James Reilly (Dublin North, Fine Gael) | Oireachtas source

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

It is my pleasure today to introduce the Second Stage of the Health (Amendment) Bill 2013 to the Dáil. The Bill amends both the Nursing Homes Support Scheme Act 2009 and the Health Act 1970, and has completed all Stages in the Seanad with no amendments. The main aim of the Bill is to facilitate the announcements made in budget 2013 with regard to public acute hospital in-patient charges, the charging of private in-patients in public hospitals, and the nursing homes support scheme. The Bill also amends certain charging provisions under the Health Act 1970 and enables the outsourcing of functions under the Nursing Homes Support Scheme Act 2009.

It was announced as part of budget 2013 that the asset contribution under the nursing homes support scheme would be increased from 5% to 7.5% and that the entitlement for State support to be backdated to 27 October 2009 for people who were in nursing home care prior to the scheme commencing, would be abolished. I wish to clarify from the outset that the increased asset contribution will only apply to new entrants to the scheme after the enactment of the Bill. Individuals who are already in receipt of financial support under the scheme will not be affected by this increase. I am aware there is concern about the asset contribution being increased. The reality is that the funding available for services for older people is not increasing at the same rate as the population. The budget for the scheme this year is €974 million. The HSE's 2013 National Service Plan sets a target of 22,761 people to be in receipt of financial support under the nursing homes support scheme at end-2013.

Given the extreme pressure that now exists on HSE funding across the full range of its services, it is necessary to increase the asset contribution. Importantly, however, contributions will continue to be based on applicants' means and on their ability to pay. Furthermore, even after the increased asset contribution comes into effect, the HSE will continue to meet the greater part of the cost of an individual's nursing home care. In that regard, it is worth noting that the average weekly contribution by the individual in receipt of care under the scheme is currently about €280. Despite the asset contribution being increased, it should be noted that the scheme contains several safeguards which ensure that both the person in the nursing home and their spouse or partner, if applicable, are adequately provided for. These are unaffected by the provisions of the Bill.

The increase in the acute public hospital in-patient charge from €75 to €80 and the charging of all private in-patients in public hospitals were announced as part of budget 2013. These measures will raise about €125 million in a full year. With regard to the private in-patient charge, the Government believes that the new charge makes sense. Up to now, we have had the situation where insurers have been enjoying a significant subsidy at the expense of the public hospital system, where private patients in public beds have only paid a standard €75 charge per night. In contrast, private patients in semi-private beds have paid up to €1,000 per night. In both cases, the patient sees his or her consultant privately and pays the consultant's private fees. In future, rather than paying €75 per night, the private patient will be charged €860, which is still well below the economic cost of those services.

The cost of providing hospital services to private in-patients is at least €200 million more than the amount that public hospitals are currently allowed to charge. Therefore, one can clearly see the imperative of addressing this situation. The subsidy is equivalent to the cost of running another significant-sized public hospital, or the cost of treating about 30,000 public patients every year. We cannot allow this situation to continue.

It is correct to state that everyone is entitled to use a public hospital. However, some people choose to be treated privately, in which case they have chosen to pay the consultant and the hospital. The Government believes that these users of private services should pay for the costs of providing them. The charge for private care in a public hospital should cover the costs of providing the service, including non-consultant hospital doctors, nursing staff, medicines, blood, medical and surgical supplies, radiology, diagnostics, operating theatres, laboratories, administration and support staff.

It does not make sense that two identical private patients getting the same medical treatment in a public hospital pay different amounts for using hospital facilities. Under the current system, one private patient pays €1,008 per day to the hospital and the other private patient pays €75 per day. The only difference is the room in which the patient is accommodated, all the medical care and treatment is identical. It is more rational that all private patients are charged in a similar manner for the public hospital resources they use. Given that all private patients are paying, it is possible to reduce the average daily amount charged by about 9%. These reductions are reflected in the rates that are set out in the Bill.

This approach is entirely in keeping with the move to universal health insurance, or UHI, where public and private providers will compete on a level playing field, free of unfair subsidies. Indeed, we will need to remove this subsidy one way or another as we move to UHI.

Other measures provided for include updating particular charging provisions under the Health Act 1970 and enabling outsourcing under the Nursing Homes Support Scheme Act 2009. Section 53 of the Health Act 1970, as amended in 2005 and in 2009, now covers three different charges. These are include first, charges for long-term residential care services under the nursing homes support scheme; second, public acute hospital daily in-patient charges; and third, long-stay charges.

The language and concepts used in the provisions for long-stay charges have become outdated over time and the replacement provisions aim to better reflect the evolution of a range of different models of residential care service provision which now addresses needs in the disability, mental health and care of older people sectors. The Bill repeals section 53 of the 1970 Act as amended and, instead, makes provision in distinct and separate sections for first, charges for long-term residential care services under the nursing homes support scheme; second, public acute hospital daily in-patient charges; and third, for an updated framework to replace long-stay charges with residential support services, maintenance and accommodation contributions.

In repealing section 53 the 1970 Act as amended the Bill provides a modernised and simplified legal framework replacing the charges currently required from those in receipt of long-stay in-patient services, other than acute hospital care or long-term residential care services under the nursing homes support scheme. The updated arrangements will require the payment of maintenance and accommodation contributions by those provided with long-stay residential care by, or on behalf of, the HSE in hospitals, convalescent homes, nursing homes or other forms of residential accommodation.

They will not apply to care services which are subject to their own distinct charging regimes, namely, acute hospital care and long-term residential care services under the nursing homes support scheme. The new arrangements are not intended to generate any additional revenue.

It is a well-established principle that those who are provided with long-stay residential care should make an affordable contribution. Maintenance and accommodation costs in providing quality services are high and it is fair and equitable that all those in receipt of publicly funded residential care make appropriate contributions towards these costs, if they can afford to do so. Funding derived from such contributions will continue to be directly applied by the HSE towards the provision of health services.

The requirement to pay an appropriate and affordable contribution towards the maintenance and accommodation costs to the State of providing such services will, therefore, continue. Contributions will be in line with current long-stay charges. The contribution will continue to be based on the individual's income level. The maximum level of long-stay charge is currently just below 80% of the non-contributory State pension and the maximum level of residential support services maintenance and accommodation contribution will continue at this level. The current long-stay charges exemptions will also continue to apply to residential support services maintenance and accommodation contributions. The HSE will retain the discretion to reduce the level of contribution required, depending on individuals' financial circumstances, the extent to which they already provide for their own maintenance and their assessed needs.

On the nursing home support scheme, the programme for Government commits to the carrying out of a Government-wide review to identify and eliminate non-priority programmes and to outsource, where appropriate, non-critical functions. With this in mind, a provision enabling outsourcing is being inserted into the Nursing Homes Support Scheme Act 2009. However, no specific outsourcing proposals are under consideration at this time.

The Bill also contains a provision which extends section 53A of the Health Act 1970 to public nursing homes. It is worth highlighting that the Government is committed to enhancing the quality of life of older people and is acutely aware of the evolving health and care needs of Ireland's older population. When the nursing homes support scheme commenced, a commitment was given that it would be reviewed after three years. A public consultation to inform the review was carried out last year and a summary report of the submissions received was published on the Department's website in December. Work will continue on the review in the coming months with a view to completion by late this year or early in 2014.

I now propose to briefly outline the main provisions of the Bill. Section 4 provides that the HSE may outsource its functions under the Nursing Homes Support Scheme Act 2009. Section 6 abolishes the entitlement for State support to be backdated to 27 October 2009 for people who were in nursing home care prior to commencement of the scheme. This provision was originally inserted in anticipation of a large volume of applications in the initial months of the scheme. It ensured that if any backlogs occurred at that time, applicants would not be disadvantaged. This provision applies only to people who were in private nursing homes when the scheme commenced. This cohort of people have had almost four years to apply for the scheme, which is more than reasonable.

Section 7 increases to 7.5% the asset contribution for new entrants to the nursing homes support scheme following enactment of the Bill. This will be capped at 22.5% in the case of the principal private residence. In the case of a couple, the cap on the principal residence will be 11.25% where one member of the couple enters long-term nursing home care.

Section 8 amends section 51 of the Health Act 1970 by adding definitions of "acute inpatient services" and "long-term residential care services" to the existing definition of "inpatient services".

Section 10 repeals section 53 of the Health Act 1970. The provisions being repealed are either relocated to or replaced by parallel provisions in new sections of the Act. The relocated or replacement provisions are inserted by sections 12 and 19 of this Bill.

Section 11 amends section 53A of the Health Act 1970. Currently, section 53A enables the HSE to charge the average cost of long-term nursing home care in public nursing homes to a person in an acute hospital who is no longer receiving medically acute care and treatment and has been certified as requiring long-term residential care services. This amendment will extend the provision to public nursing homes. Where a person enters a public nursing home for services other than long-term residential care, namely, respite or rehabilitation, and has subsequently been deemed by a registered medical practitioner to require long-term residential care services, the HSE may charge that person the average cost of care in public nursing homes. Crucially, this and the existing provision under section 53A are enabling provisions and will only apply where an individual refuses to co-operate with the application process for the nursing homes support scheme.

Section 12 inserts new sections 53B and 53C into the Health Act 1970. Section 53B is a technical amendment arising from the repeal of section 53. Section 53C provides for the public acute hospital inpatient charge and raises it from its current level of €75 to €80. Currently, this charge applies for a maximum of ten days in a rolling year. As there are no plans to change this maximum, the charge will be capped at €800 over this period. Section 53C also sets out the categories of persons who will be exempt from the charge, including medical card holders.

Section 13 amends section 55 of the Health Act 1970 and sets out the basis for the charging of all private inpatients in public hospitals. In future, where a person waives their eligibility to services as a public patient, the HSE, or someone providing a service on its behalf, may impose the relevant charge. The charge is set out in the Fourth Schedule.

Section 14 inserts section 74A in the Health Act 1970 and updates the provisions for the collection of outstanding charges or contributions where the service has been provided on behalf of the HSE in line with more recent legislation.

Section 15 inserts as a Fourth Schedule to the Health Act 1970 a list of charges in respect of inpatient services provided to private patients in public hospitals. The charges are dependent on whether a patient is accommodated in a single or multiple occupancy room or on a day case basis and to which Schedule, as outlined in sections 16 to 18, inclusive, of the Bill, the hospital concerned is assigned. Sections 16 to 18, inclusive, insert, respectively, as Fifth, Sixth and Seventh Schedules to the Health Act 1970 the lists of hospitals to which the charges set out in the Fourth Schedule apply.

Section 19 provides for the insertion of new sections in the Health Act 1970 regarding residential support services maintenance and accommodation contributions. These contributions replace the current maintenance charges required from those receiving long-stay care, excluding acute hospital care and long-term residential care services under the nursing homes support scheme.

Section 67A defines "residential support services" as services other than outpatient, acute inpatient or long-term residential care services provided by, or on behalf of, the HSE to those residing in hospitals, convalescent homes, nursing homes or residential accommodation for persons with physical, sensory, mental health or intellectual disabilities where their accommodation is provided by or on behalf of the HSE. Section 67B permits the HSE to make residential support services available to persons with full or limited eligibility.

Section 67C provides that the HSE shall collect a contribution towards maintenance and accommodation costs from a person who is in receipt of residential support services if he or she has previously received specified services on at least 30 days within the 12 month period ending on the day in question. It allows the Minister for Health, with the consent of the Minister for Public Expenditure and Reform, to make regulations specifying the amounts of the contributions required from persons or classes of persons, which may not exceed 80% of the maximum rate of the non-contributory State pension as currently applies to long-stay charges. It also exempts particular categories of people from paying the contribution, consistent with current exemptions relating to long-stay charges. Exemptions will apply to children under 18, women receiving services in respect of motherhood, those detained involuntarily under the Mental Health Acts or the Criminal Law (Insanity) Act, persons who contracted hepatitis C from the use of human immunoglobulin anti-D or from blood products or blood transfusions within the State, those being treated for prescribed infectious diseases and those receiving State support or ancillary State support under the Nursing Homes Support Scheme Act 2009 or paying charges under section 53A of the Health Act 1970.

Section 67D permits the HSE to waive the contribution, in whole or in part, in specific circumstances and requires the HSE to prepare and publish guidelines approved by the Minister, with the consent of the Minister for Public Expenditure and Reform. These guidelines will set out the circumstances in which the HSE may waive or partially waive a contribution.

Section 67D provides that the HSE may take into account, in deciding on whether to reduce a contribution, the extent to which an individual may provide for his or her maintenance or partake in activities which are, for example, beneficial towards the individual's rehabilitation or address agreed care plan objectives. This will be of particular importance to those residing in settings in the community where there is a strong emphasis placed on ensuring that each individual is supported to the greatest extent possible in managing his or her affairs and living in the community.

The main purpose of the Health (Amendment) Bill 2013 is to provide for necessary budget measures to ensure the sustainability of the HSE's provision of important services. The funding generated will be for the benefit of those in acute hospitals and nursing homes. In addition, this Bill modernises charging and contributions regimes in our hospitals, nursing homes and other residential settings. I commend the Bill to the House and look forward to hearing the views of Deputies.

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