HEALTH (GENERAL PRACTITIONER SERVICE) BILL 2014
COMMITTEE AMENDMENTS – 19 June 2014
Introductory Statement
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 rollout 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.
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