The following is the text of the exchanges between Brendan Smith TD and Health Minister Dr James Reilly during Thursday (17th April 2014) morning’s Dáil statements on the Government’s White Paper on Universal Health Insurance

Deputy Brendan Smith: Deputy Jim Daly referred to the establishment of hospital trusts. I am amazed in regard to the specific trust concerning the Cavan-Monaghan hospital group that we are not linked with the Mater hospital. The Minister, Deputy Reilly, knows as a medical doctor and a politician that there is a huge affinity, working relationship and pattern of Cavan people accessing tertiary health services at the Mater hospital. Whenever I have an opportunity to visit a patient there, I am always struck by the number of Cavan people I meet who are accessing services. I do not know if the Minister approved the trusts or if that was done at HSE level but I presume they are set down in stone at this stage. Whoever devised them made a significant mistake in failing to give Cavan General Hospital and Monaghan Hospital to continue that great tradition of work and accessing of services at the Mater hospital.

Regardless of what funding system is put in place in future, I am anxious that we ensure it is proofed at cross-Border level. The Minister will be aware of the huge potential we have to deliver services on an all-Ireland basis. Representing two Ulster counties, I am aware of the great potential we have at Cavan General Hospital and Monaghan Hospital to work with Enniskillen hospital. Sligo General Hospital also has that opportunity. The Sligo and Letterkenny hospitals can work with Altnagelvin as well. I hope that whatever funding system emerges, it ensures no obstacles are put in place to the collaboration that exists and the potential for greater co-operation on the island in the provision of services.

Not for the first time, the Government has presented the House with a debate which is wrongly titled. Today’s business is stated to be on the White Paper on universal health insurance but we are actually making statements on a Green Paper. Let us look at the standard parliamentary definition of a White Paper:

White papers are documents produced by the Government setting out details of future policy on a particular subject. A White Paper will often be the basis for a Bill to be put before Parliament. The White Paper allows the Government an opportunity to gather feedback before it formally presents the policies as a Bill.

I contrast that with the standard parliamentary definition of a Green Paper:

Green Papers are consultation documents produced by the Government. Often when a government department is considering introducing a new law, it will put together a discussion document called a Green Paper. The aim of this document is to allow people both inside and outside Parliament to debate the subject and give the department feedback on its suggestions.
What the Minister has produced more closely resembles a Green Paper than a White Paper. It raises many more questions than it answers and, certainly, indicates that we are a long way from implementation. A Government Minister was quoted in the national media recently as saying:

He [that is the Minister, who should have been referred to properly] has been allowed to call it a White Paper. He needed that at least but the reality is how is it a White Paper. A White Paper is something you produce when you are ready to go into the Dáil with legislation.

Deputy James Reilly: Is it a named Minister?

Deputy Brendan Smith: No.

Deputy James Reilly: Of course not. It is easy to quote anonymously. Dúirt bean liom go ndúirt bean léi.

Deputy Brendan Smith: It is not a named Minister and unfortunately he or she did not refer to Deputy Reilly by his proper ministerial title either. I do not like that.

Deputy James Reilly: For the Deputy’s information, the definitions he referred to are from the English Parliament not the Dáil.

Deputy Brendan Smith: I did not say they were not. There are parliamentary procedures which are quite common to parliaments throughout the world.

Deputy James Reilly: It is common to the Commons.

Deputy Brendan Smith: The Minister’s White Paper falls a long way short of the programme for Government commitment which stated that a White Paper on financing universal health insurance would be published early in the Government’s first term. We were told it would review cost-effective pricing and funding mechanisms for care and set out the care to be covered under UHI. We are now in the fourth year of the Government’s term, which is not early by any stretch of the imagination. Not only is the White Paper late, it lacks any concrete information as to how it will be financed and how much it will cost people if the policy is every implemented. The truth that the Minister and his White Paper miss is that universal health insurance does not equate to universal health care.

What the Minister is proposing here could end up being very expensive for the already hard-pressed middle income earners. All of us who are public representatives know very well that many additional burdens have been placed on the cohort of people who do not have any more to give to meet extra demands. The White Paper fails to provide clear and concise answers to a range of other big questions, such as what will happen to primary care if the Minister gets his way, and whether, by introducing free GP care, the Minister will effectively make every GP a public servant.

There is no doubt our health system needs further reform so all patients receive health care on clinical need, but there needs to be a real national debate on how best to achieve this. A national debate can contribute to arriving at the proper architecture. There is a need to assess whether the Dutch model, to which the Minister so often refers, is suitable for the Irish health system and whether in reality it will result in better health care. When the Minister was in opposition we constantly heard him refer to the attractions of the Dutch model.

While the system has some positives it also has some major negatives, as outlined by two Mullingar general practitioners, Dr. Wilkinson and Dr. Brennan, in an article they wrote some time back for Forum, the journal of the Irish College of General Practitioners. They quote the Commonwealth Fund report which ranked the Netherlands second to the UK in its ability to provide same or next day appointments to patients. Although, as they point out, Ireland was not included in this comparison, anecdotal reports from the UK suggest that waiting times for appointments in general practice are shorter in Ireland than in Britain. Will longer GP waiting times be the price of Dr. Reilly’s expensive system? Those of us who flick through the news channels when we come home late at night see reports on the British channels of the difficulties people there have in accessing not only hospital care but immediate and ready access to general practitioners. It is a real problem. There is also a problem in some parts of our country, but not the delays we hear about in other countries.

Of more concern is the fact the report rated Dutch patients as second most likely to be hospitalised due to a complication after discharge. As the doctors themselves state, this may be a side-effect of a Dutch health care system where hospitals are paid per patient treated and procedure performed. Dr. Wilkinson and Dr. Brennan quote one of the Dutch delegates to the European Society for Quality and Safety in Family Practice, Dr. Veld, who concedes the Dutch system has its downsides. He states the basic insurance package is expensive and the costs of premia have increased by 40% over a four-year period. Not only have the costs increased but the content of the packages has already been reduced with a range of treatments and medications, such as ulcer drugs, tranquillisers and anti-depressants, being withdrawn and discussions are taking place on how the packages may be reduced further. Dr. Veld sees a threat to risk equalisation as insurers may alter the conditions for supplementary packages for people with pre-existing conditions, making it harder for such patients to change from one insurer to another.

A medical system funded by insurance companies ensures a competitive market. This is acceptable when it comes to routine procedures such as cataract surgery or hip replacements. However, Dr. Veld highlights the ethical issue of hospitals competing financially in their ability to manage life-threatening conditions such as cancer care, which could compromise treatment as a result. As insurers try to source the cheapest generic drugs, many patients obtain pills with different brand names or boxes every three months. The Minister knows better than the rest of us in the House this can prove distressing for patients at times, particularly older people, and compliance is compromised as a result.

Deputy James Reilly: The Deputy would have us pay a premium price for the brand leader.

Deputy Brendan Smith: I am not suggesting that. I suggest that at times people are concerned about a change in the particular drug they take.

The 2010 Dutch Health Care Performance Report discusses the fact that insurance companies mainly compete to limit the cost of health care services, with quality of care being of limited influence. This is a worrying feature of an insurance company-dominated health service. These are not the only issues with the Dutch model but couple these problems with major questions about how the system would be financed and how much extra burden would fall on individual patients and one must ask oneself whether this is really the right model for us to follow.

This is the question Fianna Fáil asked approximately one year ago when Dr. Brian Turner, an economist in University College Cork, prepared an independent assessment for us on what universal health insurance would mean for our citizens. In his report, Dr. Turner concluded it is far from clear the introduction of universal health insurance, as envisaged by the Minister, Deputy Reilly, would be of benefit to the Irish health system.

He went further, and stated, “There is simply insufficient evidence from international systems to suggest a change in the funding mechanism would produce benefits sufficient to justify the disruption that such a change would cause, and indeed there is some evidence to suggest that such a move would lead to higher costs for the Irish public without significant improvements in health outcomes.”

Like all of us, he supports the goals of creating a single-tier health system, removing financial barriers to accessing GP services and reducing waiting times for hospital treatment but, like Fianna Fáil, he fears that what the Minister proposes will not alone fail to achieve these objectives but that radically redesigning the funding mechanism would entail additional costs. This fear of massive additional costs would seem to be borne out by estimates from the Department of Public Expenditure and Reform that this new charge could cost up to €1,600 a year per person.

According to the White Paper we are discussing, every member of the population will purchase a universal health insurance policy from his or her preferred insurer and this policy will provide cover for a comprehensive package of health care services. The package or basket of services is not outlined in the White Paper. It will be the subject of consultation. Neither are their costs as these will not be provided this year. The White Paper states that over the coming 12 months the Department will undertake a major costing exercise to ensure a full and comprehensive analysis of the estimated costs involved is available. However, the Minister, Deputy Reilly, claims we cannot know the costs because we do not know the tax rates which will prevail in 2019. This is fairly clear to all of us.

Deputy James Reilly: What is not clear is Fianna Fáil’s policy.

Deputy Brendan Smith: We are discussing the Minister’s White Paper, and from some commentary it appears to be the Minister’s White Paper rather than the Government’s White Paper.

Deputy James Reilly: We have a vacuum on the other side of the House and it is not a Dyson.

Deputy Brendan Smith: That is not true. We are discussing the Minister’s White Paper. Why, in his fourth year in office, could he not provide costings based on 2014 prices and tax rates? It is very clear from the contents of the White Paper the practicalities of universal health insurance have yet to be clearly established. It is clear the Government does not know the balance of funding for universal health insurance between tax revenue, co-payments and insurance premia.

Deputy James Reilly: What did Fianna Fáil do for 14 years in government?

Deputy Brendan Smith: There were serious difficulties in many areas—–

Deputy James Reilly: You made a complete hames of it.

An Leas-Cheann Comhairle: The Deputy has only a minute and a half remaining.

Deputy Brendan Smith: There were many improvements.

Deputy James Reilly: Fianna Fáil had 14 years when it could have fixed it. Instead it wrecked the economy and the health service.

Deputy Brendan Smith: Many improvements were made and the Minister railed against some of them with regard to cancer reorganisation. I hear some of the Minister’s party speak laudably about the cancer treatment services available throughout the country, and they are right to laud them, but many members of the Minister’s party opposed the changes when they were made.

Deputy James Reilly: Forget about the 569 people who lay on trolleys on one day after 14 years in government.

Deputy Brendan Smith: The Minister is selective.

Deputy James Reilly: No I am not.

Deputy Brendan Smith: I could give him figures also.

Deputy James Reilly: You would not even count the number of people on outpatient waiting lists. Tens of thousands of people were waiting years.

An Leas-Cheann Comhairle: Deputy Smith without interruption please.

Deputy Brendan Smith: People cannot get on the waiting list now because they cannot get an assessment done.

Deputy James Reilly: They can and we measure it.

Deputy Brendan Smith: The Minister should speak to the people waiting for an orthopaedic assessment in the north east.

Deputy James Reilly: Yes.

Deputy Brendan Smith: We table parliamentary questions but we do not receive answers. People are not even called for an assessment.

Deputy James Reilly: They are.

Deputy Brendan Smith: It is hard to get on a waiting list if one is not even called to be assessed.

Deputy James Reilly: Fianna Fáil did not even count them.

Deputy Brendan Smith: I will not take the figures the Minister selectively quoted. We can all select statistics from a particular day or month to suit the argument we are putting forward.

Deputy James Reilly: Let us talk about the relevant statistics. The previous Government did not even have waiting lists for outpatients.

Deputy Brendan Smith: The Minister quoted figures from January and February 2011 when there was a huge number of admissions to hospitals because people were afflicted with injuries due to the climate conditions and harsh weather. This could apply in any particular year and it can be cyclical.

He saw the improvements that have been brought about at Cavan General Hospital on foot of the substantial investment that was made in new facilities at the hospital between 2000 and 2010. He will be aware that many of the additional services which have been provided at the hospital were not available ten or 12 years ago. That creates extra demand on the hospital. I am sure some of those involved at management level at the hospital had an opportunity to mention to the Minister last Friday that the accident and emergency unit needs new facilities. The number of people attending that unit has increased on foot of population growth in the area and the downgrading of services at Monaghan General Hospital. I hope the Minister will ensure the proposal to provide new-build facilities is advanced as quickly as possible through the HSE. The next time I table a parliamentary question to the Minister on this issue, which is of great importance to the people of Cavan and Monaghan, I hope he will be able to give me a more positive response than I have received up to now.