Health (General Practitioners Service) Bill 2014 Committee Amendments

Minister Alex White  Mr Alex White Minister of State with responsibility for Primary Care

Minister Alex White speaking at the Select Sub-Committee on Health

Introductory Statement by Alex White, Minister of State with responsibility for Primary Care. 

I would like to thank the Chairman for allowing me to make some introductory remarks to outline the legislative proposal for the members of the committee.  I am very pleased to discuss the details of the Bill with the committee today.

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.
  • It will also remove the need for many families with children aged five years and younger to be forced into the situation where they need to consider if their child is “sick enough” to justify paying for a visit to the GP.
  • 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.

Universal GP Service

The Government is committed to introducing, on a phased basis, a universal GP service without fees for the entire population, as set out in the Programme for Government and the Future Health strategy framework. At present, just over 40% of the population can access a publicly funded GP service. The balance of the population, almost 2 and a half million people, must pay the ‘market rate’ for a GP consultation, which is currently in the region of €55 per visit. There are a number of consequences of this situation:

  • It deters some necessary medical care because it is generally recognised as unreasonable to expect an individual to make a good decision on what is necessary and what is unnecessary care. Given the complexity of health issues and modern health treatments, an individual does not have the expertise to make a fully informed decision. That is why the ability to attend a GP is so important as a gateway to accessing care in the health system.
  • This situation also works against growing the role of primary care and preventative care. Clearly, it is difficult for a person to justify spending money today on a GP visit in relation to an issue that may or may not become serious at some point in the future.
  • Finally, it impedes the reorientation of our health system from a hospital focus to a primary & community care focus.

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.

As announced in the Budget, the Government has decided to commence the roll-out of a universal GP service for the entire population by providing all children under 6 years with access to a GP service without fees. However, 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.

As recently as Tuesday, the Minister for Health confirmed that the Government is committed to implementing its agreed policy. 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 Government also announced earlier this week that an additional €13 million will be provided to the HSE to meet the cost of re-instating discretionary medical cards.

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 the under-6’s 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 when the Growing Up in Ireland survey has reported that almost 1 in 4 children in Ireland are either over-weight or obese, which is likely to lead to significant health issues later in life.

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 think it is important that we view this Bill as a “stepping stone” to a universal GP service. What I would like to see is the rapid roll-out in successive phases of more GP coverage. In fact, I would go so far as to say that I would not be as supportive of this legislation if the Bill was an end in itself. Therefore, if we, as public representatives, believe that we, as a society, should organise a universal GP service, then I would argue that we should support this Bill as the first step towards the universal service.

Policy Development Background

As I have mentioned, we should be clear that the policy objective is to have the entire population covered by a State-funded GP service. A universal GP service is a vital building block of universal health insurance and the reform and restructuring of our health service. A universal GP service will also complement the existing universal hospital system. The Government aims to achieve this objective by 2016. Therefore, from an implementation perspective, my concern was to ensure that we roll out the universal service in the quickest and most efficient way.

Deputies will be aware that the Government originally intended to phase in the GP service, firstly to those covered by the Long Term Illness scheme, and secondly to those covered by the High Tech Drugs scheme. However, this did not prove to be the most expeditious approach.

Firstly, a great deal of effort went into developing the proposal to base the first phase of the GP service on the LTI scheme. On face value, it appeared to be a reasonable approach to say that people on the LTI scheme would get a free GP service. However, the LTI scheme is somewhat anachronistic in the terminology it uses. It may have been necessary to clarify in legislation the medical conditions that were to be covered, in which case it would have been necessary to examine that choice of conditions with respect to a GP service. There was also an inherent issue of basing the first phase of a universal GP service on whether a person was taking a prescription drug for a specific condition. The largest condition covered by the LTI is diabetes. Therefore, the initial approach would have provided a GP service to persons taking drugs to manage their diabetes, but not to persons that were managing their diabetes, without drugs, through lifestyle measures such as appropriate diet and exercise.

Therefore, a second approach was developed in which eligibility for a GP service would be based on a person having a particular chronic medical condition that would be prescribed by the Minister for Health. However, as work on a draft Bill was progressed, it became clear that the legal and administrative framework required to provide a robust basis for eligibility for a GP service based on having a particular medical condition was likely to be overly complex and bureaucratic for a short-term arrangement. Relatively complex primary legislation would be required in order to provide a GP service to a person on the basis of their having a particular illness. The assessment system for such an approach would have to be robust, objective and auditable in order to have the confidence of the Oireachtas as well as the general public. This legislation would have to address how a person could be certified as having such an illness, and who could do this, and how to select the diagnostic basis for medical conditions. As well as primary legislation, there would be a need for secondary legislation to give full effect to this approach for each condition.

On my appointment as Minister for State for Primary Care in October 2012, I examined the progress made in the universal GP care plan. I was concerned that the first step was proving to be excessively complex and bureaucratic and that, ultimately, there was a significant risk that the entire universal GP plan would be delayed.

While it would not be impossible to persist with the chronic medical condition approach, it would have taken several months more to finalise the primary legislation proposals, followed then by the preparation of statutory instruments. In my view, this would have entailed putting in place a cumbersome legal and administrative infrastructure to deal with what is only a temporary first phase on the way to universal GP service to the entire population.

Consequently, I recommended a more expeditious approach, which was approved by Government. I believe that this current Bill will provide the basis for the progressive expansion of universal GP coverage to other age cohorts.

Before concluding, I would like to say that I welcome the Government decision to develop a new policy framework of eligibility for health services to take account of medical conditions. The HSE has established an expert panel to examine the range of conditions that should be considered as part of this process and has been asked to make an early report to the Minister for Health. While I do not wish to pre-judge the deliberations of the expert panel and the consideration by Government, I would expect that a number of conditions will be identified that will further expand the coverage for GP services.

Amendments at Report Stage

Finally, I would like to advise that the Government intends to table a number of amendments at Report Stage.

  • The text of section 58C, which relates to the HSE entering into agreements with medical practitioners, is receiving further consideration and I may introduce some small amendments in this context at Report Stage.
  • It is intended to introduce an amendment to the Nursing Homes Support Scheme Act 2009 at Report Stage. This is a technical amendment to the definition of “transferred assets” in that Act.
  • It is also intended, subject to the approval of the Government, to bring forward at Report Stage a number of amendments to the provisions of the Health Act 1970 in relation to residential support services. The relevant provisions, namely sections 67A, 67C and 67D, were inserted into the Health Act 1970 by section 19 of the Health (Amendment) Act 2013. The primary purpose of the intended amendments is to ensure that, in addition to those who are both accommodated and maintained by or on behalf of the HSE in the settings currently specified in section 67A, those maintained but not accommodated in those settings will also be required to make an affordable contribution towards the costs of their maintenance.
  • Finally, it is intended to bring forward an amendment to the Bill that would provide for an amendment to the Opticians Act 1956. The background to this amendment is the plan, which is well advanced, to subsume the Opticians Board into the Health and Social Care Professionals Council in accordance with the Government’s programme of rationalisation of State agencies later this year or early next year. The purpose of the amendment to the Optician Act 1956, which currently regulates the professions of optometrist and dispensing optician, would be to change the election year of the Opticians Board from 2014 to 2015. This would remove the requirement to hold elections to the board this year. It would extend the terms of office of the current members of the board for up to one year until the regulation of the professions of optometrist and dispensing optician has been transferred to the amended Health and Social Care Professionals Act 2005.  The alternative would be to hold elections and appoint a new board in 2014 to hold office for a very short period, if at all.

The appropriate arrangements will be made for the amendments in advance of the Report Stage of this Bill, including an Instruction to Committee motion under Standing Order 131(2) to allow an amendment to the Bill.

I would like to thank the Chairman for allowing me the latitude to outline policy context of the Bill and I am happy to go through the details of the Bill and deal with any questions of the committee.