Speeches

Minister White, Health (General Practitioner Service) Bill 2014 Second Stage Speech – Dáil Éireann, 28 May 2014

I move: “That the Bill be now read a second time.”

1. Introduction
It is my pleasure today to introduce the Second Stage of the Health (General Practitioner Service) Bill 2014 to the Dáil. The Bill will provide for a GP service to be made available without fees to all children aged five years and younger.

The key features of the Bill are:
• It provides an entitlement for all children aged five years and younger to a GP service without fees;
• It removes the need for children aged five years and younger to have a medical card or GP visit card under the GMS scheme to qualify for a GP service; and,
• It provides that the HSE may enter a contract with GPs for the provision of this GP service to children and provides that the Minister may set the rates of fees payable to GPs for this service.

I am also very pleased to inform the House of the conclusion of a Framework Agreement with the Irish Medical Organisation (IMO) which sets out a process for engagement concerning the GMS/GP contract and other publicly funded contracts involving General Practitioners (GPs). This Agreement has been reached following a series of discussions with the IMO and involving the HSE and the Department of Health led by myself. The process got under way following my invitation to the IMO at their Annual Conference on 26 April 2014 to enter ‘talks about talks’. I am pleased that these talks have now culminated in the drawing up of this Agreement. The Framework Agreement sets out an agreed process for engagement on all aspects of the GMS contract with GPs, with due regard to the IMO’s role as a representative body of medical practitioners, and within the context of the provisions of the primary legislation that will underpin the introduction of GP care free at the point of access. I now look forward to a meaningful engagement  with the IMO on the GP contract.

2. Background and Reasons for Introducing Bill
The Government is committed to introducing, on a phased basis, a universal GP service without fees for the entire population within its term of office, as set out in the Programme for Government and the Future Health strategy framework.

As announced in the Budget, it has been decided to commence the roll-out of a universal GP service by providing all children under 6 years with access to a GP service without fees. Additional earmarked funding of €37m was provided in Budget 2014 to fund this first phase. It is not funded on foot of savings implemented elsewhere in the health system. The 2013 Report of the Expert Advisory Group on the Early Years Strategy recommended providing access to GP care without fees to all children in this age group. There are good reasons to provide universal access to GP care in view of the health needs of that age cohort. The early identification of health issues at a younger age can mitigate or reduce the impact of ill-health later in life. We should bear this in mind, given that the Growing Up in Ireland survey has reported that almost 1 in 4 children in Ireland are either over-weight or obese, and the likelihood that this will lead to significant health issues later in life. When this first phase is in place, approximately one-half of the population will be covered by a GP service without fees at the point of use. The Government is in the process of examining the next phases of extending the universal GP service.

Deputies will be aware that our current arrangement of health care provision can be traced back to the mid-nineteenth century with the 1851 Poor Relief (Ireland) Act, where limited services were provided to those who were unable to pay for them. This, speaking frankly, I find is astounding. I believe it is an anachronistic and inappropriate basis for a twenty-first century health system and is far from any comparable modern health system of any other European country. It underpins the importance of moving towards a health system based on universality of access. The concept of eligibility has been somewhat amended by legislation, most recently in 1991 and 2005. However, the fundamental principle of means-testing access to health services was retained by the Oireachtas on both occasions.

One result has been that the means-based legislative framework has produced a very complicated eligibility system, which must take account of a person’s “overall financial situation” as stated in the Act. This system is very likely to confuse, and almost certainly makes it impossible for a person to know whether they qualify for a medical card. It is quite clear from the real concerns raised by members of the public that there are difficulties for some persons with permanent conditions obtaining access to health services under the medical card scheme. This is a problem that we must address. It is being treated as a matter of priority by the Government, and I can tell the House that we are actively examining the issues and working towards a solution.

I have stated before that I believe that 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. I recognise that a move from a means-based eligibility system to a universal-based system of health coverage is difficult, and that many anomalies arise. Members and others are perfectly entitled in the course of the debate to point to these anomalies and contradictions as they see them. We must try as best we can to address these issues in a sensitive and pragmatic fashion. However, the Government’s commitment is to fundamentally reform the Irish health system in the way we have proposed. In that context, I would like to hear more from our critics  about any alternative approaches they may have to the organising of health care coverage in Ireland, apart from maintaining the existing system.

It has been suggested – though perhaps not in this House – that people should be eligible for a medical card on the basis of their having a particular medical condition. On the face of it, it is manifestly right that if you have an illness you should be able to access the health service. This is of course at the heart of the reform we are seeking to bring about, and I passionately believe that it is something that we, as legislators, should strive together to deliver.  However, in seeking to supplement our current inadequate means-based system with an illness-based approach, there is a risk – a risk – that we could cause unintended consequences, and I think that we, as legislators, should examine and consider these risks when we are looking at changes.

Personally, I would not advocate an illness-based eligibility system as a long-term solution that would result in the health service inadvertently only treating people with certain conditions, while excluding people with other conditions from care. We are in the process of re-orientating the health system from one that only treats sick people to one that keeps people well. That is one reason why I believe that a universal system is the best option.

However, these major reforms take time. I think we should consider and explore how best the existing eligibility system can be adjusted to ensure the people on low incomes, or who have permanent or terminal conditions can obtain timely access to the health system. There is a good case to say that the existing eligibility system has become overly complex, resulting in people focusing on the assessment process rather than on the provision of services. I think we should not lose sight of the fact that an ill person should be able to receive primary health services in their own area. At the same time, we must remain steadfast, and  committed  to implementing the most radical reform of the Irish system in the history of the State – and to developing a universal system that treats all according to their health needs and not their means.

3. Summary of Substantive Provisions
The purpose of this Bill is to provide for a general practitioner service to be made available without fees to all children aged five years and younger. The Bill provides that the HSE shall make available a general practitioner service without fees to all children aged five years and younger.   The Bill also provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained General Practitioner for the provision of GP services to all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six month period following commencement of the section.  Such a contract shall specify the services to be provided by the GP.

The Minister for Health may by regulation, with the consent of the Minister for Public Expenditure and Reform, fix the rates of fees and allowances to be paid to GPs for services provided under these contracts. The section requires that the Minister in making a regulation for this purpose must engage in consultations, and it prescribes the role of the Minister and HSE, the nature and manner of the consultations, and the considerations to which the Minister must have regard in making regulations. Where the rates fixed by regulation under this section are varied under subsequent regulations, a GP who does not wish to continue providing services may terminate his/her contract by giving the HSE three months’ notice.

As all children aged under 6 years will be covered by the new GP service under this Bill,  it removes children who have not yet attained the age of six years from the existing GP service under the medical card scheme. However, it is important to be very clear that children aged under 6 will continue to qualify for medical cards, and their entitlements to other health services, such as prescription drugs, will not be affected in any way.

Among the other provisions of the Bill are amendments to the existing legislation relating to appeals under the Health Act 1970. It provides that the current HSE appeals process be extended to decisions regarding the operation of the new GP service for all children aged five years and younger, and also provides that the Director-General of the HSE appoints persons to carry out appeals. It clarifies that where the person carrying out an appeal is an employee of the HSE, that person shall hold a grade senior to the original decision maker. The existing provision in the Act that the Minister may make regulations in respect of the appeals process is re-stated without change.   The Bill also amends the existing ‘ordinarily resident’ framework in the Health Act 1970 to reflect changes made in Section 2 and extends the framework to include the new GP service for all children aged five years and younger.   Before I explain the main provisions of the Bill, I wish to advise the House that the Heads of the Bill were forwarded to the Committee for Health and Children for pre-legislative scrutiny. Unfortunately, this was somewhat delayed as operational protocols regarding pre-legislative scrutiny were not yet available at the time. As a result, the Bill was published by Government before the committee had had an opportunity to discuss the proposals. However, I do look forward to detailed discussions with Deputies at the committee stage of the Bill.

Section 2 amends the existing legislation relating to appeals under the Health Act 1970. It provides that the current HSE appeals process is extended to decisions regarding the operation of the new GP service for all children aged five years and younger and also provides that the Director-General of the HSE appoints persons to carry out appeals. It clarifies that, where the person carrying out an appeal is an employee of the HSE, that person shall hold a grade senior to the original decision maker. The existing provision in the Act that the Minister may make regulations in respect of the appeals process is re-stated without change.

Section 3 amends the existing ‘ordinarily resident’ framework in the Health Act 1970 to reflect changes made in Section 2 and extends the framework to include the new GP service for all children aged five years and younger.

Section 4 removes children who have not yet attained the age of six years from the existing GP service under the medical card scheme under section 58 of the Health Act 1970, as they will be covered by the new service under section 58B. As I mentioned above, it is important to be clear that children aged under 6 will continue to qualify for medical cards and their entitlements to other health services, such as prescription drugs, will not be affected in any way.

Section 5 provides for the insertion of sections 58B and 58C into the Health Act 1970.

Section 58B provides that the HSE shall make available a general practitioner service without fees to all children aged five years and younger.  It provides that a parent or guardian of a child seeking access to this service should provide to the HSE such evidence as it considers necessary to demonstrate entitlement to the service, and where such evidence is not provided the HSE may treat the child as if he or she is not entitled to the service.  Where possible, the HSE will offer a choice of GP to those accessing this service.

Section 58C provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained General Practitioner for the provision of GP services to all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six month period following commencement of the section.

The contract shall specify the services to be provided by the GP. The Minister for Health may by regulation, with the consent of the Minister for Public Expenditure and Reform, fix the rates of fees and allowances to be paid to GPs for services provided under these contracts. The section requires that the Minister in making a regulation for this purpose must engage in consultations, and it prescribes the role of the Minister and HSE, the nature and manner of the consultations and the considerations to which the Minister must have regard in making regulations. Where the rates fixed by regulation under this section are varied under subsequent regulations, a GP who does not wish to continue providing services may terminate his/her contract by giving the HSE three months’ notice.

Section 6 is a technical amendment necessary to enable the seamless implementation of section 2, which extends the existing eligibility appeals process to the new GP service for all children aged five years and younger.

Section 7 states the short title of the Act, provides for the collective citation of this and prior Health Acts as the Health Acts 1947 to 2014 and includes a standard provision relating to commencement of the provisions of the Bill.

4. Conclusion
In conclusion, the main purpose of the Health (General Practitioners Service) Bill 2014 is to amend the Health Act (1970) in order to provide for a general practitioner service to be made available without fees to all children aged five years and younger. The Bill provides that the HSE shall make available a general practitioner service without fees to all children aged five years and younger.

The Bill also provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained General Practitioner for the provision of GP services to all children aged five years and younger. However, the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six month period following commencement of the section.  Such a contract shall specify the services to be provided by the GP.

I commend the Bill to the House and look forward to hearing the views of Deputies.