Health (General Practitioner Service) Bill 2014: Committee Stage

Question proposed: "That section 1 stand part of the Bill."

I welcome the Minister of State at the Department of Health, Deputy Alex White and officials from the Department to the meeting. I remind them that only the Minister of State may speak as this is a Select Committee of the Dáil. I invite the Minister of State to make his opening remarks.

I thank the Chairman for allowing me to make some introductory remarks to outline the legislative proposal for the members of the committee. I am very pleased to discuss the details of the Bill with the committee today. I acknowledge the support expressed for this Bill on Second Stage from all parties and Independent Members in the Dáil, when we had a very well-informed debate. Deputies did qualify what they said in articulating some concerns about the Bill, which is perfectly understandable and legitimate. At core there seems to be good support for this measure and I am grateful for that.

The Bill will provide for a general practitioner, GP, service to be made available without fees to all children aged five years and under. The key features of the Bill are: 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 GP visit card under the general medical services, GMS, scheme to qualify for a GP service; it will also remove the need for many families with children aged five years and younger to be forced into the situation where they need to consider whether their 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 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, as set out in the programme for Government and the future health strategy framework. 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. There are a number of consequences of this situation: 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 what is 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. This situation also works against increasing and enhancing the role of primary care and preventative 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, it impedes the reorientation of our health system from a hospital focus to a primary and community care focus. 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 without fees. It is important, however, to be clear that nothing will change for families who 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.

As recently as last Tuesday, the Minister for Health confirmed that the Government is committed to implementing the policy of universal access to GP services. Additional earmarked funding of €37 million was provided in budget 2014 to fund this first phase. It is not funded on foot of savings implemented elsewhere in the health system. The Government also announced earlier this week that an additional €13 million will be provided to the HSE to meet the cost of reinstating discretionary medical cards.

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 under-sixes age cohort. The identification of health issues at an earlier age can mitigate or reduce the impact of ill-health later in life. We should bear this in mind when the Growing Up in Ireland survey has 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.

I have stated before that I believe that 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 a universal GP service. I would like to see the rapid roll-out in successive phases of more GP coverage. I would go so far as to say that I would not be as supportive of this legislation if the under-sixes' Bill were an end in itself. Deputy Ó Caoláin and others have raised this issue. This is a stepping stone; it is the first phase, not an end in itself. If we, as public representatives, believe that as a society we should organise a universal GP service, I would argue that we should support this Bill as the first step towards the universal service.

We should be clear that 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 aims to achieve this objective by 2016. Therefore, from an implementation perspective, my concern was to ensure that we roll out the universal service in the quickest and most efficient way.

Deputies will be aware that the Government originally intended to phase in the GP service, first, to those covered by the long-term illness scheme and, second, to those covered by the high-tech drugs scheme. However, this did not prove to be the most expeditious approach. First, a great deal of effort went into developing the proposal to base the first phase of the GP service on the LTI scheme. On face value, it appeared to be a reasonable approach to say that people on the LTI scheme would get a free GP service. However, the LTI scheme is somewhat anachronistic in its terminology. It may have been necessary to clarify in legislation the medical conditions that were to be covered, in which case it would have been necessary to examine that choice of conditions with respect to a GP service. There was also an inherent difficulty with basing the first phase of a universal GP service on whether a person was taking a prescription drug for a specific condition. The largest condition covered by the LTI is diabetes. Therefore, the initial approach would have provided a GP service to persons taking drugs to manage their diabetes, but not to persons who were managing their diabetes, without drugs, through lifestyle measures such as appropriate diet and exercise.

Therefore, a second approach was developed in which eligibility for a GP service would be based on a person having a particular chronic medical condition to be prescribed by the Minister for Health. However, as work on a draft Bill was progressed, it became clear that the legal and administrative framework required to provide a robust basis for eligibility for a GP service based on having a particular medical condition was likely to be overly complex and bureaucratic for a short-term arrangement. Relatively complex primary legislation would have been required in order to provide a GP service to a person on the basis of him or her having a particular illness. The assessment system for such an approach would have to be robust, objective and auditable in order to have the confidence of the Oireachtas as well as of the general public. This legislation would have to address how a person could be certified as having such an illness, and who could do this, and how to select the diagnostic basis for medical conditions. As well as primary legislation, there would be a need for secondary legislation to give full effect to this approach for each condition.

On my appointment in October 2012 as Minister for State with responsibility for primary care, I examined the progress made in the universal GP care plan. I was concerned that the first step was proving to be excessively complex and bureaucratic and that, ultimately, there was a significant risk that the entire universal GP plan would be delayed and perhaps delayed considerably. While it would not be impossible to persist with the chronic medical condition approach, it would have taken several months more to finalise the primary legislation proposals followed then by the preparation of statutory instruments. In my view, this would have entailed putting in place a cumbersome legal and administrative infrastructure to deal with what is only a temporary first phase on the way to universal GP service for the entire population. Consequently, I recommended a more expeditious approach, which was approved by Government. I believe that this current Bill will provide the basis for the progressive expansion of universal GP coverage to other age cohorts if that is the course chosen to develop the scheme.

I welcome the Government decision to develop a new policy framework of eligibility for health services to take account of medical conditions. The HSE has established an expert panel to examine the range of conditions that should be considered as part of this process and the panel has been asked to make an early report to the Minister for Health. While I do not wish to prejudge the deliberations of the expert panel and the consideration by Government, I would expect that a number of conditions will be identified that will further expand the coverage for GP services.

I wish to advise the committee that the Government intends to table a number of amendments on Report Stage. The text of section 58C, which relates to the HSE entering into agreements with medical practitioners, is receiving further consideration and I may introduce some small amendments in this context on Report Stage. It is intended to introduce an amendment to the Nursing Homes Support Scheme Act 2009 on Report Stage. This is a technical amendment to the definition of "transferred assets" in that Act. It is also intended, subject to the approval of the Government, to bring forward on Report Stage a number of amendments to the provisions of the Health Act 1970, in relation to residential support services. The relevant provisions, namely sections 67A, 67C and 67D, were inserted into the Health Act 1970 by section 19 of the Health (Amendment) Act 2013. The primary purpose of the intended amendments is to ensure that, in addition to those who are both accommodated and maintained by or on behalf of the HSE in the settings currently specified in section 67A, those maintained but not accommodated in those settings will also be required to make an affordable contribution towards the costs of their maintenance.

It is intended to bring forward an amendment to the Bill that would provide for an amendment to the Opticians Act 1956. The background to this amendment is the plan, which is well advanced, to subsume the Opticians Board into the Health and Social Care Professionals Council, in accordance with the Government's programme of rationalisation of State agencies later this year or early next year. The purpose of the amendment to the Opticians Act 1956, which currently regulates the professions of optometrist and dispensing optician, would be to change the election year of the Opticians Board from 2014 to 2015. This would remove the requirement to hold elections to the board this year. It would extend the terms of office of the current members of the board for up to one year until the regulation of the professions of optometrist and dispensing optician has been transferred to the amended Health and Social Care Professionals Act 2005. The alternative would be to hold elections and appoint a new board in 2014 to hold office for a very short period, if at all. The appropriate arrangements will be made for the amendments in advance of the Report Stage of this Bill, including an instruction to committee motion under Standing Order 131(2) to allow an amendment to the Bill.

I thank the Chairman for allowing me the latitude to outline the policy context of the Bill and I am happy to go through the details of the Bill and deal with any questions the committee may have.

I will make a general reply to the Minister of State's remarks before dealing with the detail of the Bill. I was one of the people who expressed a qualified and nuanced support for the legislation when it was discussed on Second Stage, in view of what has happened with regard to medical cards over the past two years. While the Minister of State says that GP care for children under the age of six is a stepping stone towards universal primary health care the Minister of State should note that a person using a stepping stone should not put two big feet into the water. I am afraid that is what the Government did when it decided to go down the road of the removal of discretionary medical cards. I make that comment in the knowledge that I must outline my position.

Universal health care should not be discussed as a utopian abstract concept. Universal GP services will cost money and it means that the money must be found from somewhere or else funding must be reduced in another health area. People who are obese have had their gastric band surgery cancelled. This is a death sentence for them. While services and funding of services are listed by priority, we must be conscious that certain priorities need to be addressed before we can broaden the areas of universal health care. The issue of discretionary medical cards is a case in point but in my view it is a very principled issue. We cannot tolerate a situation where very old and very sick people are no longer prioritised in our health system. What is left after looking after them should be disbursed to others. Resources will always be finite and it will not be possible to fund every strand of the health services and therefore certain areas must be prioritised in a structured manner.

The Bill provides for ring-fencing €37 million but that money is taken from somewhere. There is no point in pretending that this money can be plucked out of the air or from anywhere other than the national accounts. It is ring-fenced away from those who currently need it most because the resources are not sufficient to fund the discretionary medical card system. This was evident in last year's Estimates. As Fianna Fáil said at the time, the probity exercise was a code for the pillaging and culling of discretionary medical cards. This has been shown up by the Government's U-turn which I welcome. It is unfortunate that the U-turn did not happen some time ago when the issue was highlighted by everyone in the House. The Minister, Deputy Reilly, refers to the unintended consequences of the discretionary medical card issue. The only unintended consequence was that the Government lost a lot of council seats.

That was the real unintended consequence, and as a result of it a U-turn was performed. I am quite certain, however, that if Fine Gael and the Labour Party had enjoyed a good day at the local election polls, the so-called unintended consequences would have been allowed to continue and there would have been no U-turn on the withdrawal of discretionary medical cards.

We must have a genuine and comprehensive debate on the funding of our health service, including primary care and GP services, and prioritising access to ensure that those who need the services most and cannot afford them receive at least some assistance from the State over and above that afforded to persons who can afford them and do not need them as much. The whole regime of discretionary medical cards should be expanded in such a way as to incorporate some element of humanity and compassion into our health system. Where a person or family is visited by an extraordinary difficulty, even where the household in question can generally afford private health insurance and GP visits, the State must step in to offer support in a meaningful way. That is what social solidarity should be about, as opposed to trying to be all things to all people. The easiest thing for me to do, as an Opposition spokesperson, would be to say that the provision of free medical cards to the under sixes is a great idea but it should be extended to the under tens. That is what a populist Opposition would do. We realise that when there are finite resources, one must prioritise. However, the fact that we are still counting the number of incontinence pads being given out in nursing homes while in the same breath talking about giving GP cards to people who may be on a huge income is a little difficult to understand.

A broader debate is required in the context of this Bill. These proposals feed into the area of universal health insurance and are part of the Government's package to reform how we fund the health services and access to those services. The difficulty I have is that the words we are hearing are very different from the actions we are seeing. The Government must accept, just as it should have accepted there was a problem with discretionary medical cards, that there are inherent problems in primary care and with GP services. The ostrich syndrome can no longer continue in the Department of Health and at ministerial level. There is an inherent problem in the fact that GPs - highly qualified, professional people - are finding they can no longer contemplate working in this country and are choosing to go abroad. The solution is not just about offering attractive remunerative packages; there is an array of problems in the system. I urge the Minister of State not to deny this is an issue when the evidence is so clear. We do not want to wake up one day and discover that all our GPs have gone to Canada or Australia while we are left scouring the Third World to find replacements to fill the vacuum. That is not in any way being responsible either to our own people or to the people in other countries who also need GP services. Why are we taking their best doctors while sending our own to other parts of the First World? The Minister of State must accept that this Bill is building on a very perilous foundation, because primary care and GP services are in trouble.

I welcome the Minister of State, Deputy Alex White. The backdrop to our discussion is as inauspicious as anybody could ever imagine. I have always been willing to accept that the universal roll-out of free GP care should be done in a programmed way. As I have argued repeatedly, it must be introduced in a timeframed fashion, with a clear understanding by citizens of what is being done, which will, in turn, increase the potential for general population acceptance. I have been willing to play my part in encouraging that acceptance across the board.

However, the timing of the Government's initiatives in this regard has been terrible. Simultaneous with the proposal for the roll-out of a free GP care entitlement to all children under the age of six has been a very proactive targeting of people with discretionary medical cards based on medical need rather than the simplistic assessment that applies across the board of ability to pay. The discretionary mechanism is reflective of the fact that particular medical needs impose additional and quantifiable burdens on individuals and families. The extent of the hurt and anguish caused by this targeting is palpable. We have reflected it time after time in this committee room, in the Dáil Chamber and by every other means open to us. Until this week, however, there has been a persistent denial by the Government, despite all the evidence, of what is happening. I have concluded that we should have elections more often because they are a powerful wake-up call for the parties in government.

The situation in regard to discretionary medical cards has made the position of Government in respect of the particular proposition in this Bill very difficult. It has made it equally difficult for those of us in opposition who are willing to consider and facilitate measures which can ultimately deliver something that will not only be welcome but will most certainly be in the public interest and for the public good. Free access to GP care is an essential and integral building block towards a universal health care roll-out, which is what I want to see achieved in my time in this institution. However, I cannot be confident at this point in time that it will be achieved. The handling of all of these matters has been absolutely atrocious.

In his opening remarks, the Minister of State said: "[M]y concern was to ensure that we roll out the universal service in the quickest and most efficient way." I am up for that, but I need him to say this morning what this statement translates into at this point in time, according to his understanding. There is nothing efficient about the way in which all of these matters have unfolded. While the proposition contained in the Bill is laudable of itself, the backdrop - a backdrop created by the Government - has been deplorable.

The Minister of State also said "I believe that this current Bill will provide the basis for the progressive expansion of universal GP coverage to other age cohorts." I am concerned by the fact that the Minister did not say it would be extended to all cohorts. The use of the term "other age cohorts" indicates that the policy in this regard is piecemeal. I want to know what will be the final position and I need - and members of the general population have a right - to understand what is the timeframe in respect of this matter. That is absolutely essential.

In the context of the backdrop, I have a few short questions. At issue here are families with dependent children up to six years of age. Many of those families previously held medical cards and were among the cohort who lost those cards in the course of the discretionary medical card review process. For a variety of reasons, but primarily because such was the focus of Government intent in respect of probity, they did not fulfil all of the requirements involved and, therefore, they do not tick the box relating to the second criterion laid down by the Government, and articulated yesterday by John Hennessy, director of primary care, on "Morning Ireland", with regard to qualification for the restoration of their medical cards under the decision announced by the Cabinet on Tuesday. Among the people to whom I refer, there will be those who will not tick all the boxes when it comes to the three criteria and whose circumstances are more gravely serious than some who will have their cards restored. In other words, their circumstances are going to be compounded by that restrictive decision.

I wish to inquire about those who applied for discretionary medical cards in the period 1 July 2011 to 31 May 2014. As a result of the fact that the same criteria used during the review process were applied to them, their applications were refused. The Minister's apology is fine, as is that of the Taoiseach. However, those apologies do not correct the serious financial hit and hurt which people were obliged to endure during the period in question. Cards are due to be restored to more than 15,000 people who previously held them. However, had matters been left as they were, those to whom I refer would not have been obliged to carry a further financial burden at a time when they had no capacity to cope. I ask that the Minister of State address these matters. I am of the view that the reimbursement of those individuals and families must be a critical part of any package to be introduced.

I remind Members that we are dealing with Committee Stage, not Second Stage. Perhaps they might stick to discussing the Bill and the proposed amendments.

I welcome the Minister of State and thank him for his presentation. If we accept that this is the first step in the roll-out of universality of access to free GP care for the population, we need to know what is the overall plan, what will be the next stage, how many stages will there be and what will be the timescale involved. The Minister of State indicated that this is a stepping stone to universality. When one considers what has happened since the Government came to office, one realises the unfortunate and sad fact that we have been moving in full reverse away from universality. The Minister of State will say that there are more medical cards now than ever before. That is true but it is due to the fact that large numbers of people have lost their jobs, that there have been huge cuts to people's living standards and that there have been massive wage reductions.

It is obvious that there has been a very serious move away from universality, particularly if one considers what has happened during the past two and a half years. The position with regard to discretionary medical cards is a very good example in that regard. Huge numbers of people have lost their discretionary cards. Even with the proposals that have emerged in recent days, approximately 15,000 people who lost their cards are still not going to have them returned. These are people who, as a result of the massive pressure on them, did not pursue reviews. Those in question are entitled to have their cards returned.

Another issue which arises is that which relates to new applicants. How will the applications of individuals whose circumstances are similar to those who are going to have their cards returned be dealt with between now and the submission of the new panel's recommendations some time next year? There is also the question of refunds. People who lost their discretionary cards have been obliged to shoulder significant costs. Many have been paying €142 per month for drugs for months or even years and €50 to their GPs for each visit. These are significant costs for families which are not in a position to bear them.

The eligibility thresholds relating to medical cards have been deliberately reduced. In addition, the Minister withdrew the provision whereby the first €50 in respect of travel expenses could be offset against one's medical card. The latter was particularly important for people who live in rural areas and who do not have access to transport. Individuals in many parts of my constituency and others throughout the country are now obliged to pay the first €50 in respect of transport costs. The Minister also withdrew the offset in respect of home improvement loans. In the past, if one improved one's home by adding on a downstairs bedroom, shower and toilet for a sick relative or close family member, there was provision to offset moneys in respect of repayments on whatever loan one obtained. That is no longer the case. What we have seen in recent times represents a reversal of any progress that had been made towards universality. Another matter which arises in that regard relates to the huge reductions in the limits - from €1,400 to €900 for a couple and from €700 to €500 for an individual - relating to the elderly during the past three years.

As the Minister of State well knows, I and many other Members of the Oireachtas have been raising the issue of the difficulty relating to discretionary medical cards for the past two and a half years. Our concerns simply were not listened to. I want the Minister of State to deal with another issue I have been raising on an ongoing basis in recent years with the Minister, Deputy Reilly, and the other Minister of State at the Department, Deputy Kathleen Lynch. I refer to GPs charging for the taking of blood samples. The Minister wrote to me to indicate that this is illegal and I asked him to pursue the matter with GPs. A huge burden is being placed on people on fixed incomes who are obliged, on a weekly basis, to pay anything up to €25 for the taking of blood samples. The Minister indicated that this practice is illegal but he is allowing it to continue.

I ask the Minister of State to pursue the matter to the very end because it is a huge burden on ordinary people on fixed incomes, especially elderly people on State pensions of €230 per week. If it means having the Garda visit GP practices, that should happen. I hope the Minister of State will respond positively to the suggestion because if he does not take cognisance of the matter, it will become as big an issue as discretionary medical cards.

We are only hearing from the main Opposition spokespersons at this stage. Does Deputy Robert Dowds have a question or a comment to make?

Perhaps a comment.

The Deputy should be very brief.

I strongly support the legislation because if we look after children from infancy to the age of six years, for most people that will ensure they will have good health. Putting in good foundations at that age will stand to them for the rest of their lives. That is the strong reason for supporting the Bill. I found it very hard to listen to the Fianna Fáil spokesperson, given the many opportunities Fianna Fáil had to do something about the matter. There is a very strong case to be made for looking after children up to the age of six years, as it would help to prevent problems arising. The majority of visits to GPs are made by people with small children and the elderly. The aim of the proposed change is to look after people's health. I strongly support the Bill.

Does the Minister of State not respond?

No, only to the opening statements. This is Committee Stage, not Second Stage. The Minister of State may address some of the concerns expressed, if he considers it necessary to do so.

He might do so in his closing remarks on Committee Stage. Perhaps the Chair might give him the opportunity if he is so inclined. I would welcome a discourse. We do not get an opportunity to do so very often.

I thought the Minister of State's speech was like a leader's speech.

I hope all members will show leadership and stick to the Bill.

Question put and agreed to.

Amendment No. 1, in the name of Deputy Caoimhghín Ó Caoláin, seeks to provide that a person under 18 years of age who has been diagnosed with a serious illness or a serious congenital condition should have full eligibility for a medical card, notwithstanding his or her parents means. As the amendment could involve a charge on the Exchequer, it must, therefore, be ruled out of order in accordance with Standing Order 156.

I am sorry, but that decision has been superseded. You wrote to me, Chairman, and the Minister of State should heed this point. The amendment is now valid. It has been validated by the Minister's acceptance of it. I hope I am correct, but I have the formal document. You wrote to me on 17 June regretting the fact that the amendment involved a potential charge on the Exchequer. As an Opposition Deputy, I am well used to that type of communication as a means of blocking sensible amendments. On the following day, 18 June, the Minister appended his name to the document. I have copies with me and I am delighted to welcome his support. I do not know if there is a difficulty with it. Perhaps Deputy Denis Naughten might pass it to the Minister of State and I will give a copy to the Chairman. I would like to formally move my amendment now that it is no longer out of order because of my inability, allegedly, to progress it-----

I will clarify the matter for the Deputy in order that he can stay with us.

I was not planning to leave.

The Deputy should stay in this orbit. A mistake was made by the Bills Office and a revised list of Committee Stage amendments has been produced.

All I have is what is before me.

The Minister's title was removed and, accordingly, the amendment is out of order.

With respect, my amendment has the Minister's imprimatur. I received no such notification. I am indicating to you that the Minister put his name to the amendment. I would not be at all surprised if you were not told because I know about the communication difficulties in the Department of Health. Nevertheless-----

I am sorry, but the Deputy is being mischievous.

I am not. I did not type his name under my amendment, nor was I claiming it as my personal title either.

We could be here for the day discussing the matter; I am not in a hurry.

It is obvious that it is the Minister, Deputy James Reilly, who has accepted the amendment.

It could augur well for the future.

I regret to inform the Deputy that the amendment is not in order and cannot be moved. A revised list of amendments has been circulated.

Come the glorious day, this will never be forgotten.

I understand that. The Deputy should frame the amendment list as he has been included as the Minister for Health. He should put it on his office wall and in his front room at home.

It should be circulated to all Members of the Houses.

It probably was.

Amendment No. 1 not moved.
Question proposed: "That section 2 stand part of the Bill."

I appreciate the Chair's indulgence, but the essence of the amendment merits its acceptance by the Government. The Minister of State indicated in the course of his address that he was considering other amendments to be introduced on Report Stage. This is a very frustrating process where Deputies endeavour to improve legislation and because we are on the Opposition benches we are precluded from doing so on the basis that a proposed change involves a potential charge on the Exchequer. I appeal to the Minister of State, in the context of the Minister's momentary acceptance of my amendment which passed all too quickly, to reflect prior to Report Stage on what it is intended to achieve.

In the context of the amendment that has been disallowed, I urge the Minister of State to examine the matter again in advance of Report Stage. He has already indicated that it is his intention to introduce legislation within the next 12 months to facilitate a provision similar to that outlined by Deputy Caoimhghín Ó Caoláin covering all sections of the population over the age of six years. The amendment would be restrictive in that it would focus on those under the age of 18 years with congenital conditions or ongoing serious conditions. The Minister of State recently met the Jack & Jill Children's Foundation and the same argument was made to him. In light of the fact that such a measure will be introduced for the whole population in the next 12 months - the report will be presented by the expert group in September - will he make provision within the legislation dealing with medical cards - at a minimum for GP-only cards - for children under the age of 18 years to be the first to receive access to the new initiative? If we introduce the primary legislation, he could introduce such a measure by regulation in September once the report from the expert medical group is available.

Will the Minister of State clarify something he said in the context of the section? He said he would not introduce a medical card based on medical condition because it would be seen as too cumbersome and that there would be no point in introducing it in the short term if, in the not too distant future, universal access was provided for. Is that not the purpose of the expert medical group that will report in September, namely, to introduce medical cards on a temporary basis, pending the provision of permanent access to GP care?

The Deputy is straying from the Bill.

No, I am not straying from the Bill at all. The Minister of State might clarify that point.

Finally, the Minister of State has stated that he intends to bring forward an amendment in respect of the nursing home support scheme. I also intend to table an amendment on Report Stage in that regard because I believe that where someone is eligible for the nursing home support scheme, he or she should have an alternative to remain in the community, rather than being forced into a nursing home.

Obviously, I am in the hands of the Chair as to whether an amendment is or is not in order. It is not a matter for me but for the Chairman. However, I have considerable sympathy, certainly in principle, for the issue raised by Deputy Ó Caoláin and commented on by Deputy Naughten. I have met a number of groups, including representatives of the Our Children's Health campaign with whom I had a very good meeting two weeks ago, at which we discussed and debated this issue. The Government has decided to develop a new policy framework of eligibility for health services to take account of medical conditions but this pertains to eligibility for health services in the broadest sense and is not confined to free general practitioner, GP, care. The expert panel and the process to which the Government intends to give consideration will relate to the broad scope of services and will not be confined to GP services. However, the Bill being debated today pertains to the extension of GP services to the entire community by 2016 in the context of the commitment in the programme for Government. Whereas the two things are not unconnected - I will not suggest to Deputy Naughten they are completely unconnected - they are two separate strands on which members must be clear.

When I told the sub-committee earlier that it became clear that going by way of chronic illnesses would be cumbersome, the point I was making was that if members all are serious about moving as quickly as possible to universal access to GP services, the quickest and more expeditious way of doing that would be to at least start by this interim approach by way of age cohort. To take it at its simplest, none of this is particularly simple or simplistic, but if the criteria are that one is below a certain age and that one lives in the country, these are pretty straightforward conditions in order for somebody to qualify. However, if the conditionality is more complex with regard to a condition, an illness and so on, merely on the face of it, that quite clearly is more difficult. There is no doubt that while it is not impossible, it is more difficult. It was on that basis that I asked what was the quickest route to achieving free GP care for the entire population and in my judgment, with which the Government agreed, it would be better to proceed in the way that I propose.

However, the expert panel that has been established with regard to eligibility for broader health services will report in September. It is an expert clinical panel to examine the range of conditions that should be considered as part of the process. I do not wish to prejudge the work of the expert group. The Government has already stated it will develop legislation as necessary resulting from that expert panel's deliberations and that will take place. It would be inappropriate and I could not agree to seek to amend this legislation, either now or on Report Stage, because so doing would prejudge the work of the expert panel, which would be inappropriate. However, I make the point to colleagues that there is more than an understanding of the issue the Deputy raises in the amendment that has been ruled out of order. I can understand and am full of sympathy for the issue the Deputy raises and it will be addressed in the context I have mentioned. Meanwhile, what is being developed here is the implementation of a GP service without fees for the entire population. This is a stepping-stone, as I described it earlier. This is what it is intended to be and I again emphasise that were it simply just a once-off or a stand-alone measure, it would not have the merit I believe it has as a first phase of a population-wide scheme. I make this point in good faith through the Chairman to the Deputies. Deputy Ó Caoláin and the other members have raised this issue before and I say in good faith that I ask them to take my bona fides and that of the Government because this is the intention. The programme for Government commitment is to implement GP services without fees for the entire population. As for the future phasing, what will happen next and what are the main components therein, the first step is the legislation I will respectfully be asking the Houses to pass. The second is an engagement with the Irish Medical Organisation, IMO, which now is possible because in recent weeks, I have agreed a framework with the IMO to facilitate a real engagement and negotiation on these matters, which was not in place heretofore. It was either in 2006 or 2008 when the Competition Authority intervened in this whole area and since then, there essentially has been a stand-off between the State and the representatives of the GPs regarding a basis for negotiation, discussion and so on. That problem now has been cracked. While we do not have an agreement on the actual content of the work the Government hopes people will undertake, at least there is now a basis for people to have discussions and hopefully to agree. This is a further thing that has been achieved in recent weeks.

The final aspect about which Deputies Healy, Ó Caoláin and others asked is where does one go after the under-sixes. This is a perfectly legitimate question that I would love to be able to answer fully today. I cannot but what I will say - the Government repeated this again this week - is that by September, a comprehensive paper is to be submitted to the Government outlining the future steps and phases of the roll-out of free GP care. The Government and I are absolutely determined that the aforementioned paper will be prepared, completed and agreed at or about the same time as the other work that is being conducted with regard to the separate but connected area of the expert panel. This has been incremental and has been slower than I would have liked. Many things in the current Government have happened more slowly than many of us on the Government side would have liked but progress has been made in this regard. It is in that context that I seek the support of colleagues for this legislation. It is a stepping stone that will be followed by a paper in September with regard to the future roll-out. It also will be followed, I hope, by meaningful engagement and negotiations with the IMO to actually implement the scheme.

Briefly, I do not expect the Minister of State to be in a position to second-guess progress with the engagement with the IMO. However, there is no doubt but that the initial flagged intention of the roll-out of free GP care for all aged under six years of age in the course of this year is slowly but certainly moving more distant from our grasp. This is happening to the point that in the media this week, there has been speculation that the moneys set aside in the health budget for the current year as a provision for this particular area of entitlement now will not be employed at all in the current year. People are linking this with the expected cost of the restoration of discretionary medical cards and the €13 million involved there. Would the Minister of State like to indicate whether there is a connection? Is that where his eye is cast with regard to the restoration of the 15,300 medical cards? He should give members a sense of the position in this regard as from my perspective, that would be unfortunate. I still hold to the initial premise and still am willing to work with the Minister of State towards a much more concrete understanding of the intended roll-out, which is what I seek. It is still too unspecific but I will stay the course for now at least. Nevertheless, I would be grateful to hear whether he has anything to add. I understand the engagement with the IMO is still pending and I understand the difficulties this might present.

May I respond briefly?

I wish to make a brief comment. I understand the context of the Minister of State's observations regarding the medical review by the expert group that is taking place. Surely, however, it would make sense to make provision in this legislation, at least in the short term, for those children under the age of 18 who fall into whatever medical categories are highlighted by the aforementioned expert group. As an initial stage, they could be given free GP access. Members could make provision in this Bill that would allow for a statutory instrument to be introduced by 1 October to facilitate this measure in the short term and deal in some way with the hardship it has caused to families.

The Minister of State might consider this prior to Report Stage.

On the Deputy's last point, I will not go back on what I said about having sympathy for the point raised by Deputy Caoimhghín Ó Caoláin which was supported by the Deputy and, perhaps, Deputy Seamus Healy. For example, if we were to consider in the context of the Bill a provision that referred to a serious illness or a serious congenital condition, we would be immediately embroiled in definitional issues, making determinations as to which illnesses and conditions were and were not to be included and, more importantly, on who should decide and on what basis they should do so. This is the problem we always have to address, that there is always a selection involved. That is one of the reasons I am a universalist. Ultimately, a person should not have to apply for health services and prove that he or she is sicker than someone else or that he or she has a long-term as opposed to a short-term condition, or that he or she will or will not recover. This dogs services and is one of the reasons I am a universalist. If we were to go down the road of providing for serious illnesses, serious congenital conditions and addressing the question of aftercare services, the criteria to be used, etc., we would be embroiled immediately in complexities and there is no way we would be able to do this without at least the assistance of the expert panel that we have asked to look at these issues and, ultimately, looking at the legislative basis for selecting some and not others. I will not be in a position to agree to an amendment to the Bill along the lines suggested by the Deputy, but I hope he hears from me that there is an absolute appreciation of the issue he is raising and the need for it to be accommodated in the system. I agree completely with him in that regard, but it will not be possible to accommodate the amendment in the Bill.

I thank Deputy Caoimhghín Ó Caoláin for stating he will "stay the course for now at least." That is fair and reasonable and I thank him for what he stated in good faith.

I emphasise that we cannot spend the €37 million set aside this year until we have the scheme in place. We must put it in place and then start to pay for services. That is the way it happens. We did say it would happen in June-July, but it will not. However, I see every possibility that it will be implemented by the autumn. That is a realistic prospect. We have got the framework for negotiations and consultation with the IMO and I am hopeful they will get under way quickly.

The figure of €13 million agreed to this week for discretionary medical cards is separate. It is not coming out of the pot of €37 million, as I have made very clear.

If the Bill is passed, what services-----

We are on section 2.

Is there a basket of services identified of which a person with one of these medical cards will be able to avail? Is it the same basket or are there differences? For instance, will the issue related to the taking of blood samples which I raised be addressed?

This provides me with a good opportunity to address that issue. Under existing contractual arrangements, where it is necessary for blood samples to be taken as part of the normal diagnostic process, the patient should not be charged. That may not be sufficiently clear in the contract, which means that the new contract we want to agree with general practitioners will provide an opportunity for us to make crystal clear the circumstances that apply in the taking of blood samples.

More broadly, Deputy Seamus Healy asked what services would be available. In January we published a draft contract. It is probably fair to say it is not something that found universal favour with doctors, but it sets out what the HSE believes should be the range of services provided under the new contract. "It will be dealt with in the new contract," is the answer to the Deputy's question. We will seek to reach an agreement with doctors on the services the HSE wishes to see provided under the new contract for which they will be paid a fee.

Question put and agreed to.
Question proposed: "That section 3 stand part of the Bill."

Section 3 deals with the eligibility criteria. "Ordinarily resident in the State" is the phrase used for someone under the age of six years. I ask the Minister of State to look at linking the Department's system with the child benefit system, as well as the database of the Department of Education and Skills and the early childhood care and education, ECCE, database in order that one would have an accurate record of who was resident in the State and we would not end up paying for medical cards for children not normally resident in the State. There should be feedback between the four systems to ensure that if a medical card is not issued for a child under the age of six years because he or she is not ordinarily resident in the State, child benefit is not being paid for him or her. There are databases in the Department of Education and Skill and as part of the ECCE scheme which are effective and if the Department had access to them, there would be less chance of failure in the alignment between the systems. It might require an amendment to the Bill to access that information, but I ask the Minister of State to consider it prior to Report Stage to ensure we will not issue cards for children who are not resident in the State or do not exist.

We passed legislation last year to provide for a better exchange of data between various State agencies, including the Department of Social Protection, Revenue and the HSE on the Primary Care Reimbursement Service, PCRS. If I am not mistaken, there were provisions in one or other of the statutes we passed last year for the over 70s, although they were not confined to them. There should be a good exchange of data and I will consider the Deputy's point. It would not require an amendment to the Bill to ensure such an exchange continued and was improved. Sometimes we use terms such as "habitual residence" and "ordinary residence" which tend to be interchangeable, but they have different meanings. Some agencies deal with issues to do with habitual residence and others with ordinary residence. We must be conscious, however, that they are not exactly the same.

The issue concerns the ECCE scheme and the education system. There is a sharing of data between the other agencies, but to the best of my knowledge, there is no such provision in the case of the medical card scheme. It is my understanding that it would require a facilitating amendment to allow it to happen. We are talking about the under sixes. In the case of the over 70s, the ECCE scheme and the education system do not arise as an issue.

I note the Deputy's point.

Question put and agreed to.
Section 4 agreed to.
Question proposed: "That section 5 stand part of the Bill."

Section 5 outlines the contractual issues involved. There are a few to which I referred earlier.

In regard to GP practices, the emphasis in the 2001 primary care strategy document was on moving as many medical services as practical from the acute hospital setting to the primary care setting - GP surgeries and public health nurses - and providing care in the area where it was least complex at the least expense. That is the accepted norm and practice, both in the document and among the various professional bodies which represent the medical profession.

They would support that.

I raise this issue out of concern. We have previously referred to the pressure GPs are under, with rural GPs closing and urban GPs beginning to find things difficult. This legislation would throw into the mix many more consultations to be carried out under the GP contract for under-sixes. How does the Minister envisage moving the treatment of chronic illnesses from the acute hospital setting to the community setting? Although I do not expect the Minister of State to be able to answer this practical question now, has he considered this in terms of the development of primary care policy? If we are to treat diabetes, chronic obstructive pulmonary disease, COPD, arthritis and many other chronic illnesses in the GP surgery, there must be an acknowledgement that extra resources must be made available, because these illnesses are more complex than colds and flu. I am concerned that GPs might refer people to the acute hospital setting because they are under pressure in their surgeries around the country. Could the Minister expand on this? I do not expect him to give all the details today.

Last week at a committee meeting, Mr. Liam Doran of the Irish Nurses and Midwives Organisation, INMO, said many of his members were afraid to report issues.

We are on section 5.

Yes, but whistleblowing is the buzzword of the day. In the original contract there was the issue of GPs being unable to raise issues that might prejudice the good name of the HSE. The word "oxymoron" may come to mind. Why would there be such a curtailment? While I can understand why a person would not be allowed to prejudice the name of something because they were unhappy in themselves, a doctor in his or her professional capacity could highlight deficiencies in service and support and patient safety compromises. Has this been fully addressed in the context of the GPs' concerns? Many public representatives were also concerned about it. It was interesting that Mr. Doran said nurses on wards were afraid.

The Deputy is straying from the Bill.

I am not. It is on the issue of contracts and whistleblowers. If there is such pressure on people, maybe we should include a clause in legislation that would allow people to be confident if they have concerns, in view of the fact that they have to renegotiate contracts with the HSE at a later stage. That is what I find problematic. A GP may see a deficiency in the service and a threat to patient safety. The Bill states:

(4) Regulations made under subsection (3) may prescribe different amounts or rates in respect of different services or in respect of the provision of services to different classes of eligible person.

(5) Prior to making regulations under subsection (3), the Minister or, at the Minister’s direction, the Health Service Executive, shall engage in such consultations as the Minister considers appropriate.

The problem is that a GP, a group of GPs or a region of GPs who are in dispute with the HSE over an issue such as patient safety or lack of resourcing are expected to negotiate contracts with the same people. There could be a conflict of interest on both sides because the HSE could be vindictive if it felt certain GPs were creating difficulties. We need to explore this area because we should never discourage people from coming forward if they see patient safety being compromised. Although we ration health on a daily basis in this country, as in every other country, there should be no rationing of resources for patient safety. I am concerned about it.

One of the things we must do to make primary care work is to provide universal access to GP services. While I do not want to paraphrase or misrepresent anything Deputy Kelleher said in his earlier contribution, it is not entirely clear to me whether he agrees with a universal health care system. I am not trying to provoke an argument but to have the debate he said we should have. There will never be a perfect time for us to begin to implement a universal system. If we remove fees for people on low and middle incomes it will be good for them because they will not have to pay to go to the doctor, for all the reasons we know about. However, it has been shown that the barrier of fees prevents even relatively better off people from seeing their doctor. They have other priorities and do not attend. I have read lots of material that demonstrates this.

If one has a universal primary care system whereby people stay in the community and do not go to hospital, one must incentivise people to use it. The requirement to shell out €50 or €55 is a fundamental aspect of that. We want to eliminate the commercial barrier between people and their doctors or the primary care service and ensure they come into primary care and stay there as long as they can, unless they need to be referred to the acute services for a clinical reason. All the evidence shows that GP services without fees is the fundamental bedrock of developing primary care.

Deputy Kelleher and others often raise concerns about equity, comparing, for example, a child aged five whose parent is a Dáil Deputy and can well afford medical bills with other people. We could have a longer political debate, but equity issues regarding access to services should be determined by how people pay generally into the system, for example through taxation or insurance. We should have a pre-paid approach to health and we should all pay based on our ability to do so. Although everybody here should have to pay more into the system because we earn more, the system should be available equally to everybody, and the only criterion for somebody to use the health service should be whether they are ill and need it or not, including the preventative strategy.

Sometimes free GP care is presented as a sop or a political stunt. It is far from that. It is an essential prerequisite of a functioning primary care system. We are an outlier in the OECD and Europe in charging people €50 to €60 to see their doctor. It is a brake on developing primary care, and that is why we should provide free GP care. Let us deal with equity through the other policy instruments available to Governments, such as taxation or insurance.

The other aspect, as Deputy Kelleher will say, is that the services must be there, and he is correct. We are not resourcing primary care sufficiently and we need to resource it more. We need to adjust and move the resources as soon as we can into the primary care sector, which will be difficult. The Deputy's party was in government and saw how difficult it was, but it must be done. Free GP care is the sine qua non of doing that.

Last year we introduced 250 to 260 new posts around the country, and that is critical. We need more posts, such as speech and language therapists, physiotherapists and all the ancillary support services. We need our primary care centres, and we are developing and opening them all the time, not just before the European and local elections but also after them. Recently, I opened primary care centres in Blanchardstown and County Meath. Last week, I opened one in Schull, County Cork.

These are fantastic and really superb services in the community. They are providing excellent GP and ancillary elements in the community, and in practical terms we are pulling such services into the community and away from the acute setting. That is what we must do. Of all the areas of public policy, this is one on which we should co-operate across parties. The Deputy's party introduced the strategy in 2001 and much of that document is still extremely valid, although it must be updated in some areas and some aspects may need significant work. There have also been new developments that will help us accelerate what we need to do in primary care. No matter what party or individuals are in Government in future, there will be no answer to the proposition that a developed primary care system is the only way we can address the increasing demands on health services, the aging population and chronic illness problems.

Contract engagement was the second issue raised. There is no way I would stand over any provision in a contract that would constitute a brake on people raising issues to do with patient safety or related matters. There has been an objection to one aspect of the draft contract, which we will discuss with the Irish Medical Organisation, IMO, and resolve properly. I could not stand over that. I hope the Deputy did not intend to suggest that people would be vindictive. Knowing the leadership in the HSE for patient safety and elsewhere as I do, I know it is absolutely a priority for the HSE to maintain and protect patient safety. I would not for a moment stand over any suggestion to the contrary. We all want to achieve that goal and there is no question of a conflict between wanting to have a contract in place on one hand and ensuring that people are free to voice concerns they may have about a service they directly witnessed or which occurs across a spectrum of work. We will address the issue of the so-called gagging clause in the discussions with the IMO and I am confident that we will reach agreement on it. I agree with the Deputy's sentiment.

It is not down to individuals within the HSE, and I am quite sure all individuals in the executive are fine people. I made a point about Mr. Liam Doran of the Irish Nurses and Midwives Organisation, who stated clearly at a committee meeting that his members felt reluctant in - and were sometimes fearful about - raising issues of concern in this country's hospitals. That would be a concern, by extension, if GPs are in negotiations about contracts, as they may be reluctant to put forward concerns as well. I am just bringing the matter to the Minister of State's attention and I am not making any wild allegations or casting aspersions on individuals or organisations. We should be conscious of the issue so that down the road we will not have a GP saying to the Minister of State, me or anybody else that he or she wished an issue had been raised but there was a reluctance to do so.

Question put and agreed to.
Sections 6 and 7 agreed to.
Question proposed: "That the Title be the Title to the Bill."

Are there any concluding remarks?

I do not propose to add anything to my comments.

Will the Minister of State reflect on any of the points I made in my opening comments about the thousands of people who have had medical cards withdrawn and who have not ticked a box in the criteria as set out for the restoration process? What about those who applied for discretionary cards during the period when the same criteria were employed by the primary care reimbursement service and were refused medical cards? They have not ticked the boxes for the three points of consideration for the restoration of cards. What about reimbursing individuals and families?

We will not stray into those matters now.

That is the Minister of State's prerogative.

I want to be helpful.

We cannot discuss the matter as it is not part of the Bill and issues are still in play.

There have been briefings arising from the Government's decision on Tuesday. I am not sure if the matter was raised in the Dáil yesterday.

I do not want to be unhelpful to the committee but I am in the Chairman's hands. There is a proper forum to deal with the broader question of the Government decision on discretionary medical cards, and I am not really sure if this is the occasion.

If there are issues to which Deputy Ó Caoláin has not received a response, I will ensure that he is contacted and a full briefing can be given in respect of those.

We may deal with the issue at our quarterly meeting with the Minister and the HSE officials in July.

I will seek to help Deputies in any way I can.

I have tabled among the normal health questions a query that would allow the Minister of State to elaborate as I would wish. I was acting leader of my party yesterday in the Dáil and I had the opportunity to put these questions to the Taoiseach. I ask them of the Minister of State today because I did not get the answers I desired. I am still not getting the answers, so what forum is open to me? The 15,300 cards are welcome but we all know that they will not include everyone who has been so seriously affected over this period. Areas have not been included and the hurt and pain of some people will be compounded by their being excluded once again. It is a vista ahead of everybody in political life.

If the Deputy does not wish to wait for the appropriate committee meeting - the questions may need to be answered more urgently - he can write to me today and I will ensure he gets a response in writing within a couple of days.

I thank the Minister of State and his officials for attending.

Question put and agreed to.
Bill reported without amendment.