Kathleen Lynch (Cork North Central, Labour) | Oireachtas source

That is great. I thank the Ceann Comhairle as well as all the Deputies who contributed to this debate. As the Minister, Deputy Reilly, stated at the outset, the Bill is part of the wider health reform programme undertaken by the Government since taking office. The ultimate aim of the reform programme is a single-tier health service supported by universal health insurance in which access to services is based on need, not income. Deputies Breen, Kyne, Fitzpatrick and John Paul Phelan reiterated that point in their contributions.

The Bill will bring the Vote of the HSE, which was established under the Health Act 2004, into the Vote of the Office of the Minister for Health. It builds on the Health Service Executive (Governance) Act, which was passed by the Oireachtas last year and designed to improve the HSE's level of accountability. It is not, as Deputy Kelleher claimed, an effort to transfer power to the Minister. Rather, it is designed to increase the HSE's level of financial accountability to the Department and the Minister, a point acknowledged by Deputy Seán Kenny. Regarding Deputy Kelleher's specific criticism of sections 33A and 33B as inserted by section 11, section 33A is a standard provision in legislation for all State bodies funded through Departments. Its purpose is to enable the Minister of the day to give grants legally from the Vote as approved by the Oireachtas. Without it, there would be no legal basis for issuing funds. Section 33B is designed to put the existing procedures for approving capital plans on a statutory basis. This process was in place under the previous Government. Therefore, it is incorrect and misleading to portray these sections as a power grab.

I also reject Deputy Shortall's assertion that proper corporate governance has been thrown out the window and that all power and responsibility are vested in the Minister. The checks and balances in respect of the operation of the HSE contained in the 2004 Act remain in place. Under that Act, it is a matter for the executive to draw up a service plan for the approval of the Minister. It is through this plan that resources are allocated for different services and areas. While the executive must rightly have regard to the policies of the Government in drawing up the plan, nothing in this Bill nor the governance legislation gives unfettered powers to the Minister.

A number of Deputies raised a range of other issues. While I cannot answer each point, I wish to respond to the main ones. As the Minister has indicated, the Bill forms part of the Government's strategy to reform the health service with the objective of introducing a single-tier health system in which services will be provided to citizens based on need rather than ability to pay. This will be achieved through the establishment of universal health insurance, on which Deputy Pringle and others called for a debate.

The Cabinet held an initial discussion on the White Paper on Universal Health Insurance last week. The issue will return to the Cabinet in the coming weeks with a view to publication quickly thereafter. Following its publication, there will be extensive public consultation, including on the services to be provided for each citizen within the standard package or basket of services. This will facilitate the debate on the universal health insurance proposals and I am confident that the matter will be fully discussed in the House.

Deputy Kelleher made a number of claims regarding the effect of Government policies on the private health insurance market. The latest figures from the Health Insurance Authority show that there are now just over 2 million people, or 44.6% of the population, who have private health insurance. While this has fallen from a peak of 50.9% in 2008, Ireland continues to retain a high level of population holding voluntary private health insurance. A number of measures are being undertaken by the Department to help maintain a competitive and sustainable private health insurance market.

The immediate focus is to keep health insurance affordable for as many people as possible. As part of the work to keep costs down, the Minister appointed an independent chairperson, Mr. Pat McLoughlin, to work with health insurers, the Department of Health and the Health Insurance Authority on the issue. Mr. McLoughlin's report under phase 1 of the review process was published on 26 December 2013. The second phase of the review has commenced and will report within three months. In particular, it will further examine the factors behind rising costs in the private health insurance industry and seek to address them.

Claims were made that the introduction of charges for private patients in public beds from 1 January could seriously undermine the market. The Government strongly believes that this new charge makes sense in terms of trying to end the significant State subsidy of private patients that insurers have enjoyed to date. Despite claims by some that the charges would cost insurers up to €120 million, they are actually designed to raise €30 million. Therefore, there is no basis for claims that this measure will damage the private health insurance market.

I strongly reject Deputy Kelleher's argument that primary care has been undermined through policy and expenditure decisions. The implementation of the primary care strategy is a priority for the Government. It is central to the Government's objective to deliver a high quality, integrated and cost effective health system. This includes the development of primary care teams and primary care centres. The core objective is to achieve a more balanced health service by ensuring that the vast majority of patients and clients who require urgent or planned care are managed within primary and community-based settings. This will be achieved by increasing activity in the primary care setting and redirecting services away from acute hospitals to the community.

Some 34 primary care centres have been opened since May 2011. In 2013, primary care funding of €20 million was allocated to support the recruitment of 264.5 additional primary care posts to enhance the capacity of front-line primary care teams. These additional posts include public health nurses, registered general nurses, occupational therapists, physiotherapists and speech and language therapists. More than 190 of these posts have now been filled or start dates have been agreed and a further 50 posts are in the final stages of recruitment. The HSE is committed to filling the remainder as soon as possible.

The number of general practitioners, GPs, contracted to provide services under the General Medical Services, GMS, scheme has also increased in recent years. Some 2,413 GPs were contracted to provide services at the end of December 2013. This compares with 2,098 at the end of 2008, representing a steady increase in the number of contract holders of 15% or 315 posts.

The cumulative effect of the reduction in GP fees and allowances under the Financial Emergency Measures in the Public Interest Act yielded some €123 million from 2009 to 2013. However, the impact of these reductions has been greatly mitigated by the ongoing increase in the number of medical card and GP visit card patients. This has fed through in GMS fees and allowances paid to GPs over the last number of years. These totalled approximately €453 million in 2013, €457 million in 2012, €438 million in 2011 and €460 million in 2010.

As part of the development of primary care we are also introducing, on a phased basis, a universal GP service without fees. As announced in budget 2014, it has been decided to commence the roll-out of a universal GP service by providing all children aged five and under with access to a GP service without fees. This will mean that almost half the population will have access to GP services without fees. The Government is providing additional funding of €37 million to meet the cost of this measure. Some Deputies have criticised this plan and alleged a lack of engagement with GPs on the matter. The initiative is the first phase of the roll-out of a universal GP service. Measures are already in place to ensure that the majority of patients aged 70 years and over as well as individuals experiencing financial hardship as a result of medical expenses can access a GP service without fees pending the introduction of a universal GP service.

Deputy Shortall asserted there was a better way to roll out free GP care and, in particular, that free GP care should first be rolled out to those with chronic illnesses. The Deputy knows that when the issue was examined in the Department, it became clear that complex primary legislation would be required to provide a GP service to a person on the basis of a particular illness. The assessment system involved would have to be robust, objective and auditable. Legislation would have to address how a person could be certified as having such an illness and who would make the certification and provide for the selection of the diagnostic basis for medical conditions. As well as primary legislation, there would be a need for secondary legislation to give full effect to the approach for each condition. While it would not be impossible to achieve, it would take several months more to finalise the primary legislation followed by the preparation of statutory instruments. This would entail putting in place a cumbersome legal and administrative infrastructure to deal with what is only a temporary first phase on the way to a universal GP service for the entire population. It makes more sense to pursue the policy in the current manner.

On engagement with GPs, on 31 January last the Minister of State with responsibility for primary care, Deputy Alex White, launched a consultation process on the content and scope of a new contract for the provision of GP care, free at the point of use, for all children of five years of age and under. This is the first public consultation of its kind. The Minister of State met on the same day with representatives of the Irish College of General Practitioners, the Irish Medical Organisation and the National Association of General Practitioners. The closing date for written submissions on the draft contract was 21 February 2014. The intention is to meet with GP organisations again in the coming weeks for detailed discussions on the scope and content of the draft contract. This will afford them the fullest opportunity to raise any and all issues which they may have regarding the draft contract and, indeed, to make their own proposals as to how it may be improved.

To say that cards can no longer be awarded on a discretionary basis is completely untrue. Such spurious and unfounded comments only serve to cause concern and distress to members of the public. Under the Health Act 1970, eligibility may be granted on a discretionary basis where applicants cannot arrange general practitioner, medical and-or surgical services for themselves and their dependants without undue financial hardship. To be very clear, there has been no change to this provision. Furthermore, there is no targeting of medical cards awarded on a discretionary basis. The contention that there has been a major policy change in the awarding of medical cards on a discretionary basis could not be further from the truth. While numbers may have fallen, this can be attributed, in part, to people who were marginally over the normal qualifying limit becoming eligible for medical cards under the normal qualifying scales. Discretion is not a stand­alone exercise but has been and remains an integral part of the assessment process for a medical card. Deputy Billy Kelleher referred to the statement of my colleague, Deputy Alex White, to the effect that there is no such entity as a discretionary medical card. What Deputy White said is true. There is only one medical card. Medical cards provided on the basis of means or where discretion is involved are identical and provide access to the same set of health services.

A number of Deputies, including Deputy Caoimhghín Ó Caoláin, referred to expenditure on health services. We must acknowledge that despite the significant progress made by the Government in respect of the public finances, resources are still scarce. Despite unavoidable resource reductions, however, successive HSE national service plans have managed to a significant extent to maintain core services. This has been achieved in tandem with supporting growing demand for services arising from population growth, increased levels of chronic disease, increased demand for drugs, higher numbers of medical card holders - up by 590,000 since 2008 - and new costly medical technologies and treatments. The HSE's 2014 national service plan has again sought to minimise the impact of constrained financial resources on front line services while maintaining patient safety in line with the Minister's stated overriding priority for 2014. I express my personal appreciation to HSE staff for their ongoing efforts to maintain and enhance the delivery of quality health and social care services to the general public during particularly challenging times, a point acknowledged by Deputies Bernard Durkan and Frank Feighan in their contributions.

This year, savings of over €600 million have been targeted. The targeted reduction in the cost of primary care schemes is €294 million, in pay related savings, including the establishment of a nurse bank, €280 million and in increased generation of private income in public hospitals, €30 million. This year may be the most challenging so far. Nevertheless, it is important to recognise that the bulk of the required savings measures, including the €280 million in pay and related savings and €172 million worth of reductions in pharmaceutical prices and expenditures and general practitioner fees, will not impact on the general public. The cost of drugs was raised by a number of Deputies. There has been a series of reforms in recent years to reduce pharmaceutical prices and expenditure. These have resulted in reductions in the prices of thousands of medicines. Price reductions of the order of 30% per item reimbursed have been achieved between 2009 and 2013. The Health (Pricing and Supply of Medical Goods) Act 2013 empowers the HSE to set reference prices for medicines which the Irish Medicines Board has designated as interchangeable. The HSE implemented the first reference prices for products on 1 November 2013.

Deputy Joan Collins raised a number of issues, including the needs of older people and, in particular, a recent report published by the private nursing homes association, Nursing Homes Ireland, which sought additional resources for the nursing homes sector. Deputy John Browne also raised issues relating to our older generation. The Government is acutely aware of future demographic trends and their implications for the provision of services for our older citizens. We have put in place a range of measures to support these services. The nursing homes support scheme review, which will be published in the coming months, will contribute to this process. While there will always be a need for long-term residential care, Government policy is to allow older people to stay in their own homes for as long as possible, as most prefer to do. Accordingly, provision for community and home-based services is being strengthened in 2014 to allow more people to stay in their own homes for longer. This will continue into the future.

The national positive ageing strategy provides the blueprint for a whole-of-Government and whole-of-society approach to planning for an ageing society. The strategy provides a vision for an age-friendly society and includes four national goals and underpinning objectives to provide direction on the issues which must be addressed to promote positive ageing.

An implementation plan to be finalised shortly will be overseen by the Cabinet committee on social policy.

Although his speech did not relate to the Bill, it is important to respond to remarks made by Deputy Luke 'Ming' Flanagan about mental health services in Galway and Roscommon. The Health Service Executive is implementing the strategy for reforming the mental health services based on the report, A Vision for Change. This report recommended 50 acute general adult mental health beds for a population of 300,000. In Galway and Roscommon, a total of 79 beds currently serve a population of approximately 315,000. The overall stock of beds in HSE west is, therefore, too high in relative terms and this is allied to a corresponding underdevelopment of community based mental health services. To address this issue, a purpose built acute mental health unit will be completed in Galway University Hospital in 2015. The new unit will include 35 acute beds for general adult mental health services. The acute unit in Roscommon will continue to provide 22 general adult mental health beds. While St. Brigid's Hospital, Ballinasloe, is reducing the number of general mental health beds on a phased basis, it will continue to deliver a range of services, including a 16 bed psychiatry of later life unit, a community service for mental health of older people and a day hospital for mental health of older people. The decisions on the changes in the Galway and Roscommon service were made by an expert group established by the HSE to examine this project and were reached on an objective basis that followed the approach adopted for comparable initiatives elsewhere.

A major investment has been made to improve mental health services across Galway and Roscommon, providing an additional 44 permanent posts at a cost of €2.6 million. The majority of these positions have already been filled to instigate overdue change. A key objective of this service initiative is to balance genuine local concerns on change and patient care, as has been achieved where similar initiatives have been implemented elsewhere.

I welcome the support Deputies Terence Flanagan and Finian McGrath expressed for the Bill. Both Deputies raised the issue of the recent controversy over top-up payments and suggested the matter should be addressed in this Bill. This legislation is designed for a specific purpose, namely, dealing with the Vote. In any event, the Health Service Executive has sufficient powers under existing legislation to address the problem the Deputies cited. It is not necessary, therefore, to introduce additional legislation to enable the HSE to deal with the matter. In addition, a new assurance process has been introduced, which will greatly strengthen the HSE's governance arrangements with the voluntary bodies concerned.

Deputy Terence Flanagan was highly critical of the management of medical card applications by the primary care reimbursement service, PCRS, citing as an example the experience of one of his constituents. While I cannot comment on individual cases, it should be acknowledged that the PCRS has made considerable efforts to improve its customer service. Last year, it assessed more than 700,000 individuals. It has set a target of processing medical card applications within 15 working days and has achieved a 95% success rate in meeting this target.

Deputy Áine Collins raised the financial management of the Health Service Executive. The Government recognises the critical importance of the financial management of the health services. The successful implementation of the health reform agenda will require fundamental changes in the way financial management is delivered across the health system. Phase 1 of the financial reform programme has been completed and a new financial operating model agreed, as set out in the report entitled, Defining Financial Management: A Finance Operating Model for Health in Ireland, which is published on the HSE's website. This report encompasses a roadmap for the finance function to facilitate delivery of an efficient and effective financial service to meet the emerging requirements of the changing organisational face of the health system. A critical enabler for the transformation of financial management is the introduction of a single integrated financial management system.

Phase 2 of the financial reform programme has commenced. The approach being adopted is very much of a collaborative and partnership nature, with a joint team comprising HSE staff and external consultants working together to deliver the requirements for a new system, in particular the development of a business case to obtain the necessary approval for a new integrated financial management system.

Deputy Dan Neville referred to the use of funding for new developments in the mental health services. As the Deputy correctly noted, recruitment to the new posts for mental health services was phased in over the years 2012 and 2013. However, 366 new staff from the 2012 allocated posts and another 135 staff from the 2013 allocated posts had already started work by the end of last year. The remainder of the increase in the number of staff, which is to be funded from the additional allocation for mental health services, will continue to be recruited. The planned completion date for filling the 2012 and 2013 allocated posts is the end of the second quarter of this year. A cumulative sum of €70 million allocated over the past two years is available in 2014 to fund all the posts to be recruited from the 2012 and 2013 investment, with an additional €20 million allocated in 2014 to fund between 250 and 280 additional new posts.

Deputy Simon Harris raised a number of issues specifically related to funding for people with disabilities and St. Vincent's University Hospital. The Deputy stressed the need for a transition to greater choice and control by people with disabilities over the services and supports they receive. I share his strongly held views on this matter and assure him that the value for money and policy review of disability services, which was approved by the Government in July 2012, sets out to do precisely as he wishes. The review sets out a radical and complex transformation to the manner in which services for people with disabilities are currently funded and delivered. This change will place individuals at the centre of service provision and deliver greater accountability and transparency in respect of the use of the substantial funds the Government allocates to the disability sector each year. The review is a multi-annual and multifaceted project and the Department and HSE are working in a structured way on a number of fronts to bring it about. The move away from block funding will result in a complete transformation in the way in which we deliver and fund services and will require a great deal of planning and testing before we decide exactly how it will operate in the Irish context.

In respect of Deputy Harris's points on St. Vincent's University Hospital, he will be aware that the issue regarding the mortgage taken out by the hospital group was dealt with in a report by the Comptroller and Auditor General. The Health Service Executive has taken measures to protect the State's interests in the public hospital. With regard to the employment arrangements for consultants, as recently as last month, the HSE indicated to the Department that there are no special employment arrangements in place for consultants employed by St. Vincent's University Hospital or St. Michael's Hospital, the two public hospital components of the St. Vincent's Hospital Group.

Under the Health Act 2004, the HSE has statutory responsibility for the regulation of consultant posts in the public health system. As part of the delivery of this regulatory function, the HSE determines the location, contract type, hours, qualifications and other aspects of each consultant post. The HSE has not sanctioned any special employment arrangement for consultant posts under St. Vincent's University Hospital.

I thank all Deputies who contributed to the debate. I emphasise again that the Government is committed to the health reform programme set out in the programme for Government. The Bill will implement one of the commitments contained in the programme. While it is largely technical in nature, this legislation is part of the process of reform which is designed to give people the health service they deserve, namely, a single tier service in which they will have access to services based on need rather than ability to pay, one which will be fair and in which all those treated will feel safe and all those working in it will be proud of the part they play. I commend the Bill to the House.

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