Billy Kelleher (Cork North Central, Fianna Fail) | Oireachtas source

I welcome all our guests and thank them for outlining the position on the issues not covered yesterday. I wish to focus on some key areas. In the Minister's opening statement, he outlined progress to date and the strategy since the Government came into being in 2011. One of the key issues is universal health insurance and its roll-out and we await the publication of the White Paper on universal health insurance.

When the Minister published Future Health in 2013, hospital groups were to be established and chairmen and CEOs were to be appointed. There is concern in the community about this. We have the small hospital frameworks and the primary care strategy and now the hospital groups, but there is a concern behind all of this. People fear that when hospital groups are established and budgets are squeezed and under pressure, there will be pressure on them to reconfigure and streamline services. However, talk about streamlining and reconfiguration of services is often a coded message for the downgrading of services in a particular area. How will we be able to monitor this? We have seen the amalgamation of some services and yesterday mention was made of shared services and streamlining of back office services. This practice often creeps into front-line services. We have seen this previously in some areas, for example, in Nenagh and Ennis, where there was to be a beefing up of certain services in these hospitals following reconfiguration in the mid-west, but this did not happen as progressively as it should.

Anything that makes services more efficient is welcome, but there are concerns. For example, in the area of maternity services, there is concern in some communities that some of the maternity hospitals will not be considered fit for purpose and that following the reconfiguration and the establishment of hospital groupings, they will see a closure or downgrading of some of these hospitals. We must remain conscious of this concern and must be honest and upfront in regard to what a hospital group is, what it means and its obligations, particularly when we move to more independent type budgeting when boards are established. Who will monitor these individual trusts to ensure they provide the services expected, as opposed to being profit driven and self-financing? Who will ensure they will fulfil their obligation to provide care?

We do not want to be constantly critical of Ministers, so I compliment the Minister on the initiative he is pushing of a tobacco free Ireland and a European directive in this regard. This is positive.

The Minister mentioned the Healthy Ireland council and also highlighted the issue of obesity. We must all do more to reduce obesity. If we look at the figures from Britain, it is alarming to see the rate of increase in obesity, in particular childhood obesity. While we have talked about the issue, we must address the issue of the foods we eat and target and focus on the issue. My age generation is probably a little overweight and should be targeted, but we need to target young people in particular and do more to address this issue.

The Minister mentioned that primary care will be the bulwark for the provision of health services in the years ahead and said it is the most efficient and cost-effective way of delivering health care. I am not quite sure whether the Minister is aware, but from speaking to individual GPs and communities, it appears GP services are in crisis. Making this statement is not being alarmist. This is a statement being made by the various organisations that represent GPs. It is also evident that many of these services and GP practices are on the brink of financial collapse, which will leave gaping holes in some communities. Also, many younger GPs are leaving this country. Emigration of GPs only happens when they see no future in general practice. We must be very conscious of this as we could quickly end up in a position where we will not have enough consultants to lead our clinical care teams or enough GPs to provide the primary care that is so much talked about by the Minister. It is politically populist to point out that doctors are making large sums of money and are doing very well, but the reality is very different and the witnesses must accept that at this stage.

This is not about representing doctors, something I was accused of by the Minister of State, Deputy Alex White, but about ensuring we have a primary care resource in communities providing the best of care. Without general practitioners that is simply not going to happen. While the Minister refers to rolling out primary care centres and the primary care strategy, the fundamental principle is to have teams that are GP-led in communities. By any stretch of the imagination that is beginning to dismantle in front of my eyes and, I imagine, with the Minister's previous knowledge of general practitioners and having advocated for them, he must see that as well. This must be addressed. I recognise the financial emergency measures in the public interest legislation cuts are hitting hard and that we expect everyone to carry their fair share, but we do not expect the people to carry the burden of the difficulties.

If we have a downgrading and the closure of GP services in rural Ireland, people will suffer. Unfortunately, what will happen is that we will end up with people being referred back into the acute hospital setting, despite that we are all trying to reverse that trend. The Minister must examine that in a detailed manner to ensure we have a young cohort of GPs coming into practice, that we have a sustainable primary care service and that we do not end up with the type of service whereby there is nothing in rural Ireland, areas deprived in a socioeconomic sense will have fewer GPs and GP services will become the preserve of those who can afford it again - all this despite the Minister talking of rolling out free GP care for everyone. We must examine that in the round.

The Minister has made proposals for those aged five years and younger. We all welcome the fact that the Minister is trying to make health care accessible. However, in making health care accessible to one cohort, he is denying another cohort. This is an area that we must consider. We have fundamental disagreements on this. Anyway, I wish to put on the record again that the Minister has stated there has been no change in the eligibility for medical cards granted on a discretionary basis. I fundamentally disagree with the Minister and Mr. O'Brien on this matter. There is a large cohort of people, who, previously, had discretionary medical cards and which have since been removed. There is another group of people who have the same illnesses, needs, diseases and requirements as those who previously had discretionary medical cards but they cannot access them now. They include children with Down's syndrome and people with profound physical and intellectual disabilities, including motor neurone disease and many other cases. The idea that the Minister takes from those who need it to give to those to whom the Minister wants to give is not a coherent policy. While we have limited resources, the policy must be based on need as opposed to the way the Minister is going.

The Minister referred to the fair deal and the positive ageing strategy of 2013. I have concerns about whether a large cohort of older people, who are in the nursing home support scheme and who have medical cards, are receiving other types of treatment, including physiotherapy, speech and language therapy and many other secondary benefits, to which they are entitled under the medical card scheme. I do not believe they can access the services to which they are entitled. I am not pointing the finger at nursing homes. I simply do not believe the services are available. I suggest, in the context of carrying out audits on nursing homes and places where people with intellectual and physical disabilities stay, that the Health Information and Quality Authority should also carry out an audit not only on the physical infrastructure and the services immediately required but on the obligations on the State to provide the services as well.