Seán Power (Kildare South, Fianna Fail)

I move: "That the Bill be now read a Second Time."

I am pleased to introduce the Bill, which provides for the amendment of the Health Act 1970 to address two substantive matters: the provision of a legal framework for the charging of patients for the maintenance element of inpatient services in publicly funded long-term care residential units and the introduction of doctor visit medical cards. The Government has introduced the legislation to establish a sound legal basis for the policy of requiring a contribution towards shelter and maintenance of people with full eligibility in the long-term stay institutions.

Succeessive Governments have supported and implemented this policy. The Supreme Court recently confirmed it is constitutionally sound for the Oireachtas to legislate for this policy. The issue is finally being put beyond legal doubt after almost 29 years. We are also proposing the introduction of a doctor visit medical card as announced at the publication of the 2005 Estimates. This fulfils a key Government commitment to ensure people on low incomes have access to general practitioner services and advice. It is most efficient to address both issues in the same Bill.

The decision of the Supreme Court on 16 February 2005 in the matter of Article 26 of the Constitution and the Health (Amendment) (No. 2) Bill 2004 has brought clarity and finality to the issue of long stay charges. It has also paved the way for the introduction of this Bill to provide the legal basis for charging for inpatient services in publicly funded long stay institutions. We had a full debate in the House on the Supreme Court decision two weeks ago. The court found the Bill's provisions for prospective charging of inpatients were not repugnant to the Constitution. There is no constitutional prohibition on implementing a charge into the future for public long stay inpatient services.

The Government accepts fully that the Supreme Court found the retrospective provisions of that Bill on making lawful the imposition and payment of such charges in the past to be unconstitutional, in so far as this concerns the property rights of citizens. We are concerned with the implementation of policy going forward. I do not believe the House needs to revisit the debate we had two weeks ago on the Supreme Court decision. The debate should focus on the Bill's provisions and look forward to the clarity and benefits they will bring.

The principle that it is fair and reasonable that most people should make a contribution to the cost of their long stay care is a significant and long standing feature of our system of publicly funded long-term care. This has been restated and reinforced in the health strategy, Quality and Fairness — A Health System for You. It is recognised that quality care is expensive and the bulk of the cost of providing a high standard of quality care should be borne by the Exchequer. It is estimated the charges imposed on those in public nursing homes represent approximately 10% of the overall cost of care. It, therefore, represents a modest contribution towards the total cost of treatment and maintenance.

The services provided to people in long stay care are a valuable part of the health services. It is essential that these services should be protected and maintained. The charges in question are embraced by the concept of a co-payment, which is common throughout the health service. This is consistent with the overall principle that where individuals can contribute a modest amount to the cost of their care, it is reasonable that they do so. Other examples include the inpatient overnight hospital levy. In the latter case, the charge is €55 per night subject to a maximum of €550 in any 12 consecutive months. Those availing of private or semi-private accommodation in public hospitals are also charged.

I refer to future services for older people specifically. It has been the policy of successive Governments to endeavour to help older people maintain themselves in the community while at the same time providing for residential care which is not prohibitively expensive. The policy of the Government on the development and delivery of services for older people is to maintain them in dignity and independence at home for as long as possible in accordance with their wishes, as expressed in many research studies. People are much happier in their own homes and they recover more quickly from illness in their own environment and we will continue to allow that to happen in so far as that is possible.

The roles of all community care services are, therefore, vital to the implementation of this policy. The charges provided for in the legislation will assist in providing funds to help in the implementation of these overall policy objectives in the future. On foot of advice sought by the Tánaiste from the Office of the Attorney General, the Department of Health and Children issued a letter on 9 December 2004 to the chief executive officers of the health boards and Eastern Regional Health Authority asking them to stop making such charges immediately, pending the introduction of amending legislation. It is estimated that this is costing approximately €2 million per week. Accordingly, a statutory framework that puts the long-standing policy on a sound and statutory legal footing and safeguards the income generated from this source is vital. The provisions of the Health (Amendment) Bill 2005 will secure this source of income. Let us remember that this income is applied exclusively towards health services. It does not revert to the general Exchequer. It is part and parcel of health funding and has been so for decades past.

On 18 November 2004, in conjunction with the publication of the 2005 Estimates, the Tánaiste announced the Government's intention to introduce a doctor-visit medical card for 200,000 people. This was the most efficient way to help the most people to access primary care. It is in line with the commitment contained in the health strategy to ensure that the allocation of medical cards is on the basis of prioritising groups most in need. This is one of a package of developments that we have announced regarding the medical card scheme. The others involve adjustments to the income guidelines in respect of standard medical cards which will enable 30,000 additional people to obtain such a medical card in the current year. The new income guidelines have been in force since January 2005. Those guidelines reflect the 7.5% increase on the 2004 figures, as announced in November 2004, and include substantial increases in respect of dependent children.

Parents of children with illnesses that persist from year to year can be assured that they will not have to reapply for a medical card each year, thus alleviating the anxiety of wondering if their medical card will continue. It is intended that this arrangement should apply to a small number of children with very serious illnesses, where a review would normally result in automatic renewal of the medical card. As I stated, the Government is providing extra resources for additional medical cards in a way which benefits as many people on lower incomes as possible.

Concern has been expressed by several people and groups, including general practitioners, that some parents have been deterred from attending their family doctor, or from bringing their children to the doctor, by the cost involved. People should not be discouraged from visiting their family doctor, and especially from bringing their children to the doctor, because of cost. For this reason, the Government has decided to introduce a new medical card which will enable 200,000 people on low incomes to visit their GP free of charge. This measure will remove for individuals and families any concern about the cost of bringing their child to a doctor or attending themselves. People will be able to get the advice and reassurance that they need from their GP and, if necessary, be referred to other health services in either the community or the acute sector as necessary.

It is important to remember that not all concerns or medical conditions with which people attend their doctor necessitate the prescription of medication, so in many cases no cost need arise in that regard. For those who require prescription medication, under the drugs payment scheme no one need pay in excess of €85 in prescription drug costs in a calendar month.

The Health Service Executive is preparing for the introduction of the doctor-visit medical cards and is drawing up appropriate operational guidelines to enable applications to be assessed on a standardised basis across the country. Once that legislation has been enacted, the HSE will be able to begin promoting the scheme and inviting formal applications with a view to the first doctor-visit medical cards being issued during April.

I am pleased that the Irish Medical Organisation has welcomed the initiative and I look forward to its co-operation in the introduction of these new medical cards in the interests of the families and individuals concerned. I understand that the Health Service Executive has written to the IMO, inviting it to discuss the administrative and operational arrangements regarding the implementation of the doctor-visit card. The additional funding of €60 million provided in the current year should allow up to 200,000 doctor-visit medical cards to be issued. The Health Service Executive intends initially to set the income threshold for the doctor-visit cards at 25% higher than applies for the standard medical card. That threshold may be reviewed in light of experience to ensure that the desired numbers of cards are being issued to those intended to benefit under the initiative.

The introduction of the new doctor-visit cards should also be seen in the context of the broader modernisation agenda under way for the medical card schemes. A medical card review project was set up under the former Health Boards Executive in April 2002 to assist the health boards in the promotion of good administrative practice regarding the management of the medical card scheme and the achievement of high standards for their customers. Nine sub-projects were established undertaking the following: the management and control of the GMS register; administrative processes and standards; modernisation and development of the appeals system; modernisation and simplification of application and review forms; the development of customer satisfaction measurements; examination of IT system integration options with health boards and the GMS payments board; researching and clarifying guidelines in interpretation of legislation; developing a training strategy; and developing training in the principles of good decision-making.

The work of those sub-projects was accepted by the board of the Health Boards Executive. It is now being progressed, under the auspices of the Health Service Executive, by a national steering group set up to oversee implementation of the outputs of the Health Boards Executive process. The work of the project will modernise the operation of the medical card and related schemes to make them more customer-friendly, administratively streamlined, fair, accountable and IT-enabled.

I now propose to outline the scope and principal provisions of the Bill. For the purposes of clarity I will deal first with long-stay charges and then with doctor-visit medical cards. The Bill is designed to eliminate the anomalies that have arisen under the current legislation for raising charges for long-term care in publicly funded long-term care institutions. In addition, the Bill and regulations will promote consistency in the application of charges, with greater clarity for those receiving services and the public generally, as well as promoting administrative efficiency and transparency throughout the system.

Section 4 of the Bill provides for an amendment to section 53 of the Health Act 1970 which deals with the legal basis for the imposition of charges as follows. It replaces the existing enabling provision in subsection (2), which provides the Minister with discretionary power to make regulations by a provision, something that requires the Minister to make regulations to impose charges regarding all persons, that is, those with full and limited eligibility. As matters stand, section 53 of the Health Act 1970 provides power to make regulations to impose charges on those who have limited eligibility only. It inserts a new subsection (3) which specifies categories of person exempted from charges imposed under subsection (2). Such categories include all persons under 18, those detained involuntarily under the Mental Health Acts, those in receipt of medically acute care in hospitals and those pursuant to section 2 of the Health (Amendment) Act 1996 who, in the opinion of the Health Service Executive, have contracted hepatitis C directly or indirectly from the use of human immunoglobulin anti-D or the receipt within the State of another blood product or a blood transfusion.

We intend to insert a new subsection (4), which empowers the Health Service Executive to reduce or waive a charge on financial hardship grounds, and a new subsection (5) to make it clear that any current regulations in force under section 53 remain in force. The regulations in question are those which impose a hospital levy of €55 a day, subject to a maximum payment in any 12 months of €550. Those charges will continue not to apply to people with full eligibility — medical card-holders, including all over-70s — and a series of other exemptions, such as women in respect of motherhood.

We are also inserting a new subsection (6) to provide that the charges shall apply for inpatient services only after a period of 30 days or periods aggregating 30 days within the previous 12 months. The new subsection (6) also limits the weekly charge to an amount that does not exceed 80% of the maximum of the weekly rate of old age non-contributory pension. We will insert a new subsection (7) to clarify that the period of 30 days referred to in subsection (6) begins to run immediately the person concerned is provided with inpatient services. We also intend to insert a new subsection (8) to provide that the charge shall be in respect of the maintenance aspect of inpatient services.

I would now like to outline for the House the Bill's provisions regarding doctor-visit medical cards. Section 1 amends section 45 of the Health Act 1970 in two respects. In both cases the amendment is to ensure an alignment of the legal principles governing the award of the standard medical card and those contained in the provision to be included in section 58 of the Act in respect of the doctor-visit card.

The amendment to be inserted by section 1(a) makes it explicit that the judgment as to whether a person meets the criterion of "undue hardship" specified in section 45(1)(a) of the Health Act 1970 is made by the Health Service Executive.

The amendment to be made by section 1(b) replaces the existing section 45(2) of the Health Act 1970 with a wording which makes it clear that decisions on eligibility by the Health Service Executive must be made not just by reference to a person's means but also to what constitutes reasonable expenditure on the person's behalf. This is in line with existing practice in the Health Service Executive whereby costs associated with such matters as a person's employment, reasonable housing provision and the care needs of children or dependants, as well as nutrition and clothing needs, are taken into account in determining whether a person faces undue hardship in meeting the costs of GP services.

By amending the law in this regard we are making it a legal requirement that a person's reasonable expenditure needs are taken into account in the application of section 45(1)(a) of the Health Act 1970. In both cases these provisions reflect what is already the practice of the HSE regarding the assessment of individuals for medical cards. These amendments, therefore, will not affect the processes and practices already in place as regards the award of the standard medical card.

Section 2 amends section 47 of the Health Act 1970 by adding a reference to section 58 with the existing reference to sections 45 and 46. This is to ensure that the relevant appeals provisions extend to the scheme for doctor-visit medical cards.

Section 3 amends section 47A of the Health Act 1970 to include the doctor-visit medical card scheme in respect of the Minister's power to issue guidelines to assist in decisions regardless of whether a person is ordinarily resident in the State. Guidelines issued to the health boards in this regard in 1992 and remain in force.

Section 5 replaces the existing section 58 of the Health Act 1970, which deals with the making available of general practitioner services without charge, with a new provision. The new subsection (1) will require the Health Service Executive to make available general practitioner services without charge not only to persons with full eligibility but also to persons with limited eligibility for whom, in the opinion of the executive, it would be unduly burdensome to arrange these services for themselves and their dependants. This provides the legal basis for the granting of medical cards, the scope of which is confined to patients' attendance at a general practitioner.

Subsection (2) of the new section 58 specifies the same general requirement regarding the making of decisions by the Health Service Executive in respect of doctor-visit medical cards as is being inserted regarding decisions on eligibility, that is, they must be made not just by reference to a person's means but also to what constitutes reasonable expenditure on the person's behalf.

Subsection (3) maintains the existing requirement that there be a choice of doctor for persons obtaining general practitioner services under section 58 and ensures that this applies to holders of doctor-visit medical cards as well as holders of the standard medical card.

As the House will see, in respect of charges for long-stay care this legislation will bring clarity to an area which, it is now clear, has not been operating on a sound basis for nearly 30 years. This is a genuine move to provide that charges for long-term care that are imposed have a sound legal basis. The legislation will also ensure that the income flow from charges imposed to date is secured and that it will continue to support the provision of quality services to those in long-term care. It has been accepted that these charges, as contributions to the cost of care, are fair and reasonable.

With regard to new medical cards, Government policy is, as stated in the programme for Government, to extend eligibility for medical cards for people most in need rather than to achieve coverage of a certain percentage of the population or to issue a specific number of medical cards.

The introduction of doctor-visit medical cards will enable up to 200,000 additional people from lower income households to go to their doctor free of charge. This will help to overcome barriers to accessing GP services for many individuals and families who are above the standard medical card income guidelines. I commend the Bill to the House.

See this speech in context