Mary Harney (Dublin Mid West, Independent)

In regard to reference pricing and generic substitution, we are going to legislate for that. Generic substitution in itself would not be adequate because as I indicated, we now have an ironic situation with generics being more expensive since our agreement with the pharmaceutical industry this year than the off-patent prices. That is a ludicrous situation and it will be dealt with in September when the contract is up for negotiation.

To be fair to the generic manufacturers, when we grow the market here through reference pricing, hopefully we shall see a much greater impact with regard to generic substitution in the Irish market. We have a very high level of prescribing by brand, compared to Northern Ireland, Britain and other European countries. That is why we need to give pharmacists the power to substitute, where the branded product is prescribed when there is a much cheaper clinically acceptable alternative that can provide the treatment for the patient.

There will be exceptions, as I mentioned. I understand there are issues highlighted by people with clinical expertise in this area with regard to people's swallowing capacity in respect of some generic alternatives. This will of course be facilitated. We do not want to put patients at risk but rather to drive down costs so that all the money we can assemble for the public health services can go into providing them.

On the question of how we shall reimburse the patients, the GMS Payments Board has data on all patients. If somebody, for example, is accustomed to going to a pharmacy and is, say, in another part of the country the computer system will make the link between the medical card patient and what he or she will have paid. The intention is that there will be a reimbursement. If somebody goes over by just 50 cent or a euro, will he or she be reimbursed on a weekly basis, or should it be quarterly? My officials, the pharmacy representatives as well as the HSE and GMS officials will discuss the mechanism to be employed from a patient protection viewpoint.

With regard to the issue raised by Deputy Reilly about the adult disabled, if somebody is financially independent, he or she is assessed for a medical card based on the financial circumstances. If somebody, such as a child in education or whatever, is not financially independent, he or she remains part of the medical card of the family and is included in the €10 cap scheme that is being imposed in this legislation.

With regard to groups such as the homeless - I am sure we shall deal with this on Committee Stage - it is not possible for a pharmacist or, indeed, a medical card to identify somebody in this position. Therefore we are not in a position to say whether a person is homeless. Sometimes people are homeless for temporary periods and it is not possible to identify the position. I should like to convey that to Deputy Jan O'Sullivan.

In regard to the wider issues that were mentioned, Deputy English referred to the hospital for the north east. The intention is to have a single new hospital for the north east. It was never the intention to have it before 2014-15, in fairness, and the economic circumstances have pushed it back, for obvious reasons. However, the short-term plan was to consolidate five into two, and have two hospitals in the region which would provide critical and acute care. Very few health systems in the world would provide five hospitals for the population base we have in the north east. To be frank, we could not provide the quality care one is entitled to expect if resources were spread across so many different sites. It would become impossible from a skills-competency perspective for those working in such a system.

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