Seán Power (Kildare South, Fianna Fail)

I am pleased, on behalf of the Tánaiste and Minister for Health and Children, to introduce Second Stage of the Health (Amendment) Bill 2005 to the House. This Bill provides for the amendment of the Health Act 1970 to address two substantive matters, namely, to provide a legal framework for the charging of patients for the maintenance element of inpatient services in publicly funded long-term care residential units and for the introduction of doctor-visit medical cards.

All Governments and all parties in Government have supported and implemented the policy of requiring some contribution towards shelter and maintenance of people with full eligibility in long-term stay institutions. The Supreme Court recently confirmed that it is constitutionally sound for the Oireachtas to legislate for this policy. The issue is finally being put beyond legal doubt after nearly 29 years.

The Bill will also provide for the introduction of a doctor-visit medical card as announced at the publication of the 2005 Estimates. This fulfils a key commitment of the Government to ensure that people on low incomes should have access to GP services and advice. It is most efficient to address both issues in the same Bill.

There is close to all-party consensus that it is reasonable that people in public long-term stay places should make some contribution, where possible, to living costs, or "shelter and maintenance". The consensus on the issue is clear, given that the policy was implemented by successive Governments and Ministers for Health, albeit on a legally flawed basis, for at least 29 years. It is also clear from public debate and debates in this House over the past three months, that most people accept it is fair to require a reasonable amount to be contributed, particularly considering that older people living at home must meet their living expenses from their pensions.

On foot of advice sought by the Tánaiste from the Office of the Attorney General, the Department of Health and Children issued a letter on 9 December 2004 to the chief executive officers of the health boards and the Eastern Regional Health Authority asking them to immediately stop making such charges, pending the introduction of amending legislation.

Accordingly, a statutory framework that puts the long-standing policy on a sound and statutory legal footing and safeguards the income generated from this source is vital. Let us remember that this income is spent exclusively on health services and does not revert to the general Exchequer. It is part and parcel of health funding and has been for decades.

The constitutionality of legislating for these charges in the future was fully tested in the Supreme Court and was found by the court to be constitutional. For example, the court stated:

In authorising the Minister to impose charges on the specified category of person, the Oireachtas clearly intended that the resources of the health boards would benefit so as to better enable them to provide the services in question while at the same time seeking to avoid doing so in a manner which would cause undue hardship.

The court also pointed out:

The level at which charges can be fixed by the Minister is narrow in scope ranging from a nominal charge to 80% of the pension....It was clearly the intention of the Oireachtas that any charges would not cause undue hardship generally or in individual cases and no doubt this is why it fixed the maximum charge at 80% of the pension.

It was useful that the court recognised the importance of this source of funding for health services, in the order now of €2 million to €2.5 million per week.

The clarity provided by the Supreme Court has paved the way for the introduction of the Health (Amendment) Bill 2005, which provides the legal basis for charging for inpatient services in publicly funded long-stay institutions.

Quality care is expensive and the bulk of the cost of providing a high standard of quality care should be borne by the Exchequer. It is estimated that the charges imposed on those in public nursing homes represent approximately 10% of the overall cost of care. This represents a modest, though very important, contribution towards the total cost of treatment and maintenance.

The charges in question are embraced by the concept of what is in effect a co-payment, which is common throughout the health service. This is consistent with the overall principle that where individuals are in a position to contribute a modest amount to the cost of their care, it is reasonable that they do so. Other examples include the inpatient overnight hospital levy. In the latter case, the charge is currently at the rate of €55 per night subject to a maximum of €550 in any 12 consecutive months. Those availing of private or semi-private accommodation in public hospitals are also charged.

What we are concerned with today, therefore, is the implementation of policy for the future. In debating this Bill now, we should focus on its provisions and look forward to the clarity and benefits they will bring rather than debating how the issue of charges has been dealt with over a period of many years. I am conscious of the fact that the Travers report has been published today and I am sure the House will have ample opportunity to discuss the report in the future. The Government's policy on the development and delivery of services for older people is to maintain these people in dignity and independence at home for as long as possible in accordance with their wishes, to restore to independence at home those older people who become ill or dependent and to encourage and support the care of older people in their own community by family, neighbours and voluntary bodies. All the studies we have undertaken show that people are far happier in their own homes and want to remain there as long as possible. It is important that we make every effort to ensure that those wishes are granted.

It is obvious, therefore, that the roles of all community care services are vital to the implementation of this policy. The charges which can be raised under the provisions proposed in this Bill will assist in providing funds to help in the implementation of these overall policy objectives in the future. I am very pleased also to propose to the House those sections of the Bill providing for new medical cards to make GP services free for many thousands of people.

On 18 November 2004, in conjunction with the publication of the 2005 Estimates, the Tánaiste announced the Government's intention to introduce a doctor-only medical card for some 200,000 people. This was the most efficient way to help most people to access primary care and is in line with the commitment contained in the health strategy to ensure that the allocation of medical cards is on the basis of prioritising groups most in need.

This is one of a package of developments we have announced regarding the medical card scheme. The others involve adjustments to the income guidelines in respect of standard medical cards which will enable some 30,000 additional people to obtain a standard medical card in the current year.

These new income guidelines have been in force since January 2005. They reflect a 7.5% increase on the 2004 figures, as announced in November 2004, and also include substantial increases in respect of dependent children. Parents of children with very serious illnesses that persist from year to year can also be assured they will not have to reapply for a medical card each year, thus alleviating the anxiety of wondering if their medical card will continue. The introduction of doctor-visit medical cards is an innovation for social justice and for the effective use of public resources.

For many years, we have all shared a concern that people on low incomes should not be deterred from visiting their GP on cost grounds. In particular, we have agreed that parents should not be deterred on cost grounds from bringing their children to the GP. The Government is now acting to address these concerns.

The doctor-visit card will take away for individuals and families any concern about the cost of bringing their child to a doctor or, indeed, attending themselves. People will be able to get the advice and reassurance they need from their GPs and, if necessary, be referred on to other health services in either the community or the acute sector, as necessary. It is often the case that when a child is sick, he or she is taken to the doctor when medication might not be necessary. Although medication might be unnecessary, the parent can be reassured by the doctor's advice and we are now going to make that possible. The traditional medical card will continue to be held by some 85% of medical card holders. With this policy innovation, the same budget allows us to provide four times as many people with free access to their GP as with the traditional medical card.

It is important to remember that not all concerns or medical conditions with which people present to their doctor necessitate the prescription of medication, so in many cases no cost need arise in that regard. For those who require prescription medication, under the drugs payment scheme, no one need pay in excess of €85 in prescription drug costs in a calendar month. I am pleased that the Irish Medical Organisation has welcomed this initiative and I look forward to its co-operation in the introduction of these new medical cards, in the interests of the families and individuals concerned.

The Health Service Executive is preparing for the introduction of the doctor-visit medical cards and is drawing up appropriate operational guidelines to enable applications to be assessed on a standardised basis across the country. Once this legislation has been enacted, the HSE will be in a position to begin promoting the scheme and inviting formal applications, with a view to the first doctor-visit medical cards being issued during April.

The Government wants it to make it easy for people to apply for and use these cards. The Health Service Executive will do all it can to ensure this, including holding constructive discussions with the Irish Medical Organisation on implementation. The policy of the Government is absolutely clear. It is providing the resources to fund these new cards and is introducing the legislation underpinning them. The Government wants people to take up the new cards and visit their doctors as often as needed.

Income guidelines are set for the Health Service Executive for eligibility for medical cards on the basis of the best and latest income and expenditure information available for the population. The Health Service Executive intends initially to set the income threshold for the doctor-visit cards at 25% higher than applies for the standard medical card. The Department will monitor the uptake of the new cards closely to ensure that the many thousands of people whom we wish to have the cards actually apply for and receive them. If it is found that significantly fewer people than expected take up the cards because incomes are growing quickly, the 25% threshold will be reviewed to ensure that the desired numbers of cards are being issued. An allocation of €60 million has been provided for this initiative and must be spent as intended, as it will give assistance and reassurance to many families.

I should add that there is no question of the Government seeking overtime to reduce the number of standard medical cards in favour of issuing increased numbers of doctor-visit cards. This initiative is intended to complement the existing medical card arrangements, which have been in force for many years.

I now propose to outline the scope and principal provisions of the Bill. For the purpose of clarity I will deal with the long-stay charges first and then doctor-visit medical cards. The Bill is designed to eliminate the anomalies that have arisen under the current legislation for raising charges for long-term care in public-funded long-term care institutions. The Bill and regulations will promote consistency in the application of charges, with greater clarity for those receiving services and the public generally as well as promoting administrative efficiency and transparency throughout the system.

Section 4 provides for an amendment to section 53 of the Health Act 1970, which deals with the legal basis for the imposition of charges. It will replace the existing enabling provision in subsection (2) which provides the Minister with discretionary power to make regulations by a provision which requires the Minister to make regulations in order to impose charges regarding all persons, such as those with full and limited eligibility. Currently, section 53 of the Health Act 1970 provides power to make regulations to impose charges only on those who have limited eligibility.

Subsection (3) specifies the categories of persons exempt from charges imposed under subsection (2). Such categories include all persons under 18 years of age, those detained involuntarily under the Mental Health Acts, those in receipt of acute care in hospitals and those who, in the opinion of the HSE and pursuant to section 2 of the Health (Amendment) Act 1996, have contracted hepatitis C directly or indirectly from the use of human immunoglobulin anti-D or the receipt within the State of another blood product or a blood transfusion. We will introduce subsection (4) to empower the Health Service Executive to reduce or waive a charge on financial hardship grounds.

Subsection (5) clarifies that any current regulations currently in force under section 53 will remain so. The regulations in question are those that impose a hospital levy of €55 per day subject to a maximum payment in any 12 months of €550. These charges will continue to be inapplicable to people with full eligibility, medical cardholders, including all over 70s, and a series of other exemptions such as women in respect of motherhood.

Subsection (6) provides that the charges shall only apply for inpatient services after a period of 30 days or periods aggregating 30 days within the previous 12 months. It also limits the weekly charge to an amount that does not exceed 80% of the maximum of the weekly rate of old age non-contributory pension. Subsection (7) clarifies that the period of 30 days referred to in subsection (6) begins immediately upon the provision of inpatient services to the person concerned. Subsection (8) provides that the charge shall be in respect of the maintenance aspect of inpatient services.

Section 6 repeals section 140 of the Social Welfare (Consolidation) Act 1993 in order to remove a conflict with the provisions of the Bill which exempt persons detained involuntarily under the Mental Health Acts 1945 to 2001 from charges for the maintenance element of inpatient charges in long-stay residential institutions.

I will now outline the Bill's provisions on doctor-visit medical cards. Section 1 amends section 45 of the Health Act 1970 in two respects. In both cases the amendment aims to ensure an alignment of the legal principles governing the award of the standard medical card and those contained in the provision to be included in section 58 of the Act in respect of the doctor-visit card. Section 1(a) makes it explicit that the judgment as to whether a person meets the criterion of "undue hardship" specified in section 45(1)(a) of the Health Act 1970 is made by the Health Service Executive. Section 1(b) substitutes the existing section 45(2) of the Health Act 1970 with a wording that makes it clear that decisions on eligibility by the Health Service Executive must not be made by reference to a person's means alone, but also to what constitutes reasonable expenditure on the person's behalf. This is in line with existing practice in the Health Service Executive, whereby costs associated with such matters as a person's employment, reasonable housing provision and the care needs of children or dependants, including nutrition and clothing needs, are taken into account in determining whether a person faces undue hardship in meeting the costs of GP services.

By amending the law in this way we are making it a legal requirement that a person's reasonable expenditure needs are taken into account in the application of section 45(1)(a) of the Health Act 1970. In both cases these provisions reflect the HSE's current practices with regard to the assessment of individuals for medical cards. These amendments will not, therefore, affect the processes and practices already in place as regards the award of the standard medical card.

Section 2 amends section 47 of the Health Act 1970 by adding a reference to section 58 along with the existing reference to sections 45 and 46. This is to ensure that the relevant appeals provisions extend to the scheme for doctor-visit medical cards. Section 3 amends section 47(1) of the Health Act 1970 to include the doctor-visit medical card scheme in respect of the Minister's power to issue guidelines to assist in decisions on whether or not a person is ordinarily resident in the State. Guidelines were issued to the health boards in this regard in 1992 and remain in force.

Section 5 replaces the existing section 58 of the Health Act 1970, which deals with the making available of general practitioner services without charge, with a new provision. Subsection (1) will require the Health Service Executive to make available general practitioner services without charge to persons with full eligibility and those with limited eligibility for whom, in the opinion of the HSE, it would be an undue burden to arrange these services for themselves and their dependants. This provides the legal basis for the granting of medical cards, the scope of which is confined to patients' attendance at a general practitioner.

Subsection (2) of the new section 58 specifies the same general requirement with regard to the making of decisions by the Health Service Executive in respect of doctor-visit medical cards as is being inserted regarding decisions on eligibility, that is, they must be made not just by reference to a person's means, but also to what constitutes reasonable expenditure on the person's behalf. Subsection (3) maintains the existing requirement that there be a choice of doctor for persons obtaining general practitioner services under section 58 and ensures that this applies to holders of doctor-visit medical cards as well as holders of the standard medical card.

With regard to charges for long-stay care, this legislation will bring clarity to an area which, as is now clear, has not been operating on a sound basis going back almost 30 years. This is a genuine move to provide that imposed charges for long-term care have a sound legal basis. The legislation will also ensure that the income flow from charges imposed to date is secured for the future and that it will continue to support the provision of quality services to those in long-term care. It has been accepted that these charges, as contributions to the cost of care, are fair and reasonable.

With regard to new medical cards, providing general practitioner cover to up to 200,000 additional people from lower income households in the way provided for in this Bill is effective social justice. We are providing graduated benefits according to income. It is much better that State benefits are not all or nothing. We know from our experience of reducing unemployment how important it is, for social justice reasons as much as anything else, to avoid poverty traps. Graduated benefits are a fair and effective way to help people at different levels of income. Government policy is based on a coherent and integrated view of economic and social progress. The new medical card is one innovation within that strategy and will stand the test of time for many thousands of people in the years ahead. I commend the Bill to the House.