Billy Kelleher (Cork North Central, Fianna Fail) | Oireachtas source

I welcome the opportunity to speak to the Bill and about broader issues pertaining to the health service in general. We will not oppose the Bill. We believe in the concept of universal access to primary care. It is an aspiration of all parties and all empirical evidence shows it is the right way to prevent people from attending acute hospital settings by ensuring they are treated in a timely fashion in a less complex and less expensive primary care setting. When one considers the programme for Government, the efforts to achieve this have been slow. We are in the fifth year of the Government and a commitment was made that free GP care would be available to all within its lifetime. It has one year left in which to address the cohorts who are not under six years, over 70 or have medical cards.

The previous Minister for Health apologised half-heartedly for the distress caused to many thousands of people with discretionary medical cards. That is where we differed. We said, when universal coverage for those under the age of six years was announced, that to fund one cohort by denying another group that needed health care the most was fundamentally wrong. Discretionary medical cards were being taken from people who were sick, had profound disabilities or life-limiting illnesses at an industrial level until the Government’s change of heart last May or June and the U-turn which led to more discretionary medical cards being available based on medical need as opposed to means. That is welcome because it targets the cohort that most needs State assistance in accessing health care. That is why we consistently highlighted that particularly nasty attack on those who were genuinely vulnerable. I could never understand why in the march to universality, which we support and endorse, we were taking money to fund access to GP care from those who needed it most. That was disgusting and distasteful. It was Government policy, which was denied for 18 months when the issue was raised here time and again during Leaders' Questions and in oral and written parliamentary questions. The previous Minister, more or less, said in recent interviews that he regretted that it had happened and that it should not have happened. It caused great anxiety and anger for many. The wider public abhorred the fact that a GP card was being given to somebody ahead of a person who genuinely needed it and was quite vocal about this during the local elections last year. A lesson was learned and there was a change of policy and direction in the awarding of medical cards on a discretionary basis, which is welcome.

Now, in the context of extending universal access to GP care, there is the legislation for those aged under six years, while the Government has an agreement with the Irish Medical Organisation, IMO, on this Bill to give access to a cohort of people over the age of 70.

We must bear in mind, however, that this is not something they are getting with any great fanfare. Let us be clear that it was taken from them by the change of criteria for guideline assessments in 2013. The Government twice brought forward legislation to take medical cards off the over-70s. Not only did they have access to a medical card by entitlement taken from them, but they were also denied a GP-visit card. There were 20,000 affected in the spring of 2013 and the Government came back for more later on that year. Some 35,000 people over 60 were taken out of that bracket of automatic entitlement to a medical card due to a change in the eligibility criteria. A couple on a gross income of €900 per week, for example, would have lost their medical card and some of them would have qualified for a GP card.

The Bill is making up lost ground in terms of giving the over-70s access to GPs, but it is not reinstating the medical card per se, although that was the election campaign rallying cry for a long time. I can remember the former Tánaiste and leader of the Labour Party, Deputy Gilmore, as well as the current Taoiseach and leader of Fine Gael, standing out in Molesworth Street shouting "Shame on them". They shouted it to a receptive crowd which was aggrieved by the fact that the universal entitlement to a medical card had been taken from them. They were given an unquestioned commitment that day that these disgusting cuts would be reversed, but they have not been reversed at all. They have actually been increased because the eligibility criteria were changed. A single person on €500 gross per week now will not qualify for a medical card. A couple on €900 gross per week will not qualify either, but they will get a GP card. Prior to the changes to guidelines in 2013, they would have qualified for a medical card.

For all that, the Bill is welcome but it must be seen in the context of what has already been done to the over-70s. That process was brought to the fore in 2013 when there was an aggressive attempt to reduce the number of people over-70 who are entitled to medical cards.

In talking about universal health care, we are beginning to find that this Government is standing naked when it comes to the general principle of how it funds health services. On the Order of Business, the Fianna Fáil leader asked the Taoiseach about universal health insurance, but where are we with that concept? This is a central plank of how the Government intends to fund health services in future. The more we ask about it, however, the more it seems that there is no substance to this policy, which has been announced over the years. The Government has become very quiet about it in recent times. Ministers may talk about universal health care, primary care and access to GPs, but the substantial issues of universal health insurance and how health care will be funded in future are being slowly abandoned or forgotten.

If the Government is talking about access to GP care and a universal health care entitlement as stepping stones to universal health insurance, it is now time to see real meat on the bone regarding this policy. To date, I have been unable to find out about any costings. How much will it cost a family or the State? Who will contribute, gain or lose? What provision of services will be in that basket of cover? Will there be a flood of private health insurance companies into the market to make it competitive? Has any qualitative, substantive research been undertaken to underpin this policy? I do not believe there has.

The Dutch model, which was spoken about for a long time, seems to have been almost abandoned or at least given the cold shoulder. That model was the cornerstone of Fine Gael policy. The Labour Party had a slightly different issue, but it was still opting for a universal health insurance model funded through a social insurance scheme. Adding those two policies together has not brought us any closer to knowing how it will work. Perhaps the commitment was just a sound bite in 2010 and 2011 in the run-up to the last general election.

If this is the substantial way to provide health care into the future, one would think that after four years we would have had some access to detail at this stage, yet we have been going on this circus merry-go-round for a long time. We were told that a scoping study was being done, in addition to various reports being commissioned. Four years into the Government's term of office, however, we are no wiser and nor is anybody on the Government side of the House.

We should have some clarity because this issue needs to be debated. Within a year there will be a general election and the public is entitled to know who will fund the health services. My commitment is to a taxation-based model funded from general taxation. There should be a strong emphasis on public health services being funded through general taxation, which is the most progressive way of funding health care.

Weak as they are, the universal health insurance proposals suggest that large cohorts of people will be obliged to take out private health insurance. Meanwhile, the State will step in to purchase insurance for those currently on medical cards at a certain level. That is as much as we know. The only person who made a valued contribution in all of this was the Minister for Public Expenditure and Reform, Deputy Brendan Howlin, who effectively tried to torpedo the project some time ago. His Department undermined and rubbished it, saying it would cost a fortune for ordinary families. It is high time for us to see a substantial effort by the Government to put forward some details, if it is committed to the policy. In that way, we could have a rational and fair debate on it. We would either be won over to the proposal, or otherwise.

Fianna Fáil commissioned an independent assessment of the various international health funding models, as well as examining the Government's proposals which were limited in detail. The conclusion arrived at by an independent health economist and others was that the model being proposed by the Government will not give value to taxpayers and will not provide the essential services required in a modern health service. Neither will the proposed model ensure accessibility based on clinical need, which is the hallmark of what a modern public health system should provide.

While it is outside the scope of the Bill, this issue is critically important. We are told that this is a stepping stone to universal health care. I assume that such care will be funded by universal health insurance, which is the logical follow-on of the stepping stones outlined by the Government. Earlier today, the Taoiseach was able to tell us very little about it. What he did tell us, however, was alarming because no costings have been done on a central plank of Government policy. It is not about some inane side issue, it is about how we fund our public health system. That matter has to be assessed and addressed quickly, unless we are to continue with the pretence that somehow there is a magic solution to painlessly fund our health services without additional cost in the years ahead. Those were the indications when universal health insurance was first announced, but I beg to differ because somebody will have to pay for it. The taxpayers of middle Ireland and those who depend on health services will pay for it. Those services will be handed over to private health insurance companies that will decide how health services are rationed and who gets what.

We are still unsure of the empirical evidence for the international health insurance models the Government is trying to copy or is pretending to introduce. We do know, however, that the Dutch model has led to a dramatic increase in the cost of providing health care for ordinary families.

That is why it is important that we see some substance around the policy that is announced and stated in big bold print in the programme for Government. The Government gives us consequential stepping-stone events but none of them has happened. One of the first stepping stones was the roll-out of GP cards or universal access to GP services and the first cohort was people on long-term illness. Of course, when it came to actually rolling out the policy, the first people attacked by the Government were people with long-term illnesses through the removal of the discretionary medical card. It is only with large grains of salt that we can take anything from the Government in terms of its commitment to the accessibility of public health or the sustainable funding of public health services into the future. I am the first to stand up in this Chamber and accept that I understand the challenges and constraints this or any Government is under in terms of access to finance to fund public services. However, one would think that at this stage the Government would come clean on how it intends to fund health care into the future.

Reference has been made to the over-70s and there are bigger challenges facing them in terms of chronic disease and multiple chronic diseases, which are more prevalent in over-70s. Health services also have to adapt to new challenges in the immediate future in terms of life expectancy. More people will be living longer and healthier lives but equally there will be more chronic diseases and ailments carried into the system in the years ahead. I do not believe that anybody has sat down and looked at this although the Minister of State has referenced it in some of her remarks in recent times. We cannot deny that there is a demographic issue that we have to address which will be a challenge for society at large. The idea that we can put our heads in the sand and pretend that another generation can resolve this issue is not adequate. We have to have some foresight. We owe it to the people who will hit that age bracket in the next ten or 15 years and to the people who will be funding the health services by working and contributing taxes. The debate has to start very quickly.

We talk about over-70s and universal access to GP services and there are many reasons it should be done and was done previously in terms of giving medical cards to over-70s. The evidence is there that if people have timely access to GP services at early stages it stops the migration towards hospitals and the more acute hospital setting. However, GPs must also have access to resources to support the people who turn up in their general practices. If we are to keep more people with chronic disease out of our acute hospital setting, the whole general medical services contract has to be revisited. There must be an incentive for people to go to the GP and it must also be possible for them to be treated in that environment as opposed to heading off to the hospital with a letter of referral. This is not what I or the Minister of State wants and is not what the patients need. They need to be treated in an environment of low complexity. The GP contract as structured does not lend itself to being encouraging or supportive of GPs to treat people with chronic obstructive pulmonary disease, diabetes, arthritis or many of the illness that are prevalent in over-70s.

The Government has announced a review of the GP contract and hopes to announce that next February. I wonder whether something is earmarked in the calendar for next February that will let the Government off the hook as regards its commitment to primary care. Money could be put consistently into primary care but a system must be in place that encourages people to attend the GP service and ensures that when they get there, there are supports, diagnostics, assistants and nurse specialists through proper funding. It is not just the bricks and mortar - it is what is available to patients when they present themselves.

I do not think we have made enough effort in the area of primary care, if we are to accept that the acute hospital setting is not the ideal location for many people. That is evidenced not only by the people presenting at hospitals but also by the fact that when they are in hospital, they are not able to get out due to delayed discharges. While the Minister has announced an action group to reduce the number of delayed discharges from about 850 down to around 700, that is still an alarmingly high number of people in a hospital setting who should not be there and probably do not want to be there. The whole idea of having primary care and community care is to ensure that if people are required to present at a hospital, they are treated and discharged back to a setting that is more suitable.

While I support the idea of home care packages, I do not think they are working as effectively as they should. We have seen problems in the area of paediatric home care packages. It is very difficult to get in through the system. In some cases, it is difficult to get paediatric palliative home care packages and we are depending on the Jack and Jill Children's Foundation, the LauraLynn Children's Hospice and many others to support it. The State is not doing enough in that area and it is a group of people that deserves all the support of the State.

On delayed discharges in general, people simply do not have the support available to go home. Some extra home help hours would be of benefit. Nurse specialists attending the house to assess people on a frequent basis are needed. There should be interaction between them and the GP. It is not structured enough, which goes back to the original issue of the need to revisit the GP contract and the interaction between the GP, primary care and the responsibility of the patient.

The expert group on resource allocation and financing in the health sector was commissioned some time ago and made major findings in favour of GP services being free at the point of use. It is evidenced across the globe that without hindrance and blockages, access to GP services has a beneficial effect on the health of people. The other area in which we need a lot of work, and in which the Government has failed, is the need for security of entitlement in terms of what over-70s have regarding social welfare and secondary benefits. We have seen the eroding of their financial security and there is no point in saying otherwise. Pensions have not gone up and there has been an eroding of secondary entitlements, household benefits, etc. This is coupled with the means testing for medical cards and the reduction in the income guidelines. This is a step back to address some of these issues.

There is a long way to go, however. It was not only Fianna Fáil but also many individuals and groups in society that campaigned vigorously for fairness in the system. When we are rolling out a universal entitlement or providing a stepping stone to it, things should be based primarily on the clinical needs of those who need it most. Commitments were made in that context, but we have been told that that legal advice indicated that it was not possible to do it in terms of long-term illnesses and so on. We have not seen that advice, of course, but have been led to believe it comprises the reasoning it went down this route. The then Minister of State, Deputy Alex White, said they had exhaustive discussions with the Attorney General and many others, but that they were unable to bring about the GP roll-out of universality, starting with those with long-term illnesses before rolling it out incrementally over a period of time.

No matter what way the Government starts now, it is four years behind on its commitments. When people say over half the population will have access to GP services for free, it should be noted that many of them had access to GP services for free because they had medical cards. While the initiative is welcome, there is a great deal of claiming of credit which is above and beyond what is going to be delivered. There is a cohort who are under financial pressure with young families who will welcome this initiative, but the idea that suddenly everyone will have free access to GP services is not actually the case. Many of them already had it and it was enshrined in the context of the medical card scheme which gave them access to GPs, secondary benefits and school transport as part and parcel of the entitlement where a family was awarded a medical card based on financial means. Discretion was provided for years ago to deal with those in medical hardship facing financial and medical difficulties owing to a particular illness or condition.

Fianna Fáil will not oppose the Bill. We opposed vigorously the prioritisation being made by the Government in order to cling to whatever shreds of credibility it had when it sought to fund the roll-out of GP care universally by taking medical cards from people. Many on this side of the House opposed that move, as did some on the Government side. We welcome its abatement. While there are individuals who still have difficulties in accessing medical care and medical cards through the discretionary process, at least that process and the industrial-scale withdrawal of medical cards have stopped. The broader issue to the bottom of which we must get in the next few months is how we will fund health care. The Government cannot tell me. When I have tabled parliamentary questions about the funding model and asking how the Government intends to plan for and fund health care, I have been told it is still in a process. That process is four years old and we are no wiser. Nobody on the other side of the House appears to be any the wiser either. The Taoiseach informed us today that no costings or deep-scoping exercise has been carried out for the introduction of universal health insurance which the Government committed to putting in place by 2018-19. It is 2015, but nothing has happened.

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