Alex White (Dublin South, Labour) | Oireachtas source

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.