Matt Shanahan (Waterford, Independent) | Oireachtas source

I welcome the opportunity to contribute to the debate. We are talking about reducing the amount of money paid to insurers by way of risk equalisation on the basis of the criteria of age, gender and level of cover, also known as age-related health credits. We are introducing a new system of high-cost claim credits and reducing the stamp duty payable on all health insurance policies that feed into the central support fund. I presume these actions have been costed and are deemed to be beneficial or else I do not expect the Minister of State would have proposed them. She indicated that the scheme is revenue neutral and that any surplus or deficits that might occur will be rolled over into subsequent years. She has noted the high take-up of insurance which stands at 2.3 million. That is to be applauded. However, I would also point out that there is a large discrepancy between policies, as the Minister of State knows well. People tend to gear up their policies as they grow older because, notwithstanding risk equalisation, the chances are that policies at the lower end will not cover you for some of the serious health obstacles you may face as you age. As mentioned by previous speakers, there may be a couple of pensioners paying between €3,500 or €5,000 for a high-level scheme. That seems very difficult for people who have generally paid tax all their lives. It may be that this Bill will deal with some of those inequities.

Private and public hospitals and private and public work have been raised several times during the debate. It is very hard to compare what happens in the public hospital sector with what happens in the private hospital sector as they generally relate to different streams of activity. Someone in the private hospital system will be looking for fast, straightforward, repeatable exercises that you can turn around and that basically create fee income. That is what private hospital care is largely based on. The public system is the social contract that we have whereby we decide that we will look after everybody regardless of their health needs. That also includes those with very chronic health needs across a range of medical areas who require lots of care and ongoing treatment both in hospital and in community. That cost is picked up largely by the public purse. When we talk about Sláintecare, therefore, we are talking about trying to get the efficiencies of the private system while having public good at the heart of the policy. It will be a very difficult circle to square, to be quite frank, because there is a great deal of work to be done to try to generate that.

Others have spoken of the need to implement Sláintecare, but I would point out the significant obstacles in the recruitment of qualified medical personnel.

At present, we are engaged in talks on a new contract for hospital consultants. Many newly qualifying doctors will tell you they are not going to work in the public system for the contract that is being offered to them but are going to emigrate instead. Thus, we will have spent the money educating them but we do not have any system or bursary to provide medical training that would contract them to work in the system for one, two or five years, as is done in other countries. We just educate them and let them fly. At the other end of the scale, there are people who have worked as hospital consultants for 20 or 30 years and may still have time to run on their contracts but they are not going to stay in the system much longer because, quite frankly, they have had enough of a lot of it. We have much reform to deliver on that.

I raise also waiting lists, tests and scans. Deputy Naughten has just highlighted how level 2 hospitals can do much of this work and I agree. They should certainly be funded by the private health ensurers and that is an easy initiative to put in place if the will is there. There are also a couple of schemes around the insurance-backed long-term care. I point to the VHI Hospital@Home, which is system where a VHI patient whose needs are chronic, not acute, may be able to get minded in his or her home. Essentially, VHI will pay for people to come and deal with the patient at home. That is a very efficient system for releasing beds in our public hospitals as well as in the private ones. Similarly, there is the outpatient antimicrobial therapy, OPAT. At the moment, we have patients coming into hospital and taking up a bed for half a day or a day to receive antimicrobial therapy. That can be done quite easily in the home if we have the nurses or qualified doctors to do it. I am aware there is a pilot being discussed at the moment but we do not need to pilot that. This is simple stuff. We should just decide we are going to do it and see what resources we have to do it with. I will be supporting Deputy Naughten's amendment. It is discrimination against model 2 hospitals that any health insurer would not be paying for procedures that they pay for in other hospitals. They are the same procedures. I agree with him they should not be remunerated under the fund until that case has been levied.

As I said, I wonder if Sláintecare is realistic in the form we are currently discussing. The Minister of State knows I have been around healthcare for a long number of years. One of the things I have notice about many policy discussions is they generally do not include those who actually have to deliver the service. We talk about what we are going to do on efficiency but we do not speak to the nurses. We talk about what we are going to do on high-level clinical management but we do not speak to the clinical nurse managers and we rarely involve the consultants, to be quite frank. I do not take the view, as other Deputies might, that somehow the consultants are an outlying class in medicine and all out for money. I know very many who are quite the opposite. They are very much pastoral people and their first inclination is to serve, mind and look after their patients. We have created the consultants' contract they work under and many of them are quite happy to work under the system. However, they want support and the proper resources. They want resourcing at junior levels that is adequate to their needs, that is, they need registrars, house officers, junior doctors, clinical nurse managers or secretaries. The consultants are getting tanked off, basically, because when they go into the system they do not have that. That is why we are hearing so many people saying the system is dysfunctional. The system is difficult and it will remain so while public healthcare is offered to all. We must learn from the efficiencies in the private sector and see how we can bring them across into the public sector while getting risk and payment equalisation for all.

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