Thursday, 30 May 1991
Seanad Éireann Debate
Minister for State at the Department of Health (Mr. Flood): I am very pleased to bring the Health (Amendment) Bill, 1991, before the House today. This Bill is important legislation which will provide for the restructuring of eligibility for health services, as agreed by the social partners in the context of the Programme for Economic and Social Progress adopted earlier this year. The Bill also provides a statutory basis for the operation of a residency qualification in order to avail of health services and provides for the abolition of the income ceiling for payment of the health contributions, as announced in the budget.
I propose to discuss each of these areas in detail. First, however, I consider it important to set out the background to the Bill and the reasons for making the proposed changes to the current eligibility system.
The Bill arises from the Programme for Economic and Social Progress, which was agreed between the Government and the social partners at the start of the year. It is appropriate, therefore, that I should remind the House of the major commitments which it contains in relation to the health services. The programme commits the Government to investing, over a seven-year period, no less than £100 million of additional capital expenditure to the development of community-based services for the elderly, for persons with a mental or physical disability, for the psychiatric services, for child care, for the improvement of dental services and for the provision of new health centres. We are also committed to significant increases in the level of day-to-day spending on these services, so that we will, by the end of the seven-year period, be spending £90 million more than the present level of current expenditure, in real terms. The Government are committed to providing additional funding in each year's budget to achieve these  targets, and a significant start was made with the allocation of £8 million this year.
It is also very important to stress that the development of community-based services which will be possible as a result of this expenditure is going to take place in a very co-ordinated and planned way. Over the past few years working parties and study groups have carried out detailed reviews of the various services and have identified the necessary direction and priorities for their development. Senators will be aware of the work of, for example, the Review Group on Health and Welfare Services for the Elderly, the Study Group on Psychiatric Services and the Review Group on Mental Handicap Services. Under the programme, the key recommendations of all of these reports will be implemented.
It would be very easy to provide health services to everyone's satisfaction if money were no object. Unfortunately, the costs of providing health care are so high, and the potential demands on the service so limitless, that we will always face resource constraints and the difficult choices that go with them. This will be true no matter what level of funding can be provided. It is crucial, therefore, that our decisions on the development of services and the way in which we make them available are based on the most thorough and expert analysis of the needs to be set and the best way of meeting them. The Programme for Economic and Social Progress involves a radical overhaul of the health services, and I believe that one of its great strengths is that the various proposals are backed up by the research and analysis of the expert groups that I have already mentioned.
The programme's commitments in relation to eligibility provide further examples of the Government's approach to taking careful account of expert research and analysis in adapting the health services to meet changing circumstances in our society. The report of the Commission on Health Funding, which has been generally acknowledged as an exhaustive and most valuable examination of the funding and administration  of the health services, was published towards the end of 1989. The Government then embarked on a consultation process on the commission's recommendations to ensure that we had the firmest possible basis for our decision on their implementation.
The commission made a number of recommendations in relation to eligibility. These were subsequently endorsed by the National Economic and Social Council in their important report, A Strategy for the Nineties, which provided a significant backdrop to the discussions with the social partners on the new economic and social programme. The Irish Congress of Trade Unions, in particular, pressed for the inclusion of the measures in the programme and this was agreed between the Government and the social partners.
One of these measures, which did not require any amending legislation, was to have the chief executive officers of the health boards carry out an early review of the methods of assessment used throughout the country for determining eligibility for the medical card. There is a need for these procedures to be flexible to ensure that no person in genuine need of a medical card suffers hardship through inability to obtain one. However, the commission had also highlighted the need for uniformity and consistency in the assessment procedures so that persons in similar circumstances are assessed similarly in all areas.
I am pleased to inform the House that this review has already been completed and that, on foot of it, the chief executive officers have now agreed uniform procedures for assessing eligibility for the medical card, which will operate consistently in all areas. In addition, the chief executive officers have agreed that income from the social employment scheme and the family income supplement will in all cases be excluded when an applicant's income is being assessed. These changes are very welcome and have been sought for some time.
The removal of the income limit for eligibility for category 2 health services was one of the major recommendations  of the Commission on Health Funding. At present there are three categories of eligibility: category 1 are entitled to the medical card and to receive a comprehensive range of services; category 2 are entitled to the hospital services card and receive a more limited range of services, which does, however, include free hospitalisation subject only to the £12.50 per day charge up to a maximum of £125 in any 12 months; category 3 have the same entitlements as category 2 with two exceptions: they cannot avail of consultant care as a public patient and they cannot avail of the free maternity care and infant welfare service which is provided by general practitioners. In both cases, they must arrange to receive these services privately.
It is important to realise, therefore, that the difference between category 2 and category 3 relates only to a person's liability for professional fees. Everyone in either category has the same entitlement to a bed in a public ward, paying only the £12.50 charge where it applies. The removal of the income limit for category 2 — in other words, the abolition of category 3 — does not have any effect whatsoever on the number of people entitled to public ward services.
The commission put forward a number of arguments for removing the income limit — arguments subsequently endorsed by the National Economic and Social Council. These arguments can be summarised in two sentences: first, that it is impossible to operate the income limit fairly; secondly, that the existence of category 3 can, in practice, work against equitable access to public beds.
As regards the first of these arguments, there are several well-known difficulties in the operation of the income limit. Ostensibly, the purpose of the income limit is to identify a cut-off point beyond which a person should be able to afford to pay for any necessary consultant care for himself or herself and for any dependants. In practice, the level of income alone is far too crude a measure to identify who can or cannot afford these services, since it takes no account of differing circumstances such as the size of  the family, whether anyone in the family needs regular medical care, and so on.
Furthermore, the only way to operate the income limit without having a very complex administrative system is to rely on the document which most people can produce as evidence of their income, that is, the form P60, or similar documentation from the Revenue Commissioners. Given that half the population are entitled to category 2 services, the House will appreciate the need for a simple method of determining eligibility, and the use of the P60 is ideal in that respect. However, it gives rise to many anomalies. For example, each person in the family who has independent income, below the income limit, can obtain category 2 eligibility in their own right. Since the income limit is £16,700 at present, a family with two salaries of £16,500 is in category 2 despite having a total income of £33,000 — yet a family with a total income of £17,000, from one salary only, is in category 3; a single person earning £16,500 is in category 2 while a large family with a single income of £17,000 is in category 3; a spouse taking up employment, and thus increasing family income, can actually move from category 3 to category 2. This occurs when the spouse of a person in category 3, who, as a dependant, would also have been in category 3, takes up employment at an income below the limit and is thus separately assessed as eligible for category 2.
The second argument relates to the way in which the very existence of category 3 can, in the view of the commission, of NESC and of the Irish Congress of Trade Unions, work against equity of access to public beds. The fact that patients are simultaneously public patients of the hospital but private patients of the consultant — in other words, where a category 3 patient exercises his entitlement to a public bed — involves a danger that consultants may, all other things being equal, admit the fee-paying patient ahead of others, resulting in “queue-jumping” into public beds. There is no administrative device that can overcome this difficulty, since  the decision as to which patient is admitted first is a clinical one which can only be made by the consultant concerned. The only solution is to move away from the concept of having fee-paying patients in public beds at all. There are two possible ways of doing this. The first way would be to remove the entitlement to a public bed from those in category 3. This would mean that the difference between the costs faced by those in category 2 and those in category 3 would greatly increase. Since we have already seen the difficulties associated with the method of identifying those in category 3, the House will appreciate that this approach would only serve to increase the unfairness of the system. The second way is to give everyone the entitlement to avail of a public bed, as the public patient of the consultant, but to require fee-paying patients to avail of private or semi-private accommodation. This was the option recommended by all the groups I have mentioned, and it is the approach which is embodied in the Bill before the House.
—modifications in access to beds will be phased-in so that, in general, public patients will be accommodated in public beds and private patients in private or semi-private beds. However — and this is important — emergency cases will always be accommodated even if the appropriate bed is not available.
When the Bill has been enacted the Minister for Health will immediately be making regulations which will provide for  the designation of public hospital beds as public and private, and provide that public patients must be accommodated in public beds and private patients in private beds. There will be provision for emergency cases to be accommodated even when the appropriate bed is not available. The regulations will provide for the gradual phasing-in of the restrictions in access to beds over the next three years, to enable the Minister to ensure that the new arrangements are operating fairly and effectively.
In preparation for the new system, the Department of Health have been involved in detailed discussions with every health board and public voluntary hospital, who have been asked to draw up proposals for the designation of public and private beds and for a three-year phased implementation of the modified system of access to these beds. These proposals are being examined by the Department of Health, who are responsible for co-ordinating the overall phasing and for monitoring the new arrangements as required under the terms of the Programme for Economic and Social Progress. It is important to get the balance right in the designation of beds so as to reflect fairly the patterns of public and private practice. Hospitals have been asked to ensure that their consultants are fully involved in drawing up their proposals.
The clear identification of the status of every patient, as either the public or private patient of the consultant, will be implemented in every hospital, for every patient, from next Saturday, 1 June. Also from 1 June, subject to the enactment of the Bill by that date, the income limit for category 2 services will be removed, so that those who wish to avail of public consultant care may do so, regardless of income. The system of requiring public and private patients to avail of the appropriate designated beds will then begin to be implemented, carefully and gradually, to make sure that the transition works smoothly and effectively in the interests of all patients.
The new identification system will also apply to out-patient hospital services.  Section 7 provides that, in relation to out-patient services also, the Minister will be able to specify by regulation that where a person is the private patient of a consultant he may, as with in-patient services, forgo his entitlement to treatment as a public patient. It also empowers the Minister to specify out-patient hospital charges for private patients. This is consistent with the general approach now being taken, that is, that private patients of consultants should be regarded as private patients of the hospital as well.
Public patients will benefit by having greater access to public beds, as private non-emergency patients cease to occupy these beds. The Department of Health will be ensuring, through their monitoring of the beds designation process, that there is no fall in the number of what would have been regarded as public beds up to now. In certain hospitals there have been beds which are nominally regarded as semi-private but which have up to now been largely occupied by public patients. The appropriate proportion of such beds, based on a detailed examination of their usage, will be designated as public beds to ensure that there is no reduction in the number of beds effectively available to public patients.
The private patients who are occupying public beds will be gradually be absorbed in private and semi-private beds. To some extent, this will be possible by better management of these beds but, where necessary, hospitals will be able to increase the number of private and semi-private beds to cater for the level of private activity. Any increases in the number of these beds will be at the expense of public beds and will be introduced on a self-funding basis.
It is not expected that the changes in eligibility will cause any significant reduction in the proportion of the population who are already insured for private and semi-private care. This view is shared by the Voluntary Health Insurance Board and is borne out by independent research  by the Economic and Social Research Institute. There is, therefore, absolutely no basis for the suggestion which has been made by some Members of the Oireachtas in recent months that the new measures will lead to substantially increased pressures on public wards. All the indications are that the benefits to public patients arising from the measures can be achieved without having to increase the number of public beds or to incur additional costs in the public hospital system.
However, the programme contains a commitment to monitor the operation of the new arrangements. If there are teething problems the Minister is satisfied that they will be overcome and he will take whatever action proves necessary in order to ensure that the fundamental objective of equity of access is achieved to the greatest extent possible.
The Commission on Health Funding placed great emphasis on the complementary roles of public and private healthcare. When those who can afford to do so decide to take financial responsibility for their own hospital expenses, for example, by taking out voluntary health insurance, those who rely on the statutory services benefit also since there are more resources available to meet their needs. It is also unquestionable that public patients, and the public hospital system in general, benefit from the availability in that system of the highest calibre of consultant, which is encouraged by the existence of private practice in public hospitals. The Commission on Health Funding, whose primary concern was so much related to ensuring equity of access to services, argued clearly that there was nothing wrong with people being able to get hospital care more quickly by going privately at their own expense, provided that the public patient has a reasonable service and is not disadvantaged as a result of the private patient's access. It is the scope for such a disadvantage, through the possible queue-jumping of private patients into public beds, which is being specifically addressed in the new measures. The balanced mix of public and private healthcare will continue. The  programme contains a commitment to ensure that the public hospital system continues to cater adequately for the needs of private patients, and that the important role and contribution of voluntary health insurance is not diminished in any way. The announcement by the Minister for Finance in this year's budget that income tax relief on voluntary health insurance subscriptions will be maintained is a practical and positive demonstration of this commitment.
The Bill also deals with one aspect of eligibility which did not arise from the Programme for Economic and Social Progress. The opportunity presented by the need to amend the eligibility provisions in the Health Act is being taken to provide a statutory basis for operating a residency qualification for access to services under the Act. For reasons which I will now explain, it is necessary to do this in order to ensure that groups such as young Irish emigrants and persons working temporarily abroad are catered for fairly and on the basis of standard guidelines.
It has long been the practice to operate a residency qualification for entitlement to health services in Ireland and, indeed, this is the practice in most other countries also. A person is regarded as “belonging” to the healthcare system of the country of residence. If he needs healthcare while in another country, he is subject to whatever arrangements that country makes for non-residents. This would never, of course, mean being denied necessary treatment, but it can mean being liable for the cost of providing it.
In the absence of a statutory basis for the residency qualification, it has not been possible to have any statutory or uniform criteria for determining when a person should be regarded as qualifying. The Commission on Health Funding pointed out that this can lead to uncertainty, and the operation of different criteria in different areas. Under the Bill's provisions, the sections of the Health Act dealing with the two categories of eligibility will both be amended to insert “ordinary residence” as a qualification.  There is also a provision to empower the Minister for Health to issue guidelines on uniform criteria for regarding a person as “ordinarily resident” for this purpose. These guidelines will be for the use of the health boards in deciding on eligibility, and also for appeals officers under the new appeals system on health eligibility matters which is currently being established.
The Bill contains certain safeguards in relation to this issue. Section 9 specifies that the new provision will not in any way affect the arrangements under which residents of EC member states may obtain necessary services, while temporarily in another EC country, on the same basis as if they were living there. The Bill also provides that the powers of a chief executive officer of a health board is available to him to award full eligibility on hardship grounds to someone who would not normally qualify, and will extend to giving eligibility, where it is warranted, to persons who do not meet the criteria for “ordinary residence”.
Before formulating guidelines on the criteria for being regarded as “ordinarily resident”, the Minister for Health proposes to arrange for discussions between the Department of Health and the health boards on the common problems which arise at present in the interpretation of residence. The Minister's intention is to ensure that anyone with a reasonable case for being regarded as eligible for health services here is able to avail of them. In particular, persons temporarily abroad must be catered for. I am thinking here, for example, of recent emigrants who may not yet have established permanent residence elsewhere, and of people who go abroad to work on short term assignments but would still be regarded as maintaining their permanent residence here. The case of foreign students in Ireland is also one which has given rise to differences in interpretation, and the Minister for Health has in mind to specify, following the relevant consultations, that registration for courses of study beyond a specified duration can be taken as qualifying the student as “ordinarily resident”.
 Section 8 of the Bill provides for the amendment of the Health Contributions Act, 1979, to abolish the income ceiling for payment of health contributions. In the budget speech, the Minister for Finance announced that this contribution would, from the 1991-92 tax year, apply to all income, as is already the case with the employment and training levy. As the income ceiling was £16,700, the effect of its abolition is that 1¼ per cent of all gross income over that amount will now be payable, in addition, of course, to 1¼ per cent of the first £16,700. A person earning £20,000 per annum, for instance, will pay an additional £41.25, or approximately 80p per week. Persons earning less than £16,700 will not be affected in any way.
There is no direct relationship between the income limit for category 3 health services and the income ceiling for health contributions. They have differed from time to time and, although they have usually been the same, there is no legal or technical reason this should have been the case. It is certainly not the case that the income ceiling on health contributions is being abolished as any kind of a quid pro quo for the removal of the category 3 income limit. The purpose of the measure is to provide some of the very substantial cost of the development of community based services under the Programme for Economic and Social Progress. As I outlined earlier, this will involve capital investment of £100 million over the next seven years, and will also involve yearly incremental increases in the level of current expenditure so that annual current spending on these services will be £90 million higher in real terms in seven years time than would have been the case in the absence of the programme. The total amount of additional spending over the seven years will thus cumulate to several hundred million pounds, and this will enable us to transform our community based services along the lines recommended by the various working parties and study groups in recent years.
In this context, I believe that the decision to draw a greater yield from the health contribution, without in any way  affecting those earning under £16,700, is more than justified. This income will also enable any costs to be met which arise from the eligibility extension, although I should stress that it is by no means certain at this stage that the eligibility measure should give rise to any significant extra costs, for reasons which I discussed earlier.
To conclude I wish to summarise the various initiatives contained in the Bill. The Bill sets out new eligibility arrangements which were announced in the Programme for Economic and Social Progress. These measures go towards rectifying a number of anomalies identified by the Commission on Health Funding and the National Economic and Social Council which arise in determining eligibility for hospital services cards. I have in my speech explained in detail the fundamental problems inherent in the current practice of using income as the primary criterion.
The new arrangements will, I must stress, be of significant value to public patients and will lead to more equitable access to public hospital care. In improving the position of public patients, the new arrangements will also continue to ensure that the public hospital system continues to cater for the needs of private patients. Our public hospitals benefit greatly from having a balanced mix of public and private practice and the Government will strive to ensure that this balance is maintained.
In preparation for the new system the Department of Health have been involved in detailed discussions with health boards, public voluntary hospitals and the medical organisations to establish the actual mechanisms for the implementation of the new measures.
The operation of the new arrangements will, as provided for in the Programme for Economic and Social Progress, be monitored by the Department of Health during the three year phasing in period to ensure that the system is working as intended.
I am satisfied that these measures will be effective in improving equity of access to public hospital services and in the light  of the huge body of independent support for these measures, I am assured that they have overwhelming support. I commend the Bill to the House.
I want to put clearly the position of my party in relation to this legislation. We will be opposing Second Stage for very considered reasons and not on any loose consideration. We believe the Government are now almost officially adopting a wrong set of priorities in the health area. People earning over £17,000 per year never asked for this amendment and they were not looking for it. I do not consider it a priority item on the health agenda at present. In a Utopian situation, I would love to see the day when such would be the case. However, it is not too late for the Minister to think again and to consider going back and identifying the real priorities in health. This amendment is not one of them.
I can imagine people being impressed by it on first reading. I am convinced that Senator Farrell will make it look quite a pleasant document, and that is how it appears on first reading but the reality is something different. At present we have huge numbers of people waiting for hip replacements, 2,400 people waiting for tonsillectomy operations, 3,000 people waiting for cataract operations and 1,000 people waiting for heart by-pass surgery. At the same time, there is a massive cutback in the money for each health board area. In the North-Eastern Health Board area we will suffer a cutback of £2.5 million this year in expenditure. We have 66,000 carers around this country who should be getting assistance but they are not. We do not have an adequate system of respite care. We have huge waiting lists at present. We do not have adequate outpatient care. On top of all this, despite many platitudinous commitments to the contrary, we have never properly addressed the question of providing an adequate public health service.  That is why I do not consider this legislation a priority at present. We have 103 haemophiliacs waiting two years for compensation. It would be much better if that question were addressed.
In the Minister's constituency, the Tallaght Hospital project has been put on ice and I would consider that a great health priority at the moment. Throughout this country there will be seasonal closures of hospital wards. That is proposed in virtually every health board area. In all the hospitals at present the nursing profession, the people at the coal face of delivering our health services, are operating under incredible stress, are operating in extraordinarily difficult situations and are definitely in need of extra staff. The other night I attended a very well conducted, very reasonable public meeting on the health services in Carrickmacross organised by the Irish Nurses Organisation. All the nurses had stories to tell of incredible levels of stress, of an incredibly low level of morale and of incredible levels of need in each of the hospitals in which they were working. Their stories were extraordinarily depressing. I could not sit through an experience like that, listen to those people and come here today and do anything other than oppose this legislation which is not a priority item on the health agenda. That is what I proposed to do.
There are a number of difficulties with the legislation. The first problem is that it is almost an admission of failure on the part of Government, almost a diversionary tactic, almost a straying from the real needs of the health services. The people to whom it is directed, who are meant to benefit from it, are not looking for this facility.
The next difficulty is that there is no extra money allocated to the health services this year to match the number of new people who are supposedly going to come into public treatment. I find that an extraordinary scenario. If that is the case, then the only conclusion one can draw is that there will be a reduced level of service for existing public patients in our hospitals. There will be fewer admissions this year to our hospitals because of the  long seasonal closures that will take place throughout this country this summer. That obviously is an indication that the Bill could not possibly be intended to work properly. We are looking at fewer people being admitted because of longer seasonal closures.
According to the Minister, the philosophy behind the legislation and the rationale for it comes from the health commission report. I welcome that report and consider it to be extremely comprehensive, interesting and worthy of consideration by everybody in public life. But when the health commission recommended extending eligibility for health care they advocated it as part of a package which would include a common waiting list system. They advocated a common waiting list system in which I passionately believe and would commend as the correct strategy for the health services at present.
A common waiting list system would mean that people would be admitted to hospital irrespective of means on medical needs alone. They would gain priority for admission to hospital on the basis of medical need. That seems to me to be the only logical, equitable and decent system. That was the context in which the health commission advocated extending eligibility. The Minister has decided to maintain the existing system and not to operate the common waiting list system. We are going to continue with two waiting lists. The Minister, in his speech, said his biggest difficulty with the common waiting list was one of practical implementation. I do not accept that. Implicit in that — although it was not the intention — is an insult to the medical profession. I believe the medical profession would co-operate in operating a common waiting list system. I also believe that mechanisms could be put in place at departmental and health board levels to monitor the common waiting list system and to ensure that it worked.
After a year of operating the common waiting list system on an even more regular basis, we could look at the numbers of people, the socio-economic classes they came from and whatever, who were  gaining admission to hospitals. It could be monitored and the fact that it is difficult is no reason not to do it. If we were to operate on the principle of not doing anything that is complex or difficult, society could not evolve in any meaningful way and there would be a very little in the way of achievement. Most of the great social successes of our era have been difficult at the outset. It is a false interpretation of the health commission's report to isolate the concept of full eligibility and not to realise that that full eligibility for health services was intended in the context of a common waiting list.
The Gleeson report and the deal with the consultants was arrived at in the context of a common waiting list. That was the thinking behind the Gleeson report. We are spending £35 million on the new deal with the consultants and I am not convinced — and there is nothing in this legislation that would convince me — that that money will filter through to the benefit of public patients. I have yet to be convinced by the Minister that that will be the case.
There was one fascinating aspect of the Minister's speech. The Minister says — and I know this to be the case from media reports and from casual conversations here and there — that there will be the same level of take-up of the VHI. He argues that this is clear from independent evidence and I accept that that might be the case. The consultants have been given an assurance on this basis that there will be no fall-off in VHI take-up. This raises a fundamental question: if there is going to be no drop in the number of people taking up VHI — and that contention is explicit in the Minister's speech — how in God's name will it be attractive for people to stay in the VHI, people who are already in very difficult economic circumstances with mortgages, university fees and a range of personal expenditure? How will those people find it attractive to be in the VHI unless — and this is critical — the public health sector will be worse and that it will be at such a level that it will not be attractive to participate in it. That is the fundamentally obnoxious aspect of this legislation. That is the most  damning feature of it. For what the Minister hopes, in terms of VHI membership, to remain the case, there is an acceptance that there will be a second rate public health system. That is very saddening.
Assuming that large numbers of people stay in the VHI — and I am of the view that they will because of the fact that we are not taking on the health system properly — and pay the extra health levy proposed in the legislation, on the Minister's own admission there is no return for those people who will be the victims of a new and extra taxation load at a time when they are crippled by over-taxation. That is a shocking indictment of the legislation.
The Minister makes the point — and it is a valid observation — that consultants are taking in private patients at present and admitting them to public wards, and that this has to be dealt with. It is the view of my party that this should be dealt with but I do not accept that this legislation is the way to deal with it. I argue that the way to deal with that is to implement, as the health commission and the Gleeson reports intended and as the principles of equity and justice would suggest, the common waiting list system.
We were told on numerous occasions publicly, and indeed recently, that a patients' charter is on its way. In principle I welcome the concept of a patients' charter. It is necessary and can only be a good thing in the health services. However, I find it extraordinary that the Minister has missed an opportunity to incorporate the health charter in this legislation. If it is not incorporated in the legislation and if it is not given some statutory basis it will be nothing more than a sort of statement of what should be the case. There will be no recourse for people to actually gain redress under it. I am not convinced that the Minister is serious about the patients' charter when in fact it is not incorporated in this legislation.
The fundamental position I would put to the Minister on this legislation and the reason I am opposing the legislation and that my party will be opposing Second Stage is that we as a party are absolutely  horrified with the gross tragedies and the gross needs throughout the health services at the moment, with the huge waiting lists, the absence of a complete service and at a time when that is the case the Minister is introducing something we consider to be unnecessary. On that basis all this House can reasonably do is reject this Bill and refer it back to the Dáil because I consider it a waste of time. What we should be doing this evening is discussing how in God's name we can deal with the crisis in the health services at every level and how we can deliver a quality of health care to people in need, how we can deal with the carers, the nurses, with all of the people at the coal face of the health service. That should be our agenda today, not providing eligibility for people who are not looking for it. It is a whole wrong set of priorities. It is quite bizarre and on that basis could not be accepted.
An Cathaoirleach: I must put on the record of the House that Second Stage is intended to deal with the specific purposes for which this Bill is intended. Unfortunately that has not been the case in relation to Senator O'Reilly's contribution. I hope that other Members will adhere to the essential direction in which we should be going on Second Stage.
Mr. Farrell: Fáilte mór roimh an tAire ar an céad tám atá sé ins an Teach seo. I welcome the Minister of State to this House. He had wide experience of health matters before he took up office. His involvement with the health board and in the health services in the city of Dublin has given him a broad experience of dealing with health. I wish him every success in his new ministry.
I welcome the Bill. I will quote the old old proverb: He that has no time for his health today may have no health for his time tomorrow. At present this is the biggest problem we have, so many people are abusing their health to such an extent that they are putting increasing demands on the health services, particularly in regard to the abuse of alcohol, drugs and so on. This causes many serious road  accidents and other problems and is putting great strain on the health services. This year we are spending £1,500 million on health services, that is £400 per head of population. When you consider all the people who do not go to hospitals, when you consider all the people who are in the VHI, what is it costing per head of those who are attending hospitals? We always talk about there not being enough money. Of course there will never be enough money for anything. It is only a short time ago since we were told that if we got £1 million more per health board, it could leave us quite happy, £8 million would solve all of our problems. The Minister gave us that £8 million, £8 million extra this year. It has allowed much good work to be done and to continue to be done but I would also like to point out that during the run of this programme before us each health board will be receiving £11 million extra because there is going to be £90 million extra provided under this Bill, that is £11 million extra per health board. To say that there will not be sufficient money to run this does not make sense. There was no real opposition to this Bill from the other side.
I welcome the change in regard to medical card eligibility. This is something we have been talking about for a long time. Under the medical card system, when applicants were being assessed, social employment scheme money and family income supplement were taken into account. We always opposed this. Indeed the North Western Health Board sent in resolutions which I gladly supported, to have that system abolished. It was very unfair that we should take that type of income into account when assessing means for a medical card. Under this Bill such income will not be taken into account. We are going to have a more solid and honest base for assessing medical card eligibility. I believe that will be a great advantage to many people in the lower income groups.
It is right and proper that everybody should be entitled to free hospital beds. What happened in the past was that there was a certain number of beds. Many consultants ensured that they put the  maximum number of private patients through their practice and they put them into public beds. Medical card people and the public health people were left in the queue longer and longer, many of them hoping that some rich uncle or someone else would come along and give them the money. There is one thing I can never understand about hospitals. We hear all about people being overworked and overwrought but we should have a balance, and we do not have that balance. There must be good wages, good conditions but there also must be good production.
It always amazed me how you could be on a waiting list and have to wait perhaps two years while at the same if you decided to go private the same staff could take you in straight away. There would be no problem. If staff are so overworked how can they take in people who have money in their pockets? It makes a farce of saying that they are overworked. I am pleased that this Bill will put an end to that system and put an end to queue jumping. Those who go private will go into private beds and the public beds will not be taken up by fee-paying patients. People with medical cards who want to go public will be able to do so and get full treatment. That is the good thing about the Bill before us. It is flexible because often people who go to England for a short time are taken off the register, which is the usual way of knowing whether a person is in residence or not. If they are off the voters' register they must not be in residence. Even if they are not on the register they could still be in residence because they might have gone for a short time. I am pleased also that tourists will be covered under EC regulations and nobody will be left in need of medical care.
A point was made about the closure of beds during the summer. This is nothing new. Much has been made of this in recent times but the beds are those reserved for patients for elective treatment, that is, treatment that is not urgent. In many cases the people waiting for elective treatment never go for it. We are told by the professionals that they  cannot carry out this treatment without having a full backup service and assistance. Therefore, if we were to keep this system going all year round we would have to double the number of staff, appoint more consultants and more backup service. That would be impossible. It is only to facilitate people going on holidays that wards are closed. Wards have to be refurbished, decorated and maintained and a period in the year has to be set aside to do this maintenance. While the ward may appear to be closed it is being refurbished for the coming year. It is not right to be making this hullabaloo about closure. This has always been the case down through the years.
The previous speaker referred to the waiting list for hip replacement operations. I am pleased to say that in my health board area we have now four orthopaedic surgeons while a few years ago we had only one. I believe that the hip replacement waiting list will be up to date very shortly. It started only a few years ago and for a number of years people were afraid to go for the operation. It has become so successful that people are availing of it and it is great that they can do so. We are going to have more problems in this regard because joint replacement is now becoming the big thing. Hips, knees and other joints are being replaced. High tech medicine is very good but there is a limit to what we can spend. It is in high-tech medicine that the holdup and delays occur; it is not in the ordinary medicine as we knew it some years ago.
There is no such thing as an emergency that cannot be treated. No matter what emergency there was here over the years, the one thing every public representative did was to pay tribute to the hospital services for the able manner in which they dealt with each emergency that arose. There is no problem about emergencies.
I welcome the Bill. I have no doubt that it will be for the betterment of all. Many people have been asking for years that everybody be entitled to free hospital treatment. In the past people paid consultants for the operation and then the  hospital had to provide the remainder of the services. Under the new system, if patients go private, the hospital will get money; everybody will get money. It will not be a question of the consultant being paid and the hospital providing the services. That will work for the benefit of everybody.
Mr. B. Ryan: The only way to describe this Bill — since it attempts to go in the direction in which I would like the medical services to go, but does not go half far enough, and I cannot oppose it — is that it is profoundly dishonest, because it does not do what it sets out to do. It does not give people free hospitalisation in a public ward. The best it does is to guarantee people that for the first 30 days of a year that they are in hospital they will not have to pay more than £125. After that the people are caught by a classic Catch 22, which, may I say, has characterised Governments since 1987 in which they appeared to do one thing on the surface and do the exact opposite underneath.
If I am permitted I will mention two areas as examples. For instance, in the area of poverty they have given the impression that they are doing wonderful things about certain groups while at the same time reducing the taxation element of expenditure on social welfare, and they were actually spending less up to this year than they were four years ago. They reduced expenditure on social welfare and gave the impression they were doing something about poverty. They have done the same job of reducing expenditure on local authority housing in a dramatic fashion, but giving the impression that they were doing something about some of the more spectacular needs. What they are getting very good at is identifying the area of need in a particular category and saying, “We will target that group and we will be very good about this group.” They are doing things that of themselves are extremely good, for instance, about homelessness, homeless children, certain categories of poor people and the unemployed, while at the same time cutting back severely on  all other areas of expenditure in those areas.
What we have is a very clever way of making the less poor pay for some remedial action on behalf of the extremely poor. We do it via social insurance on small incomes to pay for higher unemployment assistance for long term unemployed people. We do it by reducing public authority housing and using a proportion of the money saved to do very publicly acceptable high profile things about homelessness. That is a very clever trick that both the present Coalition and the previous Fianna Fáil Government have become expert at. This one is a classic of its kind because nowhere in the Minister's speech or in the legislation will one see any reference to Statutory Instruments No. 180 of 1976, which states:
A charge towards the cost of inpatient services provided under section 52 of the Act may be made on a person who is not a person with full eligibility where a person (a) has no dependants and has been in receipt of inpatient services for 90 days or for periods aggregating in total 90 days within the previous 12 months. The charge under this article shall be at the rate not exceeding the income of the person, less a sum of £2.50 a week or less such larger sum as may be determined by the chief executive officer of the health board.
What that means is that after 90 days a person could be charged their full income, less £2.50 a week. That was the figure in 1976 and it is still the figure today. The health board on the arbitrary judgment of a chief executive officer can deduct everything out of a single person's income except £2.50 if they are in a hospital for more than 90 days. The rationale behind that was that they were people who were in long term institutional care.
However bad that was, it went from being a reasonable object of complaint to being entirely ludicrous when the Minister  for Health, Deputy O'Hanlon, introduced Statutory Instrument No. 300 of 1987, which sought to bring the other one up to date by reducing the period from 90 days to 30 days. The situation today is that after 30 days in any hospital — and there are no exceptions to this — a single person may have their whole income deducted to pay for the cost of hospital care. Something that began as a provision for long term patients has become a backdoor method for health boards to raise funds. The only statutory limit is the cost of care or the person's income. Generously enough, they have provided that the person can have £2.50 a week left out of their income. That is the only guarantee people have in legislation about what can be done.
How can we wave a bit of legislation around and say, this is great; this is free hospitalisation? It is free hospitalisation if you are not sick for longer than 30 days in a year, but if you get sick for any longer it is far from free. If you happen to be confined to a psychiatric hospital and you observe the obscure regulations of the VHI, you will discover that if you are actually at work and on sick leave the VHI will not cover you either. This is, as I have said, a classic.
It is disappointing in the extreme that neither the Commission on Health Funding nor the trade union movement or anybody else seems to appreciate that we do not have any right to free hospitalisation for anybody for more than 30 days. For the first 30 days the most you can be caught for is £125. After that you can be caught for the full amount of your income, less £2.50 per week, and the upper limit for what you can be caught for is the economic cost of that bed. It is profoundly dishonest to describe that as free hospital care. It is not free hospital care, but it is a backdoor charge under a gloss of doing something very impressive.
I have a specific case in mind of somebody in one of the health boards. I am not going to say any more than that, because the last time I mentioned a specific case it involved the school where my own children attend and I had the Minister's office on to me wanting to berate the board of management in the school for something I would blame the  Department of Education for. I do not want that to happen, so I will not be specific. But I know somebody got a bill for £2,700 from a health board because they were seriously ill and had to be in a psychiatric hospital. This is a simple person at work and because the individual has a relatively large income the bill was £2,700. He was in a public hospital, in a public ward, and he got landed with a bill for that amount. This legislation will make not one scrap of difference.
We also know what happened under these two wonderful little regulations that float around on the periphery and which undermine all the wonderful phraseology of all this. These two pieces of subsidiary legislation mean that at least in the health board area I live in, the Southern Health Board, they have a little trick. If you are in hospital for more than 30 days they withdraw your full eligibility on the grounds that you are no longer eligible for a medical card because you are in hospital care. They take away your medical card and then they start charging you after 30 days if you are in the sort of hospitals where you are less likely to protest. They do not do it in acute hospitals, but not because there is any prohibition on it. Let us remember, these regulations apply, there are no qualifications, no limitations, this is a charge for in-patient hospital care. I find it quite extraordinary that we are talking about legislation to make hospitals free while we have regulations under the same 1970 Health Act to charge people for hospital care.
I find the whole thing quite astonishing. It is meaningless. It is a fine and noble gesture for people who have occasional serious illnesses that do not last for more than 30 days. There is no guarantee in this legislation that people will not be landed with enormous hospital bills. Cash strapped health boards have become positively rapacious in their endeavours to collect money. Debt collection agencies have been engaged in my own area to put pressure on old age pensioners to pay their hospital bills under these regulations. These poor people are persuaded by the Government — and, I regret, with the apparent unwitting cooperation  of the trade union movement — that they have an entitlement to free hospital care. They have, if they do not get sick for more than 30 days. The whole thing is ludicrously meaningless. It is a smokescreen because of the existence of those regulations. There may have been some logic to long term patients, that is, those who are in hospital for more than 90 days, having to make a contribution. There is no logic other than the cutback mentality that has run away with this Government in the area of health care, to this 30 day restriction.
It is so extraordinarily ludicrous, I have seen eminent economists of a right wing persuasion talking about the country operating a free national health service that we cannot afford. What really cannot be afforded is the sort of bills that some people are getting when they have the misfortune to be in hospital for longer than 30 days. I find the whole thing ludicrous in the extreme: that people can be stuck with those sort of bills and at the same time we are told we have free hospital care. That is the first major problem.
The second major problem is the extraordinary optimism of the Minister about the capacity of health boards to regulate some of these things. It is a phrase that I think is familiar to everybody. He talks about the improved management of beds as a way of guaranteeing that there will not be any problems with this. We have had four years of ministerial exhortations to improve the management of beds. What we have had is the tragic signs of a particularly non-militant trade union, the Irish Nurses Organisation, who do not have a reputation of being anything other than intensely committed to the welfare of patients, feeling obliged to put their members on strike in the South-Eastern Health Board region because of the state of the hospitals. They are not making it up. Nurses do not go on strike, do not withdraw their labour, particularly nurses in the INO, without considerable provocation and considerable upset to themselves.
That is the reality of this exhortation to good management. It is a reality of overstretched people, nurses in particular, whose commitment to their  patients is being presumed upon shamefully by many health boards, people who are racing around in a state of near exhaustion from overwork, trying to keep up with a burden of work that is ludicrously disproportionate to the resources they have at their disposal. To talk about, as the Minister did, the idea that somehow better management will work is a nonsense.
There are a couple of other things in the Minister's speech that bother me. One is this idea of the categorisation of beds as private or public in public hospitals. It has echoes that trouble me. My view, for what it is worth — and like most middle class people I have Voluntary Health Insurance cover — is that if people want private medicine they should have it in private hospitals. So be it, if they want it let them have it. My view also is that it is a particularly slight assessment of the worth of the best of our medical profession to assume that if we did not allow them to have private practice in public hospitals they would all desert the public service and run into the private sector. There is no evidence to sustain that.
In the United Kingdom many consultants by deliberate choice do not do any private practice, because they are happy to work in the public service on a good salary, doing a public service and doing it in a way which means that medical priority alone will be the criterion on which they will decide to deal with patients. There is this sort of trite suggestion that the justification for continuing to have private beds in public hospitals is so that these poor, sensitive, delicate consultants, who need, apparently, these enormously inflated incomes that they will get out of private practice to keep them in the public service, will not desert the ship. I do not think it is true. I do not think many of them want to.
My view is if the only motive a good consultant has for working in a public hospital, if the only thing that keeps him there is the extra income he gets out of private practice, the public service would be better off without him, because if that is his or her priority then quite clearly the service they will give will not be based on any sort of profound medical reasons but  it will be based on — and this is the Minister's perception not mine — their own greed and their own need to have more and more money. As if the new salary of £35,000, £40,000 or £50,000 was not enough, we have to let them have private practice so that they can achieve whatever sort of inflated income they want, and many of them appear to have a perception of an income that is in excess of that of the Taoiseach.
I do not believe that people need this sort of income, nor do I believe that all of the good recently highly qualified young doctors this country has produced, many of whom are living abroad, would need that sort of income to come home to work full time in a well run public hospital care system. That is entirely ludicrous. It is quite offensive, when you read about it, to assume that this sort of private practice is a necessary incentive to keep good doctors in the public sector. It is not in other countries where they have comprehensive national health services and there is no reason it should be here. If they want to make money let them take all the risks and run a private hospital, not have a foot in each camp with a guaranteed income from the State and a guaranteed guarantee from the State to be able to extend their income by private practice essentially at the State's expense.
The Minister also referred to outpatient services. Can he give us a guarantee that people who are entitled to free outpatient services will be seen by a consultant? From what I know the health system in many cases it is rarely a consultant who conducts those clinics and it is often a junior doctor. The phrase “junior doctor” is one of those concoctions of the medical profession that is profoundly offensive. Some of the junior doctors are senior to half the Members of this House in age and also have perhaps ten to 15 years' experience. But the medical profession has created this kind of profession where the only people who are permanent are consultants. It is a wonderful hierarchial system which keeps everyone else in a state of considerable obeisance to the wonderful consultant, but it is a ridiculous system. There should be career levels for doctors in hospitals at all levels  in the same way as there are in every other area of work. In universities you do not have career professors, with everyone else on their way to some where else. You have people who are employed at various levels and you should have people in various levels in hospitals, not just consultants who are permantent with pensionable positions — not all of them, but you should have some.
What guarantee do the poor misfortunate people who have to depend on the public health service have, if they go to an outpatient department, that they will be seen by a consultant? What guarantee do we have that the people who are not going to be charged for going to outpatient departments and who will get a bill from the hospital will be seen by the consultant and not by one or other of his or her juniors? The truth is we have no guarantee, because nobody can guarantee that these services will be delivered. This legislation is so riddled with presumptions and assumptions about what is happening in the health services as to be almost meaningless. It incapsulates within itself a principle, and therefore you cannot vote against the Bill on principle, but you have to deal with the realities.
I am still intrigued as to the state of play with the new consultant salaries. I have long said that I would be quite happy to support the idea of a dramatic and significant increase in consultant salaries if that would get us cast iron guarantees that consultants in public hospitals would devote their talents exclusively to the service of patients in public hospitals; and if people were not happy with that let them go to private hospitals where the private consultants, taking the risk of working in the private sector, could earn whatever they could command from selling their service on the private market as a perfectly legitimate and reasonable thing to do. As far as I can see — and I have a certain insight into it for domestic reasons — we are far from getting any cast iron guarantee that under the new and extraordinary salaries that have been paid to consultants there will be such a guarantee that they will actually be working in the public sector.
 I do not understand at present how a consultant who is supposed to be in the hospital for 33 hours a week, can also be running a lucrative private practice in a private hospital. For instance, in Dublin many of the consultants in the Blackrock Clinic are attached to other hospitals. Do they have the powers of bilocation, or are they working 19 hour days to be able to look after patients in the public hospitals and patients in the private hospitals at the same time? What is going on? Does anyone know, or are these people accountable to anybody? In my own small area of work in the public sector I have to be in a certain place at a certain time to do a certain job, and it is very easy to identify whether I am there or not. Apparently, it is not possible to identify under the present regime whether a consultant is in the hospital on a particular day, will be there on a particular day or will be there for a particular set of hours. The common contract — and I have read it — has so many bolt holes and ways out.
If the rest of us in the public sector had a similarly benevolent contract available to us, in terms of what cannot be done to us by our management, we would be most grateful to our unions; but apparently our unions, for reasons that are perfectly reasonable, would not be able to extract similar concessions to those that the present Taoiseach granted to the consultants when the common contract was introduced in his period as Minister for Health.
The legislation is riddled with inconsistencies. It is profoundly dishonest. It is a meaningless standing on its head of legislative priorities to produce a Bill which says it is giving people free hospital care while at the same time two pieces of theoretically subsidiary legislation say the exact opposite: that after 30 days you pay up limitless amounts, £200 to £250, if you can afford it, less £2.50. I know it does not operate. In the Southern Health Board area it is 80 per cent of your income. Are they not very generous? They leave you with 20 per cent of your income if you are in hospital for more than 30 days. That is what is wrong with the Bill.
I do not want to spend too much time  on the Minister's speech. There are some things in it which, if they work, are very worthwhile, particularly his reference to some sort of rational approach to eligibility for medical cards. I read somewhere that part of that rational approach would be a rational approach to the process of appealing against refusals of medical cards, because that has been for a considerable period of time a matter of extraordinary injustice. I have always felt it was one that was ripe for challenge in the courts, because in some health boards the appeal against a chief executive officer's decision to refuse a medical card goes to the chief executive officer. You have a person adjudicating on the appeal on his own decision. Could anything be more ludicrous than that? I am glad that that is being dealt with. I am glad that the philosophical principle that underlines this has been accepted, the philosophical principle that people should not be able to jump queues and get into private beds in public hospitals.
I am worried about some of the phraseology about beds being identified as public or private, because the Minister's speech is full of these optimistic assumptions that they will work out precisely to a “t” what proportion of beds are public and private in terms of demand for hospital care. If these workings out are not possible, are we going to end up in a situation with private beds remaining empty in a public ward and public patients being refused because the only beds that are empty are private beds? I accept that in emergencies this will not happen, but for non-emergency care in a hospital are we going to end in a situation where we will have private beds empty, public beds all full and people being told: “Come back next week? There are no beds available for you because you are a public patient” or will we have the reverse? Will we have consultants telling their private patients: “I am sorry, all the private beds are full. There are only public beds empty and you cannot have one of those?” I doubt if we will have that. My view is that at the end of the day it is the poor who will suffer when choices like that have to be made.
I will conclude on this. In regard to these famous regulations that I have  quoted at length, it is wonderful to watch in a cynical sort of a way how they are operated. They are not operated generally in acute hospitals, because patients in acute hospitals usually have articulate families and are often articulate themselves and they can howl. The views about psychiatric patients in psychiatric hospitals are perhaps different. It is one thing to get somebody up at a public meeting and say “I had a hernia and I could not get into a hospital because there were no beds”. It is another thing to say “I was psychiatrically ill and I could not get into a hospital because there were no beds”. Because of the nature of society's perceptions of psychiatric illness most people will not publicly campaign and complain about the quality of psychiatric care because it targets them as being somehow, in terms of public perception, unwell.
Would any member of either House of the Oireachtas get up in public and say “yes I was in a psychiatric hospital for a period of a week or a month” whereas all of us will happily talk about our experiences in general hospitals. There is a stigma and because of that people will not complain very much about what happens to them in psychiatric hospitals and because of that I suspect many health boards believe you can get away with things in terms of psychiatric patients that you would not get away with in terms of patients in the general medical service; hence the application of these mysterious little regulations, where we have the definition of a long-stay patient being anybody who is in hospital for any more than 30 days.
It is another of the sleights of hand that have characterised the last four years where a good thing appears to be being done, while nothing is being done. It is something that, philosophically, if it actually meant anything, would be very worthwhile but, in fact, in the way it will operate will be quite meaningless. We will still, as I said — and this is the fundamental issue — leave large numbers of people liable to substantial bills, old people liable to have all of their pensions taken from them if they are in hospital  for more than 30 days, single working people liable to have all of their income up to the cost of the bed, less £2.50 statutorily and perhaps a bit more, taken from them if they are in hospital for more than 30 days. In such a regime where that sort of unqualified right to charge still exists, to talk about the provision of free hospitalisation is a joke.
Minister of State at the Department of Health (Mr. Flood): I thank those Senators who have contributed to this afternoon's debate which we all found very informative indeed. It is an expression of their own commitment to the Department which I operate in, the Department of Health.
I want to respond to a few points which were made by the various contributors. Senator O'Reilly said he welcomed, in principle, the question of the provision of a patients' charter. This is something that has been welcomed by many people with an interest in the health service, bearing in mind, of course, that the patients' charter will be based on a number of very specific principles. Very briefly, they are: the right of access to services in accordance with need; the right of considerate and respectful care; the right to privacy; the right to information, the right to confidentiality of all medical records; the right to refuse to participate in research projects; the right to respect for religious and philosophical beliefs; and, of course, the right to make a complaint. We all agree that a patients' charter is long overdue. The Minister has given a specific undertaking to have all of those issues contained within the charter implemented without delay. That is something I am quite sure Senator O'Reilly and the other contributors here and in the Dáil will welcome.
Senator O'Reilly also referred to waiting lists. Waiting lists, unfortunately, whether we like it or not, are a feature of all health systems, particularly all modern health systems. The Government have placed strong emphasis on tackling the waiting lists in a co-ordinated way. I wish to give Senators some small example of progress which we have made: the waiting list for hip replacement  operations has decreased by 16 per cent since April 1990; the waiting list for cataract operations has decreased by 12 per cent since 1989. We are making some significant progress in dealing with these waiting lists and indeed for open heart surgery and ear, nose and throat surgery. The purpose of this Bill, obviously, is to help reduce waiting lists for public patients by making public beds more available to them.
Senator O'Reilly also raised the very important question of VHI membership. The Economic and Social Research Institute have carried out an independent research into this issue which concludes that the extension of eligibility for professional fees will not have any significant effect on the proportion of the population who opt to join the VHI. That is an independent research carried by the Economic and Social Research Institute and that is the information available to us.
It is interesting to note also that the majority of the membership of the VHI are in category 2 in terms of health eligibility and are, therefore, entitled to public consultant care. This is some further evidence that extending the entitlement to higher income group should not be expected to affect VHI membership to any significant extent.
At this point also Senator O'Reilly went a little parochial, if he does not mind me saying so, and referred to the North-Eastern Health Board allocation. May I put on the record of the House that the North-Eastern Health Boards 1990 allocation was £61.050 million and 1991 the allocation was £63,855,000, a 4.6 per cent increase.
Senator O'Reilly referred to the Tallaght Hospital, a project in which I have had very great interest. The capital allocation for 1991 for the Department of Health did not allow for the commencement of any major new capital project. In the circumstances the building of the new Tallaght Hospital could not commence in 1991. The Minister for Health is currently drawing up a submission which he will be putting to Government on the capital requirements of the health services in future years. This will include provision for the Tallaght  project. Obviously we are all anxious that the project proceed as quickly as possible. It is a major project at £120 million. It will be no mean achievement to assemble that kind of financing and guarantee it during the course of the construction period. All of us with an interest in Tallaght will be anxious to see the hospital coming forward as quickly as possible.
With regard to the common waiting list to which Senator O'Reilly also referred, this matter was raised in the context of the Commission on Health Funding. There are two serious reservations which we have about the commission's recommendation in this area. First, the recommendation could result in the public patient being disadvantaged. The commission's recommendation relied on the monitoring of admissions to ensure that private patients were not admitted to the available beds ahead of public patients with greater medical need. There could be great difficulties in practice with this recommendation since the decision to admit a specific patient is, and must always be, the clinical decision of the consultant concerned. For this reason the Government and the social partners believed that the public patient would be best protected by ensuring that for non-emergency treatment public beds were available exclusively to public patients.
On the second reservation, I am very much aware that it is the view of those involved that, in the interests of the public hospital system and of the public patient, it is important to maintain the balanced mix of public and private care in our public hospitals. The public patient benefits from the availability of the best and most skilled consultants who can be retained in the public hospital system because of the opportunities for private practice there. Under the new arrangements any increased demand for private care can be met by expanding the number of private and semi-private beds in the public hospitals without disadvantaging the public patient. This expansion will be possible because it will be self-funding. If there was a common waiting list applied to these beds such an extension would not be possible. The likelihood is that the focus of private practice would begin to move away from the public  health hospital system. In the long run this would be much more to the disadvantage of the public patient.
Senator Ryan raised the question of long-stay charges after 30 days. The Minister for Health, Deputy O'Hanlon, stated in the Dáil yesterday that, following the raising of the matter during the Committee Stage debate on the Health (Amendment) Bill, 1991, he has been in contact with a number of health boards to establish the position in relation to acute hospitals. It was the Minister's understanding from his inquiries that the charge was applied in some cases where patients were receiving services of a long-stay nature although they might, in fact, be in acute hospitals. This would include, for instance, certain patients in psychiatric units in acute hospitals and also certain geriatric patients who might, for example, be maintained in an acute hospital awaiting transfer to a geriatric facility. The Minister also announced that, in view of the fact that these charges which have been in operation for 15 years going back to 1976, and are now giving rise to certain problems of application, he was arranging to have a whole area of long-stay charges reviewed by his Department.
Senator Farrell spoke strongly in defence of the public patient. I want to confirm that the whole purpose of the Bill is to ensure that public beds are available for public patients and that, as was the case up to now, private patients will no longer be able to occupy public beds, which may have caused disadvantage to public patients in the past and that in future a private patient who opts to go privately will have to occupy only a private bed except in certain cases of emergency which will apply to both public and private patients.
Senator Farrell also referred in general to the funding of the health service and the provision of high-tech treatment. This is a very important aspect of the delivery of health services involving increased growth in expenditure whereby high-tech treatment can be very costly. This has to be taken into account and is being examined by the Minister in every appropriate case.
Senator Ryan was critical of what he  might have termed as good management aspiration in the hospital setting, particularly as it applied to nursing staff. Good management in any centre is always a good objective, a meritorious objective. One can always improve in management whether it is in the management of technology, the management of base or the management of outpatient departments, etc. Good management is something we need to address in a specific way to the health service in an effort to improve conditions for those who need to do business with the health service. We would all be in agreement on that.
With regard to private medicine being practised in public hospitals, it has been the tradition to mix public and private practice in our hospitals. It has proved useful and assured that consultants are available to the public patients as well. We are anxious that that continues. The mix has also been good. In this Bill we are talking about designating the public bed or designating the private bed and being quite clear in the management of hospitals as to what is a public bed and what is a private bed. It is time that the doubt that existed in people's minds about the classification of beds was removed. That is a primary part of this legislation.
Senator Ryan welcomed the changes in dealing with medical card applications. All of us, who have been involved in any way in public life through our clinics or on a health board, as I have been, will know that there has been very great concern by the public as to the uniformity of approach in awarding the medical card.
I want to confirm, for the benefit of Senator Ryan and others in this House, that the independent medical card appeal system is being established. It will probably be something along the lines of the independent appeals system recently established in the Department of Social Welfare. It gives people an opportunity to have their say and have their cases dealt with rationally, with a high degree  of uniformity which was lacking up to now. We all agree that this decision, with regard to medical card applications, is most welcome.
Senator Ryan also raised the question of consultants and the common contract. Some issues which he raised this afternoon in the course of Second Stage debate have been part of the negotiations with the medical profession which have now been concluded. Many of the points he raised have found their way into the discussions on the common contract and have been included.
I hope I have covered most of the points raised. I want to return to the primary purpose of the Bill which is to provide for the new eligibility arrangements arising from the Programme for Economic and Social Progress. As we have already stated the Programme for Economic and Social Progress provides for the extension of eligibility for public consulant services to the entire population. The programme also provides for the introduction on a phased basis of modifications to the arrangements for admission to public hospitals. These new arrangements will improve equity of access to public hospital services by removing these elements of the present arrangements which may in practice be unfair to the public patient.
I am also very pleased that the Bill provides a statutory basis for the operation of the residency qualification to determine eligibility for health services in Ireland. The operation of the new arrangement for public hospital services will be monitored closely by the Department of Health as provided for in the Programme for Economic and Social Progress. It is clear to me, in the light of the discussions with the social partners, the report of the Commission on Health Funding and NESC, that there is a wide measure of support for the course of action set out in this legislation.
Ó Cuív, Éamon.
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