Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein) | Oireachtas source

I am sharing time with Deputy Sandra McLellan.

The Bill before us amends the Health Act 1970 to provide a free universal GP service for all persons aged 70 years and over and also for their dependants, spouses or partners where income criteria are met. There has been some confusion about this in the public domain. It must be noted that this is not the same as a medical card and that it only allows for free attendance at one's GP clinic. It does not allow for X-rays, blood tests or emergency department visits and will also have no effect on charges for medications. Those with medical cards will still have to pay the prohibitive extra charges per item. Those with newly acquired free access to their GPs will still have to pay the going rate for their medication. We know that having cost as a factor can be a barrier which stops people accessing GP care. However, we also know that it stops people purchasing necessary medications. Unfortunately, the Bill will do little to address this. It also makes provision for dependants of the over-70s. The dependant of a married or cohabitant-civil partner of a person over 70 years will qualify if the combined income does not exceed €1,400 per week.

Primary care should be one of the foundation blocks of the health service. This has nominally been a policy of the Government since 2001, but aside from the sluggish construction and suspect placement of the primary care centres introduced to date and an even slower refocusing on the management of chronic disease in general practice, we have seen little of the radical change needed. We know that between 90% and 95% of the population are treated at primary care level. It is the side of the health service with which most of us engage. We know that if we wish to contain cost and remove pressure from acute hospitals, we must give adequate resources to primary care services.

We also know that the Government has delayed the introduction of universal health insurance. We have been informed that a costing analysis will be available over the summer months and that a roadmap for the next steps is being prepared. We in Sinn Féin are against universal health insurance, certainly the model the Government proposes. Sinn Féin wants to see universal public health care based on medical need and funded from fair and reformed general taxation, but the Government is still proposing to bring forward a multi-player universal health insurance model in which the State will have a huge regulatory, managerial and funding role. Private for-profit insurance companies will be afforded a central place in the system. Why not cut out that profit for the privateers and keep the money in the health system or the pockets of citizens?

Universal health insurance is a deeply flawed funding model. It is a model that has been widely criticised, including by the medical profession, both here and abroad. Private health insurance companies and for-profit health care companies look forward to the introduction of universal health insurance. As I have stated in the House previously, similar models in the Netherlands have seen the quality and range of care services provided continually reduced, with premia rising by up to 40%. Furthermore, the majority of the population purchase additional insurance cover to make up the shortfall in the UHI basket of cover. Another important fact is that the Dutch had made a large investment in primary care prior to the introduction of universal health insurance. Governments here, however, have under-resourced primary care in all of its facets. The USA shows us that the system of privatisation simply diverts badly needed funds away from front-line services towards administration. The multi-payer model also requires much regulation, again taking the focus away from treating patients.

We in Sinn Féin want a system of universally accessible health care, not the compulsory insurance model of Fine Gael and the Labour Party. Our model is based on equal access for all on the basis of need and need alone. We want it to be State-provided, funded from fair general taxation and free at the point of delivery. This would involve a higher contribution in tax from the highest earners than they contribute. It is also possible that some of these might pay less than they do to meet their health care needs when tax, health insurance and money payments are all added up.

Focusing on primary care, we need to look at the overall portion of the health budget allocated to primary care and general practice. This proportion must be increased, as has been called for by many, both nationally and internationally. What plans does the Minister have to do this? How will rural practices and general practices in deprived urban areas be made a priority?

We need additional comprehensive chronic disease management plans for general practice and supports for existing services that are challenged, and there are many. While there has been some talk about an additional focus on dealing with chronic conditions in the latest agreements, in terms of its scope and depth, it is simply a drop in the ocean. There have been successes in the management of chronic disease at primary level, for example, Heartwatch, a GP scheme that targeted secondary prevention for patients who had suffered a serious heart problem or from significant cardiovascular disease. It had a 5% five-year mortality rate compared with almost 15% for those not participating in the scheme. However, only 20% of GP practices around the country were involved in the programme. Further schemes such as this, including Diabetes Watch and measures for mental health services, need to be resourced and rolled out.

Will the Minister update us on the drawing up of a new GMS contract? It must be the basis for a move away from reliance on tertiary care. We need an integrated system of care for those with chronic and complex conditions. Someone who leaves hospital must be supported back into full engagement in his or her community. If we fail to do this, we will simply overload acute hospitals. It should come as no surprise that patients will reattend at an emergency department. The Government knows this, but it is more concerned about paying back the masters of finance who landed us in our current position than in reforming health services in a real way.

We must talk about primary care teams and networks. We were told that by 2011 we would see 530 primary care teams across the country. At the end of 2013 only 419 were in place. I have asked the Minister on several occasions to outline how the rest of the teams will be delivered and when the primary care networks will be in place and functioning fully. I am not satisfied that enough has been done. Buildings alone are not enough. We need more staff and disciplines, specific skills and a change in working patterns.

If certain GPs, particularly in rural areas, do not accept the new scheme, what provisions will be in place for elderly patients who might have to travel significant distances to access the care they need? What will happen if the only GP available to them is unknown to them or has no expertise in the area in which the individual is looking for advice and, if necessary, care? Section 58A(13) of the Bill provides that in so far “as practicable” a choice of GP will be offered by the HSE. This provision needs to be strengthened as the Bill proceeds through the Houses. It appears to be the case and ever more likely for more and more people that patients will have no accessible GP, never mind a choice.

The announcement made in the past few days that children under the age of six years will have free GP care if GPs sign up to the deal is inextricably linked with the Bill before us. We cannot forget that in 2014 medical cards were withdrawn from some children with serious medical conditions. Reports that children and families were still having difficulties in accessing medical cards long after this vexing cull had been officially halted suggest the policy was still being implemented, be it in error or by design, at another level. The Minister of State has stated it would be lovely to believe 100% of GPs would sign up and that she would be very optimistic in those terms. She has stated the Government will be looking for 80% to sign up, but that it is hopeful 100% will do so. We all hope 100% of GPs will sign up. That would be great. However, what the Minister of State has said and the reality behind it means that, in truth, it will very possibly be the case that 20% or more of young families will have to find GP care elsewhere.

I note that representatives of the National Association of General Practitioners have used the term “medical apartheid” when commenting on the scheme as it relates to the under-sixes. While I do not believe that is the case, if the position stays the same and there is no further extension of care to all those from age six to 70 years, there is a danger that a two-tier system divided on lines of age will develop. The Minister of State must commit to a limited timeframe for the extension of free GP care to all.

Many voices have raised concerns about the expected increased workload for GPs. While some GPs might view it as a way to claw back some of the resources losts through the FEMPI cuts and cuts to the rural GP grant, others will struggle to deal with the increased volume of attendances. The fact that GPs must accept the scheme for the under-sixes or, as is likely, lose all of this age group means that they will be between a rock and a hard place if they are struggling with patient numbers. It has been reported that the scheme for under-sixes will cost approximately €70 million per year. This is almost double the Government's initial estimate of €37 million. Will the Minister of State explain where the discrepancy occurred in arriving at the earlier calculation? We, as politicans, whether in government or opposition, must ensure all of the population have access to free GP care and commit to provide the necessary funding to achieve this. In doing this, we must ensure the best possible deal for all taxpayers. Universal access must be achieved and must be achieved sustainably.

There are issues with the registration of patients. I am also troubled by many of the elements on chronic care management under the Bill and the scheme for under-sixes. On the surface they might appear to have merit, but in reality, they are extremely hit and miss. The proposed asthma scheme will only be available to children aged between two and four years. The scheme for those with diabetes is very limited. My colleague, Deputy Sandra McLellan, will discuss these points and GP care for under-sixes in more detail.

In the midst of the Government’s trumpeting of the Bill and the scheme for the under-sixes, it is easy to forget what was originally promised, namely, universal access to free GP care for the whole population by 2016. We are well into the fourth month of 2015 and it is only now that we see free GP care for these very limited groups. The Government is only doing this now as the next general election is in sight.

A World Health Organization report from 2012 recognised that Ireland was the only EU member state that did not offer universal primary care coverage. These latest measures by the Government can only be seen as a tiny step on the way to providing for the levels of service that are accepted as totally basic across the rest of the European Union. The Government has failed to ensure the rest of the population that do not have access to a medical cards or a GP visit card will have free GP care extended to them. Universal primary care must be extended to all within the earliest possible timeframe. It is essential that the roll-out to the rest of the population is achieved within a very limited timeframe. The period of time that has passed must also be part of the ticking clock. The current extensions of GP care will benefit those on low incomes, particularly those just above the qualifying cut-off points for a medical card. However, they will not benefit those children who are very sick and above the age cut-off point. It is critical that the Minister of State indicate the timeframe involved for the rest of the population. I hope that before we conclude Second Stage we will have certainty on the Government's intentions in this regard.

There are also some changes to GPs' contracts more generally, including longer working lives and more flexible contracts. I await further details, but they are to be welcomed as they offer the possibility of increasing the GP workforce.

Up to 30 villages and towns have found difficulties in attracting GP candidates recently, including my home town of Monaghan, a county town and a considerable market town with a significant population and work-life base. We must be able to reassure non-consultant hospital doctors, NCHDs, and GP trainees that general practice is a viable and sustainable option for them. Losing so many of our highly trained medical graduates to countries across the world has dealt a massive blow to our system and represents a terrible national return on the time and money invested in their education and training at university level.

Tacaíonn Sinn Féin leis an mBille seo ach is gá a chinntiú go mbeidh cúram dochtúirí teaghlaigh ar fáil do gach aon duine sa phobal gan mhoill. Is maith an rud go mbeidh páistí faoi bhun 6 bliana i dteideal dul chuig an dochtúir teaghlaigh gan chostas anois ach, fós féin, beidh costas orthu ó thaobh leighis agus seirbhísí breise de. Arís eile, ní hionann seo agus na seirbhísí atá ar fáil le cárta leighis. Iarraim ar an Aire rá linn anois cén tráth a chuirfear cúram dochtúirí teaghlaigh mar seo ar fáil don phobal i gcoitinne.

Sinn Féin will support the Bill but with the proviso that the Government must act urgently and indicate a timescale for when free GP care will be extended to all citizens. It is welcome that those aged over 70 years will be afforded free GP care, but it is important that we recognise this for what it is - a limited and very small step. As I have indicated, this is the only state in the European Union that does not offer universal coverage of primary care. This must change quickly. The Minister of State must indicate the timeframe for an extension to the rest of the population or risk creating a further two-tier element in the health service of two tiers which it undoubtedly is, one that is failing vulnerable groups across society, including the elderly, low income families and those with significant health problems. I invite the Minister of State to do this now.

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