Thomas Pringle (Donegal South West, Independent) | Oireachtas source

That is correct. We have ten minutes each.

Our health system is in itself unhealthy. Based on a two-tiered system, it both perpetuates and exploits inequality by prioritising those who can afford health care over those who need it. Privatisation has destroyed our health care system and it is the antithesis to a community-based approach. The large number of people on medical cards, accounting for 43% of the population, and the falling number of people availing of private insurance are all signs of an unaffordable system due to these privatisation policies. Privatisation has exacerbated the crisis of waiting lists in the public system across the country and elderly people have literally been pushed aside to the margins, on trolleys in accident and emergency department corridors, living in emergency wards for months on end, unable to afford a place in a nursing home or with insufficient care packages or for some, none at all. That is the most shameful aspect of privatisation policies imposed by consecutive governments; it is a system that marginalises the most vulnerable. Elderly people have not only been dragged through numerous Government policy changes over the years but they are the most vulnerable to those changes in the health care system. Age Action Ireland states, "it is those with the least means, often needing the most intervention and care, who are the current losers". It is clear that we must move away from a privatisation model towards a universal one based on the need of services. The only way to achieve that is through the development of a primary care system with universal health care at its core.

Unfortunately, this Bill, although positive in its intention and for its recognition of carers, contains unrealistic expectations. First, it assumes that a primary care system already exists which could support the introduction of GP cards for those aged over 70. Second, it assumes a free GP card will be sufficient to meet the needs of people aged over 70. Research has consistently proven that primary care is the best system both in terms of equal access and cost effectiveness. Strong primary care is associated with better population health, lower rates of unnecessary hospitalisations and relatively lower socioeconomic inequality. Countries with strong primary care systems spend less on health care. However, Ireland is the only EU health system that does not offer universal coverage for primary care. Nearly 1 million people will be aged over 65 by 2031, which will be an increase of more than 86% or an extra 20,000 people per year. How can the Government expect our current system to facilitate such an annual increase in the demand of our health services? How can we expect GPs to alleviate this pressure on top of existing costs and demand?

GP care is central to the primary care model. In the words of the authors Freeman and Moran, GP care "represents a powerful means of alleviating the anxiety, discomfort, and incapacity that come from sickness and ill health". GPs could provide many outpatient procedures, tests and check­ups in primary care centres, moving patients away from hospitals and into our local communities but that could only be done with adequate investment. In a primary care setting GPs would essentially take a medical advocacy role co-ordinating patient care according to the needs of the individual.

While GPs are central to primary care, other health care professionals also need to be supported. Nurses, physiotherapists, occupational therapists, speech and language therapists and others all contribute to a community model of health provision. However, structural issues exists which are not recognised under this legislation. Less than 20% of GPs work with more than four other GP colleagues in the same practice, suggesting it is not the norm for GPs to work alongside other health professionals. This work culture will make it difficult to establish a fully integrated health care system.

While this Bill attempts to respond to an ageing population, it has avoided responding to the changing profile of the GP sector. The sector is also ageing as younger doctors are emigrating or moving away from GP practice. There is a growing preference for flexible hours and early retirement and an increase in the numbers holding vocational training.

There is now significant shortfall and geographical disparity in the supply of GPs and health inequality is becoming an increasing worry. We are witnessing, especially in Donegal, a declining proportion of GPs working in rural areas, a decline from 33% in the early 1990s to 22% in 2005, and in Donegal there are only 48 per 100,000 of the population compared to 64 nationally. Therefore, long-term planning and investment are vitally needed to ensure that our health service can sustain the pressure of an ageing population as well as meeting the needs of those through all stages of the lifecycle.

The Government needs to prioritise the rollout of these proposed primary care networks and move away from damaging privatisation policies. Primary care has been talked about for over a decade now with very little results. The Government's report card on health care investment has shown there has been a failure in terms of progressing it and we still have not seen a primary care Act, a primary care fund or recruitment of additional doctors, nurses and other professionals in the primary care area. It was envisioned that 400 to 600 of primary care teams, two thirds of the full requirement, would be established by 2011, but only 247 have been established four years on and to date there are 85 primary care centres in operation. It was also envisaged there would be 90 primary care networks across the country, each with about four or five primary care teams, essentially acting as a one-stop shop providing a wide range of health services at a local level. The Minister recently announced that 17 integrated service areas are being replaced by nine community health care organisations and that existing resources will be reorganised into 90 primary care networks but we still do not know what is the status of the primary care networks. Many organisations representing elderly people have been critical of the pace at development of primary care health centres and health teams. Unfortunately, at this late stage, moving towards a community-based approach will take time as large-scale structural reforms need to take place.

According to the National Association of General Practitioners, we are so far away from achieving this model that it is too late for the current Government to make any changes in time for the next election and it will not be until the middle of the term of the next Government that we might see some changes being made. Instead of using the elderly population as political capital in time for the next election, why not use the funding, time and resources to invest in a primary care infrastructure to ensure that universal health care can become a reality for all?

The Bill is naive in assuming that GP cards given to all those aged over 70 means their needs will be met. It presumes that our current system is highly developed with enough GPs and a fully comprehensive health system to address the complex nature of elderly health needs. The principle makes sense but the Bill is misleading. People are often put off going to the doctor because of costs, and those who have a GP card tend to visit the GP on average two visits more per year, which means that overcrowding in emergency departments may ease.

However, a GP card will not grant those aged over 70 access to the wide range of community services available under a medical card. A GP card does not cover hospital visits, community health services, dental services, prescription medicine costs, hospital care, optical or aural services, social work services and community services. The IMO expressed concern that GP cards are seen as an alternative to medical cards, when the two are not comparable. What use would a GP card be to someone aged over 70 whose visit is paid but whose further needs will come at a cost?

If we were cynical we might assume that the PCRS will use the fact that the over 70s have GP cards as a way of reducing the number of medical cards given to people in that age group. I envisage that the more elderly people visit the doctor, the more treatment they will need and the more they will need access to other primary care services which they currently cannot afford or cannot access. Could this mean that the quality of GP care to patients across the population will decrease as a result of this cyclical pressure? Already our community-based services cannot meet demand from elderly people for supports to live in their own homes and communities. There has also been a lack of capital investment to replace or refurbish community nursing facilities.

It must be made clear that a GP card does not mean universal health care and it is not correct to say that universal health care means only a free visit to a doctor. The two should not be confused. Today there is still no right to health care in the Irish Constitution or through any statutory provision even though Ireland is a signatory to Article 12 of the International Covenant on Economic, Social and Cultural Rights, ICESCR, which recognises the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Universal access to health care on the basis of need must be recognised in our legislation as a right for all citizens before it is at risk of privatisation again. Recently the Minister for Health imposed a deadline for those under 34 years of age to acquire private health insurance and we have seen Government proposals to increase nursing home charges for elderly people using community-based services. We also saw the Minister for Health appear in advertisements for private health insurance companies, encouraging people to take out health insurance. How does this equate with the commitment to a universal health care system? These are worrying developments as they signify the possible privatisation of our entire health care system in the future. In the meantime, doctors and patients do not want to see another primary care strategy or a mini-primary care strategy. We all want to see a structured, reliably funded investment programme for GP practice so that our primary care system can be developed. Building primary care clinics does not equate to the development of integrated primary care services; nor does the number of team meetings happening indicate progress in this regard. Only the health of our patients will indicate this Government's progress.

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