Thursday, 11 June 2015
Health (General Practitioner Service) Bill 2015: Second Stage
It is my pleasure to introduce Second Stage of the Health (General Practitioner Service) Bill 2015 to the Seanad. The Bill will provide for a universal GP service to be made available to all persons aged 70 years and older. This is the second phase of introducing a universal GP service in Ireland which builds on the under-sixes first phase. Together with the under-sixes phase, the second phase will see more than 300,000 children and senior citizens who currently must pay to see their GP no longer having to decide whether they should spend €50 to visit their GP. This phased extension of universal coverage will come as a relief to many young families and pensioners. Under the new legislation, access to a GP service will be provided for all persons over the age of 70 years on a universal basis. This will replace the existing GP service arrangement for those over 70 years where their income must be assessed before they can access a GP without charge. Their dependants, including spouses or partners, under the age of 70 years will continue to have access to a GP service without fees where they meet the existing income limits.
The Government remains committed to the introduction of a universal GP service for the entire population in line with the programme for Government. As set out in its statement of priorities 2014– 16, it prioritised those over 70 years in the next phase of the roll-out of free access to GP care. It is now living up to that commitment.
General or family practice is often viewed as the core of primary care. The GP plays a crucial role as gatekeeper for the whole health system. The generalist and patient-centred GP approach guides the patient through the referral process and the health care system. It is widely considered that a well developed system of primary care has beneficial effects on the health care system as a whole. As previously announced, the Government decided to commence the roll-out of a universal GP service for the entire population by first providing all children under six years and, second, persons over 70 years with access to a universal GP service. The decision to prioritise those aged over 70 years next for the roll-out of a universal GP service had regard to the significant prevalence and co-morbidity of chronic diseases in this population cohort. Therefore, there is a significant benefit to be achieved from improved GP access in terms of health and well-being.
There are approximately 400,000 people in Ireland over the age of 70 years. It is estimated that about 36,000 people over the age of 70 years must pay to attend a GP because they are not covered by a medical card or a GP visit card. Medical evidence suggests there is a significantly greater incidence of multiple chronic conditions among persons over the age of 70 years. This emphasises the benefit of access to GP care without fees for persons in this age category. It is important to be clear that nothing will change for people over 70 years of age who have or who are eligible for a medical card. They will continue to receive all of their other medical card entitlements as normal.
We must move towards a health system based on universality of access which must be sustainably funded to enable the provision of services to meet health needs. While we recognise that a move from a means-based eligibility system to a universal-based system of health coverage is challenging, the Government is in the process of reorienting the health system from one that only treats sick people to one that keeps people well. That is why we believe a universal system is the best option. It can be argued that the existing eligibility system has become overly complex which has resulted in people focusing on the assessment process rather than the provision of services. We should not lose sight of the fact that the key issue is that an ill person should be able to receive primary health services. At the same time, we must stay committed to completing the most radical reform of the system in the history of the State to develop a universal system that will treat all according to their health needs, not their means.
I will briefly outline the main provisions of the Bill. Section 2 amends section 58 of the Health Act, 1970 to remove all individuals aged over 70 years from the scope of the means-tested service based on holding a medical card or a GP visit card. Instead, all persons over 70 years will automatically qualify for a GP service and it will not be necessary to hold a means-tested medical or GP visit card.
Section 3 amends section 58A of the Health Act, 1970 which sets out the existing GP service arrangements for those over 70 years to provide access to a GP service for all persons over the age of 70 on a universal basis. Section 58A(1) establishes a new universal arrangement for the HSE to provide a GP service without fees for all persons aged 70 years and over who are ordinarily resident in the State. The HSE will also provide a GP service for the dependants of such persons where the existing income criteria are met.
Subsections (2) and (3) outline the income conditions that the person over 70 years must meet for his or her dependants who are under 70 years to qualify for a GP service without fees. The dependants of a single person over 70 years will qualify if the income of the person over 70 does not exceed €700 per week. Alternatively, the dependants of a married person aged over 70 years will qualify if the combined income of the couple does not exceed €1,400 per week.
In general, the remaining subsections maintain the existing administrative practices of the GP service for those over 70 years. Subsections (4) to (7), inclusive, deal with the application process, the decision-making process and the provision of information. In line with current arrangements, subsection (8) requires the HSE to provide assistance for persons over 70 years in making an application, if needed. Subsections (9) to (12), inclusive, address the income limits and the calculation of gross income. Subsection (13) provides that the HSE, in so far as practicable, will offer a choice of GP to an individual.In conclusion, this legislation will deliver universal GP care to a second age cohort. By the summer, all 800,000 of those over 70 and children under six will be able to visit a GP without facing a financial barrier. This Bill represents another step towards a universal GP service for the entire population of our country. I commend the Bill to the House and I look forward to hearing the views of Senators.
Gabhaim buíochas leis an Aire Stáit as teacht isteach sa Teach le míniú a thabhairt ar an mBille seo. I welcome the Minister of State to the House to discuss the Health (General Practitioner Services) Bill 2015. The general effect of this Bill is to give back to the over-70s what has been taken from them, partially by the previous Government but mainly by this Government when it massively reduced the threshold on the over-70s medical card. The taking away of the automatic over-70s medical card was a major mishap by the previous Government in October 2008 and Fianna Fáil never fully recovered from that event, never mind the other events that followed. Following the public reaction to that measure, an extremely high threshold was put in place which effectively meant that everybody except the super-wealthy got a medical card at that time. There were probably too many people getting the card at that time and they included some very wealthy people. However, the threshold has been reduced dramatically since then, meaning many people over 70 on low to average incomes do not qualify for a medical card and did not qualify for a GP card before this Bill. Many of them have lost medical cards since the thresholds were brought in. Now they will all, including the super-wealthy, get free GP care. That is important for many people. We will not oppose this Bill but one has to question the logic of giving free doctor visits to some very wealthy people while some middle-income people with no children under six do not qualify for doctor's cards or medical cards, even in the case of extreme medical need. They are being left in the lurch because of this.
With the Minister of State present, we have an opportunity to look at what is happening in terms of the contracts that have been signed for the over-70s and the under-sixes. In my county of Meath, there has been a 29% uptake on the part of GPs with respect to under-sixes, and I am sure the figure is the same for the over-70s, and in Louth, it is 22%. In some other counties, it is very low while in others, there has been a high uptake, such as Donegal, Carlow and Kilkenny. Does that correlate with the fact that those counties already have a high number of medical cards? If a doctor already has a large GMS practice they are incentivised to provide the new services. If, however, a doctor does not fully depend on that, the incentive to do this does not seem to be very strong. I am very concerned that only 20 contracts have been signed in County Meath for the under-sixes and I presume it also applies to the over-70s. What will happen to those parents who need free GP care? Will they have to pay after July if they want to go to the doctor of their choice but who has not signed up? Will the Government fulfil its promise to them that they will get GP care free of charge?
The priorities have been wrong and we have not learned the lessons of the past. Fianna Fáil probably should not have given a medical card to everyone over 70 and should have put in a much higher threshold than the standard medical card threshold. Families with children would probably have benefitted more than the very wealthy over-70s. My family always seem to be at the doctor's but while we have been waiting for the Government to deliver on its promise to the under-sixes, two of them have gone past the age of six. We only have a year left and my own doctor has actually told me he will not be signing up anyway.
Many families have been asking me for the past year and a half, since this was first announced, when it would come in. Many families will not benefit from this at all as their children have gone past six years of age. The demographics are changing in this country. There was a baby boom a few years ago.
As a former leader of my party might have said, the baby boom is not as boomy as it was, but the Government seem to be categorising groups in the hope of getting a few votes out of it while people in the middle are really struggling. There is a case in County Meath at the moment where a child cannot get treatment in Ireland, or in England for that matter.
I assume the child has a medical card. The treatment is not available here, so the child has to go to America for treatment. I had another case last year but that child seems to have recovered. There are a lot of problems with the health service and it is wrong to suggest this will change things. It will not.
Does the Minister of State have the up to date county by county figures? Figures given in today's Irish Independentshow a wide divergence in take-up. Is it because of the existing level of medical cards? It is very worrying that a large number of doctors, particularly those in the National Association of General Practitioners, do not want to be part of it and are worried about the huge burden being put on them. The extra work they will have to do does not appear to be fully funded.
Is it intended to roll out the provision for asthma across all age groups? At the moment, it is only intended for the under-sixes but somebody asked me about it last week.
I welcome the Minister of State to the House and thank her for bringing forward this Bill to introduce GP cards for the over-70s who are beneath a certain income level, which is €36,400 per annum. That is substantial income and the threshold for a couple would be €72,000. Some 36,000 people will benefit from the introduction of this Bill. The scheme will also be rolled out for the under-sixes and the number of people with GP cards will increase from 164,000 to over 412,000, which is a substantial increase meaning that over 46% of the population will have either medical cards or GP cards. We gave a commitment to try to introduce a universal health care system and this is only part of the process because we cannot do it all overnight. The argument has been made, particularly in respect of the under-sixes, that there should be a means assessment but that would have an administrative cost. We are removing administrative costs to a large extent in the way we are rolling this out.
As the Minister said, when the scheme is up and running it will benefit over 800,000 people who are either under six or over 70. There is a cost to this and while we would love to roll out free GP care for everyone, it is not financially possible and we have to use the budget of the Department of Health with care, as the Minister of State and the Minister, Deputy Leo Varadkar, do. We have given a commitment to roll it out for everyone in the long term but it will depend on income and on the taxation coming into Revenue. It is also important that the number of discretionary cards has increased quite substantially. I understand that the total figure is now over 126,000 between GP cards and medical cards, which is a substantial number. In fairness to the Department and the HSE, each case in which a person is over the income limits is being examined and discretion is being applied in a careful manner. While I accept that not all cases which one would expect to go through do so, if a strong case is presented, all of the issues are taken on board. I like it when people raise a medical services issue with me and ask, "Why can we not do this?" It is all about having the finance available. We are spending over €13.2 billion in the health budget, which is a huge budget providing a huge level of services.
The one major challenge we will face over the next 10 or 15 years is the increase in the number of people over 65. At present we have over 585,000 people over 65, which I understand will increase by about 20,000 per annum so that, by 2030, we will have 990,000 people over 65. It is not only about medical care, it is also about pensions and a whole lot of issues we will need to keep in mind in forward planning. Whatever parties are in government - I hope it will be Fine Gael and Labour the next time around - we will have to be mindful of planning expenditure. An additional 20,000 people over 65 means that, by the time the next Government finishes its term in 2021, there will be an extra 100,000 pensions to be paid out. There will also be a certain percentage of people who will need additional support, for example home care, nursing home care or medical care.
While I am talking about elderly care, it is appropriate to bring up the issue of home care and the need to further develop that service. While we have put additional money into nursing home care over the last six months - a welcome development in respect of freeing up hospital beds - in the long term, we also need to plan carefully home care for those who do not want to go into a nursing home. The overall cost in real terms is less than one third of the cost of nursing home care. We must make sure not only that we have an adequate number of people available to provide home care, but also that adequate facilities and training are available. We need to start focusing on this issue and to develop it over the next two to three years. The figure of 580,000 to 650,000 people will not be long growing. In the last six years, I understand that the number of people over 85 has gone up by 20%, which is a significant increase in a very short period. We currently have an average of 3.5 people working for every retired person. If we want to have the same ratio in 2030, we will need to have 2.7 million people working. That is a huge challenge for which we need to start planning.
I thank the Minister of State for bringing forward the Bill, which I fully support.
I welcome the extension of the provisions to the over-70s. It is overdue and while it is, as the Minister of State has said, a step along the road, it is a very long road and a lot needs to be done. I am not happy that the basic tenet on which the Government was elected, namely fundamental reform of the health service, is not being honoured. I do not wish the Minister of State to take that personally. The Minister for Health made a public commitment to making those fundamental reforms, yet soon after assuming office he stated that they would not happen within the first term of Government but in the second term. It then became apparent that there were major administrative impediments, and it looked like the Government was swimming through treacle.
The Bill provides for a restoration of something that was there previously, in what was generally recognised to be a fairly bad health service. I understand this is a step along the way and do not want the Minister of State to think I am being unduly critical. The Bill is bringing the service back from a real nadir of deprivation to where it partially was prior to the economic decline.
We need to keep our eyes on the prize. A lot of very good things are happening at the scientific end of medical research right now. We are going to face incredible challenges in paying for new treatments and will have patients who are living long enough to get them. We will also have patients living longer as a result of receiving those new treatments. Unless we do some proper forward planning of how we are going to structure the health service, we are not going to make much progress.
With regard to this legislation, I know from dealing with many patients that it was a cause of pain and anguish to people that they thought they were losing and, in many cases, did lose, their medical cards. It was a source of extreme annoyance and worry to people who had other things to worry about at their age, including their health. I am glad they are at least being relieved of this one little worry. With the co-operation of our very fine body of general practitioners, who keep the whole system ticking over in difficult circumstances, I hope the Bill will have other spin-off effects, such as decreasing the pressure on the emergency rooms.
Without seeking to be too dramatic about it, the situation in emergency rooms around the country in this last week has been terrible. I had occasion to visit one of them several times and to speak to doctors working in another. It is as bad as it has ever been. I am not sure the metrics the Minister of State is getting are reflecting the reality of what we are seeing. One or two of my own cancer patients had to engage with the emergency services and, despite what they acknowledged were truly heroic efforts by the staff, they did not get a standard of care appropriate for a modern western country. I have to be careful how I say this. I was in one emergency department during the week that I thought would have trouble passing a fire inspection. What should have been walkways through the department were blocked by doubled-up trolleys. There was not just one trolley against the wall but a trolley against the wall and another trolley against that one. Moving one trolley from one part of the department to another involved moving someone else's trolley as well.
There has been a little step along the way today and a little box ticked for an election promise but we have a long way to go. Somebody else once said, "A lot done, more to do". In this case, it is a little done and an awful lot to do. Let us do it.
I welcome the Minister of State. Universal GP services for citizens over 70 are most welcome. It is a very good day for our health service as we put in place the legislative underpinnings for this. It represents the second phase of our reform of the health service, following on from free GP care for the under-sixes.
The small step to which Senator Crown referred directly affects 300,000 people who, at the moment, are paying their GPs for a visit and, in many cases, are deciding whether they should spend the €50 or €60 on a GP or on food for their family.It is not a small step but a significant one. While in the grand scheme of things I would probably take Senator John Crown's point, to downplay or minimise the effect of it is a little ungenerous.
The universal basis of the provision for the over-70s with no income assessment is a fundamental principle of the Labour Party. The Minister of State will remember that the Labour Party ran its entire 2007 general election campaign on the provision of universal health care, which was rejected at a time when former Deputy Bertie Ahern announced a tax reduction of a couple of pence in the pound. Nobody was more surprised than we were.
We have learned our lesson; however, some of the problems we now face stem from those times and the lack of reform. Let us not enter into a blame game. This is part of the programme for Government. Senator John Crown is correct to remind us that the former Minister for Health, Deputy James Reilly, told us that it would take two terms to deliver universal health care. It is a reasonable timeframe. While many of our critics say we have abandoned universal health care, we have not abandoned it in any sense. We are realistic enough to know and accept the challenge it presents in realistic terms and plan accordingly. To say we have abandoned our position on universal health care is dishonest.
GPs are crucial to the provision of universal health care. Not only are they crucial to the provision of primary health care, they are also the gatekeepers to all facets of the health service. Senator Thomas Byrne has chosen to highlight the most minimal figures rather than being more rounded in his analysis, which is the job of the Opposition. However, more than 50% of GPs across the country have signed up to the scheme, which is very promising. It was said it could not be done and it was argued ferociously in this Chamber that nobody at all would sign up to it. However, 50% of GPs signed up in the early phase, which is a decent start, although there is much more to be done. The Minister referred to universality of access, which is the key to delivering what I consider to be a fair health service. The health service is not fair, but we cannot change it in the space of four years. It will take much longer than four years to achieve real and lasting results based on health promotion in the first instance, disease prevention, early detection and treatment delivered as close to home as possible, with the lowest level of complexity and in the most efficient and sustainable way. Nobody can argue with this.
Senator John Crown referred to the crisis in the accident and emergency service. It is an appalling crisis, but I hope it will pass with the good weather, although the evidence is mixed. We will see a reduction in the necessity for people who might not be able to afford to go to their GP to take their children to an accident and emergency department instead, despite the €100 charge. People who come to my clinics have told me that in a situation where they cannot afford €50 for the GP, they will bring their children to an accident and emergency department, given that the €100 charge will be deferred and they might be able to save €20 here and there towards it in the meantime. Perhaps, this measure mightl alleviate the pressure on accident and emergency departments to some extent, although I am not suggesting it will solve the problem. Much more needs to be done in that regard.
The period of transition and change the health service is going through is very difficult. Senator Colm Burke referred to a budget of €13 billion. While finance is very important, the human resources within the health service are equally and perhaps more important. Medics, nurses and all health professionals and staff are working above and beyond the call of duty to provide a service in very strained conditions, for which we commend them. Managing the change is the most important thing we can do.
When this scheme is in place, 800,000 people aged over 70 years and under six will be able to attend a GP at no charge. This represents one fifth of the population and is a good start by any standard. Taking into account the significant overlap between the 800,000 people concerned and the 43% of the population who have medical cards, I hazard a guess that over 50% of the population will be in receipt of free medical care.
Free for them, that is. We have discussed the first and second steps. Presumably, a third step will be taken shortly. Will it involve free GP care based on an age cohort or another model? Will it be, perhaps, in blocks of six years, up to the age of 12 and later up to the age of 18 when resources and finances become available? While it is a small step, it is more than the minimal step that some have portrayed it as and will continue to portray it as until the Opposition finds some other Government measure to minimise. It is a good day for the Minister of State, the Department and the people of Ireland.
I welcome the Minister of State. While I missed her initial contribution, I listened to some of it in my office and also listened with interest to the contributions of Senators John Crown and John Gilroy. I would not describe the measure as a small or big step backwards or forwards. It will regularise the position for the over-70s who, for a short period, had an automatic entitlement to a medical card before it was withdrawn and a means test system introduced. At least, we are back to a position of certainty for those aged over 70 years, which is to be welcomed. It is interesting that it is happening at approximately the same time as we are receiving the first strong projections on the take-up by GPs of the scheme for those aged under six years at the opposite end of the spectrum. Some of the difficulties in the scheme can be ironed out. Obviously, if the figure remains at 50%, it will be unsatisfactory. I hope further time and negotiations will help to resolve the issue.
Everybody appears to be at one in attempting to move towards some degree of universal health care provision. I have been here long enough to have heard all of the debates and proposals on the Canadian, Australian and Dutch models and sometimes one would think we were talking about a Miss World contest. There is general political agreement that we want every citizen to be fully covered by the provision of at least very basic health care. It has always struck me as unusual when we have had the great political debates on and divides about health care that, since the foundation of the State, whether due to political decision making or the scheme of administration we inherited from the British, we have had, for all its faults, a very basic but effective scheme of universal education. Every child has access, in the broad sense of the word, to free education at primary, secondary and now third level. If we can do it in education, we should be able to do it in the health care system. However, we have a long way to go.
Reading the briefing notes on progress in providing for universal health care and what has and has not happened since 2011, I appreciate that there have been many road blocks and that the final product may be very different from what was initially proposed a number of years ago. All of us together must try to ensure that, to use the phrase often used, the state of citizens' health should not depend on the size of their wealth. That should be our starting principle. I have never engaged very much in the debate on public versus private health care. As long as health care is provided, the provider does not concern me greatly.
Where does the scheme fit in in the move towards universal health care? Is it a component or a separate part? Senator John Gilroy also raised this question. Is it expected that in the next stage it will be rolled out to those aged under 12 years and over 60, for example? It would still be a welcome stand-alone solution to a problem. Part of the problem has been that the over-70s, for a limited period, had a so-called free medical card which was then withdrawn. That problem needed to be solved and this measure will solve it. Is it a separate resolution of that issue or an integral part of a universal health care model? I welcome it.If we can do it for over-70s and get GP buy-in, which appears to have been obtained, we can, I hope, manage it at the other end of the spectrum as well.
Many GPs have expressed to me in a fair and balanced way their strong concerns about some of the implications of the under-sixes scheme. Some feel simply that it is not fair that children, regardless of income, have access to care, while others fear the knock-on effects in their surgeries with the number of people arriving under the scheme. I hope the Minister and Minister of State are at least taking their concerns seriously. We must all recognise that if only 50% of GPs have signed up to a proposed national scheme, it is not a protest but rather a sign of problems which need to be addressed on an ongoing basis. As such, I welcome the legislation and look forward to the Minister of State's response to our observations.
I thank everyone who made a contribution to the debate. It is such a small Bill that it is difficult to take it apart and analyse it. I have always listened to and respected what Senator John Crown has to say as anyone who works within the system must be listened to, but in my view this is an incredible step in relation to the circumstances of the country. I am not talking about the economic circumstances now, but about where we find ourselves and the type of access we have had to primary care in the main in the past. Once one has a means-tested system, one will always have someone who is just outside of it. There is always the hard case in that scenario. We would love to be able to introduce a system of universality right across the population but we cannot, unfortunately, afford that right now.
There are issues around the principles attached to this. As Senator Bradford rightly points out, we do not ask people to pay for the education of their children no matter what their income is. We take it as a given. It is a benefit to the country that people are educated and, therefore, we find that investment is good for both the population and the country. Good health is equally important and as beneficial to the country as a whole as it is to the individual, which is hugely important. This is a significant step. For the first time ever, we are rolling out universality to a particular block of people and that will progress. The promise in the programme for Government is that it will extend to 12 year olds, which is what Senator Gilroy asked about. That is to say children of primary school age will be covered and then it will progress to 18 year olds. There is no commitment beyond that. However, it is hoped it will move on to a different cohort under the next Government, which, again it is hoped, will be composed of the parties to the current Administration. I hope it will move to the group of people who are the wealth producers and who should be the healthiest within the community. That is a significant step forward. Other countries looking in at us will probably say: "What is the big deal? We have always had this." That simply indicates how far behind we have been in terms of how we have provided access to health care to people.
I note to Senator Crown that, thankfully, this is one of the few areas for which I do not have direct responsibility even though I have a huge interest in what happens in our accident and emergency units and acute hospitals. I hope the changes we are making in primary care will have an impact on the acute hospitals. They should. Another programme we are about to roll out very shortly is the minor surgeries programme for which we have earmarked 20 sites nationally. At these, minor surgery will be carried out in the GP surgery setting. That should have an impact on our accident and emergency units and attendance at our acute hospitals. The building up of the primary care sector should relieve the pressure on our acute hospitals. I will not say here and now that it will, nor will Senator Crown, as we cannot be certain. However, I cannot think of any other way to do it other than to ensure people who have a difficulty with their health go to the most appropriate place. That is rarely an accident and emergency unit, which should be reserved for exactly what is indicated in the protocol.
The asthma checks are simply for the under-six cohort. We already have dedicated specialist nurses in place in certain primary care settings. I note to Senator Thomas Byrne that, as we all know, asthma is about control and management and we hope this will benefit children into the future. As such, this will naturally continue along in the process of the roll-out of the medical card to under-12s and under-18s. I am hopeful about that.
I heard recently on "Morning Ireland" something that comes up time and again, which is that we are giving medical cards to the children of wealthy people while sick children are not getting it. The number of discretionary medical cards has increased since January 2015 from 50,000 to more than 80,000. It is a better and more sensible and sensitive way of doing things. Any child in those circumstances who makes the right case to the PCRS will get a very good hearing. The discretionary element of the scheme is how it should be handled as no one wants to see a family with a child in distress having to go through the trauma of trying to get the services they need. That is one way of dealing with it.
I have already noted that we are rolling out minor surgery at 20 sites nationally. If the project is seen to work, we will roll it out further. All of these things coming together should provide greater access to primary care at local level. At the end of the day, the last place most people want to be is in hospital unless there is no other alternative. We all want to be treated near our own homes and in the most appropriate setting possible.
I commend the Bill to the House. It is a good piece of work for the country and while it is a fulfilled promise and commitment of the Government, every politician should be able to take pride in it. It is something we will look back on and ask why we did not do this sooner.