Leo Varadkar (Dublin West, Fine Gael)
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I move: "That the Bill be now read a Second Time."

I welcome the opportunity to address the House on the Second Stage of the Health Insurance (Amendment) Bill 2015. For many decades health insurance has operated alongside our public health service and has grown and developed. Health insurance in Ireland is based on a core principle of community rating. All policy holders are charged the same premium for a particular plan which is adjusted to reflect any loadings applicable under lifetime community rating, irrespective of their age, gender or health status.

This system of health insurance requires intergenerational solidarity whereby younger and healthier people effectively subsidise older and less healthy people. The understanding is that these younger people will themselves be subsidised by later generations when they reach old age or suffer ill health. The risk equalisation scheme is essential to the operation of community rated health insurance. Its purpose, and the purpose of this annual update to the scheme, is to ensure that health insurance is affordable for older people and those with a chronic disease and not just for the young and the healthy.

Risk equalisation is a process that aims to neutralise in an equitable manner differences in health insurers’ costs that arise due to variations in the health status of their members. The risk equalisation scheme is designed to protect community rating and make it easier for older and less well people to afford health insurance. The scheme operates by compensating insurers for some of the additional costs of insuring older and less healthy members. Insurers receive risk equalisation credits for insured members funded by a levy payable by health insurers on all contracts written.

Amending legislation is required each year to revise the support provided under the scheme. The last 12 months saw a number of changes to health insurance. In July this year, VHI Healthcare was regulated as an authorised company by the Central Bank of Ireland in line with the regulatory position of the three other health insurers. This is a significant achievement by VHI and it is a vote of confidence in the health insurance sector and the improved economy in which it operates.

To be able to continue to offer affordable health insurance to older and sicker people, health insurers require a steady influx of younger healthy people. It is clear that the economic downturn had a significant negative impact on the number and age profile of the insured population. The number of policyholders fell from just under 2.3 million at the end of 2008 to just more than 2 million in 2014. In response to the decline, the Government introduced two important initiatives from May of this year. These are lifetime community rating and young adult discounts. These measures work to secure the future viability of community rating and protect access to affordable health insurance.

Encouraging more people to take out health insurance at younger ages helps to spread costs across all policyholders and ensures affordable premiums for all insured people. Without these necessary measures, there would be a continued deterioration in the age profile of the insured population which in turn would contribute to claims inflation and higher insurance premiums. Under lifetime community rating, late entry loadings apply for those aged 35 and over who buy health insurance for the first time. This is applied at a rate of 2% per year. Some 74,000 people avoided loadings by taking out health insurance before the deadline of 1 May 2015.

Young adult discounts are based on a sliding scale of maximum chargeable rates up to the age of 26. This new approach helps to ensure the smooth phasing in of full adult rates and eases the effect of dramatic price increases experienced when student rates no longer apply. The vast majority of policies now held by consumers aged 21 to 26 years offer young adult rates. These rates range from 51% of the full adult rate at age 21 to a 100% rate at age 26.

These two measures aim to increase the number of younger people with health insurance as well as retaining those who already have policies. I welcome the significant growth in the number of people with health insurance over the past 12 months, which saw an increase in membership of 100,000. I want to keep health insurance remains affordable for all those who wish to avail of it.

As a necessary support to community rating, I am committed to making risk equalisation schemes as effective as possible in a way that promotes fair and open competition. The risk equalisation scheme has operated in Ireland since 1 January 2013. The scheme is funded by stamp duties levied on health insurance policies payable by open market insurers for each policy written. The money generated is used to pay risk equalisation credits to take account of the higher costs of insuring older and sicker people. Currently the scheme provides credits based on age and gender and a utilisation credit based on an overnight stay in hospital of €90.

From 1 March 2016, the credits payable in respect of age and gender for those aged 65 and over on policies written from that date will be increased. However, I propose to set credits for the 60 to 64 age group at zero, which will also come into effect from 1 March 2016. It is not only older people who have high claims so I remain committed to developing a refined health status measure in the risk equalisation scheme using data based on diagnosis related groups, DRGs. This will require the collection and coding of all hospital activity data for both public and private hospitals under the system overseen by the Healthcare Pricing Office. Structural and legal changes will be required over time.

The immediate priority for the Healthcare Pricing Office is to provide the main technical support for implementation of activity based funding, ABF, in public hospitals. The conversion year for the new funding system is 2016, which will see hospital budgets translated into ABF allocations for the first time. In the meantime I want to improve the health status measure that we do have. In addition to the overnight credit of €90 I propose to expand the setting in which utilisation credits will be payable to include day case admissions. These will be paid at a lower rate of €30. This enhancement to the scheme will increase the support provided for less healthy people of all ages. Providing a utilisation credit reflects the fact that 30% of hospital inpatient activity for insured members is now carried out on a day case basis. It will also incentivise clinically appropriate treatment on a day case basis, freeing up overnight accommodation for those who need it.

Under the scheme, health insurers receive risk equalisation credits from the risk equalisation fund to compensate for the additional cost of insuring older and less healthy members. The credits are funded by stamp duty levies payable by open market insurers for each policy written. The stamp duty levies are collected by the Revenue Commissioners and transferred to the fund which is administered by the Health Insurance Authority.

In previous years, it has been necessary to increase significantly the stamp duty on all policies in order to fund the rising costs of an older and less healthy population of insured people. Last year, in order to make health insurance more affordable, I took the decision to reduce the stamp duty rates for non- advanced products by €50 per adult and €20 per child to 60% of the rate for advanced products. At the same time there was no increase to the rates for advanced products. I am pleased to confirm that the levy on the lower-level products will be reduced again in 2016 to 50% of the rate for advanced products, down by €38 per adult to €202 and down by €13 per child to €67. There will be a slight increase of €4 per adult to €403 for advanced products and a reduction of €1 to €134 in the case of children.

The decision to set credits at zero for those aged under 65 was taken primarily on the basis that retention of credits for this age group would have led to an increase in stamp duty by approximately €34 for everyone holding health insurance. I believe the credits and levy rates proposed for 2016 strike a fair balance between the need to sustain community rating and the need to ensure that younger people continue to avail of health insurance. The credits proposed by the Health Insurance Authority do not fully compensate for the cost of insuring older and less healthy people. The risk equalisation scheme benefits all consumers by encouraging insurers to compete on the basis of value for money, customer service and product design, rather than competing on the basis of risk segmentation. This approach supports a fair and open competition, giving those who wish to avail of health insurance access to a range of affordable policies from which to choose regardless of their age or health status.

I turn now to the Bill. The main purpose of this Bill is to specify the amount of premium to be paid from the risk equalisation fund in respect of age, gender and level of cover from 1 March 2016 and revise the stamp duty levy required to fund the risk equalisation credits for 2016. The Bill provides for consequential amendments to the Stamp Duties Consolidation Act 1999. A technical amendment to the Health Insurance Acts is also included. I will now outline the specific sections of the Bill.

Section 1defines the principal Act as the Health Insurance Act 1994. Section 2 amends section 6A(1) of the principal Act by the proposed amendment of three definitions. In section 2(1)(a), the proposed amendment replaces the current definition of hospital bed utilisation credit or HBUC with a definition of "hospital utilisation credit". The scheme provides for a HBUC as a proxy for health status. Currently, health insurers receive a retrospective payment of €90 per night for an overnight stay in hospital by one of its members. The proposed amendment will expand this credit to include day case inpatient admissions. The HBUC payment will be replaced with a hospital utilisation credit. Under this, credit insurers will receive a payment from the fund for day case inpatient admissions and for inpatient admissions on an overnight basis on all policies written on or after 1 March 2016.

Section 2(1)(b) proposes a technical amendment to the definition of private hospital accommodation. The amendment reflects the enactment of section 55 of the Health Act 1970, as amended by the Health (Amendment) Act 2013, where private patients incur a hospital charge in respect of inpatient services provided in a public hospital. Section (2)(1)(c) amends the definition of "relevant amount" to include day case inpatient admissions in the calculation of the hospital utilisation credit.

Section 3 amends section 11C of the principal Act. It provides for 1 March 2016 as the effective date for revised risk equalisation credits to be payable from the risk equalisation fund.

Section 4 amends Schedule 3 of the principal Act. It provides for the amounts payable from the risk equalisation fund for the hospital utilisation credit in respect of health insurance contracts renewed or effected from 1 March 2016. Schedule 3 will now contain two amounts, one for the provision of inpatient services on an overnight basis and one for the provision of inpatient services on a day case basis.

Section 5 replaces Table 2 in Schedule 4 of the principal Act with effect from 1 March 2016. The applicable risk equalisation credits payable from the risk equalisation fund for certain classes of insured persons are revised. Section 6 amends section 125A of the Stamp Duties Consolidation Act 1999. It specifies the applicable stamp duty rates from 1 January to 29 February 2016 and from 1 March 2016 on. Section 7provides for the Short Title, collective citation and construction of the Bill.

Given the other events of the week, it would be remiss of me not to comment on the broader issue of health reform and the move towards universal health care. I reiterate the Government's commitment to introducing a system of universal health care in the State. That means access to affordable, quality and effective health care for everybody in a timely manner and in a way they can afford. Our preferred funding model is to use a system of health insurance whereby everybody will be insured. We must look at different models, including single-payer and multi-payer models, to assess how that can be done best in the years ahead. However, it is clear that if we are genuine about achieving universal health care we must put the building blocks in place first. If a new service is to work, it must be built on sound foundations. This will require four foundation stones - Healthy Ireland and the public health agenda; sufficient capacity to satisfy unmet demand; the expansion and development of primary and social care; and reformed structures, ICT and financial systems.

When considering vision and policy for the future we should always start with Healthy Ireland, the Government-led programme to improve our personal and public health. It is the best way to ensure that we all live longer and healthier lives and the best way to tackle rising health costs in the long term. We have made great progress on smoking and now we must have a similar focus on alcohol misuse, obesity and physical inactivity. Last week I launched our sexual health strategy and I look forward to publishing our first public health legislation on alcohol in the next few weeks. It will go to the Cabinet next month.

For too long health and wellness programmes have been seen as important but not critical and have, therefore, often been overlooked when additional resources were being allocated. We must change that by making a commitment to increase the total budget for Healthy Ireland and the HSE health and well-being programme every year by more than the average increase in health spending. Important evidence-based initiatives, including the extension of screening and the childhood vaccination programmes, cannot wait until some point in the future when every immediate issue has first been dealt with. The same applies to programmes such as smoking cessation and other public health campaigns and programmes. The required additional funding could be sourced by ring-fencing the proceeds of a tax on sugar-sweetened drinks or excise on cigarettes.

With the current staffing levels of specialist doctors, general practitioners, GPs, midwives, specialist nurses, allied health care professionals, critical care beds and other capacity, no system of universal health care introduced immediately or in the near future will be able to deal with unmet demand. We must get a clear fix on the workforce requirements across the health service now and into the future. I have initiated a process to prepare a clear plan within 12 months. We must then work to fund it and implement it over a number of years. We must also reassess the number of acute hospital beds we require. The Organisation for Economic Co-operation and Development, OECD, statistics indicate that the number of hospital beds we have is low relative to other countries but this does not take into account private hospitals to which half of the population have access. OECD numbers also indicate that we use our public hospital beds relatively efficiently, with a short average length of stay.

No matter how much one reforms the service, unless the necessary resources and capacity are in place, there will always be long waiting times and potential overcrowding. An under-resourced system of universal health care which puts everyone on a lengthy waiting list, albeit everyone waiting for the same length of time, does not have much appeal. At the same time, no matter how much money one has, it will never be enough if one does not spend it well and efficiently, hence the need for the organisational and financial reforms which we are undertaking. On a positive note, in 2015 we secured the first budget increase in seven years for the health service. We anticipate that the service will spend €700 million more this year than it did last year. A further increase was secured in the recent budget for next year. The increases have allowed the health service to take on or regularise 4,000 more staff and to fund new treatment programmes. None the less, it is still operating with approximately 10,000 fewer staff than was the case at the peak, and since then our population has grown and aged further. Based on a clear vision and a solid commitment to adequate resources, we can put in place the foundation stones of a reformed service.

The key challenge for the Government is to find a way to deliver universal health care at a cost that is affordable and sustainable. This cannot be achieved without refocusing our health service from a hospital-led model of care to one that is more preventative, a less acute model that is grounded in more comprehensive and developed primary and social care. We must continue to strengthen and enhance primary care provision in Ireland through the ongoing development of comprehensive chronic disease management programmes. We are already showing form in this regard, with better asthma care written into the new contract for children under six years of age and a new diabetes contract for GPs, alongside better access to ultrasound and a GP minor surgery pilot. Nearly 14,000 children have registered for the asthma cycle of care since the middle of this year and 37,000 patients have registered for the diabetes cycle of care.

I look forward to concluding discussions with the Irish Medical Organisation, IMO, on further extending the scope of, and access to, general practice in the new year. As part of the new contract, I hope to see more GPs encouraged to provide expanded services such as chronic disease management, minor procedures and first-line investigations like 24-hour blood pressure and cardiac monitoring. However, I have no wish to see GPs becoming de factopublic servants, entirely dependent on the State for their income. Their autonomy and business-orientated approach are among the factors that make general practice work. As part of the negotiation with GPs, the State will seek to continue the implementation of GP care without fees on a phased basis, with the next phase bringing in all children up to 12 years of age and thereafter children up to 18 years of age.

In July this year, we took the first step in realising timely access to safe and quality health care for everyone with the extension of GP services without fees to 270,000 children under the age of six and an enhanced and better funded service for 150,000 children under six who already have a medical or doctor visit card. The second step came in August with the inclusion of another 36,000 people aged 70 or older. Of course, we should never make the mistake of thinking that primary care is just about GPs. Dentists, therapists, nurses, community midwives and psychologists play an increasingly important role. For example, we identified in the recent budget the importance of prioritising resources for speech and language therapy.

Community pharmacists are enthusiastic to do more and to manage patients as well as dispense prescriptions, and we should aid them to do more, for example, to manage minor ailments, administer more vaccines and do more medicine management and monitoring. We need to develop social care provision so that people, especially our elderly, can stay in their homes or supported housing with care for longer rather than in nursing homes. Modern technology will allow more people to stay at home for longer and nursing homes should enhance the level of nursing and medical care they provide to avoid unnecessary admissions to hospital.

To deliver reform it is necessary to be clear about the architecture one is seeking to build. The HSE is far too large and far too remote from the front line. It has been successful in some of its national functions, such as models of care, national clinical programmes and the national ambulance service. However, the centralised command and control model is not conducive to good management of hospitals or community services. It makes accountability almost impossible and will have to be dismantled over time and replaced with new structures that will devolve more decision-making to the level of the hospital or community and ensure greater accountability.

International evidence demonstrates that well-designed commissioning approaches and payment systems may have the potential to increase transparency, drive efficiency and encourage the provision of quality integrated care at the lowest level of cost. A new health commission could be established based upon a re-shaping of the existing responsibilities and expertise in the HSE and the National Treatment Purchase Fund, but also, crucially, with the input of new people who bring additional skills. The commission would purchase services from hospital groups and community health organisations.

The development of commissioning will require the establishment of the health care pricing office on a statutory footing, although it already exists on a non-statutory basis. It will be independent of commissioners and service providers in order to develop objective pricing mechanisms and determine standard national prices. It will also require the extension of coding and costing beyond the hospital walls to allow, where appropriate, more to be done in primary and social care settings. Most important of all, it will be necessary to drive the introduction of activity-based funding, ABF, for public patients in public hospitals, while also developing a complementary system of case-based charging for private patients in public hospitals. The conversation year for ABF is 2016 and hospital budgets for the first time will be based on this principle. It means money will follow the patient or service user, and hospitals and other health care providers will be funded for the work they do and the outcomes they deliver, rather than being funded on the basis of historic budgets. It will mean that hospitals and community health care organisations are incentivised and paid more to do more work, whether that involves more hip operations, more home help hours or more dermatology clinics.

In my view, linking spending to activity is the biggest single reform that will make the most difference for the better in our health service from the point of view of patients and taxpayers. Much work has already been undertaken and more can and will be done over the next five years on this crucial initiative. However, the commissioning approach will only work if the new health service is capable of responding to the introduction of stronger incentives. Therefore, a major reorganisation of health care delivery structures is underway, with the aim of strengthening local responsibility, accountability and responsiveness. This involves the transformation of all HSE and voluntary hospitals into seven major hospital groups, each of which will develop a strategic plan describing how they will operate as a cohesive entity which delivers safe, high quality and cost effective health care. I am strongly of the view that hospital groups should be truly autonomous to the extent that any body or organisation funded mainly by public money can be. The hospital groups, or trusts if one prefers, should also have the authority and freedom to make collective agreements, manage their own assets and payroll and negotiate independent contracts to recruit managers and specialists outside of the constraints of public sector rules, which in many ways are tying the hands of the health service when it comes to recruiting the right people.

Voluntary hospitals have made a valuable contribution to the development of health services in Ireland down the years. I value their ethos and history and, where their financial affairs are in order, it is our intention to retain their boards and governance. Where earned, their autonomy will be expanded, provided they fulfil contracts or service level agreements with their hospital group or trust. Voluntary hospitals may come together to lead their hospital groups. In others, new governance arrangements will be required at group level and in some they exist already. The groups are now in place and the CEOs, chairs and management teams are appointed. However, we will need to put this on a legislative basis by 2018.

Service delivery reform also involves the restructuring of all health services outside the acute hospitals, that is, primary care, social care, mental care and health and well-being, into nine community health care organisations, CHOs, with the aim of providing the maximum proportion of care to people in the most appropriate settings in the communities where they live. These CHOs have been established and their chief officers appointed and their development now needs to be driven forward.

A crucial element in the reform programme must be investment in information and communications technology. Partially as a result of past failures, but also because of competing demands, investment in ICT in Irish health care has fallen behind international standards and developments in the private sector, including general practice, pharmacy and private hospitals. The recently announced capital plan will allow us to start catching up on ICT modernisation, including a new financial management system, facilitating the provision of important and timely information. I look forward to a close collaboration with the private sector in the development and full utilisation of this technology in the period ahead. I commend the Bill to the House.

Billy Kelleher (Cork North Central, Fianna Fail)
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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.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The Health Insurance (Amendment) Bill 2015 provides for the introduction of risk equalisation fund payments to health insurers for hospital day case in-patient admissions redefining the heretofore hospital bed utilisation credit, now to be known as the hospital utilisation credit, providing for a €30 payment for day cases and continuing the €90 payment for in-patient admissions on an overnight basis. Other amendments in the Bill apply to the principal Act, the Health Insurance Act 1994, and include definition changes, while others apply to the Stamp Duties Consolidation Act 1999. In the context of where health services are, Sinn Féin will not oppose the passage of the Bill.

There is an irony in the timing of Second Stage of this legislation in that it coincides with the Minister for Health’s memo to the Cabinet this week on the unaffordability “now or never” of the multi-payer model of universal health insurance, UHI, his party’s and the Government’s central plank of their health policy. Proposed by the Minister’s predecessor, Deputy James Reilly, the Fine Gael UHI plan was front and centre of that party’s manifesto in the run-up to the last general election in 2011. It was subsequently adopted as Government policy in the programme for Government adopted by Fine Gael and the Labour Party. From the outset I described it as unworkable and unaffordable in placing our health and very lives in the hands of for-profit insurance companies. While mine was not the only voice, we, in Sinn Féin, have been consistent opponents of this proposition for almost the past almost five years of the Government and previously.

The blind adherence of the former Minister, Deputy James Reilly, and the Taoiseach to the proposed funding model raises serious questions about their competence and suitability to hold high public office. It was not just me as an Opposition spokesperson on health who spelled out the dangers of the course the then Minister, the Taoiseach and their Fine Gael and Labour Party colleagues in government were planning to take. Their lauding of the multi-payer system in operation in the Netherlands attracted expressions of caution from within that country, including from less expected sources. The director general of Nefarma, the Dutch pharmaceutical industry lobby group, Michael Dutrée, in addressing the 2011 annual conference of the Irish Pharmaceutical Healthcare Association stated health care in the Netherlands under the multi-payer system was based on cost, not need.

The Dutch introduced their model of private-public health care, with private insurance companies competing to access public health services in 2006. By 2011 the cost of an ever reducing basket of services had increased by almost 10%, with the cost of unincluded, uncovered services increasing by 50%.