Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Before the Minister replies to the contributions Deputy Naughten and I made, I again emphasise the seriousness of the proposed increase from 5% to 7.5% of the net asset value calculable in terms of the individual's contribution under the terms of the nursing home support scheme. It is wholly inappropriate and excessive. Irrespective of current market values, there is no provision to reverse what is proposed if property market values were to improve. This is about taking more money from the net worth of individuals who have given a lifetime of work and contributions to the Exchequer and to providing for the essential services on which we all depend and which they need now in their latter days. I again urge the Minister to accept the proposed amendments.

James Reilly (Dublin North, Fine Gael)
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I have nothing to add.

Denis Naughten (Roscommon-South Leitrim, Independent)
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I had hoped the Minister might respond to some of the questions I had raised on the issues regarding the nursing home support scheme, as they require clarification. Does the Minister wish me to repeat the questions?

James Reilly (Dublin North, Fine Gael)
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The increase in asset contribution helps balance the decrease in property values as the income asset disregard has not been changed. I know the Deputy made some points that will be considered in the context of the review of the fair deal. It is based on ability to pay and the rent generated from a property is considered income for the purpose of the scheme. The property is also considered an asset and assessed accordingly. All those in receipt of subvention are entitled to remain on subvention. This was to ensure those in residential care on the introduction of fair deal would not be disadvantaged by the scheme. However, if they choose now to go on to fair deal, it will be at the 7.5% rate.

Denis Naughten (Roscommon-South Leitrim, Independent)
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What happens to applications that are pending at the moment? Is it based on the date of application rather than the date of the determination?

James Reilly (Dublin North, Fine Gael)
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Until the Bill is enacted, it remains at 5%.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I move amendment No. 4:

In page 6, line 15, to delete “7.5 per cent” and substitute “5 per cent”.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I move amendment No. 5:

In page 7, line 40, to delete “7.5 per cent” and substitute “5 per cent”.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I move amendment No. 6:

In page 8, line 23, to delete “7.5 per cent” and substitute “5 per cent”.

Seán Barrett (Dún Laoghaire, Ceann Comhairle)
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Amendments Nos. 7 and 15 are related and will be discussed together.

James Reilly (Dublin North, Fine Gael)
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I move amendment No. 7:

In page 9, line 44, after “treatment” to insert the following:

“(including care and treatment in respect of motherhood)”.

Denis Naughten (Roscommon-South Leitrim, Independent)
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I have one question on this amendment. The Minister is aware that as maternity services currently apply, a woman has the option of booking into the private or the public clinic at the outset for her first appointment and based on this, she then presents for delivery and goes into a private or a public bed, as the case may be. It is not possible for a woman to go into the public clinic, go through the public process and go to the hospital under the public system and be in a private bed. The Minister should correct me if I am mistaken but on foot of this legislation - I am unsure how this waiver will work and how it will be presented, which also will have implications for the implementation of this legislation - one could quite easily see a situation in which a woman with private health insurance could attend a public clinic as a public patient and yet be charged under her private health insurance for a bed, even though she has no access to a private hospital bed. I ask the Minister to elaborate on this point.

James Reilly (Dublin North, Fine Gael)
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It is very straightforward; that is not possible. If she does not declare to go privately to the consultant, she will not be charged as a private patient in the hospital regardless of whether she has insurance. If she elects to go privately to the consultant, she will be charged in the hospital.

James Reilly (Dublin North, Fine Gael)
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I move amendment No. 8:

In page 10, lines 14 and 15, to delete paragraph (c) and substitute the following:

“(c) in subsection (3)--(i) by the substitution of “Where,” for “Subject to section 54, where,”,

and

(ii) by the substitution of “does not avail of or waives his or her right to avail of, some part of those services” for “does not avail of, some part of those services”.”.

Denis Naughten (Roscommon-South Leitrim, Independent)
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On the structure of the waiver, while I discern the logic behind it, what are the implications of this measure as it is worded for someone who does not have an entitlement on the basis of legal status or where he or she has made his or her PRSI contributions here? This issue traditionally has been raised in this House in the context of the Immigration, Residence and Protection Bill, whereby people would have access to a basic level of medical care, particularly in respect of emergencies. Does this waiver, as it is constructed, have implications in this regard?

James Reilly (Dublin North, Fine Gael)
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No, this Bill does not relate to emergency care. I hope that clarifies the point.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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While I will be opposing both sections 11 and 12, I will deal with section 11 first. When the nursing homes support scheme was introduced, Sinn Féin and others expressed concern that it removed the universal eligibility for a place in a public nursing home as provided for under the Health Act 1970 and this Bill reinforces the position. This is a serious matter because it is drawing major distinctions between certain sets of circumstances that may present in the life of any citizen. The statutory eligibility to a bed in a public nursing home was provided for in the aforementioned 1970 Act but was never vindicated in terms of the provision of resources to make available those beds. This led to a huge reliance on the private nursing home sector, something which continues to a worrying extent. Even in respect of the ever-reducing number of public nursing home beds, I note that with the advent of the accepted standards being imposed by the Health Information and Quality Authority, HIQA, rather than actually carrying out the necessary alterations, renovations and so on, it is becoming evident that to meet that measurement, there is an ongoing and critical reduction in the capacity of the public nursing home network. This is an extremely serious matter and further evidence of this came to light in recent weeks in my constituency. I believe the situation must change. One cannot continue to have an ever-contracting provision of public nursing home care. Moreover, worrying potential developments arise from the statement at the end of last week by the Minister of State, Deputy Kathleen Lynch, to the effect that means testing is to be introduced with regard to home care. That certainly will have consequences and one will find that where the State currently is saved significant sums of money by the heroic and at times herculean efforts of family and friends to allow for older people to remain where they are happiest and most wish to be, that is, in their homes, this situation will be challenged by these further measures now signalled. There is no evidence of any intent on the part of the Minister or the Government to address seriously the ever-decreasing capacity in respect of public nursing home provision.

That is a very serious matter and accordingly I am opposing section 11.

Denis Naughten (Roscommon-South Leitrim, Independent)
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The amendment of the primary section, section 53A of the 1970 Act, allows for persons residing in nursing homes to be charged the costs which are based on the average costs of long-term residential care in a public nursing home. As the Minister knows, there is significant variation in the care provided in public nursing homes depending on the type of patient and level of dependency. Why has the Minister decided to go for an average rather than the actual cost of operating a nursing home? The calculation is already factored into the treatment purchase fund figures.

I wish to flag section 19. There seems to be an anomaly in regard to the charging structure which is being proposed. It is based on the State non-contributory pension. People who will be charged under that will receive €188 a week, which is significantly less than the State contributory pension. People could contribute the vast majority of their social welfare payments for those services.

James Reilly (Dublin North, Fine Gael)
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On Deputy Ó Caoláin's opposition to the section and his contention that the review will introduce means testing, that was not said but means testing may be introduced. The current fund, which is very heavily funded, is for long-term care. The Deputy rightly pointed out that most people want to stay at home, yet the funding is not in place in the manner in which it might be. I am sure when his party talks about wealth taxes it would not have any issue with people who are quite well off paying some contribution towards home care or home help, rather than having to pay a contribution for long-term care before they need it.

The advent of the single assessment tool is something which I welcome because it will allow for a uniform approach to assess how the needs of older people can be met, including whether they need long-term care. The current situation has demonstrated that over the past number of years people in certain parts of the country went into long-term care before they needed to. In other parts of the country people cannot access long-term care even though they badly need to. This is due to a lack of uniformity in a single assessment tool and its application, something which we are correcting.

In regard to the comments of Deputy Naughten on averages, the National Treatment Purchase Fund does not purchase from the public sector, rather it purchases from the private sector and some NGOs and voluntary organisations. I will not accept the amendment.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I can assure the Minister that neither I nor my party would countenance those charges applying irrespective of the income stream of individuals. We believe in universal healthcare and its provision on the basis of need. We believe in a progressive form of taxation that will provide for these services. A wealth tax is exactly that, where people who are in a position to pay more should pay more based on a formula we have provided in recent years to the Minister's colleague, the Minister for Finance, and other members of the Cabinet. We argued that over a number of years with the preceding Government but it did not listen either.

There is a resolution to the difficult financial challenges which prevail but what is incorporated in this Bill, as in so many others presented to the Houses, is ill-suited to the purpose. All we are doing is penalising people who, invariably, are not in a position to take on further burdens. Section 12 proposes a €5 increase on the €75 charge for inpatient care. These may seem like small sums to the Minister but I happen to know people for whom they will be a significant additional burden.

I hold to public nursing home care provision. I am very pleased that, based on a recent engagement with senior HSE officials in regard to St. Mary's hospital in Castleblayney in my home county of Monaghan, required capital works will be undertaken in line with HIQA recommendations in its most recent reports. The net effect of that in terms of the capacity of St. Mary's is the loss of six beds. I have provided a specific example, but I could cite a number across any number of constituencies in the country. We fully understand and accept the criteria being applied by HIQA in terms of better standards of accommodation provision for residents, but we have to wake up to the fact that the ever reducing number of beds is having a deleterious impact across the board and is driving people ever more, not by choice but by necessity, into the private care providers.

I put it to the Minister that section 11 does not merit support. I will conclude because I will become annoyed about specific cases on which I am currently working. I do not want to go into any of the details, although I am sorely tempted to do so. I am opposing section 11 for all the reasons I have explained.

Denis Naughten (Roscommon-South Leitrim, Independent)
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I ask the Minister to respond to my question on people with an intellectual disability. As I read the Bill, they will receive one third the amount an older person will receive under the nursing home scheme because of the manner in which section 19 of the Bill is constructed. I presume that is not the intention.

James Reilly (Dublin North, Fine Gael)
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It is not the intention and it is not the case.

Deputy Ó Caoláin seems to have a problem with very well off people making a contribution towards care in the home, as opposed to not having a problem with them being charged for their care in long-term care. I find that very inconsistent, to say the least. It is all very well for Sinn Féin to talk about progressive taxes and a wealth tax. The bottom line is that the sort of money it attributes to what a wealth tax would raise is fantasy economics.

The reality is that we have an ageing population, something for which we should be very grateful. People are living longer. We want them to live well and at home for as long as possible, and to retain their independence for as long as possible. Something needs to be asked of a system which heavily supports long-term institutional care but not long-term care at home. It begs a serious question. Talking about wealth taxes as the solution to all of our ills and problems does not wash.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Of course the Minister resorts to silly nonsense when he no longer has any cogent argument. Nobody ever suggested a wealth tax was the panacea for all our economic woes and financial ills; far from it. It is part of a package of measures which we have consistently commended to a series of Governments. It is well-documented and well-costed, not by Sinn Féin but by the Department of Finance. Let there be no doubt about it, the facts and figures we present can be stood over and are sustainable. They are political choices and are clearly not the choice of the Minister.

He prefers to impose these measures and thereby heap further difficulties on people who are already overburdened. Those are the facts. I am absolutely committed not only to having the level of care provision meet the highest possible standard but also to ensuring capacity will be increased. Such an increase is not happening and all that is occurring is continual contraction. I instanced one example in this regard but I could cite more.

With this Bill, the Minister has created a compendium of measures with which he is pressing forward and in respect of which a guillotine will apply in the next 20 minutes. This is par for the course for Governments in the closing days of any particular Dáil session. We need not revisit the contributions of the Minister, when he was Opposition spokesperson on health, to remind ourselves of how he reacted when those in the previous Administration did exactly what he is doing now.

Seán Barrett (Dún Laoghaire, Ceann Comhairle)
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Amendment No. 9 is in the name of Deputy Kelleher. As the Deputy is not present to move the amendment, it cannot be discussed.

Robert Troy (Longford-Westmeath, Fianna Fail)
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Deputy Kelleher is away this evening and the Whip's office made arrangements to allow me to move the amendment.

Seán Barrett (Dún Laoghaire, Ceann Comhairle)
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Is it agreed that Deputy Troy can move Deputy Kelleher's amendment? Agreed.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I move amendment No. 9:

In page 12, line 49, to delete “15 days” and substitute “10 days”.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I support the amendment, which Deputy Troy has moved on behalf of Deputy Kelleher. The Deputy quite rightly highlighted the increased level of charges that will apply. The argument to reduce the period in respect of which charges will apply to ten is reasonable. I am opposed to this section in its entirety but I would be willing to accept the arguments in respect of the amendment if the Minister were to do likewise.

Catherine Murphy (Kildare North, Independent)
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The people who are most affected by this type of change are those whose incomes are just above the threshold relating to the medical cards and below the level at which they would be able to afford health insurance. This matter is of serious concern to them. There is no way they can be dealt with if they cannot afford health insurance. Many people are paying the universal social charge and pay related social insurance but they have access to a diminishing range of services. This is at a time when they are at breaking point. The least we can do is provide them with some certainty. The Minister is being given discretion to change the period, even though it is increasing in any event and people are paying more, and I am of the view that we should oppose this.

James Reilly (Dublin North, Fine Gael)
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There has been a great deal of discussion with regard to public capacity vis-à-vis long-term care and the public option. I wish to place on record the fact that we are committed to maintaining that option.

In framing his amendment, Deputy Kelleher, in whose stead Deputy Troy moved the amendment, has misunderstood the purpose of the Bill. What is at issue here is a statement which limits capacity. At present, it is open to the Minister of the day - that is, me or any of my successors - to apply the charge in respect of a period of 20, 30, 40 or 100 days. What I am doing is limiting the period up to a maximum of 15 days. While the new limit will be ten days and, as a result and in light of the increased charge, the maximum amount payable will be €800. If I were to leave matters as they stand, there would be nothing to prevent me or one of my successors from increasing the period to 20 days at a cost of €75 per day. What I am doing is providing, in the context of the maximum of 15 days, the certainty to which Deputy Catherine Murphy alluded. However, I am not saying that I intend to increase it to 15 days. My intention at present is to leave it at ten days. I am also putting in place a limit whereby I will be prevented from increasing it above 15 days. Currently, I could apply the charge in respect of a period of 15 days, 100 days or whatever.

Robert Troy (Longford-Westmeath, Fianna Fail)
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If it is the Minister's intention to leave it at ten days, why will he not accept the amendment and substitute the term "10 days" for that of "15 days"? This would provide the clarity and certainty he indicated he wishes to give public patients who will be liable for the charge to the effect that, upon being hospitalised, they will not be obliged to pay more than €800 in a calendar year. I accept his bona fides with regard to the fact that at present he could charge for periods well in excess of 15 days. However, that is no reason for him to refuse to accept the amendment and limit the period to ten days. I hope the Minister will take the amendment on board, particularly as he stated that he has no intention of increasing the period. If that is the case, he should accept the amendment.

James Reilly (Dublin North, Fine Gael)
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I repeat what I said earlier, namely, that there is currently no limit in primary legislation on the number of days for which a Minister for Health can impose a charge on a public inpatient. Under existing regulations, the maximum number of days for which the acute public inpatient charge applies is ten. I reiterate that I have no plans to increase this. If, however, a future Minister for Health wished to increase the charge, under the Bill both his or her agreement and the consent of the Minister for Public Expenditure and Reform would be required. The leeway allowed to the Ministers before they would be required to return to the Oireachtas to increase the number of chargeable days further stands at a maximum of 15. That is a reasonable constraint and, therefore, I do not propose to accept the amendment.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Under section 12, we are having higher and further charges imposed, and for what? At the end of the day there is no doubt that it is for shrinking services. That is what we are looking at here. The Bill increases the daily charges for public inpatient services to acute hospitals from €75 to €80. If we consider the cohort of people who will be impacted by that increase, as I said in relation to section 11, the Minister might not think that extra is excessive but I can assure him that in many of the cases I know and represent in this House, that additional €5 is a substantial further burden and it does have consequences. Already, countless numbers of people, as many Deputies in this House can attest, are making the decision not to go to their general practitioner or not to go to hospital when they need to because of the cost. That is a fact of life. Parents with children are particularly vulnerable in this regard and many of them make the decision, and perhaps a number of times even in a single year, to put the health and other needs of their children before their own health considerations. That means, ultimately, they are neglecting their health and providing for their children, which is an understandable choice, but the consequences for themselves, while perhaps not immediately presenting in any severe way, will build up and there will come a day of reckoning. They pay a very serious price for their care pattern.

The Minister will say services have to be paid for and of course they do. We have made the case for this repeatedly. We have repeatedly proposed ways of raising and saving revenue. This has been made clear time and again by political voices in engagement with the troika. I have been a party to that engagement on a number of occasions, in addressing excessive salaries at the top of the HSE and in terms of the Department and the Minister's adviser staff, and in addressing the hugely excessive costs of medicines, which was highlighted again on the national airwaves today where the differential between the cost of medicines for the public on this side of Border is multiples of what people pay north of the Border and in a variety of European and other settings. As was highlighted today on the national broadcaster, people pay in excess of €100 for the same medicines here that they can buy with the words "made in Ireland" on the cover of the box overseas in Turkey for €3. What is being made in Ireland? The Irish public are being made a scapegoat for something and this is not being grabbled with in any serious way despite all the Minister's negotiations and the alleged €400 million savings in the cost of drugs.

I have highlighted again and again that a new top rate of tax and a wealth tax should be introduced. These are the alternatives the Government will not choose and that it has repeatedly rejected. It is indicative of a closed mindset in this regard. It is a very sad and sorry situation. We are asked to pass this and other legislation on the promise that all will be well under the Government's universal health insurance system, but we have yet to see the Government's White Paper in this regard. We have none of the detail only the continued mantra that all will be well once the universal health insurance system is presented. This is supposed to be a cornerstone of Government's health policy and not only of Fine Gael but of Fine Gael and Labour. There is no cornerstone and therefore we know what the health policy really is - it is a shambles. The idea that it is going to be resurrected out of these unseen proposals is nothing other than a trundled out mantra. It will never be reformed under this Government and under this Minister.

James Reilly (Dublin North, Fine Gael)
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After that long diatribe, which is all I would call it, I would be delighted to respond and remind the Deputy across the floor that last year when we were facing a reduction in manpower, he was the one who went shroud waving telling women they would not have a safe health service in which to have their babies and advising cancer patients they would not be able to get the treatments they needed to save their lives. I am happy to inform the Deputy and the House that since that time, thanks to the extraordinary and sterling work of the men and women who work on the front line in our health services, supported by the clinical programmes and by the SDU, we have seen 95% of inpatients at the end of last year treated under the nine-month target and that target is set for eight months this year. We have also seen 95% of inpatient children treated under 20 weeks, 95% plus treated in under 13 weeks for endoscopies; and a 24% reduction in the number of people who had to endure long trolley waits last year with a further 9% reduction this year. There are still too many people waiting and more will be done.

The Deputy said people are getting shrinking services when in fact we have a stroke programme which is saving a life a day now. We have gone from being at the bottom of the league in Europe for thrombolysis, the drug which busts a clot people have in a certain number of strokes, to being at the top of the league. We have a new congestive heart failure care programme. We have a frail older patient care programme for patients who are now admitted to specialist wards where their medical problems can be addressed aggressively and their rehabilitation can begin and as a result fewer and fewer people will end up in long-term care and more people will get home to live independent lives.

The Deputy mentioned the cost of drugs and passed over the €400 million saved in the IPHA deal over the next three years. Those savings will allow us spend €210 million over that period on new life-saving drugs for problems such as cystic fibrosis, malignant melanoma and other cancers. We have passed the drug reference pricing Bill which will now allow for the price of generics - something about which I have been concerned for some time - to fall considerably here.

During our Presidency of the EU we completed the cross-border health threats directive which allows us to join other countries such as the UK, Germany or France when ordering vaccines. A small population like ours does not have the same buying power as bigger nations and that directive will be to the benefit of our people.

We have made real improvements in our health services. We have much more to do and it will be done. We have brought in for the first time the biggest re-organisation of our hospitals through the hospital groups mechanisms which will give us the scale of hospital groups that will allow them to buddy-up with international partners and interest has already been shown in this. We will get much greater scales of economy in terms of management and human resources. It will help us to address our European working time directive, something that is of particular concern to me, and it will also greatly help in attracting and retaining the best of staff as people move to join these bigger groups, rather than smaller hospitals having to struggle to attract personnel who are difficult to attract and sometimes difficult to retain.

I will not accept the proposal and I ask Deputies not to support the proposed deletion of section 12.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The Minister cannot all the time claim that the heroic efforts of front-line service providers is to his credit. It is to their professional credit and integrity and we all acknowledge that.

James Reilly (Dublin North, Fine Gael)
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The Deputy twists everything I say. That is a sad but, unfortunately, consistent feature of his contributions in this House.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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If the voices of those who are medical practitioners across a range of disciplines could be heard here - rather than the voice of the Minister, who is a medical practitioner by profession - many of them would totally reject his claims. This Bill is deleterious to the health services and to the finances and health of ordinary citizens. I roundly reject the passage of section 12 and of this Bill in its entirety.

Seán Barrett (Dún Laoghaire, Ceann Comhairle)
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As it is now 10 p.m., I am required to put the following question in accordance with an order of the Dáil of this day: "That the amendments set down by the Minister for Health and not disposed of are hereby made to the Bill; in respect of each of the sections undisposed of, other than section 18, which is hereby deleted, that the section or, as appropriate, the section, as amended, is hereby agreed to in Committee; Schedules 1, 2 and 3, as amended, are agreed to in Committee; Schedule 4 is hereby deleted and the Title is hereby agreed to in Committee; the Bill, as amended, is accordingly reported to the House; Fourth Stage is hereby completed; and the Bill is hereby passed."