Róisín Shortall (Dublin North West, Labour)

The Government is not proposing to introduce the Dutch model here. We are proposing a hybrid model for universal health insurance that will draw from the best models throughout Europe. The details in that regard will be worked out by the implementation group. As stated earlier, the implementation group on universal health insurance is to be established very shortly. It will be charged with designing a system which will apply to existing needs and which will address the particular difficulties that have obtained in the health system for many years. It is important to clarify that said system will be a hybrid and that it will meet Irish needs. I hope the implementation group will produce the White Paper, sooner rather than later, because there is a need to carry out the relevant groundwork in respect of this matter.

Senator Bradford voiced many people's feelings on this subject. I welcome his comments and would concur with many of them. In the context of trying to introduce fundamental reforms to the health system, the Government is attempting to move towards a lower cost model of health care. There are far too many vested interests in the health service. Reference was made to protected professionals and action must be taken in respect of such individuals. We should not have tolerated the existing system for so long. There are those who are extremely well compensated - from both the public and the private purse - for the work they do and in the course of that work they often operate in an extremely uncompetitive way by allowing closed-shop situations, restrictions on entry to professions and training, etc., to continue to hold sway. That type of carry on is nonsense and it must be brought to an end. We need to move towards a modern democracy in which there is accountability. In that context, we must end the type of anti-competitive practices that have obtained within the professions in particular.

I welcome the requirement placed on us by the troika to open up access to the GMS. It should not have taken an intervention from the troika in order to encourage us to do this. The process of opening up access to the GMS is under way at present. For many political and historical reasons, closed shops have been in operation. I am glad, however, that progress is at least being made in this regard. The Committee Stage debate on the legislation to open up access to the GMS began this morning. I hope the Dáil will conclude its deliberations on that Bill in a short timeframe and that it will then come before this House before being passed into law as quickly as possible. I know of several very well-qualified GPs in whose training we invested a great deal. It is inexcusable that these individuals have not been able to establish practices under the GMS. A number of them are waiting patiently for the legislation to be passed. I hope it will be enacted as quickly as possible in order that the highly qualified people to whom I refer might set up practices and bring their skills into the health service. Their entry to the health service will increase competition and give patients a much greater choice in the context of the type of service they can access.

Overall, there are difficulties with regard to the high cost base that exists within the health service. These difficulties apply in the context of the lack of competition in the primary care sector. They also apply with regard to the lack of competition among and the general lack of numbers of consultants. The latter have managed to carve out a very special role for themselves within the health service. That is an issue which must be addressed.

There are also difficulties regarding the high cost of medicines. Many Senators referred to this matter and I hope we will make real progress on it in the new year. We will be introducing legislation which will allow for reference pricing and generic substitution. I look forward to the support of both Houses in the context of passing that legislation as quickly as possible in order that significant savings might be achieved for the Exchequer and for individual patients. Everyone is aware of the huge differential that exists in the price of medicines here and that which applies in Spain, Portugal or other countries people visit on holiday.

In the context of the model of care, it is the Government's intention to move as much activity as possible out of the acute hospital setting and into community and primary care. This will allow us to achieve a much lower cost model of health care provision. What we are doing in this regard makes better sense from a health point of view because there will be better outcomes. It also makes sense from a cost perspective.

Various points were made in respect of the VHI. I am not sure to whom Senator Barrett was referring when he used the phrases "We were trying to achieve this", "We claimed this", etc. I do not know whether he was referring to the industry or to a group of academics. I take it that he is not opposed to the principle of the common good in the context of health insurance and that he subscribes to community rating, open enrolment, lifetime cover and minimum benefits. There is strong support for these throughout the country. A great deal of people's concern in respect of health insurance relates to the lack of regulation. They are also concerned about the lack of transparency regarding the way in which the various insurance companies operate and the fact that side deals can be done. If, for example, one is prepared to pay cash, one will be quoted a particular price but if one is paying through one's insurance, the price is much higher. There is a need for much greater transparency in respect of the base for the kind of prices insurance companies are paying and on how they reach various agreements with public and private hospitals and, in particular, with consultants. We must move towards a much greater level of regulation in this area because I do not believe that consumers are being well served at present.

Senator Clune referred to public beds being used by private patients and the fact that the matter was examined in some detail by the Comptroller and Auditor General before being discussed by the Committee of Public Accounts. There is a considerable loss of income to the Exchequer as a result of the failure to charge the economic rate for public beds used by private patients. That matter must be addressed. There is general agreement that where money is owed to hospitals it should be paid. I am concerned that what we are discussing in this regard could provide hospitals with a perverse incentive. When this idea was first mooted, I raised that concern. I am aware that work is being done within the Department in the context of putting in place safeguards to prevent that which we are discussing from happening. Given that hospitals are under such pressure in the context of their budgets, I am concerned that there might be an incentive for them to take in more private patients at the expense of their public counterparts.

We must move quickly to ensure that there are safeguards in place for that, and I will be pursuing that within the Department of Health.

Senator Moloney raised a question about older people who are not in the tax net and whether they get the benefit of the tax relief, and the answer is, "They do". That is deducted at source.

Senator Cullinane raised the question of the slow progress of UHI. I have responded to that. It is a very big undertaking and we are doing it in the shortest possible timeframe.

I would also make the point to Senator Barrett that the Mr. Justice McKechnie High Court judgment in the Bupa case stated:

Therefore the creation of a risk equalisation scheme, pursuant to s. 12, is in my view a pressing and substantial need in a free and democratic society.

It is important to point out that unlike the Supreme Court, which did not need to go on and deal with the substantive issues, the High Court judge and the EU court fully endorsed risk equalisation. This High Court judgment is persuasive until any further Supreme Court judgment rules otherwise. It is important to bear that in mind. There was no question of being opposed to the principle of risk equalisation.

Senator Colm Burke raised a question about the Cork Medical Centre. I would point out that the VHI has not approved the Mater Private in Cork and has also refused a proposal from the Bons Secours group for an increase in the size of its existing facility. It is important to point out that the Minister has no role in directing health insurers to enter into agreements with service providers. The Minister has engaged with the VHI on this issue. Even though he has no specific role, he is concerned about it.