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

Fianna Fáil will be supporting the Bill. We have always been very supportive of the concept of lifetime community rating, solidarity and intergenerational support. This is a key aspect of our philosophy in the context of how we develop society and support the various cohorts and age groups in society, but also in the context of private health insurance. Lifetime community rating and intergenerational solidarity are critical components in this regard. It is about encouraging people to take out private health insurance so there is a buoyant market where younger, healthier people contribute to the costs associated with supporting older and sicker people. It is a very simple philosophy.

On the one hand, the Minister speaks about health insurance, universal health care and the previous Government policy of universal health insurance. On the other, we have the views previously expressed by the Minister and others, including the Taoiseach, with regard to community rating and risk equalisation, which were fundamentally opposed by Fine Gael for a long time. As a result, I find it hard to understand what the Government envisages for the future, either in the context of the private health insurance market or the public health system. The speech the Minister delivered today is the one he delivered at the Institute of Chartered Accountants recently but it does not leave me any clearer on what commitment the Government is making about the public health system and how it will be funded, supported and expanded in the years ahead to meet the critical demands that will be placed on it in terms of the demographic changes in our population, in particular the increase in population, as well as the advances in medical technologies and medical procedures. While the Minister does talk about hospital groups and hospital trusts being more integrated within the regions, I am still unsure the Government actually knows what road it is taking in regard to the public health system.

The Minister then throws in the issue of outside consultancy companies or others coming in to manage parts of our public hospital system, which means they will be able to deviate from, for example, the strict pay and conditions in the public health system and across the broader public service. While I accept that should always be looked at in terms of whether it could bring advantage, it can certainly bring a lot of disadvantages if the Government is beginning to farm out certain areas of the public health system to private operators. This would begin to lead down the road of privatisation and, in that context, we would be very concerned about the undermining of the public health system.

To take the Bill itself, there is nothing in it we would not support in general and in principle. As I said, it deals with the concept of risk equalisation and lifetime community rating. Of course, lifetime community rating only comes about in a voluntary health insurance market and, until Tuesday morning last, we had assumed it would be a compulsory health insurance market in the context of universal health insurance. Of course, the cat was out of the bag some time ago when the Government started to develop this concept we have been proposing for some time in regard to lifetime community rating. In the Dáil and elsewhere, I and many others said that once the Government had acknowledged lifetime community rating, it was effectively abandoning the core policy that had been proposed by the Government, which was compulsory universal health insurance.

There is no need to have an incentive to join the health insurance market if it is compulsory. I would say that deep down, the Minister was trying to wiggle his way out of this particular universal health insurance model for some time. He was probably looking for a timely time to do so. I suppose the expectation was that the election would be over at this stage and he could have kept the cat in the bag until afterwards. That has not transpired, however, and the Minister has been flushed out in doing what is a genuinely massive U-turn on a core principle of funding our public health system.

We are no wiser as to what type of system will follow on now. In the meantime, however, we know for sure that our public health system is underfunded, underresourced and is meeting massive daily capacity challenges. If one looks at our public health system, one can see that staff face a huge difficulty every day in trying to deliver care while patients try to access care.

Reference was made to the number of hospital beds available. For years I was told by the previous Minister that there were sufficient beds and that it was not all about beds. He also said that changes in admission or discharge policies and day-case procedures would all help to reduce the demand on beds. I accept that but the bottom line is that there is a capacity issue in our public hospital system given the lack of beds. There is also a capacity issue in the step-down area. A critical issue, which is always forgotten in this debate, is that of intensive care unit beds. We have to accept that ICU beds constitute the workhorse of any modern medical system yet, pro rata, international comparisons show that we are light years behind. It creates huge difficulties in terms of theatre time and getting throughput for elective and emergency surgeries.

All the planning that goes into assessing and diagnosing patients, as well as preparing them for treatment, including surgery, goes out the window when something happens due to the pinch-point of a complete lack of capacity in intensive care unit beds. That is a key issue if we are to reduce the daily chaos of waiting lists and emergency department trolleys and yet it has almost been forgotten in the debate on our public health system. We may pretend that things are improving but until that particular issue is addressed in a meaningful way in all major hospitals, we will have the continual problems of waiting lists and cancellations of elective surgeries. That is because when there is any unexpected increase in demand, it all falls apart. This happens in January each year, for example, and in other key periods of the year when there is a spike in demand for hospital services.

While the Minister is looking at grand plans, he might also look at the pragmatic and practical steps that need to be taken to ensure patients can access health care in a timely fashion. The ratio of staff to ICU beds is extraordinarily high but it is also very necessary. That fundamental area must to be examined.

As the Minister outlined, the Bill makes a number of changes to credits and levies in health insurance products. It revises the rates recommended by the Health Insurance Authority and this will take effect from 1 March 2016. The Bill also provides for an increase in risk equalisation credits for those aged over 65 years, based on age, gender and level of cover. Meanwhile, credits for insured people aged 60 to 64 are set at zero. The Bill also provides for a change to the proxy health status measure by expanding the circumstances where a utilisation credit is payable to include €90 for each overnight stay in hospital and €30 for day-case submissions. In addition, there will be a reduction in stamp duty on products not providing advance cover for an adult from €240 to €202, which is a reduction of €38, and from €80 to €67 for children, which is a reduction of €13. That is all very welcome.

We are trying to enhance and stimulate the health insurance market by encouraging people into it or, at least, not discouraging them from joining up. In that context, however, we do not want to encourage people to join private health insurance by starving the public health system. It is not a case of the public health system versus the private health insurance market because their work is complementary. Those who avail of private health insurance reduce the capacity in the public health system. We certainly do not want a situation where we are forcing families to take out private health insurance because they fear that without it, they cannot access services.

The obligation on any government or political party is to ensure that we have an adequately funded public health system. If people wish to take out private health insurance, they should make that choice of their own volition instead of being afraid that if something happens, they will not be able to access diagnostics or treatment. The latter concept must be changed.

The Minister cannot pat himself on the back for saying that there is an increase in the numbers taking out private health insurance. There are many reasons people do so and there may be many circumstances for such an increase. These reasons include the life-time community rating, which is an incentive for people to take out private health insurance. In addition, the economy is picking up so people who had previously cancelled private health insurance are returning to the market.

Another issue which must be addressed is that more than 400,000 people are waiting to see a consultant. People are afraid that if anything happens to them or their families, they must have private health insurance. The notion that starving the public health system and driving people into private health insurance is a reasonable decision by the Government is simply anathema to basic decency. People should take out private health insurance by choice and not due to the waiting lists for inpatient or outpatient day-cases and the alarming consequential causes, including delayed diagnostics and treatment.

While we await new proposals from the Minister on how he intends to fund the public health system in the years ahead, in the short to medium term he has a few fundamental issues to address. All the grand changes he is proposing across the board may or may not come to anything. Regardless of what policies he sets in train for the coming years, they will be ineffective if he, or his successor, does not address the fundamental issue of resources in key areas of our public health system and we will be continually debating people waiting on trolleys for inordinate lengths of time, as well as those who are unable to access diagnostics, treatment or therapies. The Minister has acknowledged that is happening every day of the week and he even pointed out that things could get worse before they improve. We cannot just wait for reform. We must have some commitment to resources and fund the key areas of difficulty.

The Minister has said it is not always about throwing money at problems, and he is correct. The fair deal scheme is one example of where it was obvious that there would be major problems. Some people simply could not access beds while others were waiting up to 20 weeks to get a nursing home bed. That was directly down to a lack of resources. The Minister placed a cap on that beyond which people could not access private nursing home services. Resources are required to fill the vacuum in key areas where there is an obvious demand. The Minister starved the fair deal scheme of funding needed for many people across the country.

The Minister has made great play about the number of consultants who have been recruited and there is movement in that regard. It is slow in many cases, however, and it seems almost impossible for the HSE to attract people with certain skill sets into this country.

This is an issue that must be addressed. I said this years ago when the former Minister was on a populist campaign talking about cutting salaries here and there. Everybody had to share pain but the idea that we would drive people we need abroad does not stack up. I am not advocating for consultants who are well able to advocate for themselves but we must retain a special cohort of expertise in our health services. The Government has failed to do that and now faces the consequent difficulties.

The Government took the same approach to nurses with its graduate grade. Nurses who qualified and went to work in the health service worked for sums that were far less than those who had only qualified a few years previously, for no logical reason other than what seemed to be a populist view that the Government was challenging the public health system and taking it on. What the Government was doing was dismantling the cornerstone of the delivery of health care. We need doctors and nurses in our health system and by discouraging them or encouraging or forcing them to go abroad, the Government undermined the ability to deliver services.

Speech and language therapy is another key area involving our best and brightest. There are inordinate delays in accessing speech and language therapy. Parents are simply at the end of their tether trying to access assessment, diagnosis and therapy. They are waiting inordinate lengths of time. The Minister will say, and it has been said in replies here and elsewhere, that priority is always given to people but a parent whose child may have speech and language challenges wants an assessment first and then wants to be able to access therapy. However, as things stand they cannot do so. For a three, four or five-year-old child, a waiting list of a year is a long time in their formative years when they need access to therapy. In key areas where professionals are required to deliver health care, the Government has been very slow in trying to ensure we do not have a haemorrhage of people - a drain of the best and brightest.

At the same time, one could argue that the Government has been handy in recruiting at management level within the HSE. We would like to see a re-balancing of that so the issue of front-line staff - those who are delivering health care in our emergency departments and wards and throughout the broader health system - must be addressed quickly. I know the Minister is saying that the Government is recruiting extra nurses and this is welcome but if you look at what is required in terms of manpower, the manpower surveys, or the workforce requirements as they are now called, that are taking place will show that there is a dearth of certain specialties within our health system which is causing huge difficulties.

The Minister will say that this will all cost money and it does, which is why we must prioritise. Very often one will hear Opposition parties, organisations and advocacy groups simply campaign for additional resources. That comes with a cost, which is why we need to have a genuine debate among ourselves about the political campaign that will be held over the coming months. How much are we willing to pay for health services? What type of health service do we want? Every day of the week, we are being told that Fine Gael will consistently cut taxes, including taxes for the highest earners. The Minister will then come along and tell me that we intend to do so much in the years ahead. I find it difficult to square that circle because a simple mathematics exercise would highlight the fact that this is not a credible position to hold. If we are to be committed to a public health system, we must commit ourselves to funding it and funding it in a way that allows people to have confidence in it as opposed to what is happening at the moment, namely, forcing people to take out private health insurance out of fear and concern for themselves and their families. Private health insurance should be based on complementary services as opposed to not being able to get services in the public health system.

The Minister spoke about the various other areas of the health service that need to be addressed to arrive at a situation where we do not have continuous chronic overcrowding in our emergency departments and where people present in hospitals unnecessarily. He referred to primary and community care and the GP being central to that. He also spoke about public health nurses, community care workers and other specialists who work and provide care in the community. Everybody has bought into the primary care strategy and the philosophy behind it, which involves caring for people in the community and in the primary care setting. The Minister spoke about the need to encourage GPs to specialise in the areas of chronic disease and minor procedures. This is outlined in the primary care strategy. Of course, it needs resourcing, support for GPs and additional training for them and for other health care professionals working in the community. It requires extra resources in terms of personnel.

We have a situation where public health nurses, who are very valued contributors to the delivery of care across the country, are no longer able to carry out their functions because there are not enough of them. If we are to be honest with ourselves in terms of GP care, the primary care setting and caring for people in the community and the home, we must admit that the key link, of having public health nurses available to ensure there is a link between the GP and the primary care and home care settings, has been completely starved of any resources. It is being severely undermined at a time when it is greatly valued by those who benefit from it. Traditionally, public health nurses would support people who do not have medical cards but we now find that they are under so much pressure they cannot see people for a number of days. Services like changing dressings and administering medication are simply not deliverable in the way they should be. If we are talking about grand plans, how they function on the ground is critically important. We need a key analysis of our public health nurses, the role they play in the community and that link between discharge from hospital to the home or community care setting and preventing people from having to visit hospital in the first place because of the inability of the primary care setting to support a person in the home.

GPs are under huge pressure. We now see delays or GPs being unable to see people on a same-day basis. Traditionally, that was part and parcel of the health system. Most health care is provided by GP services throughout the country. There was always the comfort that a person could access his or her GP in a timely fashion. We now see delays in terms of being able to see a GP on a same-day basis. This is an indication of pressure points. If the Minister wishes to bring in the concept of chronic disease management and minor procedures in the primary care setting at GP level, which is the right thing to do, he must accept that capacity must be enhanced and increased. This requires support for GPs and nurse specialists coming into the community.

When one looks at the demographic pressures we are facing and the profile of our population, and this goes back to health insurance, one can see that we will have two huge challenges in the years ahead. There will be a pensions issue, which we have acknowledged is a concern and will be a huge challenge for the State in terms of how it is to be funded.

The National Pension Reserve Fund was established and has been raided a few times to fund essential short-term measures. We have to start accepting that we must replenish the fund quite quickly in order that we will not end up funding pensions from current expenditure on a continuing basis.

We are not doing anything near what is required to enhance capacity in the way of bricks and mortar, personnel and supports in the community for elderly people. The Minister seems to have a very weak commitment to increasing home help hours to prevent people from going into hospital, step-down, community or long-term care facilities. Elderly people have to wait a long time to access home help support. A person deemed to be in need of home help is told to wait some time before accessing it. An 85 year old cannot afford to wait some time for such help. A person deemed to require home help should receive it immediately. Otherwise he or she cannot stay at home or will need other supports that may not be available and can very quickly end up in a long-term care or an acute hospital setting. Priority must be given to trying to maintain as many people as possible in their homes and the community care setting, but I do not see this happening in the short term.

The Minister has committed in the capital expenditure programme to enhance community care settings around the country, but that has been delayed for several years because of the Health Information and Quality Authority's requirements for the licensing of public nursing homes and inspections and qualifications. We need to accept that we will need more capacity as time passes to ensure that will happen.

We need more community geriatricians and nurse specialists to visit nursing homes and save bringing a patient from a nursing home to a hospital. The number of geriatricians is very small and people working in this area say it is very difficult to get a specialist out to make a diagnosis. General practitioners are very often brought out and may come from the co-operative such as South Doc or West Doc. They may not have the necessary expertise or confidence to make a call because they may be locums and not know the patients involved. Very often an ambulance is called and the patient is taken to hospital. The Minister should consider bulking up the geriatric expertise available in the community setting in discussions he holds about primary, community or home care services.

The Minister referred to technology. Ireland is at the cutting edge of software development and design. There is a huge opportunity for the country to be at the cutting edge in using technology to care for and monitor people at home. We have to start being very creative and imaginative in that regard. People still fax information. There should be real-time information sent by public health nurses who visit patients back to the GP who could feed it to hospitals. With the creation of the individual health identifier, this concept needs to be embraced very quickly to enable the health system to assess and plan a patient care pathway and identify the resources required if a patient is to be discharged from hospital to home or the community care setting. A real-time response and flexibility within the workforce to deal with these demands should be considered. We can be creative and imaginative in that regard. It is being done in other countries. Technology could help to break down the silos in which the health system sometimes works.

We welcome the Bill but not the complete confusion in government about how to fund the public health system in the years ahead.

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