Alex White (Dublin South, Labour) | Oireachtas source

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

It is my pleasure to introduce the Bill, which will provide for a general practitioner, GP, service to be made available without fees to all children aged five years and younger. The key features of the Bill are the provision of an entitlement for all children aged five years and younger to a GP service without fees; the removal of the need for children aged five years and younger to have a medical card or GP visit card under the GMS scheme to qualify for a GP service; and a provision that the HSE may enter a contract with GPs for the provision of this GP service to children and that the Minister may set the rate of fees payable to GPs for this service.

I am also pleased to inform the House of the conclusion today of a framework agreement with the Irish Medical Organisation, IMO, which sets out a process for engagement concerning the general medical services, GMS, general practitioner, GP, contract and other publicly funded contracts involving general practitioners. This agreement has been reached following a series of discussions with the IMO and involving the Health Service Executive, HSE, and the Department of Health, led by me. The process got under way following my invitation to the IMO at its annual conference on 26 April to enter "talks about talks." I am pleased that these talks have culminated in the drawing up of the agreement. The framework agreement sets out an agreed process for engagement on all aspects of the GMS contract with GPs, with due regard to the IMO's role as a representative body of medical practitioners and within the context of the provisions of the primary legislation that will underpin the introduction of GP care free at the point of access. I look forward to a meaningful engagement with the IMO on the GP contract.

The Government is committed to introducing, on a phased basis, a universal GP service without fees for the entire population within its term of office, as set out in the programme for Government and the Future Health strategy framework. As announced in the budget, it has been decided to commence the roll-out of a universal GP service by providing all children under six years with access to a GP service without fees. Additional earmarked funding of €37 million was provided in budget 2014 to fund the first phase. It is not funded on foot of savings implemented elsewhere in the health system. The 2013 report of the expert advisory group on the early years strategy recommended providing access to GP care without fees for all children in this age group.

There are good reasons to provide universal access to GP care in view of the health needs of that age cohort. The early identification of health issues at a younger age can mitigate or reduce the impact of ill-health later in life. We should bear this in mind, given that the Growing Up in Ireland survey has reported that almost one in four children in Ireland is either overweight or obese and the likelihood that this will lead to significant health issues later in life. When the first phase is in place, approximately half of the population will be covered by a GP service without fees at the point of use. The Government is in the process of examining the next phases of extending the universal GP service.

Deputies will be aware that our current arrangement of health care provision can be traced back to the mid-19th century with the 1851 Poor Relief (Ireland) Act when limited services were provided for those who were unable to pay for them. Frankly, this is astounding. It is an anachronistic and inappropriate basis for a 21st century health system and far from any comparable modern health system of any other European country. It underpins the importance of moving towards a health system based on universality of access. The concept of eligibility has been somewhat amended by legislation, most recently in 1991 and 2005. However, the fundamental principle of means testing access to health services was retained by the Oireachtas on both occasions. One result has been that the means-based legislative framework has produced a very complicated eligibility system which must take account of a person's "overall financial situation" as stated in the 1970 Act. This system is very likely to confuse and almost certainly makes it impossible for a person to know whether he or she qualifies for a medical card. It is clear from the real concerns raised by members of the public that there are difficulties for some persons with permanent conditions in obtaining access to health services under the medical card scheme. This is a problem that we must address. It is being treated as a matter of priority by the Government and we are actively examining the issues involved and working towards a solution.

I have stated previously that I believe 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. I recognise that a move from a means-based eligibility system to a universal system of health coverage is difficult and that many anomalies arise. Members and others are perfectly entitled in the course of the debate to point to these anomalies and contradictions as they see them. We must try as best we can to address these issues in a sensitive and pragmatic fashion. However, the Government's commitment is to fundamentally reform the health system in the way we have proposed. In that context, I wish to hear more from our critics about any alternative approach they may have to the organising of health care coverage in Ireland, apart from maintaining the existing system.

It has been suggested, although perhaps not in this House, that people should be eligible for a medical card on the basis of their having a particular medical condition. On the face of it, it is manifestly right that if one has an illness, one should be able to access the health service. This is, of course, at the heart of the reform we are seeking to bring about and I passionately believe it is something we, as legislators, should strive together to deliver. However, in seeking to supplement our current inadequate means-based system with an illness-based approach, there is a risk that we could cause unintended consequences. As legislators, we should examine and consider these risks when considering possible or potential changes we might have in mind. Personally, I would not advocate an illness-based eligibility system as a long-term solution. It would result in the health service inadvertently only treating people with certain conditions, while excluding others with other conditions from care. We are in the process of reorientating the health system from one that only treats sick people to one that keeps people well. That is one reason I believe a universal system is the best option.

However, these major reforms take time. We should consider and explore how best the existing eligibility system can be adjusted to ensure people who are on low incomes or who have permanent or terminal conditions can obtain timely access to the health system. There is a good case for saying the existing eligibility system has become over-complex, resulting in people focusing on the assessment process rather than the provision of services. We should not lose sight of the fact that an ill person should be able to receive primary health services in his or her own area. At the same time, we must remain steadfast and committed to implementing the most radical reform of the system in the history of the State and developing a universal system that treats all according to their health needs, not their means.

The purpose of the Bill is to provide for a general practitioner service to be made available without fees to all children aged five years and younger. The Bill provides that the HSE shall make available a general practitioner service without fees to all children aged five years and younger. It also provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services for all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six month period following commencement of the section. Such a contract shall specify the services to be provided by the GP.

The Minister for Health may, by regulations and with the consent of the Minister for Public Expenditure and Reform, fix the rates of fees and allowances to be paid to GPs for services provided under these contracts. The section stipulates that the Minister, in making a regulation for this purpose, must engage in consultations. It prescribes the role of the Minister and HSE, the nature and manner of the consultations and the considerations to which the Minister must have regard in making regulations. Where the rates fixed by regulations under the section are varied in subsequent regulations, a GP who does not wish to continue providing services may terminate his or her contract by giving the HSE three months notice.

As all children aged under six years will be covered by the new GP service under the Bill, it removes children who have not yet attained the age of six years from the existing GP service under the medical card scheme. However, it is important to be very clear that children aged under six will continue to qualify for medical cards and their entitlements to other health services such as prescription drugs will not be affected in any way.

Among the other provisions in the Bill are amendments to the existing legislation relating to appeals under the Health Act 1970. The Bill provides for the current HSE appeals process to be extended to decisions on the operation of the new GP service for all children aged five years and younger and also provides for the director general of the HSE to appoint persons to carry out appeals. It clarifies that where the person carrying out an appeal is an employee of the HSE, that person shall hold a grade senior to the original decision maker. The existing provision in the Act that the Minister may make regulations in respect of the appeals process is restated without change.

The Bill also amends the existing "ordinarily resident" framework in the Health Act 1970 to reflect changes made in section 2 and extends the framework to include the new GP service for all children aged five years and younger.

Before I explain the main provisions of the Bill, I advise the House that the heads of the Bill were forwarded to the Joint Committee on Health and Children for a pre-legislative scrutiny process. Unfortunately, this was somewhat delayed as operational protocols for pre-legislative scrutiny were not available at the time. As a result, the Bill was published by the Government before the committee had had an opportunity to discuss the proposals. However, I look forward to detailed discussions with Deputies on Committee Stage of the Bill.

Section 2 amends the existing legislation relating to appeals under the Health Act 1970. It provides for the extension of the current HSE appeals process to decisions on the operation of the new GP service for all children aged five years and younger and also for the director general of the HSE to appoint persons to carry out appeals. It clarifies that, where the person carrying out an appeal is an employee of the HSE, that person shall hold a grade senior to the original decision maker. The existing provision in the Act that the Minister may make regulations in respect of the appeals process is restated without change.

Section 3 amends the existing "ordinarily resident" framework in the Health Act 1970 to reflect changes made in section 2 and extends the framework to include the new GP service for all children aged five years and under. Section 4 removes children who have not yet attained the age of six years from the existing GP service under the medical card scheme as provided for in section 58 of the Health Act 1970. They will be covered by the new service under section 58B. As I mentioned above, it is important to be clear that children aged under six will continue to qualify for medical cards, and their entitlements to other health services, such as prescription drugs, will not be affected in any way.

Section 5 provides for the insertion of sections 58B and 58C into the Health Act 1970. Section 58B provides that the HSE shall make available a general practitioner service without fees to all children aged five years and under. It provides that a parent or guardian of a child seeking access to this service should provide to the HSE such evidence as it considers necessary to demonstrate entitlement to the service, and where such evidence is not provided the HSE may treat the child as if he or she is not entitled to the service. Where possible, the HSE will offer a choice of GP to those accessing this service.

Section 58C provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and under. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six-month period following commencement of the section. The contract shall specify the services to be provided by the GP. The Minister for Health may by regulation and with the consent of the Minister for Public Expenditure and Reform fix the rates of fees and allowances to be paid to GPs for services provided under these contracts. The section requires that the Minister, in making a regulation for this purpose, engage in consultation. Further, it prescribes the role of the Minister and HSE, the nature and manner of the consultations and the considerations to which the Minister must have regard in making regulations. Where the rates fixed by regulation under this section are varied under subsequent regulations, a GP who does not wish to continue providing services may terminate his or her contract by giving the HSE three months' notice.

Section 6 is a technical amendment necessary to enable the seamless implementation of section 2. It extends the existing eligibility appeals process to the new GP service for all children aged five years and under. Section 7 states the Short Title of the Act, provides for the collective citation of this and prior Health Acts as the Health Acts 1947 to 2014 and includes a standard provision relating to commencement of the provisions of the Bill.

In conclusion, the main purpose of the Health (General Practitioner Service) Bill 2014 is to amend the Health Act 1970 to provide for a general practitioner service to be made available without fees to all children aged five years and under. The Bill also provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six-month period following commencement of the section. I commend the Bill to the House and look forward to hearing the views of Deputies.

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