Seanad Éireann díospóireacht -
Wednesday, 24 Sep 2014

Vol. 234 No. 4

Medical Practitioners (Amendment) Bill 2014: Second Stage (Resumed)

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

Senator Colm Burke

I welcome the Minister to the House, and join with my colleague in wishing him well in his new portfolio of health. It is a difficult challenge and there are a lot of issues that need to be dealt with. I have no doubt whatsoever that he is up to the challenge and will continue to improve and reform the current health service.

I welcome the publication of this Bill. It follows on from the work done by the former Minister, Deputy James Reilly, who published a Bill on this matter in October 2009. He was concerned about the fact that in this country one could not drive a car or practise as a solicitor without insurance but there was no insurance requirement for medical practitioners. The then Minister, Mary Harney, stated that by January 2010 the Department would have examined the matter and it would go forward in implementing legislation in this area in the early part of 2010. Unfortunately, that did not happen. As a result of a consultation I had with Deputy Reilly in 2012, I took on the challenge of meeting the various groups involved in the health care sector and produced a draft Bill. The Bill that the current Minister has produced is a further improvement on what was drafted in 2009 and what I drafted in 2012. Therefore, I welcome the publication of this Bill.

It is important that every medical practitioner has insurance. It is also important that medical practitioners have insurance to cover all the work they carry out. One of the issues that is beginning to arise in this country is that of medical practitioners who have insurance that does not necessarily cover all of their work. People have raised with me the issue of whether scanning services are covered by insurance. Another issue is that of people who are setting themselves up as cosmetic surgeons and whether their insurance is adequate to cover their work. This is not just about having insurance but is also about ensuring that the insurance covers the work done, which is an important part of the legislation. We must make sure that when medical practitioners get insurance they have checked that everything done in their medical practice is covered by their insurance policy.

One of the people I met during the consultation process in 2012 was Dr. Peter Meagher, secretary of the Irish Association of Plastic Surgeons. One of the big issues he raised with me was the fact that at the time people were coming into the country, particularly Dublin, and carrying out procedures, but at 5 p.m. their practices closed, which meant that if anything went wrong those patients ended up in public hospitals. Dr. Meagher said that he and his colleagues, who work permanently in Dublin, had to pick up the pieces. One of the consultants also made the point that 10% of his work was redoing work that had been badly done by people who had come to Ireland from abroad. That is one of the reasons it is important that everyone who is practising here has adequate insurance.

In terms of the consultation process, I thank all of the people involved, with whom I am sure the Department of Health was also involved. In particular, I thank the Medical Council, Mr. Ciarán Breen of the State Claims Agency, the Medical Protection Society, which was very helpful in giving advice, the Irish Medical Organisation, the Irish Hospital Consultants' Association and all of the people involved in medical practice. They were very forthcoming in giving their views on what the legislation should contain. I have no doubt whatsoever that those consultations were also held by the Department of Health in the preparation of this legislation. It is only through working together that we can make sure all of the t's are crossed and the i's are dotted when it comes to having adequate insurance.

My colleagues raised the issue of the cost of insurance, which is something we need to examine. Recently I met a medical consultant who started working in a private hospital in Ireland about 18 months ago. His insurance premium for his first 12 months was €20,000, but the premium for his second 12 months has increased to €70,000.

If there is movement away from the private sector back into the public sector, the public sector will not be able to accommodate any further increase in demand for services.

One of the issues we need to examine is that of the current capping procedure in the area of insurance. Insurance companies provide cover up to a certain figure and the State then takes over. In some areas the capping level is too high. The MPS is not a profit-making organisation, rather it is non-profit. All of the premiums it receives are used to meet compensation and administration costs. I understand MPS pulled out of Australia a number of years ago and concerns were raised during the summer that this was its long-term plan. It was in contact with me and reassured me that there was no intention on its part to move out of the Irish market. However, the capping levels need to be reviewed. We need to take this into account.

We also need to take into account how we can decrease the level of litigation and restructure the way in which medical negligence claims are handled. We fundamentally changed the way in which we dealt with claims relating to road traffic and industrial accidents, but we did not change how we deal with medical negligence claims. We still have a long-drawn out procedure at huge cost to the State. This is something we need to examine and we need to put in place a better structure sooner rather than later. We could study how other jurisdictions deal with this issue and how we could reduce the cost of litigation and the number of claims made.

Insurance compensation does not necessarily put a person back into the position he or she was in prior to a procedure going wrong; it is important, therefore, to reduce the number of incidents from which claims arise. Every effort should be made to try to improve safety to ensure the work carried out is of the highest possible standard and the level of litigation reduced. In recent years the level of litigation has increased and we need to consider how we can tackle the problem. Insurance cover is only one aspect; the other is making sure the number of claims is reduced substantially. We all have a part to play in that regard.

I refer to medical practitioners and the role of the Irish Medical Council. Many stay on the medical register, even though they might be working outside the country. I am not sure what we can do about this or whether the matter has been dealt with. Some people have paid the registration fee and want to return to Ireland to practise. The figures published recently by the Irish Medical Council showed that there were over 18,000 on the register, but they did not state whether all of those registered were practising in Ireland. The report published lacks clarity on the issue; it is important, therefore, that we have the figures.

I am concerned about other figures included in the report. The numbers registered decreased by 800 between 2011 and 2013, a decrease of about 3.5%. I have had no indication of the decrease in the number of medical practitioners actually working in the country, but this is something we need to examine and address. I have already said the number of non-EU doctors who will come into the country in the next 12 months will reduce, something which will present a major challenge for the health service and up to which we will have to face. We have to do so before 31 December to make sure we can reverse the trend of Irish graduates leaving and non-EU graduates no longer coming here. I welcome publication of the Bill, the decision of the Department to proceed with it and ensure the participation of all parties concerned to make sure we will have comprehensive legislation in place to deal with the matter.

Senator John Crown

I welcome the Minister. I am very proud that he, as a representative of my profession, is in this high office and I have no doubt that he will bring his well documented and considerable organisational, intellectual and analytical skills to bear on the broad array of problems he faces. I am very taken by the fact that at the outset of the debate six Members of Parliament are present in the Chamber, two of whom have medical degrees and one of whom is a nurse. This is perhaps the highest level of technically relevant representation we have had in either House since the last occasion on which the Dáil debated the registration of public houses Bill.

It is well recognised that in Ireland we have a crisis in medical litigation. We have one of the highest medical litigation rates in the world. This is considered to be one of the most dangerous environments for doctors to work in; historically it has been one of the most challenging environments in which medical indemnity insurers such as the Medical Defence Union and the Medical Protection Society act. Premiums in many specialties are typically many times higher than for equivalent specialists in the United Kingdom, reflecting the sense that there is a much higher rate of risk associated with practice here.

I tried to find the exact figures. I teach a course on risk management and oncology. The United States is No. 1, but historically Ireland and New Zealand have been behind it. There will be much cultural analysis of what aspects of the Irish personality or the structure of Irish society lead to a high rate of medical litigation. The explanation is simpler and sadder than one might think. We have generally a fairly mediocre health service which is in urgent need of improvement and reform. The Minister knows these facts, but it is important, given that this is one of our first public engagements, that I have the chance to make some points that I know he will consider and address.

We have the lowest number of career level doctors per head of population of any country in the OECD. The closest country to Ireland, the United Kingdom, is not particularly close. The United Kingdom is substantially below the third closest country. We have a very abnormal career structure in Ireland. Built into the health system, especially the hospital component, is an understanding that most of the care provided will be provided by trainees. We use highfalutin terms like "registrar" and "specialist registrar", but they are trainees. If the Minister or I lost a wedding ring or a precious piece of jewellery down a drainpipe, we would call a fully trained professional plumber to find it. If, however, one of our precious children appeared in a public hospital and required surgery for acute appendicitis or an injury, there would be a very high chance that his or her care would be provided by a trainee. This is wrong and it is not because of some closed shop operated by consultants because no consultant can create consultant jobs. Only the Government, through its agents which historically have been Comhairle na nOispidéal and the HSE, can create jobs. Successive Governments and Ministers from different political parties have made a structural, ongoing and, as yet, unreformed decision that this is the shape the health service will take. As a result, many people who engage with the health service do not engage with a fully trained specialist in a specific area and receive care which, I am afraid, does not meet the standards to which a modern, educated, sophisticated country that is in the top 22 of the OECD's list of economically developed countries would aspire. That tension will cause medical malpractice.

The case for fixing the problem of medical malpractice in Ireland is not, as is the case in the United States, based on a case for tort reform but rather on health care reform. We urgently need to reform the system. We need to make sure decisions are made by fully trained, rather than junior, doctors. We need to do something to address the extraordinary shortage of specialists. I include specialists in family practice in that. We have an extraordinarily small number of specialists.

We are hanging off the bottom of the charts in respect of everything from neurosurgeons to oncologists to cardiologists to urologists to neurologists and, as a result, even if a person is in a system where it is likely that he or she will be seen by a fully-trained specialist, this will not happen for a long period because there will be waiting lists involved. Bad things happen to people who are on waiting lists.

I have stated for many years that if - as both the Minister and I do - one believes in social democracy as it applies to medicine and health care, then it is not a question of public versus private or whether the system is run by the State. Rather, it is a question of what is the right way for society to assume collective responsibility in order to ensure that what would be regarded as a basic set of guarantees will be extended to people. The most basic of these guarantees is that if one needs care or treatment, one will receive it and that this will not be determined by one's ability to pay. I am of the view that there is general agreement throughout society in respect of this matter and I suspect no one would suggest that we should adopt a more neo-Darwinian approach based on the survival of the fittest. The consensus will break down in the context of how we achieve that to which I refer. A large number of theoreticians believe that such services can only be administered if they are delivered by a single entity, namely, the Republic itself via its Government, and that the system must be funded, regulated, delivered, staffed and policed by the same monopolistic entity. I differ from the group that espouses the view of social democracy to the effect that everybody should pay their taxes to the State and that the latter should decide how health care should be provided.

The most successful social democratic health systems in the world, namely, those which according to OECD figures and statistics on speed and quality of access and outcomes, deliver alternative models which are firmly based on the precepts of social democracy and which involve a diversity of contracts and providers. There is, however, one aspect to these systems which is not diverse, namely, all of those in society are in it together, everyone pays over what is probably a fixed percentage of his or her income and this is specifically invested in health care. Rich people pay more, poor people pay less and those who have no incomes pay nothing at all and are paid for by others, which is fine. With such systems, everyone has a freely negotiable insurance instrument which he or she can take to the doctor or hospital of his or her choice. This instrument may be administered by a state-run insurance company similar to the VHI or some of the non-for-profit health systems in Canada, Israel and elsewhere. Some of the entities involved may be private concerns but they should only be allowed to enter the market on the proviso that they play by the same rules, namely, community rating, no cherry-picking and equality of access. If such providers want to put in place additional policies whereby people can obtain access to different types of hospital rooms or menus during their stay, that is fine. However, the actual care provided must be the same.

I am not describing some pie-in-the-sky utopia, I am outlining what happens in most of the countries which have Bismarckian systems of health-care delivery. The cliché that was thrown about in the run-up to the most recent general election - during which I specifically espoused the cause of the Minister's party and that of its prospective coalition partner because I liked their health policies - involved reference to the "Dutch model". What actually emerged from the synthesised post-election negotiations was the Deutsche or German model. Germany has the most successful health care system of any large country in the world. A salutary lesson can be learned from the fact that such a large, complex and diverse entity which faced extraordinary challenges in the past retains the system introduced by the Iron Chancellor, Otto von Bismarck, in the 1880s as a bulwark against the encroachment of the new movement of Marxism. The system in question survived the Franco-Prussian War, the First World War, the abdication of the German monarchy, the Great Depression, the Weimar Republic, the rise of Hitler, the Second World War, the partition of Germany, the Cold War and the reunification process. It remains in place and is essentially the same as when it was introduced 140 years ago. I accept that the German system is a little more expensive than others.

One final message I wish to convey to the Minister from the John Crown book of guerilla health economics is that there is nothing wrong with spending money on health care. It is always wrong to waste money and Government should never waste money on anything. However, the mere fact that money is being spent on health care does not mean it is money badly spent. It must, however, be spent efficiently and in a fashion which incentivises appropriate social outcomes and economic returns.

I have really great hopes for the Minister. I informed his predecessor that he was dealt a rotten, awful set of cards when he entered office and I still believe that to be the case. I also believe that members of the previous Minister's party, when they had voted in favour of the various austerity budgets, did not treat him particularly well when expressing great surprise about the fact that things were not going well within the health service. That is the reality but let us draw a line under the matter. The new Minister will have a relatively short tenure in his current position. He may enjoy a longer tenure there if his party is returned to power and if he elects to remain in the Department of Health rather than moving elsewhere. I hope he takes an ambitious attitude to the cause of health care reform and understands that the opportunity is there for the taking. The person who has the vision to tackle the bureaucracy and who understands how the system can be made to work can put his mark on Irish history if this is done right. I am certainly of the view that what I have outlined can be achieved in a year to 18 months.

Senator John Gilroy

I welcome the Minister and wish him well in his new job. The magnitude of the responsibilities involved and the frustrations to which the job gives rise turned his predecessors grey, not just in terms of their hair but also, perhaps, in the context of their reputations. I have every confidence that this will not happen to the Minister. He has begun his tenure very well and some of his recent pronouncements have brought certainty in respect of the position with regard to health care. He will enjoy the support of the Labour Party as long as he continues to do that. If he fails to do it, however, our support cannot be automatically taken for granted.

The legislation before the House is extremely important. As Senator Mooney pointed out, it is more or less the same as that which was introduced by Senator Colm Burke some time ago. Senator Colm Burke has been gracious and generous enough to state that the Bill is an improvement on his legislation. I am not sure whether that is the case or whether the Senator's natural generosity prompted him to make his statement to that effect. As Senator Mooney also indicated, there is something wrong if perfectly good legislation is introduced and then the Government finds it necessary to remove it before bringing forward a virtually identical Bill.

While I may have been surprised by the fact that Senator Colm Burke's legislation was not accepted, I was even more surprised when I discovered that medical practitioners have heretofore not been required to provide evidence of indemnity cover. That is extraordinary. Is the Minister in a position to indicate the number of medical practitioners who have been operating without indemnity cover? Is he aware of any instances where people before the courts have been found not to have indemnity and can he outline what were the consequences in that regard? The legislation before the House addressed two aspects of this matter, the first of which relates to public safety. When practitioners are registering, they will now be required to provide proof of competency, experience and indemnity cover. That is only right and proper. The second aspect relates to public confidence. Patients are going to be able to rest assured that the medical practitioners under whose care they may find themselves will all be in possession of the relevant insurance.

My colleagues have already covered the various matters which arise in the context of the Bill. However, Senator Colm Burke referred to the fact that the amount of indemnity or insurance cover which medical practitioners are obliged to pay is €70,000. Is account taken, in section 6 or elsewhere in the legislation, of people who are not full-time medical practitioners? I refer, for example, to people who may be job-sharing and who might see three or four patients per week? I refer to individuals who may wish to keep their hand in, so to speak, but who are not practising on a full-time basis. These people would not make a fraction of €70,000 in terms of their annual income, so the cover may prove to be out of their reach financially.

The Minister stated that the legislation will fulfil Ireland's obligation under the EU directive relating to medical practitioners and that similar legislation that will apply to other registered health professionals will be drafted as soon as possible.

Who might these other health professionals be? Senator Crown referred to the fact that I am a psychiatric nurse. Will nurses fall under this legislation? There is already a requirement for a professional register for nurses. I understand that when nurses are practising within the health service they are automatically covered by their employers, but in certain circumstances nurses work for agencies in the private sector - for example, looking after patients in their own homes. Is there a requirement in such cases for the agency to provide indemnity, or is the individual practitioner required to so provide?

I look forward to discussing this in greater detail on Committee Stage and I will have more questions for the Minister at that stage. Anyway, if the Minister could have my considerations addressed at this time I would be most appreciative.

Senator David Cullinane

I welcome the Minister to the House. I gather it is his first time here since his recent appointment, or perhaps not, but it is the first time I have seen him. I commend Senator Burke on proposing a similar Bill some time ago. It was not accepted but the substance of what he proposed at the time is largely in this Bill. He deserves credit for his work on this issue and for bringing this issue to the Seanad initially.

Senator John Crown

Hear, hear.

Senator David Cullinane

We welcome this Bill. For many people, it seems strange that such a system was not in place already, and people have been surprised to learn that it was not. I imagine the current status whereby medical professionals have no legal obligation to have adequate medical indemnity insurance seems strange to the vast majority of citizens. Under this Bill, medical practitioners must ensure they have suitable cover. The Medical Council will be in a position to sanction a medical practitioner engaging in medical practice without indemnity. I welcome the fact that there will be an exemption from indemnity for those who are not actively engaged in medical practice. This is a common-sense and necessary exception.

This is a short Bill and one that we certainly support. I am taking this opportunity, as previous Senators have done, to discuss briefly issues in the health service, given that the Minister is in the House. We have called for statements on health care. I hope that at some point in the coming weeks the Minister will be able to come to the House and take part in a more thorough debate. People have serious concerns about the Government's health policy at the moment. With the greatest of respect to the Minister's predecessor - he did some good work in the health service - he talked tough and promised a good deal. Senator Crown referred to his having had a vision and a plan and so on. He certainly seemed to have a vision, but the plan was not in place and we did not get the delivery. We were promised that the HSE would be abolished and that it would be replaced with a more accountable body, but that has not happened. We are unsure where universal health insurance has gone. That is something the Minister will have to work out. Then he will have to come back to all of us and spell out not only his vision but also his plan in terms of how he will make it a reality. Promises were made for free general practitioner care for those under six years of age. Where is that? When will that be up and running and when will people be able to avail of it?

Bizarrely, as we are discussing this issue, and for the first time in my lifetime in politics, I have seen GPs protesting outside Leinster House, and I believe they have a valid reason. Our health service is under serious pressure. I accept that the Minister is aware of this. He is conscious of it and, if we are to believe what we hear and see in the media - although I do not always believe it - he is making the case for more investment in health care and the need for a triple approach involving reform of the system, efficiencies and greater investment in the health service. That is certainly to be welcomed. There is a need for the Minister to come to the House again to have a more thorough debate. We are owed that much by the Minister.

The horrors of the Michael Neary and the symphysiotomy scandal highlight why it is important to have robust and transparent systems in place for those who are injured by medical practitioners and who seek redress. The House must also be able to ensure that the public can trust the medical profession. It is alarming that someone irresponsible could practise here without the appropriate medical negligence insurance and that in the event of negligence or unsatisfactory treatment a patient may have no redress or recourse to compensation. That is something I do not believe any of us can stand over. It seems now that it is something that will be finally addressed. I commend the Minister on his introduction of this Bill. I commend Senator Burke on his work in this area and on bringing forward a similar Bill in the past.

I agree with many of the statements Senator Crown made about the Minister in respect of his ability. Ability and vision are one thing, but the Minister needs a plan and to be able to spell out to us exactly how he will reform the health service in the coming 18 months. Major changes can be made. We hear all the time from the media and those within the political establishment that the health service or the health Ministry is a poisoned chalice. It is only a poisoned chalice if we do not reform it or if we make the wrong policy choices. Far better to deliver on a plan and a vision that improves the health service generally, reduces waiting times across the board and takes the pressure off front-line services to ensure that people are treated on the basis of equality rather than how much money they might have in their pockets. If the Minister were to reform the health service along those lines and end the two-tier health system, he would be seen as one of the greatest health Ministers of our generation. Anyway, that is up to the Minister, and he must decide how that will be delivered. I wish the Minister well in that work and I welcome the Bill.

Senator Feargal Quinn

The Minister is very welcome. He has been a regular in the House not only in his previous ministerial post but in this post as well. I am pleased to see him in the House again. Senator Crown, in particular, and Senator Cullinane used the opportunity to remind the Minister of the confidence we have in him. There is confidence in the Minister. The fact that he has such a good background means we believe he can get the job done. It is not an easy task to get done.

Credit must go to Senator Burke for his hard work over the years on this legislation. It is perfectly sensible to make it compulsory for medical practitioners to have insurance and it surprised us that this was not in place already. While his name is not on the Bill, I reckon Senator Burke should get great credit for the Bill before the House. In this respect, I am pleased to see another clear tranche of law that aims to improve the lives of citizens coming from the Seanad. The legislation clears up an apparent loophole, one which surprised all of us. Insurance is in the interests of the customer - I always refer to patients as customers. I was chairman of a hospital at one time and I tried to get the term "patient" substituted by the word "customer". I was not very successful in that, but I did my best.

Senator John Gilroy

Rightly so, thanks be to God.

Senator Feargal Quinn

Insurance is in the interests of the customer - that is, the patient - and the doctor as well. Such required insurance is the norm in many European Union countries and we need to move towards that standard. I am pleased to note that the Bill also brings the EU directive regarding patients' rights into effect. Will the Minister give patients more information on how they can get some sort of redress or compensation if they believe they have been mistreated abroad? This is relevant given the considerable number of people who go abroad for treatment.

Every patient should be allowed to get his medical records online in a simple manner. It is technically correct and possible to do. Unfortunately, the HSE has not done this heretofore, but across the water in the United Kingdom the health services are planning to allow the public access to online records by 2015 - that is, next year. We should allow patients access to online medical records to empower them to make better and more informed decisions on their own health. The old cliché holds that information is power. That is exactly the case when it comes to health care and the patient. Previously, I have called for the HSE to be far more progressive in this area. In this day and age and with the Government insisting that the country is cutting-edge in terms of technology, it should be no problem for the Government to introduce measures to ensure that a patient can access all his medical records online.

It would allow patients to track their health and make educated decisions. According to a study conducted for the European Commission, only 4% of European hospitals grant patients online access to their medical records. Surely they should be available online here in order that people could make their own decisions. Why can the HSE not allow patients greater access to their medical records? What is it doing in this regard, considering the hundreds of millions of euro available in its budget? Under EU law, the right to access personal health data is guaranteed; however, patients often need to submit a formal request and procedures can be long and complicated, with the result that it can take time to access records. How can we reduce red tape? Information is power and having access to such information could allow people to make better decisions on their own health. Patients could educate themselves about their health and possible treatments and, with their doctors, decide on the way forward.

It is a pity that this is yet another example of HSE inaction in giving people the tools to make more informed decisions. The deterrent effect of the legislation will be great. The Bill states there will be no additional costs to the Exchequer, although the Medical Council of Ireland will incur costs of approximately €200,000. The cost will have to be borne by doctors. Can we get any guarantee that no additional costs will be passed on to patients?

The Bill is worthy of support and there will be no opposition to it. While there may be amendments to try to improve it, the Minister has the House behind him and I wish him well.

Minister for Health (Deputy Leo Varadkar)

I thank Senators for their contributions and the broad welcome for the Bill from all parties and independent Members.

Senator Paschal Mooney mentioned issues around medical indemnity insurers, which have increased their premiums considerably. There is a cap of €565,000 in a case of negligence, above which the Government picks up the bill, even when the negligence occurs in a private hospital on the part of a fully private consultant. There are issues of equity as to whether the taxpayer should be liable for this. The Senator made the valid point that if all of these patients were to appear as private patients in public hospitals or the public system, there could be potential costs and issues. There was an element of this regarding Mount Carmel Hospital, a private obstetric hospital which became unviable for various reasons. Many of the patients who would have attended the hospital are in the National Maternity Hospital and other hospitals. The Senator’s point is well made and valid and we are examining it. I will bring an amendment before the Government in the coming months after we have assessed the case on both sides because there is always a risk that the case being made by the consultants is being overstated and we must ensure we protect the taxpayer’s interests.

Senator Paschal Mooney

Of course.

Deputy Leo Varadkar

We can take a number of measures to reduce liability costs. The Department of Justice and Equality is introducing legislation to allow for periodic payment orders. In Ireland people receive a big lump sum up front, which can be very large and costly, whereas in other jurisdictions payments are made periodically over time. This is less costly and allows the courts and others to assess a person’s needs, instead of guessing what they will be for the rest of his or her life. I would like to re-examine the possibility of having a no-fault system in the case of cerebral palsy and birth injuries because the current position is very unsatisfactory. Parents who have children with cerebral palsy have to go to court to prove negligence and it can be many years before they obtain a settlement. There must be a better system all round for us to look after children with cerebral palsy. Some work was done on the issue 13 years ago, but it was not followed through. The time has come to revisit it.

For the medical profession in general, it is very important that we adopt a greater duty of candour. Doctors and hospitals should not be afraid to tell patients if something went wrong and explain it. Doctors and hospitals can sometimes be too defensive and fear being sued. When litigation occurs, it is often compounded by the fact that patients were not given all of the information or treated disrespectfully. There is enormous evidence to support the view that where there is candour, mistakes are admitted and restitution is offered immediately, the litigation we have seen does not occur. I understand Senator John Crown’s point on doctors in training, which may or may not be true, but I have yet to see evidence to support the view that many adverse events occur because of the high number of doctors in training rather than consultants. It may be that consultants do not take responsibility for what has happened to patients under their care and do not show candour and honesty in explaining to patients what happened and offering restitution. The Senator’s separate point, that fully qualified consultants would provide better and safer care than those in training, must be logically true; however, I do not know if there is a direct link between this and the high level of litigation in Ireland.

Senator Colm Burke asked about people who were registered and out of the country. I do not have figures, although the Medical Council produces very detailed figures which may include the information sought. Because of continuous professional development, CPD, requirements it is increasingly difficult for people to maintain their registration when they are no longer in the State. As far as the Bill is concerned, those who are out of the State will not be required to have insurance in Ireland.

There were questions about the number of incidences of people being on the register but not being insured. Although the legislation does not yet require it, the Medical Council asks doctors, at the point of annual retention, whether they are indemnified and follows up with those who are not. Very small numbers – two or three – are registered but say they are not indemnified. There could be more who say they are indemnified but are not and that does not become apparent until a case arises. If other professionals such as dentists, therapists and nurses are working in a State or private hospital or for an agency, it is expected that their employers would cover their insurance. However, we will see more nurses such as clinical specialists and others operating independently and they will need to be insured.

Senator David Cullinane mentioned the GP protest. I am under no illusions about the fact that GPS are under pressure. Their incomes have decreased and their workloads increased. It is also important to know the facts. While many young GPs may be emigrating and many GPS are approaching retirement, the number of GPs contracted to the HSE is at an all-time high, up from 2,258 at the end of 2010 when the Government took office to 2,416 today. We have never had more GPs contracted to the State and looking after GMS patients. Listening to some of the commentary one would think the number of GPs was decreasing. While it may need to increase faster, it is certainly not decreasing.

Similarly, the amount of money paid by the Government to GPs under the GMS scheme has increased from €438 million in 2011 when the Government took office to €447 million in 2013. GPs will, rightly, argue that they have to see more patients because there are more patients with medical cards than before. While that is true, funding has not been cut to general practice in cash terms since the Government took office - it is the reverse - and people have to do more for more, not more for less. There is an opportunity to provide more resources for general practice. The Government wants to do this by extending GP care to all those aged under six years and over 70 and has initiated contract negotiations with the IMO on a new replacement contract to replace the Childers contract which, believe it or not, is still in operation in general practice. I hope the IMO and GPs seize the opportunity to obtain more resources for general practice because they might not be there forever; they might not always have a Government or a Minister in office that is as committed to general practice as the current regime is.

The protest today is by the National Association of General Practitioners which does not have a negotiating licence and is, therefore, not involved in the talks. The IMO is.

There were some good questions about records being online and people having access to them. The fundamental problem in Ireland is that most records are not available online. We still largely use paper records in the health care system and hospitals. There has been enormous under-investment in information and communications technology, ICT, in the health service in the past decade or so. I assume this is due the aftertaste of the personnel, payroll and related systems, PPARS. It did not go as wrong as people claimed, but it did go wrong and became very expensive. As a result, there has, unfortunately, been huge under-investment in ICT in the health care system. General practice has embraced IT and most GP surgeries will have electronic patient records, but that is not the norm in hospitals where there is a huge distance to catch up in ICT. However, it is intended that the new children's hospital, the design team for which I launched today and which will be under construction by the end of next year, will be fully electronic and virtually paperless when it opens. In the case of children, at least, we can start the process of putting records online.

Another initiative that will be rolled out from the start of quarter one of 2015 involves the individual patient identifier or health identifier. Everybody will have a single number which can be used to identify him or her. It will be a little like a personal public service, PPS, number for health. There are many reasons one cannot use the PPS number, into which I will not go, but it will be similar to it. It means that we will be able to identify people. At present, if one is attending a GP practice and one or two hospitals, the records do not talk to each other. The first step in doing this is to have an individual health identifier for everybody. It will be very messy because there are different systems throughout the country and somebody will have to tag this new number to all of these records. It will be far easier with children. We hope to register with it all children under six years of age next year, but seeding the old data and getting to these numbers will be complicated. It is not a project that should be rushed.

Senator John Crown made a number of points. I do not have time to deal with all of them, but I will address a few. While I acknowledge that the health service is consultant-led rather than consultant-delivered which is a fancy way of saying most of the doctors the patient sees are in training and not specialists, we have more consultants than ever working in the health service. There are also in total more doctors than ever working in the health service. Although there has been a recruitment embargo in the health service in recent years, it does not apply to doctors. A record number of doctors and dentists are working in the health service. As that fact is not well known, it is important to highlight it. In contrast, the number of management and administration grades has fallen to a ten year low. One would not think this when one sees what passes for media commentary these days, but it is the case.

Over time we will have to increase the number of consultants considerably and reduce the number of doctors in training somewhat. However, the first step is the far more practical one of filling the 200 vacancies across the health service for consultants. We are finding it very difficult to recruit them for a number of reasons, not all of which are financial, but finance is part of it. I hope the IMO will ballot in favour of the new salary scales, thus allowing us to fill these 200 vacant posts next year. Currently, they are filled through agencies and by locum consultants at enormous cost for reduced quality. That is the first thing to be done. If we can get it done next year, it will be good progress.

On the general issue of health reform, I am a strong supporter of universal health care. I agree with Senator John Crown and many other Members of the House that it is not a radical idea. It is the norm in almost all of the western world. Ireland missed the boat in embracing the concept in the 1940s and 1950s for various reasons. There are many models and the German model is as good as any. I will not go into the detail of it today, but I will in time. The first step for this country is the introduction of universal GP care. I hope to make this a reality in the coming months in extending GP care without fees to young children and everybody over 70 years of age. People will only believe universal health care will happen when they start to see practical things such as this. We have had many White Papers and plans, but it is only when people see it start to happen that they might start to believe it.

On the wider issue of universal health insurance, the Health Research Board, with the assistance of the Economic and Social Research Institute, ESRI, is doing detailed work on universal health insurance and its cost. We hope to have the findings of this work by the end of the first quarter of next year. It is an interesting piece of work which will give an indication of what the cost will be. As Senator John Crown said, it might well cost a little more and we should not tell people anything other than this.

One can use many statistics such as gross domestic product, GDP, and gross national product, GNP, per capita and so forth, but health services in Ireland are under-funded relative to most such services in Europe. It is not the case that one can deliver universal health care simply through efficiencies. Universal health insurance will involve costs and payments. What we must do is calculate the cost for individuals and families and work out how they pay for it. Whether it is the German model proposed by Senator John Crown - a percentage of income and an opt-out for the better-off - or a compulsory insurance system, as is the case in other countries, if there is to be a proper debate on it to find out what people want, it will be necessary to have figures to show them what it would cost. I hope to have them next year.

The difficulty in making it happen in 18 months, of course, is that the public system must be reorganised and become competitive in order that it can compete with private hospitals for patients. It is not in that position and the hospital groups are a big step in the direction of making the public health service competitive with the private health service. However, there are many other issues involved. We are locked into public pay scales and other terms and conditions that do not make implementation straightforward. However, as far as the Government and I are concerned, there is no departure from the vision of universal health care. That is still what we intend to do, but we will try to be very practical about it in the short term.

Question put and agreed to.

Acting Chairman (Senator Diarmuid Wilson)

When is it proposed to take Committee Stage?

Senator Colm Burke

Next Tuesday.

Committee Stage ordered for Tuesday, 30 September 2014.

Sitting suspended at 1.40 p.m. and resumed at 2 p.m.