Mary Harney (Dublin Mid West, Independent)

They have considerable potential that we have not tapped. Sometimes, we seek to include new professionals in providing services. For example, I have provided for nurse prescribing in terms of X-rays and medication and for the involvement of nurses in the forensic examination of sexual assault victims. These initiatives are greatly enhancing the role of nurses and make more sense, as nurses comprise 35% of health care professionals.

The new legislation on generic substitution and reference pricing will provide pharmacists with the opportunity to substitute. For example, if a doctor prescribes the branded name, the pharmacist will be able to substitute and will only be paid where there is an appropriate substitute. That legislation will be before the House later this year. While it will enhance the role of pharmacists, I want it to do more. They could play an important role in the management of medication. For instance, they are equipped to administer vaccines. At a time when there is a recruitment moratorium and staff shortages in the public health care system, we need to avail of expertise in the most sensible way possible. I intend to do so and we had a good meeting with Dr. White on these issues. When one engages with professions about new services, people sometimes raise the question of additional money. In this case, it must be a question of switching the money around so that it can be provided elsewhere.

There are a number of exemptions and the Minister has the power to award further exemptions. There are few places in western Europe, North America or Australia where co-payment is not found. For many years, Senators told me there should be a small charge for going to a general practitioner. Senator Feeney made an interesting point. If we say that people will not take their medication because they must pay 50 cent and the amount is capped, it is like saying people will not eat food or drink water if we begin to charge for those. This aside, there are a number of exemptions.

As to the 50 cent, Colm McCarthy recommended €5 per prescription, but that would have been too much. A small amount would collect for us €2 million per month. Putting this in perspective, we were able to invest an extra €10 million in home care packages this year. Would it not be great if we could have invested an extra €24 million? Some €12 million is not an inconsiderable amount, although it looks small alongside €15 billion. It is amazing what this type of money can do. We will probably deal with this matter on Committee Stage. Senator Healy Eames cited the literature, but literature is like statistics, in that there is plenty around to support both sides of an argument. The literature equally shows that people do not reduce essential medication and that the charge will change prescribing behaviour. Clinicians will take into account costs in respect of the number of items being prescribed. There is no doubt that we have a high level of antibiotic prescribing. This has contributed to our high levels of MRSA and other health service-acquired infections in recent years in comparison with the Netherlands, where the level of prescribing is relatively low.

Everyone on a long-term illness card will be exempt, including diabetics, people with mental illness, people aged less than 16 years, people with a mental handicap, haemophiliacs and people with cerebral palsy, phenylketonuria, PKU, epilepsy, cystic fibrosis, multiple sclerosis, spina bifida, muscular dystrophy, Parkinson's, acute leukaemia and so on. I will also exempt children in care and people on methadone. If the evidence suggests we should exclude other categories, I will be more than happy to do so. We will discuss homeless people later. It is not for me to be to be able to distinguish when somebody has a medical card whether he or she is homeless. There are practical difficulties around some of the amendments that have been tabled.

On crutches, I have had discussions recently with the HSE around how appliances may be used. Obviously, they have to be sterilised. In some appliances there are safety issues, as well as the question as to whether the manufacturer will guarantee them if they are passed on. We are trying to address these issues because every single saving matters. Not alone does it matter from a money perspective, but also from a perception perspective, if people believe there is a non-utilised pair of crutches, wheelchair, chair for stroke patients or whatever.

Many years ago after my father died, I gave a chair to a neighbour which I thought would be very comfortable for him, as we no longer needed it. This was before I had become aware of all the infection and sterilisation issues, prior to coming to the Department of Health and Children. However, that neighbour was very grateful for that chair, for which we had no use, and it was great. I felt very good about it and the neighbour felt very good as well. We need to do more, and much of it has to do with points of collection, sterilisation and so on. In an environment where we are constrained, we have to look at all these issues.

I will not address Fine Gael's FairCare programme, except to say that I look forward to having it costed. I wish Fine Gael would submit it to the Department of Finance to be costed, and then we could have a real debate.

If we were not constrained by the financial environment, would we do this? Probably not, to be honest. We have looked at all aspects of the pharmacy chain. We have reduced the wholesale margin, from 17.6% last year to 10%. We have reduced the manner in which we remunerate pharmacists, from a 50% mark-up to 20%, and we have changed the manner in which we pay for prescriptions in the GMS. The first 20,000 are paid at a higher rate than the subsequent number. We have reduced the off-patent price paid to the producers of medication by 39% this year. That alone is €100 million. The irony now is that generic products are dearer in Ireland than the off-patent products. That contract comes up for renewal in September, and we intend to drive further reductions there.

The reason the generic market is small in Ireland is that the products have not been prescribed, or dispensed. With the changes we are making, the market will grow, and we should get better value. The whole market is only worth €300 million, although I have heard people argue that if we opted for generic substitution, we would save €300 million. We could only do that if we got them all free. That is the total size of the market. However, the market will grow when we bring in reference pricing and generic substitution. A bigger mark-up obviously leads to additional savings.

I welcome the debate on Second Stage and I look forward to Committee Stage. I hear what the Senators opposite are saying, to the effect that they will not support it. However, and I say this very genuinely, it is important that all of us think around the medication we take. Doctors frequently tell me that if they do not give prescriptions, the patients believe they are not doing their job, although that argument has not been advanced by the professional organisations per se. Sometimes as patients we believe we need things that we do not. Often I am amazed at the number of items people get on prescription, and the amount of medication they are holding as a so-called "crutch" in the event of needing it. Most of that is wasted, and subsequently dumped.

On medical cards, Senator Buttimer is incorrect. Some 140,821 new medical cards were issued between June 2009 and May 2010, and an extra 16,336 doctor-only cards. More people now are on medical cards than ever before in the country's history. There are 1.622 million on full medical cards, until the end of May and 115,900 on doctor-only cards, equivalent to 1.7 million cards. Some people are losing their cards as we centralise medical cards. There was one case where somebody had something like €3 million in the bank, and for some reason, under the old health board system, that person managed to get a medical card.

We are adhering to the criteria. Whether one lives in Donegal, Galway, Dublin or Kerry the same criteria are used. That is fair. That is what happens with the welfare system and there is no reason the health system should be different. Clearly, hardship cards are given in genuine hardship cases, particularly to people with difficulties that cannot be defined in legislation. Some 70,000 hardship cards are given on the basis of the particular circumstances at the time of an application.