend of mine who left for Canada recently. She is not a GP and I suppose I am digressing from the issue but it is relevant to the overall issue. She was told by a would-be mentor in the department to go and stay away for at least ten years because things would not improve. I would be interested in hearing the Minister of State's comments to counter that argument when it comes to that particular difficulty we are having in our medical services.

The framework agreed with the IMO is welcome and removes the most significant stumbling block to the rolling out of this service. There had been well-publicised concerns from GPs about this but one underlying problem, which I am not sure has been addressed, has been the idea that if a service is free, people are inclined to use it when it is unnecessary. It would seem to me that even if we were to introduce a nominal fee of say €5 or €10, it might prevent this from happening. In saying this, I do buy into the argument that once a charge is introduced, it could be subject to being increased so I would be interested in hearing the Minister of State's comments on that.

The medical card issue arose during the local and European elections. In my view, there is a lack of informed debate on the real cost of maintaining this system and how the system can be substantially funded.

There is also a lack of honesty about the figures. Nearly 2 million medical and GP cards are in circulation, covering more than 40% of the population. Under this Bill, 420,000 children will receive free GP care, and the 181,000 who already have GP cards or medical cards will be joined by a further 240,000 who will gain entitlement under this Bill. It is most welcome and will ease the pressure on parents, particularly those who are under financial pressure, and will lead to better health care overall from the point of view that people will not delay accessing our health services through their GPs in the first instance. Studies indicate that the number of GP visits made is related to price and that free GP access results in more frequent visits to the GP. However, all evidence shows that earlier detection and treatment of illness ultimately reduces both the long-term cost to the system and, hopefully, the impact on the patient.

The measure is not being funded as a consequence of savings implemented elsewhere in the health system and is an entirely separate budgetary measure. It will provide a GP service to approximately 240,000 children who currently must pay to see a GP. Providing access to a GP service without fees to all children aged five and under will mean that almost half of the population will have access to GP services without fees and will see us a long way towards implementing the Government's strategy.

I acknowledge the contribution of GPs to restoring our economy and the very significant role they play. GPs have experienced a reduction in fees paid under the general medical services, GMS, scheme. In 2008 they received €353 per patient per year, and this was reduced to €243 in 2012 and further in 2013. The overall figure the Government paid to GPs under the GMS scheme remained at €450 million as a result of an extra 600,000 people becoming eligible for medical cards. I welcome the Bill. The acceptance of the scheme by the GPs and ongoing dialogue is very important. I commend the Minister on his work in the area, to which he is very committed.

It is good to see the Minister here again today, and he looks very relaxed considering what is happening in his political life. I wish him the very best in his endeavours. Senator MacSharry led out for our party on the issue. I have a number of issues and questions. The Minister will not get everything right immediately, and that is the purpose of debate. I welcome the reinstatement of medical cards, particularly to children. The Government acknowledged that the HSE made mistakes which caused much distress. I was glad to see that cards are being reinstated in my area. It is important we keep on top of that and ensure it happens. I support this legislation, subject to the assurance that people who are sick and require medical cards will receive them. Over the past two years, particularly since the review was brought forward, I have had grave concerns about this. Given that this is only Second Stage of the Bill, we will seek further figures on the number of medical cards that have been reinstated, which the Department will have.

The review of medical cards on which the HSE and the Department insist is, in many instances, a waste of time and money. While I have heard the Minister talk about this, and I agree with him, nothing has been done as yet. We are asking people who have life-long illnesses, ailments and disabilities that will not be cured to renew their medical cards. It must be a waste of capacity in the Minister's Department, particularly in the medical card unit. While I will not go into specific details of cases, every week I deal with numbers of people who will clearly retain their medical cards but who have to fill in the forms and send in the financial data. I see the Minister nodding and I am glad. I hope it will be addressed because we could save a lot of money, time, hassle and effort.

When people aged under 70 apply for a medical card there seems to be an insistence that they are applying for their families and spouses and the Department requires the spouses' financial data. In one case, a child aged over six years requires a medical card but the Department has asked for all of the data for all six people in the family. Again, it is a waste of time, money and effort. While we all want children and sick people to be able to access GPs for free, it is not really free; the taxpayer pays for it. Whatever we do, we must be fair to the GPs. I hope the new mechanism the Minister will use to discuss the draft agreement will be that. While there are certain constraints under legislation including the Competition Act, to insist upon items such as a gagging clause so that no GP who signs up to this can be critical of the HSE is ridiculous in a democratic country such as this. GPs who do not sign up to the scheme for the under sixes is being threatened with the prospect that medical card patients aged under six will be removed from them and the contract is for five years.

While I agree with all the HSE's stipulations to ensure the GPs' practices are up to scratch, GP practices will need to make a substantial capital investment to meet the requirements set down by the Department and HSE. While any GP practices that are limited companies or partnerships will be able to offset the requisite capital spend against future income, no grant is available. The Minister will know through his work that while everybody has the view that GPs are loaded, many of the GPs I know are not, particularly those who have started practices in the past five to ten years. Having invested heavily in their practices, buildings and facilities, many of them are heavily indebted.

It is about time somebody said that GPs are a very important part of our health system. In my area we have the D-Doc system, which works very well and provides a service 24 hours a day, seven days a week, 365 days of the year. The more people can be dealt with by GPs instead of attending hospital accident and emergency units, the better. We should take a step back on this. While I do not know who will be the Minister for Health next week, whoever it is needs to find a new approach to our GP services because this will not work without their approval and support, and we do not need to fight them. Under the previous Government, there was a serious situation regarding pharmacists, who had very serious concerns about issues such as dispensary fees. Over time, they were dealt with. We all want what is best for our citizens, but let us be fair to GPs. We do not need to hold up examples and say these people are minted and can take it on the chin. Many of them cannot, and we must support them.

I broadly welcome the Bill. While I take the Minister at his word, I do not know whether he will be in the same position next week. I do not mean this in any flippant way. Whoever is Minister needs to ensure fairness exists throughout the system. If he does not have the answer today, maybe on Committee Stage the Minister could report on the number of medical cards that have been returned to children and people with illnesses. Let us deal with the renewal of medical cards once and for all.

I have no idea why the HSE continues to insist that people with conditions such as serious epilepsy or amputees seek to have their medical cards renewed. It is a joke and a waste of money.

I thank the Minister of State, Deputy Alex White, for his presence and for his contribution this afternoon.

Before I call Senator Crown, I welcome to the Chamber the newly elected first chairman of the expanded Limerick City and County Council. Councillor Kevin Sheahan is very welcome to the House. He is with Deputy O'Donovan and friends in the Chamber. We are seeing a bit of history in the making with his appointment and his presence in this Chamber.

It is obvious that circumstances have changed somewhat since this Bill first saw the light of day in a context when radical changes were taking place in the provision of medical cards. We had a new Bill which, taken on its own, could only be welcomed. Anything that seeks to expand the access and reach of the medical card scheme can only be seen as a positive thing. Taken on its own, it is not particularly progressive. It is expanding access to medical cards but, given the context of what was happening at the time, originally denied but now all but tacitly acknowledged - the attempt to row back on the interpretation of who would qualify for a medical card in other age groups on the grounds of need due to the alleged stringencies of probity - we now know there was a double-edged approach to the issue. The overall effect of this would have been to decrease the number of people who had medical cards, to reduce the expense of the system. While we were taking cards from people who, by virtue of illness and age, were more likely to incur an expense to the State through their medical cards, we were giving them to a demographic who in relative terms was less likely to cost money. One would have to say - I am sorry if I sound unduly cynical about this - that these two measures together, in the absence of a more fundamental approach to health reform, would appear to have been populist, vote-getting measures rather than substantive efforts at reform.

Who could oppose this Bill? I will not oppose it, but I cannot let the opportunity pass to make a few points that need to be made. Others have made them and I am sorry if I sound repetitive, but I work in one part of our health system and I am a close observer of the other parts. The hospital-based system is highly dysfunctional. It is unfair. It systematically incentivises inefficiency and inactivity. Its core business plan is to keep people on waiting lists as long as possible, because once they come off the waiting list they cost money. In this time of stringency, the only good that we are advocating in the health services is to come in under budget. We have an incredibly dysfunctional public hospital system which urgently needs reform.

We have quite a functional GP system. It works quite well.

The major problem with the GP system as presently constituted is that for some people who do not have medical cards it is a bit expensive. We would welcome as a society any attempt to roll out free GP care, and most of the GPs I know would too. If this under-six scheme is the beginning of a roll-out, I ask the Minister of State - I am delighted to see he has a pencil in his hand - to give us the timeframes for the roll-out to under-eights, under-15s, over-70s and over-65s. When does it become a comprehensive free GP scheme? If it is part of a phased introduction of free GP services, the logic of it would seem to be that there will be further milestones along the road. Instead, it is impossible to escape the conclusion that when this was conceived it was taking with one hand what was being given with the other, which was meeting a pre-election commitment to expand GP care to a particular age group while at the same time funding the expansion by taking services away from people who needed them the most. Collectively, the two initiatives, thankfully, were caught out by the political process at the time of the local and European elections. This, as has been admitted by members of the Minister of State's party and the other party in the Coalition Government, caused a certain amount of soul-searching and has led to a change. It has had the unintended effect of making this better legislation.

I will support the Bill. If one takes away the attempt to remove medical cards from others, this as a stand-alone Bill makes more sense. We will try to pin the Minister of State down to the timeframes and scale of the roll-out and whether it will be phased or whether we are waiting for the great moment - as they used to say, after the revolution - that moment when suddenly we will have universal health care for all. Everything is on hold until then.

I welcome the Minister of State, Deputy White. This is a Bill to implement the Government's commitment to provide GP care to all children under the age of six years. Like Senator Crown, I want to see universal primary care for all citizens that is free at the point of delivery. I will not oppose the Bill. Senator Crown made the point that the Bill needs to be the start of a transparent roll-out of free GP care for all over a particular timeframe. Otherwise, it will only further emphasise the inequalities in our health system.

The context of the debate is the Government's U-turn on discretionary medical cards. We were told by Ministers in the months leading up to the recent local and European elections that there was no such thing as a discretionary medical card. It was something the Taoiseach repeated over and over when he was questioned about the issue during Leaders' Questions in the Dáil. We are now being told that 15,000 discretionary medical cards have been removed from people since 2011, and these will be returned. These cards should not have been removed in the first place. We in Sinn Féin said so, as did others, but the appeals fell on deaf ears. We also appealed to the Government in a motion in advance of the elections on 23 May to restore them, and I am sure the Minister of State was one of those who voted against the Bill at the time. It was only after the elections - in which both parties, but particularly the Minister's party, got a good kicking - that there was a wake-up call and the soul-searching that Senator Crown spoke about, and the U-turn followed.

The Government's decision leaves many unanswered questions. It leaves out many people who have been refused medical cards. We are told that some 15,300 people who have lost their medical cards since 2011 will receive notices by letter in the next few weeks that their medical cards will be reinstated. This is confined to former holders of medical cards on a discretionary basis related to hardship caused by particular illnesses, conditions or disabilities. Of course that is fair, and we would support that. Those concerned submitted documentation to the HSE when they were notified that their cards were being reviewed. There is a huge discrepancy between the number of people in the above category and the number of cards that have been removed, which is 30,000. I have no doubt that many people who had their discretionary medical cards taken from them looked at the situation and decided there was no point in proceeding with a review process because what they could see at the time was a roller-coaster of culling and cutting. As they did not proceed with the review process, where will they stand? Are people who validly held medical cards but did not proceed with the review process to be excluded from consideration? Will there be a process of appeal or review for those who had their cards removed over the relevant period but do not receive a letter in the coming weeks? Will there be an opportunity for them to apply again? What about those who applied for cards on discretionary grounds over the relevant period and had their applications refused? Given that the same criteria of assessment were applied to such people between 2011 and 2014, surely they are equally entitled to have their situations taken into account?

I will now address the Health (General Practitioner Services) Bill 2014. People understandably ask where is the fairness in giving free GP access to a healthy child of four while denying it to a very ill or disabled brother or sister who happens to be more than six years old. Where is the fairness in giving free GP care to a disabled child from birth and taking it away from him or her on reaching the age of six? These are the anomalies and inequities that are built into a system that is not based on true universality of access, which should be based on medical need alone, regardless of income or age. The Government will argue that it cannot roll out universal free GP access in one go.

I believe that is fair enough and it is a valid response. As we support the principle of universality, we will not, of course, oppose this Bill. We are prepared to regard it as a first step and take the Minister's word that this is what it is.

My concerns are very similar to those of Senator Crown. Where is the timeframe and the programme to roll out universal free GP care in a progressive and transparent manner? It is most certainly not in this Bill. We are being asked to take a very big leap of faith where we are not getting the details of any timeframe in regard to how this will be rolled out. The Bill lacks clarity in that area and it certainly lacks a timetable for the rollout of universal free GP care for all, to which I know, with respect, the Minister of State is personally committed.

We also need to take into account the concerns of GPs regarding the under-resourcing of primary care. They have stated that their workload has increased while resources have been cut. While I would obviously argue with the Minister about medical cards which have been cut, the people who have lost their medical cards and so on, we all accept there are more medical cards out there. The reason for this is that people have lost their jobs or are on low pay, and they are entitled to medical cards based on income grounds. At the same time, however, the resources to GPs have been cut by €160 million. The Government spends just 2% on general practice out of the total health expenditure, both public and private, compared to 9% in the North and in Britain, and practices are struggling both financially and in terms of capacity, as a number of other Senators pointed out. We have to listen to the concerns of GPs and make sure they are properly resourced and can roll out free GP care for all when the time comes. While we will meet with resistance from some, I would hope the majority will see this as progressive and as something that should be embraced and delivered. The test of that will be how this is rolled out and accepted.

As a first step, the Bill is to be welcomed. It is something that is hopefully the start of a process that will lead to universal free GP care for all and a serious investment in primary care. Huge strides have been made in recent times in primary care centres and in far more integrated care at primary care level. It is the way to go, it is revolutionary, it is delivering best practice health care and it is something I am very much supportive of. The more we invest in primary health care, the better it will be for all and the less pressure we will end up having on our acute services.

I thank all of the Senators for their extremely insightful contributions on this Bill. I interpret the general thrust of what has been said, with perhaps one exception, as support for the Bill, although not unqualified support. I have very much taken note of, including physically in my notebook, the various comments and observations that speakers have made. I find myself in much agreement with almost everything that has been said by those who have welcomed the Bill, although not in an unqualified way, particularly given the context of the recent controversy about medical cards awarded on the basis of discretion and the decisions that were required to be made in that regard. I understand what Senators are saying and also the context in which they have welcomed the Bill. On a personal note, I thank all of the Senators who wished me well in another matter in which I have been preoccupied to some extent in recent weeks.

Senator MacSharry made the point at the outset of his speech that early intervention in health and well-being, and the importance of promoting and enhancing primary care, is what he termed a "noble cause". If I may say so, Senator MacSharry very much gets it in terms of what this is about. This is about putting in place a system of primary care, free at the point of access, which is consistent with all of the international literature and research in regard to health services.

While I do not want to come directly to what Senator Barrett said, it occurs to me that all of the international literature, experience and insight suggests we should have a robust system of primary care that does not have the barrier of fees in respect of access. There is very substantial evidence that fees are a very real barrier even for people who are relatively well off. This is about the health needs and the well-being of the population, and it is not just about access for people of low means, although I do not want to underplay that. The question is how best to configure the health services. All of the international evidence is that the best way, and I would venture to say the only way, for us to even begin to hope to reform the dysfunctional system Senator Crown talks about is to put in place a primary care system that works, is properly funded and does not rely on the kind of market-driven approach that has characterised a good proportion of the health service.

I do not believe the necessity to pay a fee should ever be a barrier for anybody attending a doctor. That is well established in practically every other country in the OECD, certainly in the European Union. We are a complete outlier with regard to the demands we make on so many people to pay fees to attend their general practitioner. I believe very strongly that we must address this now. There will never be a good time to do it, certainly not when coming out of a catastrophic economic collapse. If one had a chance to pick a period in history to reform the health service, reorient it towards primary care and introduce free GP care, one would probably not pick the current period. This is where we are, however, and we have to start from where we are.

Senator MacSharry made a point about negotiations and said he was not sure we were going about this in the right way. I take him to refer to the consultations and negotiations with GPs. I have always made the point that it is critical we have a meaningful engagement with the representatives of general practitioners - I have made that point from the outset and it remains my view. The negotiation and agreement of a framework agreement, signed at the beginning of this month, is the basis for that to now happen. The GPs, the IMO in particular, have very real, understandable and legitimate concerns about the obstacles that were there or appeared to be there in respect of the meaningful engagement they need to have with the State in order for them to be sure they get paid a proper fee for doing what they are doing, that there is a contract that is fit for purpose and that they have an input into the content of that contract.

Senator Noone made the point, and I agree, that doctors are crucial to this and their confidence in this is hugely important. The framework agreement facilitates that. It did take a number of months to put together and we did have a period in which there was a stand-off, which was unfortunate. Nonetheless, I attended and addressed the IMO annual conference, and engaged with the members there. It was a very good engagement, although it was not always the friendliest or the easiest for doctors in circumstances where they felt something was being imposed on them. However, we got through it. We talked through the issues, we engaged together and we then managed to get this process going, which I call talks about talks. This was literally to get a framework agreement in place that can actually be the basis for us moving ahead. Substantive discussions, not just talks about talks, have now commenced in regard to this matter. I will say no more than that they have commenced, I hope they will proceed and I have every confidence that they will.

Senators MacSharry and Noone both raised an issue regarding young GPs and the pull to leave the country and go abroad. These are very real workforce planning issues but they are also very real issues for the individual doctors themselves, men and women who are trained in this country and would like to see themselves working in this country, raising families and having a good and fulfilling professional life. I want to see that as well. A report from Professor Brian MacCraith is beginning to address these issues and has been brought forward by him to the Minister for Health. It is a very real issue. I am sorry Senator MacSharry is not still present, although I am sure he is busy.

He has a Private Members' Bill straight after this.

I realise it is not the practice to draw attention to that. I was actually making a positive point about him. I was in Sligo recently and spent two and half hours with a group of general practitioner trainees. I heard their perspective on the world and on their prospects as GPs, as well as their criticisms and concerns with regard to the system. It was a useful engagement for me, as Minister of State, to hear what they had to say and it will certainly inform my thinking and knowledge on the issue. There is a capacity issue as well and we must keep that very much to the fore as we continue to implement the system.

Senator Burke made a point about a universal system. I address the point with respect to my friend Senator Barrett as well. We have known each other for many years and we may have had this conversation in other areas of public policy, not only with regard to health. I repeat my view. All the evidence suggests that to have a properly functioning primary care system we must have a universal system. We must remove the barrier of fees. We must have a system that we can manage as a whole. We must take away the notion of a commercial relationship between the individual and the doctor. It is a question of public health as much as anything else. I accept that it is a distributional question from an economic point of view. The term "rationing health care" is awful but we know and we all accept that we ration health care. How do we ration it? The rational way to do it is for everyone to pay into the system according to our ability to pay so that it is there for us when we need it. It is a universalist approach. Senator Barrett would not necessarily share that view intellectually, but I believe in the fundamental principle that we should all pay in as a community, whether it is through taxation or social insurance, and build up a proper system so that it is available for any of us when we need it. This should provides a proper basis for the types of preventative strategy that we need in our primary care system. It is accepted throughout the world that such strategies are the only way to fund our health services and system in the future. It will be necessary to have proper health and well-being realised as much through preventative strategies as through caring for people when they become ill, which is the most immediate preoccupation of any health service.

Senators Burke and Noone raised the issue of possible nominal charges. Co-payment is a controversial area in health care. I do not exclude the possibility. Earlier this year at my party conference I made the point that it is something we should not take off table. Then I found myself on the front page of one of our national newspapers the following day supposedly announcing that it would happen. One of the problems with the environment we live in at the moment is that we cannot even canvass public policy options, accept that there may be a case for them and then debate them. If we do so, we are suddenly on the front page of the newspaper of record as if we have announced that the Government has decided to do something when, in fact, the Government has made no such decision. We must have an intelligent debate on the matter. There is a case for nominal payments in some situations, but I do not believe there is a good case in respect of children. We have no intention of providing for co-payments in this legislation for those under six years. I do not favour it for children up to 18 years of age. I believe children up to 18 years of age should go free, if I may use that phrase, but there may be a case to be canvassed for the broader population. There are countries in Europe which essentially have free systems but with nominal co-payments.

I will have to come back to Senator Burke on the nursing homes scheme and the particular case that he raised because I am not fully familiar with it. I can certainly do that for him. It is not germane precisely to the contents of this Bill. It is a separate issue, but we could try to get some answers on the matter.

I welcome what Senator van Turnhout has said and I entirely agree with her that one of the lessons from the recent controversy is that we should have a rules-based and rights-based system such that people know where they stand. We must get away for all time from the business of form-filling, as mentioned by Senator O'Brien, from the notion of discretion and the notion of who exercises discretion and in what circumstances. We must get away from a situation in which people have to fight for the health care they need when they become ill or where there is an emergency or a sick child. Our system should not work that way. Again, I make the point that a universal system would mean that we all pay in advance and in accordance with our ability to pay so that we have a proper system in place that is available for people when they need it. Senator van Turnhout is correct in this regard. The Pfizer survey also made the point that there is significant support for this measure, and I welcome that. I put it to the Senator that this provision will comprehend all children under six years. Eligibility will depend on ordinary residence. We are not seeking to import the other regimes of habitual residence and so on.

Senator Gilroy welcomed the Bill. He said, correctly, that it was a first step. Along with Senator Crown and Senator Cullinane, he asked whether any thought had been given to the next steps. I will come to that in a moment. The point was made about GPs and the importance of meaningful engagement. That is certainly going to happen, absolutely.

Senator Barrett made a point about there being no reference to cost. This proposal has, in fact, been costed. A sum of €37 million was set aside in last year's Estimate. Therefore, there is a costing. Senator Barrett may wish to maintain opposition to it for the reasons he gave, but it would be wrong to say it has not been costed. Respectfully, I disagree with Senator Barrett on the notion that the management or funding of the health service or decisions about the distribution of resources in the health service constitute interference - that was the word he used - with doctors. Doctors are entitled to a high level of professional autonomy; there is no question about that. They are the experts in their field. However, we are the Parliament. We should determine the proper distribution of resources and people's entitlements or eligibility. We could do so in line with what Senator Barrett advocates or in line with what I advocate, but either way, we are the people who make the laws. Of course doctors are entitled to be consulted, but we as the Legislature make the decisions about the distribution and allocation of resources.

Senator Noone made a point about the importance of engaging with doctors. I agree with what she said. I have covered the points on the nominal charge and the contribution of GPs.

Senator Darragh O'Brien can rest assured that we will we keep the House updated with the progress in returning cards awarded on a discretionary basis. The Senator may have these figures already but, as of 27 June, a total of 4,151 cards have been returned. As he rightly said, the process is continuing. He has observed it in his area and I agree that the process is continuing. Anyway, we will give a further update as soon as it becomes available.

I take Senator O'Brien's point about the review process and questions that are repeated even where information may be available on the system. This has occurred in circumstances where a person's medical condition is unlikely to change, where it is relevant to his application and where he has expenses associated with it. It should be possible - I understand it is now possible - for the HSE not to repeatedly ask questions that have already been asked and settled in a particular application. The Senator is right about that.

The Government's approach to GPs must be fair. I have made that point. We have a framework agreement and we are proceeding on that basis. There are live issues in the discussions and negotiations, such as the gagging clause and the five-year contract limit, and these will be addressed. I accept that many doctors have legacy costs and investments and so forth, and I understand the environment we are dealing with in the case of many GPs. They have explained this to me and I accept it.

Senator Crown made a point about the hospital system being dysfunctional, although he said he supported the legislation. The notion that we were taking cards from one group to give to another was put forward. I have never accepted that this was what was intended, although I accept that this is the way it was represented. I believe this very good proposal was discredited or that people sought to discredit it in circumstances in which people were pointing to mistakes and decisions that had been made elsewhere. Naturally enough, in public discourse people set one off against the other. Anyway, that was never the intention and it is not the intention. Senator van Turnhout made the point that it is not about taking from one and giving to another; it is about trying to expand or introduce a proper system.

I was the person who was quoted as saying there is no such thing as a discretionary medical card but I was merely trying to say that all medical cards are the same. If people make an application for a medical card they go through the means test system first. If they do not succeed in that, they can then invoke the discretionary element. I was trying to make the point that a medical card is a medical card, irrespective of how one got it but, again, it was interpreted as me trying to say there was no such thing as discretionary medical cards. It may have been picked up wrongly and I regret that people may have received it in a dismissive way from me. It was never intended in that regard.

I agree with Senator Cullinane. We are trying to reform the system we have, and I accept that anomalies and contradictions are being exposed in the course of that. If we go for a cut-off point of six years of age there will always be the question, "What about the seven year old?" However, I question the argument about giving the card to children under the age of six whose parents are wealthy and so on. We have a primary school system where we do not charge the children of millionaires, TDs or Senators to send their children to primary school. Another Senator made the point that there are many low and middle-income earners who cannot get a medical card. The argument about the children of millionaires is nonsensical but to the extent that we are talking about the children of millionaires, we have ways of dealing with social equity, whether it is through the taxation system or otherwise, that we can all debate on another occasion but the universal system should be in place just as much in the area of health services as it is in the area of education where I support it. Those arguments are weak but they arise from the contradictions that will inevitable emerge from only providing it for young people up to the age of six when we would love to do it for everybody in one fell swoop, and we cannot.

Can we have the timeframe for it?

Senators Gilroy, Crown, Cullinane and others asked me about that. I am very conscious of the issue of the timeline, particularly now that there seems to be such wide support for this legislation in the other House and here. It is under active and current consideration by the Government. I cannot say too much more than that because it is in a deliberative process but I would be hopeful of early decisions on it.

If I am pressed for my view, I have said previously that with regard to the next steps, we have gone to six years, and my personal view - I need to be careful because I am referring to the way I would like to see it rolling out - is that children and older people are public health priorities; all the literature tells us that. If we could move the provision to those under the age of 12, for example, or to those under the age of 18, and universalise it for the over 70s, that would be where I would be coming from in regard to this, but my Government colleagues will not thank me if I was to canvass it any more than that. I repeat that it is under active and current consideration in Government and it is fortified by the wide support here and in the Lower House for this legislation because it needs to be seen as the first step in the process and not as something that stands on its own.

Question put and declared carried.

When is it proposed to take Committee Stage?

Committee Stage ordered for Tuesday, 8 July 2014.
Sitting suspended at 4.45 p.m. and resumed at 5 p.m.