Stephen Donnelly (Wicklow, Fianna Fail) | Oireachtas source

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

It is my pleasure to introduce the Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020 to the Dáil. Today marks another important step in working towards achieving the Sláintecare principle of universal access to care at low cost or no cost.

This Bill provides for two key measures that are central to achieving universal access to healthcare in a manner that is fair and affordable: a welcome increase to the gross income limits for medical card eligibility for persons aged 70 or older and the phased expansion of general practitioner care without charges to all children aged 12 years of age and under. We are all aware of the barriers that exist in the health system that prevent people from accessing the right care at the right time in the right place. The measures being debated here today will enable us to progress towards the achievement of the core message of Sláintecare, which I know is supported by all parties in this House. These measures will provide a significant benefit to cohorts at different ends of the life spectrum but who each have their own identifiable health needs. A range of measures have already been implemented to expand access to persons in receipt of medical cards and GP visit cards, which has resulted in almost 43% of the population having access to GP care without fees at this time. However, while these initiatives are welcome, this Government recognises the need to do more. That is why we have committed in the Programme for Government: Our Shared Future to implement new measures to expand access to GP care without fees and to wider health services. As Minister for Health I am delighted, therefore, to be bringing forward this legislation for debate today and affording it the priority that it deserves.

The first key measure provided for in this Bill is a welcome increase to the gross income limits for medical card eligibility for persons aged 70 or older. Expanding eligibility for medical cards to this cohort is an important initiative in ensuring better health and active ageing for older persons. As we seek to support older persons to live independently in their own homes and communities for as long as possible, we must put in place policies that enable them to access high-quality care close to their home, where feasible, to prevent unnecessary admission to hospital. This very measure is a key enabler to achieving this as it will increase the number of people who can access a wide range of services in the community at no cost or at very low cost. Health and healthy ageing are undoubtedly key determinants in the quality of life experienced by older persons. The Health in Ireland - Key Trends 2019 report identified that life expectancy in Ireland has increased by almost 2.5 years since 2007. It also highlights that each year the number of people aged 65 or over is increasing by about 20,000, a trend that is likely to continue. This is a positive and welcome development and reflects the decreasing mortality rates for major diseases. However, these factors also remind us that there are resultant implications for individuals living longer and for how we plan our health system to meet the needs of the inevitable increase in demand for health services. It is important that we put in place now the policies that will enable this older cohort to live well.

We know that the prevalence of frailty and chronic disease increases as people age. Therefore, having affordable access to a range of health services is key to both preventing and managing the impact of frailty and chronic illness. This is why this measure being debated here today is so important, especially when one considers that a significant number of people may benefit from its implementation. For many older persons, an immediate benefit of qualifying for a medical card is that they will be able to have affordable access to medicines. For example, we know that while persons aged 70 or over only account for 23% of all medical card holders, they account for over half of the spend on medications dispensed under the medical card scheme. Thus, expanding access to the medical card will ensure that a greater proportion of older persons will have affordable access to medicines, which is essential in managing chronic disease and enabling people to have better health and to live well.

Living well and healthy ageing not only benefit the individual, they are also important for society generally. Older persons are the fabric of our community. They undertake many important roles and their contribution is vital. This was borne out in a recent Trinity College Dublin study which utilised data from the Irish Longitudinal Study on Ageing, TILDA. That study identified that almost one-third of people over 70 are caregivers and that many are caring for their spouses. Additionally, it found that older people participate both economically and by volunteering in the community and they undertake caring responsibilities for relatives and grandchildren that enable others to participate in the workforce. This demonstrates the need to ensure that policy measures are implemented so that older people are supported in achieving healthy ageing so that they can contribute and continue to play an active part in their families and wider communities. The implementation of this measure will support this by giving access to health services at a time when their health needs are greater and undoubtedly more complex.

It is also important to highlight the sacrifices made by older persons in our society in response to Covid-19. I know that social distancing and cocooning - an awful word - were and remain very challenging for many older persons and have resulted in a rise in levels of loneliness and social isolation which have impacted on many people's well-being. Many people who have lived through this have shown incredible spirit and commitment. I acknowledge that today. It has not been an easy time for an awful lot of people. It is still not an easy time for any awful lot of people.

I turn now to the second key measure for which this Bill provides: the phased expansion of free GP care to primary school children. Deputies will be aware that the Programme for Government: Our Shared Future also includes a commitment to expanding to more children access to GP care without charges. It is an important deliverable in terms of Sláintecare and its implementation strategy which commits to expanding eligibility for access to heatlhcare on a phased basis. Already since 2015 all children under six are automatically eligible for free GP care. Today's Bill provides a legislative framework to continue this path of universal expansion. It is a significant milestone and I am proud to be welcoming this beneficial public health measure.

There are many good reasons to provide universal access to GP care to children. Studies have shown that the identification of health issues at a younger age can mitigate or reduce the impact of ill health later in life and that the health and well-being of children is linked to the economic and social environment in which children are brought up. The measures being debated here today will, therefore, ensure that irrespective of the social and economic background of children, each child up to the age of 12 will have access to GP services without charge. We know that the cost of GP visits acts as a barrier to accessing care. The Growing Up in Ireland study, for example, showed that those who face out-of-pocket expenses to access GP care make significantly fewer GP visits and that children from high-income families are more likely to visit their GP. Therefore, there is a clear rationale for children having access to medical care in their own right, regardless of their parents' economic circumstances.

Providing this access will also bring great peace of mind to many parents who, perhaps, would previously have avoided attending a GP clinic due to unaffordability. Removing cost as a barrier will not only enable better utilisation of GP services but will also play a critical role in helping to address important health issues for children such as childhood obesity. As the vast majority of health needs of children can be met in the primary care sector, the GP is well placed to address early health issues arising, which helps to mitigate their impact in later life. It is estimated that the phased expansion of GP care without charges to children between six and 12 years of age will benefit approximately an additional 300,000 children.

Such positive large-scale reform of GP expansion will have inevitable costs attached with its implementation. These will depend on several factors, including the timing of the phases, the number of eligible children, the uptake and determination of fees payable to GPs and so forth. Furthermore, the implementation of this measure will require negotiation with GP representatives to address issues such as fees payable and the scope of services to be provided and, critically, whether there is capacity in the community and in general practice for it. I also recognise that such reform cannot happen overnight.

The initial stage of this phased expansion, therefore, will be first to all children aged between six and eight years so as not to overwhelm the health system. Specifically, the legislative framework provides a roadmap for the phased expansion to the following three age categories: phase 1 is to children who are aged under eight, that is, children who are six or seven years of age; phase 2 is to children aged under ten years, that is, children who are eight or nine years of age; and phase 3 is to children who are under the age of 13, that is, children who are ten, 11 or 12 years old. This approach will ensure that the expanded service can be introduced in a way that will meet the ongoing health needs of children and also be sustainable for general practice in the current Covid environment.

In that context, it is important to acknowledge the impact of Covid-19 on general practice. During this pandemic, GPs have remained at the heart of service delivery, demonstrating fantastic flexibility in adapting to new norms and taking pressure off the acute hospital system. This is unlikely to change as we move into the latter part of the year. In the likelihood of reduced hospital capacity for the forthcoming winter as a result of Covid, it is anticipated that a greater burden of care will fall on GPs to manage patients within the community wherever possible. In that regard and taking account of the forthcoming winter season, it is important that an expansion of GP care will not inhibit general practice from delivering appropriate care in the community for all patients. Thus, the implementation for the expansion will require careful consideration by officials in my Department and the HSE in consultation with GP representatives.

The purpose of the Bill is twofold, to provide the legislative framework for the further expansion of GP care and to increase the gross income limits for medical card eligibility for persons aged 70 and over. Before I outline the Bill's main provisions, I draw the House's attention to a miscellaneous provision included in the Bill, namely, an amendment to the Health Act 1970 that is provided for to take account of the new governance structures of the HSE.

Section 2 will amend the existing legislation relating to the gross income limits for medical card eligibility for persons aged 70 or over under the Health Act 1970. The amendment of section 45A of the Health Act 1970 will provide for an increase to the gross medical card income limits for persons aged 70 or over from €500 to €550 for a single person and from €900 to €1,050 for a couple.

Section 3 will provide a technical amendment to section 53C of the Health Act 1970 to replace the reference to "Director General of the Health Service Executive" with a reference to "chief executive officer of the Health Service Executive". The Health Service Executive (Governance) Act 2019 established a board and the chief executive officer governance structure for the HSE, replacing the directorate and director general structure. Part 3 of that Act amended reference to the "Director General" of the HSE, replacing this with reference to the "chief executive officer" of the HSE. This necessary technical amendment, therefore, will ensure that section 53C is consistent with the amendment approach previously provided for in the Health Service Executive (Governance) Act 2019.

Section 4 will amend the existing legislation under the Health Act 1970 that relates to the making available of a general practitioner medical and surgical service without charge to persons who are ordinarily resident in the State and under the age of six. The amendment of sections 58 and 58B of the Health Act 1970 expands the availability of these services to persons who are ordinarily resident in the State and have not attained the age of eight. This is the first age category being provided with eligibility for free GP care under the first phase of expansion.

Sections 5 and 6 will provide for the further making available of a general practitioner medical and surgical service without charges to persons who are ordinarily resident in the State and have not attained the ages of ten and 13 years, respectively. These are the second and third age categories being provided with eligibility for free GP care under the two remaining phases of expansion.

Section 7 will provide for the Short Title of the Act and for the introduction of both GP expansion and an increase to the gross medical card income threshold by commencement orders as required, with the consent of the Minister for Public Expenditure and Reform.

The measures provided for in the Bill are good news for all of us, for our children, parents and grandparents. I am confident they will significantly improve access to GP services and to a range of services for both older and younger people in our society. I commend the Bill to the House and look forward to hearing the views of Deputies.

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