Health (General Practitioner Service) Bill 2014: Committee Stage (Resumed) and Remaining Stages

NEW SECTIONS

I move amendment No. 2:

In page 7, between lines 10 and 11, to insert the following:

“6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) The agreement, referred to in subsection (1) shall not include greater specification of the services to be provided by any general practitioner than is included in the GMS contract.”.

May I speak again on this amendment as we are resuming Committee Stage?

The amendment has already been discussed with amendment No. 1.

Amendment put and declared lost.

I move amendment No. 3:

In page 7, between lines 10 and 11, to insert the following:

“6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) The agreement, referred to in subsection (1) shall not require any general practitioner to perform annual, or otherwise periodic assessments of patients who are healthy.”.

Amendment put and declared lost.

I move amendment No. 4:

In page 7, between lines 10 and 11, to insert the following:

“6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) The agreement, referred to in subsection (1) shall be of continuous duration, modelled on the GMS contract, and shall not be a temporary contract between the Health Service Executive, or the Department of Health, and any general practitioner.”.

Amendment put:
The Committee divided: Tá, 12; Níl, 27.

  • Barrett, Sean D.
  • Crown, John.
  • Daly, Mark.
  • Heffernan, James.
  • Leyden, Terry.
  • O'Brien, Darragh.
  • O'Brien, Mary Ann.
  • O'Sullivan, Ned.
  • Power, Averil.
  • Quinn, Feargal.
  • Walsh, Jim.
  • Wilson, Diarmuid.

Níl

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Kelly, John.
  • Landy, Denis.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Donnell, Marie-Louise.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Sheahan, Tom.
  • van Turnhout, Jillian.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared lost.

I move amendment No. 5:

In page 7, between lines 10 and 11, to insert the following:

“6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) No part of the agreement, referred to in subsection (1) shall set minimum requirements for practice premises.”.

Amendment put and declared lost.

I move amendment No. 6:

In page 7, between lines 10 and 11, to insert the following:

“6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) No part of the agreement, referred to in subsection (1) shall require any general practitioner to share any patient's medical information with anyone other than a medically trained professional for the specific purpose of enabling the appropriate medical treatment for that patient.”.

Amendment put:
The Committee divided: Tá, 14; Níl, 28.

  • Barrett, Sean D.
  • Crown, John.
  • Daly, Mark.
  • Healy Eames, Fidelma.
  • Heffernan, James.
  • Leyden, Terry.
  • Mullen, Rónán.
  • O'Brien, Darragh.
  • O'Brien, Mary Ann.
  • O'Sullivan, Ned.
  • Ó Clochartaigh, Trevor.
  • Quinn, Feargal.
  • Walsh, Jim.
  • Wilson, Diarmuid.

Níl

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Kelly, John.
  • Landy, Denis.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Donnell, Marie-Louise.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Sheahan, Tom.
  • van Turnhout, Jillian.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared lost.

I move amendment No. 7:

In page 7, between lines 10 and 11, to insert the following:

“6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) The agreement, referred to in subsection (1) shall not be restrictive in terms of who might enter into it, excepting that they are a registered general practitioner who has a high competency in the English language, and that the agreement, referred to in subsection (1) might be terminated only where the Irish Medical Council fitness to practice committee has found that the general practitioner is no longer fit to practice, or where the general practitioner voluntarily decides to no longer be party to the agreement.”.

Amendment put and declared lost.

Amendment No. 8 in the name of Senator Crown has been ruled out of order as it involves a potential charge on the Exchequer.

Amendment No. 8 not moved.

I move amendment No. 9:

In page 7, between lines 10 and 11, to insert the following:

“6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

“(13) No part of the agreement, referred to in subsection (1) shall require the general practitioner to prescribe a particular treatment regime to any patient.”

Amendment put:
The Committee divided: Tá, 15; Níl, 26.

  • Barrett, Sean D.
  • Byrne, Thomas.
  • Crown, John.
  • Daly, Mark.
  • Healy Eames, Fidelma.
  • Heffernan, James.
  • Leyden, Terry.
  • Mooney, Paschal.
  • Mullen, Rónán.
  • O'Brien, Darragh.
  • O'Sullivan, Ned.
  • Ó Clochartaigh, Trevor.
  • Power, Averil.
  • Quinn, Feargal.
  • Wilson, Diarmuid.

Níl

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • D'Arcy, Michael.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Kelly, John.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Brien, Mary Ann.
  • O'Donnell, Marie-Louise.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Sheahan, Tom.
  • van Turnhout, Jillian.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Ivana Bacik and Paul Coghlan.
Amendment declared lost.

I move amendment No. 10:

In page 7, between lines 10 and 11, to insert the following:

"6. To amend section 58C of the Act of 1970 by inserting the following new subsection:

"(13) The agreement, referred to in subsection (1) may facilitate the modernisation of diagnostic services on a national basis including the instigation of pilot schemes, but may not require any general practitioner to be included in such a scheme.".

Amendment put and declared lost.
Sections 6 to 9, inclusive, agreed to.
Title agreed to.
Bill reported with amendment and received for final consideration.
Question proposed: "That the Bill do now pass."

I welcome the Bill, notwithstanding the genuine concerns which prompted me to bring forward the series of amendments we have discussed. It is important to consider the context in which these provisions are being introduced. As we know, a draft contract was circulated to GPs earlier in the year. One could argue that this did not represent the Government's final position but was essentially the first salvo in the negotiating process. Even if that is the case, however, the inclusion of a gagging clause must give cause for wonder as to what kind of message the Government was hoping to send. My amendment No. 1 serves to remove that provision, which corresponds to section 28.4.4 of the draft agreement, specifying that service providers shall do nothing to damage the reputation of the HSE.

GPs have also expressed concern that the Bill seems to be transferring a number of new services to them - services which traditionally were fulfilled by other parts of the health service - without adequate consultation. There are specific concerns regarding public health nursing, for example, and the impact of the introduction of new screening and diagnostic technologies. The more general concern is that GPs might find themselves effectively in the position of a basket or holdall group because they were corralled into signing a very broad, general contract. In other words, the fear is that any development in the health service could, without any further negotiation, be put on the door of GPs.

The GPs I know want to see the introduction of universal coverage for general practice health care. They would prefer to see it done in a post-austerity environment, as soon as the national emergency is resolved, and on the basis of need rather than purely on the basis of age. I have the sense they were not opposed to this Bill because of the proposal for free GP care for under sixes but because they were concerned about some of the implications of these provisions, in particular the attempt to impose a gagging clause and the potential for the legislation to be used as a type of basket negotiating position for further services, as yet undetermined, without putting any effort whatsoever into ensuring GP services are adequately resourced.

I made the point to the then Minister of State, Deputy Alex White, last week - I am sure the Minister of State, Deputy Kathleen Lynch, will agree with me - that general practice is the least dysfunctional part of our health system. It is a service within which all patients, whether public or private, see the same doctor, are placed on the same waiting list, attend the same waiting and consultation rooms and will, with the exception of certain treatments which may or may not be made available by the HSE under the general medical services scheme, be given the same level of treatment. This is not something we should be seeking to threaten, corral or overburden. Instead, we should be holding it up as an example of the way the rest of the health system should work.

We have a new health administration. I would like to pay tribute to the efforts of the former Minister for Health, Deputy Reilly, who made honest efforts to launch the health system on the path of genuine reform for the first time. The obstructions and the delays he encountered did not come from the health care professions but from behind his back. It is sad for me that everybody on the other side of this Chamber and the other House knew the policies they were adopting in 2011. They knew they were assuming a package of austerity-based policies. I am not going to recite the arguments concerning bank guarantees and macroeconomics, because they have been done to death already, but people knew what they were voting for. What happened over the past year was entirely consistent with those austerity policies. What happened with medical cards was always going to happen when people voted for those measures. I think it was cynical beyond belief to try to victimise one or two political figures who actually did what the massed ranks of their two parties told them to do. When the votes in the local and European elections went the wrong way, it was somehow as though there was a unique level of responsibility devolving to these people for doing what they were told. I think it is unfair and I wish to put it on record in respect of the then Minister for Health, Deputy Reilly, and also the then Tánaiste and Minister for Foreign Affairs and Trade, Deputy Gilmore.

With the new dispensation, we have the chance to look forward to what the new Minister for Health, Deputy Varadkar, and his Minister of State, Deputy Lynch, will do. They will be a formidable, forward-looking, clever and potentially radical reforming team. This is the chance to reform our health system, which is full of dysfunction. This very day, when I was making inquiries about why a huge chunk of elective surgery in my own hospital appears to have ground to a halt - we have already discussed the issue of anti-obesity bariatric surgery in this House - a wholly unrelated area emerged. When I was trying to work out exactly who was making the decision that a certain procedure should be put on to such a long waiting list that it was effectively being suspended, the clinicians came to me rather timidly and said they were not very happy about being quoted in public in a way that made them appear to be criticising their institution, and they would prefer if I did not talk about it. This is the culture that the Minister of State, Deputy Lynch, and the Minister, Deputy Varadkar, must deal with. There is a culture which is inimical to dissent, disclosure and whistleblowing. Such advances as did occur in the health service in the past decade in areas such as cancer care had their origins in the fact that there were people who were prepared to stand up, speak out, point out deficiencies and point fingers where they needed to be pointed.

As we go forward, it will be critically important that we look at the model of universal health insurance - a socialised model of uniform health care - under which different people will pay different levels of premium but will all get the same freely negotiable insurance instrument. They will have the choice of going to a hospital run by the State, a hospital run by a university or a hospital owned by a for-profit corporation, locally or internationally. There are a number of different ways in which this could be done. People may go to doctors who have different kinds of contracts, some in full-time paid employment of the State, some as independent contractors and some working as university academics. This is the ultimate logic of the model, and there are many people surrounding the Minister of State and the Minister who will not like it. They may say they like it but they do not, because there is a colossal transfer of power to the consumer when this type of model is introduced, away from those who rule the health system by fiat. I believe that is the central challenge that the Minister will have to address.

I welcome the Minister of State, Deputy Lynch, and commend her on her new enhanced portfolio. I commend the former Minister and Minister of State at the Department of Health, Deputies Reilly and White, and their officials on the progress of this Bill. I welcome its imminent passage and I very much hope it will be passed shortly today. I wish the Minister of State and the Minister, Deputy Varadkar, very well in continuing the reform of the health care system. All should agree that this is progressive and important reform which seeks to ensure that all children under six years will have access to free GP care. This is of major importance to parents and families. It is par for the course for this Government to roll out proper reform for the first time in the history of the State, to end the current model of a two-tier health service and to move towards a system in which people are genuinely getting treatment on the basis of need and not means. I really welcome that. I very much welcome this Bill as a first stage in that reform and I thank the Minister of State, Deputy Lynch, for her continued commitment.

I welcome the Minister of State and wish her well in her continuing role in the Department of Health. The Minister of State is from my constituency and it is great that she is continuing in that role because the work she has done in the past three years has been extremely progressive and reforming. I hope that will continue.

I also join with colleagues in wishing the former Minister for Health, Deputy Reilly, well. He has done a great deal of work in a very short time in an area in which it is very difficult to get reform. I have evidence of that. In the past three years I have been pushing for reform in how we deal with junior doctors, but it is only now that the issue is being dealt with. I hope that the MacCraith report that was published last Monday week will not be parked for another ten years. In fact, it took me four days to get a copy of that report from the Department of Health. I thought it was unfair that Members of this House and the members of the Joint Committee on Health and Children had to wait four days for a Department of Health report to be made available to them.

I agree with the point made by Senator John Crown about the lack of consultation and the fact that a contract was put up online before there was any meeting with the representatives of the medical organisations. That is not the way to do business. It is important that we emphasise that this was a draft contract. It was being approached in the way I would approach any legal matter I am involved in: one puts one's best foot forward in the hope of gaining the maximum out of it. I think that is exactly what the Department did, but I think it was the wrong way to start off because one of the things that we need if we want a successful health care system is to have the people on the front line - the GPs - on board. GPs make a significant contribution in the provision of health care and the last thing we need to do is to produce contracts that antagonise them. This will not keep them on side. Publishing the draft contact in the way it was published was not the way to do business, and I hope that will never happen again.

I hope the Department is taking on board the concerns that have been raised by GPs at public meetings right around the country. They have genuine concerns and I ask that their concerns be taken on board. I do not like being accused by GPs of voting for a gagging clause. I did not vote for one. This was a draft contract, and nothing had been signed off. I have said publicly that any such clause was unenforceable and that, in respect of health issues, it is in the interests of the public to be aware of an issue arising in the health services. It is important that the people who are on the front line can comment on it and help to move the debate forward, making sure that we arrive at a solution to the problem rather than pushing it under the carpet and hoping the problem will go away. This reform is a welcome one and it is important that we get everybody from the health service on board, right across the front line, from the GPs to the administrators.

I wish to raise an issue that arose at last week's meeting of the Joint Committee on Health and Children on the draft contract for GPs. In a reply that I got at the meeting last week, it was confirmed that more than 1,000 people in the HSE were given permanent jobs without interviews. We are hiding behind the recruitment embargo and people are going into positions without proper procedures being followed in terms of an interview process. I really think that is an issue that needs to be tackled. One group has a 42-page contract while another group did not go through an interview process. That does not sound right. The Department should deal with this at the earliest possible date.

I thank the Minister of State, Deputy Lynch, and wish her every success in her role in the Department.

I oppose the Bill. When introducing the Bill, the Minister of State said: "The Bill will provide for a GP service to be made available without fees to all children aged five years and younger."

In a country where the problem is that the rich get richer, the response of the Oireachtas is "let's give the rich free health care." The evidence from the ESRI studies on EU-SILC is that 69.5% of children reported not having to go without any item in the indicators of poverty. The Legislature at the behest of the richest people in society is saying "have free medical care for your kids and by the way, as the Taoiseach said last week, bring in the oldies as well". Redistribution in society involves those who can putting money into the kitty so that we can give it to those who cannot. We are giving medical cards to people without a means test in a year in which we withdrew them from people who were in genuine need. This is what people voted against in the local elections. It related to the way the medical cards were withdrawn.

One cannot live in a dream world where one redistributes towards everybody. Somebody has to put money in. Coupled with the measure announced by the Taoiseach, this is one of the most regressive measures that has ever come before the House. I disagree with my learned and respected colleague, Senator Bacik. This is not progressive. It is regressive in income distribution terms. With the Irish tax system, there is no doubt about what the Government is doing. It is giving a gift to the richest people in a country where the top rate of tax is paid by people on below average incomes. This is what the Government is doing. It should be under no illusion that this is progressive in social terms. It is giving to the richest people in society. I am very sorry that so many people in Government see it that way but that is why there is such alienation from politics in Irish society. We always listen to the wrong people when we are engaged in income distribution policies. This is why I oppose the Bill.

I will add a word or two to what Senator Barrett has said because I can understand exactly the point he has made, which he has made on so many other occasions. There was a great deal of discussion here about the medical profession, the Department of Health and the HSE but very little mention of the customers - the patients themselves. I do not hear them mentioned. To a very large degree, the discussion was about running the health service but there was not enough reference to the customers. I believe Senator Barrett has just touched on that topic and that this is what we must do. We must find some way of focusing attention on those who need this service rather than on those who provide it.

As usual in the Seanad, I get so engrossed in listening to the debate as it goes backwards and forwards, I forget it is my turn to speak next. I thank those who contributed to the passage of this Bill. I know it is not quite there yet but I thank everyone involved. It is important to thank Senator Crown and comment on Senator Barrett's contribution because it is hugely important that we have opposing views when it comes to legislation.

In response to Senator Barrett, the only time I have ever been threatened with jail was when I was taken to the High Court by the Irish Dental Association. It was a long time ago. Senator Bacik is trying to look up exactly what year it was. So much happened in my busy life that I can never recall dates. It basically concerned the introduction of free dental care for the spouses of people who were PRSI contributors. The Irish Dental Association issued a statement to say that we were now going to introduce free dental care for the well-heeled and articulate. Do Members remember it? While I will not say I was inarticulate, I was definitely not well-heeled at the time. I thought that it was the greatest insult because the well-heeled and articulate make up very little of society, as do the very rich. It was very important that we extended it because means testing is a very blunt instrument. I agree that we must have an element of assessing means but there is a difference. The only people I know who will benefit from this are those of quite limited means. They may be working. Both parents may be working but it is the most expensive time in a child's life. Amazingly, once children reach the age of five, the ear aches, the sudden rise in temperatures, the coughs and the fright of them waking up during the night with a massive temperature seem to dissipate and they become healthier and able to access the world and their friends in a much easier way.

This Bill will take that worry away from an enormous number of families, which is what we really need to do. I understand Senator Barrett's concerns. He is right. It would be lovely if we were doing this in a time of plenty where one could introduce it in one fell swoop but what we are doing here has to be done on an incremental basis. Those over 70 and those under the age of five are at times of their lives where they need additional health care and it is these areas on which we need to concentrate. It is not as if this Government is saying that it is giving them €1,000 each and telling them to access their own health care. We are doing it in a very conservative way.

In response to Senator Crown, the IMO is in regular discussions with the Department of Health and my information is that it is going very well. As someone who has had regular enough contact with GPs, not just my own but those who I know as friends, I must say to the Senator that we cannot carry out any reform relating to primary care without GPs. They will be key to the Government's reform policy. I think the Senator is right. It was the former Minister, Deputy Reilly, who started this entire discussion and brought to us the challenges that may arise as a result of introducing it. We owe him a debt of gratitude for that because perhaps all of the heavy lifting is done and because the fact that he pointed out the obstacles and the opposition when it arose was hugely important for those of us who will build on what he has done because that is really what it is about. We are not starting from a greenfield space here. We are building on what others have contributed. This piece of legislation will make an enormous difference to both working people and unemployed people in respect of their children and the fear of not having sufficient money to go to a GP when they feel their child needs to be seen by a professional. GPs by their very nature will be central to that and must be part of it. The Senator can take my word for it that this will be a partnership approach. I could not agree more with the Senator regarding the gagging clause. Does he know any GP or doctor who when they see something going wrong would not feel obliged to speak out? Of course, they would. It is part of what they are. It is their duty but I would expect that they would not bring the organisation charged with delivering the health service into disrepute and I think the Senator and I would agree on that. However, I do not expect it to happen.

This is the first step in transforming primary care in this country and I believe it is a significant step. I compliment my predecessor in this role, Deputy White, for bringing it this far and for ensuring that the IMO and the various organisations that represent the medical profession are now at the table. I have no doubt that there is a solution to all of this. I believe there is a solution to everything. We just have not found it yet. I believe they are now in negotiations and that those negotiations will be successful because without them, we cannot do it.

I thank each and every Member for their contributions. I know Senator Barrett is still not convinced. I am sure that if in ten years time, he is right, he will come back and tell us. It is the first step in making us fall in line with what the rest of Europe has.

Question put and agreed to.
Sitting suspended at 3.10 p.m. and resumed at 4 p.m.