Róisín Shortall (Dublin North West, Social Democrats) | Oireachtas source

At the outset, I congratulate the Minister formally on his appointment and wish him well in the job. He certainly has spent a good bit of time studying the area. From the Social Democrats point of view, we will fully support him if he is ambitious for the health service and if he delivers and makes progress on Sláintecare in a reasonable timescale. If not, we will criticise him. I hope it will be the former rather than the latter.

There are two issues I want to raise before dealing with the Bill. Yesterday, I got figures in regard to what is happening at our ports and airports with tourists coming into the country in the context of Covid. Shockingly, I was told that only 7% of people who arrive here are being followed up with a telephone call and only half of that number, 3.5%, are answering those calls. This is unbelievable when we consider the threat that is posed to the country, all the sacrifices people have made and the absolute priority of protecting people's health, ensuring schools can reopen and seeking to get the domestic economy up and running again. It was made quite clear to me by the Department of Justice and Equality that it is only doing this work on an interim basis and that it is the responsibility of the Department of Health to do it. The latter Department is waiting for the health authorities to take over. This is an absolutely urgent issue. Can the Minister tell me this afternoon, or come back with an answer tomorrow, when his Department will be in a position to ensure there is proper follow-up on these cases? It makes a mockery of all the hard work that has been undertaken over recent months if we are wide open and exposing the Irish people and the Irish economy to this level of threat.

The second point I want to mention concerns something that has just come to my attention. The Minister will be aware that €25 million in funding is threatened to be cut from disability services. His predecessor gave an absolute commitment, following meetings with the various organisations working in the area, that this funding would be reinstated. My understanding is that the Minister also gave a commitment, as did his party, that the €25 million provision will be reinstated. My information this afternoon, however, is that one of those organisations has been told by its local community health office, CHO, that the cut is going to be implemented. That cannot happen. We have been talking for some time about the huge pressure on the disability organisations in trying to provide services to people in very difficult circumstances, their fundraising capacity having been hugely reduced. They simply cannot sustain this level of cut and nor can the many vulnerable clients they serve. Will the Minister clarify for us, either this evening or tomorrow at the latest, that this cut will not go forward and that the funding will be reinstated?

The Social Democrats will not be opposing the Bill. However, it is very underwhelming as an initiative aimed at improving access to healthcare. It completely lacks ambition. In the context of the Sláintecare commitments to which the Minister's party and the other parties in Government signed up, the Bill is desperately disappointing. It falls far short of what they committed to achieving.

I refer to the issue of eligibility because that is what the Bill is about. I do not know how familiar the Minister is with the fact that Ireland is unusual in that access to healthcare is dealt with as a matter of eligibility rather than entitlement. This issue was teased out in some detail at the Committee on the Future of Healthcare. Access to healthcare is a matter of eligibility rather than entitlement and that is the difficulty. Various legal provisions set out the categories of people who are eligible for access to services, but they are only eligible if those services are actually provided. There is no legal entitlement to healthcare. There is a right of access to social protection and the various schemes thereunder, but there is no similar legal entitlement to healthcare. That is a fundamental problem in the context of how we provide services. It is one of the reasons for there being a postcode lottery when it comes to accessing services. Certain areas operate the schemes differently from other areas, depending on their funding and share of the healthcare budget, which varies significantly. The issue of eligibility and entitlement is at the heart of many of the problems relating to the lack of access to healthcare.

Eligibility for services is divided into those who have a medical card and those who do not. Those who do not have a medical card are required to pay the full cost of GP care and other primary and community care services, as well as a very significant portion of prescription charges and the cost of prescription medicines. The World Health Organization has called Ireland's approach to determine eligibility for publicly financed health services "unusually complex". It stated that it has led to notable gaps in coverage and inequalities in accessing essential health services. The heavy reliance on the private health insurance market mainly benefits wealthier people and has a negative impact on equity. That is at the heart of the problems in the health service. The lack of equity within the health service is a significant issue. If a person can afford to pay for private health insurance, access is quite good. If a person cannot afford health insurance, he or she may qualify for a medical card which may give eligibility to access services that are not really good enough, but those who are left in the middle must pay for everything.

Reference is made in the Sláintecare recommendations relating to universal health access to Ireland still being a far cry from the universal cover enjoyed in most other European countries. Ireland is very unusual in the context of such a large proportion of our population having to fork out for access to primary care. We are on our own in Europe in that regard. There is no other country in Europe in which such a large proportion of the population is charged the full rate to see a GP. It is unheard of. People in other countries would not tolerate it and there is no reason we should tolerate it here.

The Bill aims to introduce an extension of access to GP care for children in three phases. As Deputies are aware, and as the Minister frequently stated while in opposition, access is the key issue in the context of healthcare. Far too many people do not have access to primary care, which is the most basic level of healthcare. We know that cost is a significant barrier. It makes absolute sense to ensure wider access at primary care level. If cost continues to be a barrier to accessing GP care, we will undoubtedly end up with higher costs overall. We should be encouraging people to get their medical concerns and conditions addressed at the lowest level of complexity. That means people going to or bringing their children to a GP when issues first arise. That is what makes sense. That is how one ensures there is early intervention and early treatment of conditions and, as a result, heads off more serious conditions. If cost continues to be a barrier, people who have developing health conditions will inevitably end up with a more serious condition and may have to attend an accident and emergency department, see a consultant or be admitted to hospital.

As Members are aware, the health service is overly hospital-centric. Services are provided at the most expensive level rather than ensuring we have preventative medicine, early intervention and early access to care. We are doing the opposite of what we ought to be doing. Not only does that lead to poorer health outcomes, it is a much more expensive system. As the system is so hospital-centric, we are spending more than most other OECD countries - we are very much at the top level of health spend - but we are at the lower level in terms of access. That makes no sense whatsoever. That is why Sláintecare, our agreed plan, is about completely reversing the manner in which we provide care.

The Bill only takes baby steps. It falls far short of what is required and what was promised. Ireland remains the only European country that does not have universal coverage for primary care. Irish GP payments are the highest formal payments in Europe, with 60% of the population paying non-reimbursable fees of between €50 and €70 per GP visit. That is a significant amount of money, particularly for working and other families who, in the main, have no access to free GP care. Health spending in Ireland is approximately one fifth higher than the EU average, but public funding of health spending is only 73%, 6% lower than the EU average of 79%. Out-of-pocket payments for GP visits are far more significant in Ireland than in other EU states.

It is important to bear in mind the length of time for which the various parties, including that of the Minister, have been discussing universal healthcare. In 2001, the then national health strategy, entitled Quality and Fairness: A Health System for You, made universal coverage a guiding principle for the health service. The Minister's party leader, who is now the Taoiseach, was central to the primary care strategy discussed at that stage. Little or no progress has been made on it since. In 2011, the programme for Government referred to universal primary care which would remove fees for GP care. It stated that would be introduced within the term of that Government. In 2016, A Programme for a Partnership Government referred to extending in phases the introduction of free GP care to all young people under the age of 18. Very slow progress has been made in that regard. We have not got anywhere near that objective.

The recent programme for Government refers to extending free GP care to more children. That is really disappointing. On the one hand, it refers to accelerating the implementation of Sláintecare while, on the other, it mentions extending free GP care to more children. Even the Bill before us, which contains a phased measure, deals with children up on 13 years. It is fairly pathetic in the context of all of the commitments that were made. I say that it should be extended to the entire population. That is what Sláintecare is about.

On the programme for Government, it is important to bear in mind that earlier commitments never came to fruition in the lifetime of any of the previous Governments dating back to 2000. The level of ambition has regressed since 2011. Universal GP care is not just about providing better access to healthcare, it is also about raising the health status of the whole population. It is also about ensuring better quality of care and longer life free of disability or chronic illness. Further, it is about enhancing economic liberty. If Deputies want to use that argument about the economic impact of universal access to healthcare, we know that the high cost of healthcare is a significant factor in our loss of competitiveness, as are the high costs of housing and childcare.

There are also very significant GP supply issues that need to be addressed. I am not sure what the Minister is doing in that regard or what his plans are. There are 64.4 GPs per 100,000 people in Ireland, significantly lower than the EU average of 91 GPs per 100,000. In order to support universal healthcare policies, the Government must also support GPs. It is important to listen to what the data are telling us about GPs. We urgently need a new GP contract. The one in place is completely outdated and does not serve the objectives set out in Sláintecare. Nor does it help us in terms of the recruitment of GPs. People spend many years training to be GPs and provide healthcare services. We should not expect them to be businesspeople or to have capital behind them to set up private practices.

A great many of our qualifying GPs end up going abroad simply because they cannot work as GPs in this country. They are expected either to have the money to set up private practice or to go as an assistant to somebody else. That is not what they want. Various surveys in recent years show that they want to work as part of a multidisciplinary team. They do not want to be carrying the burden of running a private practice. Nor do they want to be without the benefit and support of a multidisciplinary team which is so essential for the provision of comprehensive healthcare. They also want better work-life balance. None of those things are available to people at the moment. Nor is a sufficient salary or guaranteed secure salary available to them. The previous Government promised to move to a system of salaried GPs. A lot of newly qualifying GPs would be very interested in being employed by the State for a decent salary. I cannot understand why the previous Government did not and this Government will not commit to progressing that.

I want to make a point about medical cards for the over 70s. The income limits are being increased to a small extent under this legislation. I have stated previously in the Dáil that the income limits for over 70s are based on gross income. They are extremely low for under 70s but at least there is provision for disregards for particularly high health or living expenses that can be offset against the income limits. In the case of over 70s, only gross income is taken into consideration, irrespective of what a person's outgoings are. It is a fundamental weakness in how we operate the income limits for over 70s. The Minister referred to high-quality care for people in this age category. There is not high-quality care available to people over 70 who desperately need home-care services. I do not know if the Minister is aware that at the moment there are some 6,000 people living at home in difficult circumstances with various medical conditions, who have met the difficult criteria in terms of qualifying for home care and who are on the waiting list for home care because insufficient funding is provided. That makes no sense. It is inevitable that many of them will end up having to go into nursing homes or hospitals.

There is a promise in the programme for Government - it was also made in the context of the budget - to reduce prescription charges. That was to be done by July but I have not heard anything more about it. Has the Minister any information on that? Is the promise going to be upheld? The bottom line is that Ireland lags far behind all of its European neighbours when it comes to access to healthcare, particularly primary healthcare. It makes no sense on any level. It is quite disappointing to see the baby steps that are being taken in this legislation. What is proposed falls far short of what was promised in Sláintecare. This is year three of Sláintecare. Access to free GP care was to be introduced across the population in the first five years of Sláintecare. We are many years behind the commitments that were made. Not only does this deny people access to basic healthcare and impact hugely on their quality of life, ensuring there is a lack of equity in how we provide healthcare; it also means that we are not getting value for money on the significant spend that we have relative to other countries. That needs to be addressed quickly.

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