Seanad Éireann - Volume 144 - 19 July, 1995

Draft Health Insurance Regulations: Motion.

Acting Chairman (Mr. Calnan): The time limit for spokespersons is seven minutes and for all other Senators it is five minutes.

Mr. Finneran: I move:

That Seanad Éireann calls on the Minister for Health to defer the signing of the Draft Regulations pursuant to the Health Insurance Act, 1994, to allow new negotiations to take place with hospitals and health insurers, in view of the very serious implications that these regulations would have for public and private psychiatric patients and services.

I welcome the Minister, Deputy O'Shea, to the House. As the Fianna Fáil frontbench spokesperson on health I am calling on the Minister for Health not to sign the new regulations pursuant to the Health Insurance Act, 1994, because in their present form they will discriminate against people who suffer from psychiatric illness. Under the proposed new regulations VHI cover will reduce from the present 180 days to a minimum of 40 days psychiatric in-patient treatment per year. This is a major change and a clear attack on one of the most vulnerable sections of society. If the Minister [1264] signs these regulations it will result in over 1,000 patients leaving psychiatric hospitals each year before their in-patient treatment is complete. Other medical illnesses will continue to have 180 days insurance cover. This clearly discriminates against psychiatric illnesses such as depression, manic depression and schizophrenia which have just as much medical and biological basis as diabetes or heart disease.

The Department of Health maintains that these regulations are necessary to enable other insurance companies to enter the Irish market. Through these regulations the Minister is following the requirements of insurance companies which have always discriminated against people with psychiatric illnesses when providing travel insurance, mortgage protection and critical illness cover. Insurance opportunities are being taken up here by companies from outside the State which have traditionally discriminated against people in the psychiatric sector.

It is one thing for insurance companies to discriminate but it is quite another matter when the State joins with them in that discrimination. On this occasion, the Minister should show a firm hand in not signing these regulations. The Minister's first obligation is to provide proper medical care for the citizens of the State and to protect their interests. If that means standing up to the vested interests of health insurers then the Minister should not be found wanting as far as psychiatric patients are concerned. I call on the Minister, as a matter of duty and responsibility, to stand up for such patients.

There is grave concern among health care workers about this matter. I have been contacted by private hospitals, Aware, the Schizophrenia Association and Alzheimer Association, all of which are perturbed about what is being proposed.

I know that regulations have to be brought in under the new terms of health cover because the sector is not regulated at the moment. I compliment the VHI on the excellent cover they [1265] have provided over the years and the great service they have given to the public. Now, however, we will have competition which usually means an even better service but instead of that a diminution or removal of services is being proposed.

The reduction from 180 days to 40 days for psychiatric in-patient treatment cover is to accommodate outside insurers operating here. Elsewhere, in the past, these people have not provided the same level of cover as the VHI. We should not and cannot allow them to discriminate between general medicine and psychiatric medicine. Why should someone who is psychiatrically ill have a different set of rules governing their health cover from someone in a general hospital? It is totally obnoxious that this regulation should be introduced at all. I call on the Minister to stand up for psychiatric patients. He should indicate that under no circumstances will he sign these draft regulations and that new negotiations will be entered into.

Proper insurance cover and equal treatment should be provided to psychiatric patients. I hope the Minister will respond positively. Psychiatric patients and health care workers throughout the country are listening to this debate and the Minister's response is eagerly awaited. I hope the Minister will respond positively and we can promise equal treatment for psychiatric patients. We should be able to promise the level of cover provided to physically ill patients and that we will protect their interests, not the interests of those providing insurance cover.

Mr. Lydon: It is a great pleasure for me to second this motion. I sincerely thank the Leader, Senator Manning, for having so kindly arranged this debate which I specifically requested. I do not want a Minister bashing session; I have no wish to score political points. My concern was and remains the plight of a large body of patients who suffer from psychiatric illness. We are all familiar with the caricature of a person who buttonholes [1266] one at a party to tell one about the intricacies and intimacies of his or her latest operation. However, it is not so common to be buttonholed by someone who has recovered from depression or from an acute psychosis. Generally these people like to forget about their illness and get on with their lives. I wish to be a voice for the voiceless on this occasion.

Recently there has been much greater public acceptance of mental illness following public education through debates, lectures and so on. Indeed, St. John of God and St. Patrick's hospitals have been to the forefront of the provision of public education on mental illness. To date the sufferings of the mentally ill have not been voiced. Thankfully the Minister has not yet signed the draft regulations.

Up to now people in need of in-patient psychiatric treatment and insured with the VHI have been entitled to 180 days in-patient treatment in each year. People suffering from alcohol dependency and other forms of substance abuse have been entitled to 90 days in-patient treatment every five years. If the Minister signs these regulations, companies who in future wish to offer health insurance in Ireland need only provide a maximum of 40 days in-patient treatment per year and, for alcohol or other substance abuse, only 40 days in-patient treatment in a patient's lifetime. That cannot be fair. I have been reliably informed by insurers that the proposed minimum cover period will become the norm if these regulations are signed.

Many patients recover quickly from psychiatric illness but a substantial number require long term in-patient treatment and the patients who will be most seriously affected by these changes include sufferers from serious psychiatric illnesses such as manic depression, schizophrenia, anorexia nervosa, and psychiatric disorders associated with physical disease and ageing. In psychiatry we do not use millions of pounds worth of expensive equipment, we do not use highly expensive diagnostic tests, or high technology therapy, yet if [1267] the Minister signs these regulations it is only the mentally ill who will be discriminated against. The physically ill will get maximum, highly expensive cover and hospital care, but not those with a psychiatric illness.

This is happening because the terms have been dictated by British health insurers. If these major players in the health insurance field have their way and if the Minister gives in to their pressure, the result will be nothing short of catastrophic. Some 90 per cent of all in-patient psychiatric treatment within the health insurance sector is provided by two hospitals, St. John of God and St. Patrick's. Both are non-profit hospitals and the imposition of these changes will compel them to increase costs to a level close to that charged by equivalent private psychiatric hospitals in the United Kingdom. That is a rate between two and four times what they currently charge.

These hospitals have long traditions of quality care. I worked with one of them for 25 years. Not only do people come from all over Ireland to these hospitals; they come from abroad. There is no questioning the care that is provided. We have received letters from many people including directors of both these hospitals, Dr. Conall Larkin of St. John of God and Dr. Anthony Clare from St. Patrick's. Both men are competent, brilliant, caring doctors and are concerned that their hospitals will have to increase costs to patients. These restrictions on in-patient psychiatric care together with the miserly recommended minimum rate for psychiatric day care, £25 per patient per day, will in effect mean that the role currently played by the private psychiatric services which accounts for 15 per cent of the overall provision of in-patient psychiatric care will be substantially eroded. That is not what the Minister wants. He is a caring man, from what I know of him, and perhaps his advisers did not give this matter sufficient thought before recommending this course of action to him.

[1268] I ask him not to sign these regulations but to defer them. He should talk to the people involved and come up with a solution that will not discriminate against psychiatric patients. The real impact of these changes will be borne by patients who are most seriously affected by psychiatric illness and by their families. I demand that the mentally ill be treated no differently from patients suffering from physical illness and I beseech the Minister to see that the levels of cover currently provided by the VHI for psychiatric in-patient treatment should be the recommended minimum levels in the new regulations pursuant to the Health Insurance Act, 1994.

Minister of State at the Department of Health (Mr. O'Shea): The Third EU Directive on Non-Life Insurance came into effect on 1 July 1994, throughout the European Union. This directive, which was part of the development of the Single Market, provided for competition in the private health insurance market and meant that overseas insurers were free to enter the Irish private health insurance market if they wished.

When the directive was being drafted by the European Commission, it was agreed, on this country's initiative, in the interests of social and intergenerational solidarity, that the Directive should allow member states to sell policies which were community rated and also to practice open enrolment and lifetime cover. It also allowed member states to require insurers to provide standard contracts-minimum benefit and to participate in a loss compensation-risk equalisation scheme.

The Health Insurance Act, 1994, which came into effect on 1 July 1994, was designed to allow for competition and to regulate the private health insurance market in accordance with the provisions of the Third Non-Life Directive. It requires health insurers to comply with the principles of community rating — an insurer must charge the same rate of premium for a given level of benefits irrespective of age, sex or [1269] health status — open enrolment under which an insurer is required, with certain qualifications, to provide cover to any individual who wishes to enrol and lifetime cover under which an insurer may not, with certain qualifications, refuse to renew cover once an individual has enrolled. The protection of these principles was seen as crucial in ensuring access to private health insurance.

The draft health insurance regulations, published by my Department in March, give effect to the supporting framework necessary to ensure the successful operation of the system of community rated health insurance provided for in the 1994 Health Insurance Act.

The principal objectives in framing the regulatory framework for private health insurance are to maintain the current system of community rating, open enrolment and lifetime cover, to provide a “level playing field” for all health insurers with the minimum regulation possible, to structure the regulatory environment in order to maximise the incentives to heath insurers and health care providers to operate efficiently and to maintain the position of private practice within the well established public/private mix.

The draft health insurance regulations comprise of five sets of regulations. These are regulations on registration, open enrolment, lifetime cover, minimum benefits and risk equalisation. The minimum benefit regulations set out a level of cover across a broad range of services which every insurer operating here must offer as a minimum. The minimum range includes general hospitals, outpatient and maternity benefits, convalescence, psychiatric treatment, substance abuse and day care.

The minimum benefit levels have been set at the lowest level so as not to be perceived as presenting a barrier to trade while at the same time giving a protection to consumers by ensuring they will at least receive a minimum level of cover across a broad range of services.

[1270] In respect of psychiatric in-patient treatment, the regulations require insurers to provide minimum benefit in respect of in-patient psychiatric treatment for a period of 40 days in any one year. I must emphasise that this is only a minimum period which is designed to set a basic level of cover for in-patient psychiatric treatment. It is the first time that insurers will be required to provide cover for psychiatric treatment on a statutory basis.

The draft regulations had contained a provision which allowed insurers to require that treatment plans for psychiatric treatment be submitted to them for approval prior to admission, other than in an emergency. Following representations, this has been withdrawn.

When deciding to include in-patient psychiatric treatment in the minimum benefits regulations, we were aware that many overseas insurers do not cover psychiatric in-patient treatment or if they do so, cover up to approximately 30 days only. Almost all require prior approval of treatment plans. By including psychiatric treatment in minimum benefits, we are ensuring that all insurers wishing to operate in the Irish private health insurance market must offer at least a minimum cover of 40 days. If it were not included in the minimum benefit regulations it is likely that insurers would treat it as they currently do in their home State.

On arriving at 40 days as a minimum figure, we had to try to strike a balance between protecting the consumer and ensuring that we were not placing a barrier to trade to insurers who wished to enter the market. Over 70 per cent of all discharges from psychiatric hospitals occur within 40 days. It should also be noted that 15 per cent of all psychiatric in-patient treatment is provided by private psychiatric hospitals.

The minimum benefit requirements for in-patient treatments for alcoholism, drug or other substance abuse is for a total of 40 days in-patient treatment for the whole period for which cover is provided by one or more insurers.

[1271] In relation to the benefits payable to private psychiatric hospitals for in-patient and day-patient services, these have been set at the lowest market level so as not to be inherently inflationary. If they were set any higher a situation could arise whereby a hospital which charges rates lower than the minimum benefit would be paid at the higher level.

The specific issue of day care cover is ill-defined. The Department is currently examining the possibility of dropping the requirement for day care cover in the regulations and having it studied by the assessor later this year in a review of the minimum benefit regulations.

Concern has been expressed at the arrival of profit motivated commercial companies in this country on the grounds that they will put profits before the welfare of their members. The reality is that as a consequence of our membership of the EU, we must participate in the development of the Single Market which means allowing overseas commercial companies to operate in our country on a commercial basis. However, the Health Insurance Act, 1994, and these regulations allow us to ensure that competition in the private health insurance market will take place on terms which ensure the greatest possible equity for all those who wish to buy private health insurance.

It is essential that the minimum benefit regulations do not adversely constrain the development of a competitive market in private health insurance in Ireland. We must leave insurers with sufficient flexibility to develop imaginative, innovative packages of health cover in the interest of the customer. The EU Commission would not accept a regulatory framework which would require insurers to offer benefit which simply repeated the 180 days hospital cover available from the dominant insurer.

Mr. Finneran: Why?

Mr. O'Shea: We must demonstrate that we are genuinely creating an open [1272] market in private health insurance. If this is not demonstrated to the satisfaction of Brussels, then much of our legislation on private health insurance may be seen by them as invalid.

The Minister for Health will appoint a minimum benefits assessor in the autumn as provided for in the Health Insurance Act, 1994. The assessor's role will involve the review of the minimum benefit regulations to take account of developments in the private health insurance market, new technology and procedures and inflation. The regulations can be changed to incorporate the recommendations made to the Minister by the assessor.

Departmental officials have consulted a wide range of interest groups, including public and private sector providers, since the publication of the draft regulations. It is expected that these consultations will be completed in the next week. The Department will then consider all the issues which have been brought to their attention during the consultation phase. I will, of course, bring to the Minister's attention the views expressed in the House this afternoon. It is anticipated that a final copy of the regulations will be submitted to the Minister for his approval and signature in the near future. The regulations will then be laid before each House of the Oireachtas as provided for in the Health Insurance Act, 1994.

Ms Honan: I welcome the Minister to the House.

I thank the Leader of the Opposition for giving us an opportunity to again raise this matter.

Acting Chairman: Is the Senator sharing her time?

Ms Honan: Yes. I would like to share my time with Senator Quinn.

Acting Chairman: Is that agreed? Agreed.

Ms Honan: I raised this issue last Tuesday on the Adjournment and I was [1273] not satisfied with the reply given by the Minister of State, Deputy Currie.

As other Senators said, the proposed changes will discriminate against the psychiatrically ill. The levels of treatment and support will be eroded leaving only crisis management in the private psychiatric service and the burden will fall on the families of the sufferers. I cannot understand why the Minister refused to meet concerned professionals in this area if he is so sure of his views and of how right he is in introducing these regulations.

I am extremely concerned at the effects of these changes on the future availability and quality of psychiatric care. We all know what the proposed changes entail: the reduction from 180 days, which is the extent of cover provided by the VHI at present, to a minimum of 40 days' treatment per year and the provision of only 40 days' treatment in a subscriber's lifetime for sufferers of substance abuse. These regulations are totally unacceptable. While it is true that many people suffering from psychiatric illnesses recover quickly with treatment, many more need long term care and support to fully recover.

There is no other area of treatment in which the Minister proposes to set minimum cover periods. By doing so in the area of psychiatric illnesses, he is discriminating against sufferers in a way which would be unthinkable if any other form of illness was involved. If it was proposed to limit the number of days, for instance, which a patient who was having a by-pass operation could spend in hospital, it would not be acceptable and it is not acceptable in the psychiatric area.

The alteration in cover for people suffering from psychiatric illnesses will reduce the role of private psychiatric services. The introduction of such a severe minimum period will have damaging effects on sufferers of psychiatric illnesses and their families, who now must bear the burden of caring for them when their health insurance cover runs out.

The Minister refused to meet representatives of the two major providers [1274] of private sector psychiatric care, St. Patrick's Hospital and St. John of God Hospital, and with the patient support bodies of voluntary organisations working in the area. I cannot understand that and it is unacceptable.

I call on the Minister not to sign these proposed regulations into law at the end of the month and to meet these representatives immediately. He should give a commitment that the level of cover currently provided by the VHI for psychiatric in-patient treatment should be the recommended minimum level in the new regulations and that the psychiatrically ill should not be treated differently from patients suffering a physical illness.

I thank Professor Anthony Clare and Dr. Conall Larkin for providing helpful briefing documents. Members have had many representations from families of psychiatrically ill patients and from patients themselves who are disturbed and concerned about this matter. There is widespread support for changing the proposed regulations.

Insurance coverage and benefits for patients with psychiatric conditions have traditionally been more or less in line with general medicine. This approach has led to the development of the psychiatric services in the private sector, which is very different from what happens in other countries, and is something we should be proud of. For example, in the USA, President Clinton's task force on health has attempted to look at treating psychiatric illness equally with other forms of illness. The task force is trying to move towards our situation, while we have now decided to move away from it.

The Minister for Equality and Law Reform will introduce equal status legislation later this year. It is in preparation at present and will guarantee equal treatment in the provision of goods and services to everybody, irrespective of gender, disability, race or whatever. I cannot understand how one arm of Government is introducing legislation to give equality to everybody, while the [1275] Minister is introducing regulations which would fly in the face of it.

Over the years private psychiatric hospitals have played a major role clinically, through their teaching and research. As such they play a different role from private psychiatric services in other countries. The Minister's proposal regarding the reduction of in-patient benefits will have a huge effect on those who are suffering from schizophrenia, on those who are single, divorced or separated, on the young, on women and on patients who have to be admitted on a temporary certificate.

It is apparent that the consequences of the Minister's proposal are not obvious to him. We must defend the rights of the mentally ill, a very vulnerable group whose voice is seldom heard and for whom in the past society has often had little sympathy. We have moved away from that, and I hope we have done so permanently.

Mr. Quinn: I am impressed with the case made by the Minister and I understand it much better. Some of the terms he used were excellent, for example, “customer benefits”, “competition” and “market place”. This will further what we are attempting to achieve. However, it is impossible to introduce change unless one has the support of those working in the area to be affected. Dr. Larkin and Dr. Clare are very unhappy with the Minister's proposals. If the Minister is intent on pursuing them he is unlikely to succeed unless he is able to listen to such voices.

Senator Honan said that the burden will fall back on families. I understand that it will also fall back on the taxpayers, who will find that the Minister's proposal is false economy. The wording of the motion is moderate and temperate. It states: “That Seanad Éireann calls on the Minister to defer the signing of the Draft Regulations...”. Motions such as this usually contains words like “deplore” and “condemn”. These words were not used. I urge the Minister to rethink and to defer the signing of the [1276] regulations until he has had the opportunity to listen to those concerned in Saint John of God Hospital and Saint Patrick's Hospital as they are close to the patients and to the real problems.

The Minister says that the regulations provide for only a minimum and other foreign health insurers do not even provide a minimum. However, I understand this minimum will effectively become a maximum and those providing the service will be unable to provide the same level as hitherto. I urge the Minister to reconsider and delay until he has had the opportunity to listen to those who are deeply involved.

Mr. Cosgrave: I welcome the Minister of State to the House. As the Leader of the House stated this morning, anybody who wishes to contribute to the debate will be afforded the necessary time to speak. I welcome the debate. Senator Maloney, Senator Finneran, Senator Lydon and other Senators have better knowledge of this subject than myself and some others.

Any of us who know those who are psychiatrically ill and who have visited St. John of God Hospital and St. Patrick's Hospital know the great work that takes place there. While hopefully many patients reach the end of the tunnel, unfortunately there are cases which are more difficult and profound. These must be looked at. Following the extra time and care they require, problems can be resolved. Those of us who have known people, whether friends or relatives, suffering from a psychiatric illness know the difficulties and problems involved and how it falls back on members of their family to deal with their GPs and those who are trained in this field.

I am pleased the Minister has advised that consultation is taking place. From my dealings with the Minister and the Minister of State, I know that any meetings which experts in the field wish to have with the Ministers or their officials will take place, in the same way that such meetings between these experts and other public representatives have [1277] already occurred. We should get the views of experts on this matter.

The whole question of insurance cover must also be looked at. While not knowing the full details of the treatment provided by these hospitals for those suffering from this type of illness, I am aware that with regard to other aspects of the insurance industry there are restrictions, such as cut off limits and policy excesses, where one pays the first stated amount of each claim. In this respect, perhaps the impending competition will be good. The VHI has served the country well but there have been complaints about the level of cover in certain areas and about risks which are not covered.

It is important that we remember the patients. As Senator Lydon remarked, they probably will not be shouting loudest, which I can confirm, having visited people in St. John of God Hospital and St. Patrick's Hospital. EU regulations may come or go but ultimately we are dealing with people who must be helped.

I ask the Minister of State to ensure that the necessary consultation takes place. He is always available to listen, as is the Minister. There are only a certain number of people in this field who must be talked to. If changes are to take place so be it, but at least let us ensure that, as far as possible, it is not the patients who will suffer in the long term. If people have to stay an extra week or month they should be looked after.

I welcome the debate. There is unity across the House on the issue. I hope the debate, combined with the consultations that must take place, will ensure that matters are resolved satisfactorily.

Mr. Daly: The net effect of these draft regulations, if they are signed in their present form, would be seriously to curtail insurance cover for patients suffering from psychiatric ill health. I appreciate the consultations that have occurred at official level and with representatives of those who represent the psychiatrically ill. Nevertheless, there is a widespread view that they are not [1278] advancing any change in the regulations as currently drafted. A number of requests have been made to the Minister for Health to intervene before the draft regulations are finalised and meet with the representatives of the two main institutions involved, St. Patrick's Hospital and St. John of God Hospital, the representative organisations and others who are concerned about these developments, organisations such as Aware, which has done such tremendous work on behalf of patients suffering from depression and other psychiatrically-related illnesses. It would be an advantage if, as a result of this discussion, the Minister of State could impress upon the Minister for Health to intervene with the officials of the Department and the institutions mentioned so there can be more detailed discussion with a view to arriving at a draft agreement acceptable to the private institutions involved.

The directive is sufficiently vague to allow for latitude in drafting these regulations. As the Minister of State is aware, these regulations will be laid before the Seanad for 21 days as per section 3 of the 1994 Act. If we are not satisfied with the final draft regulations we will have the opportunity to vote them down. That, as the Minister of State knows, is a real possibility. The Government barely won a vote here earlier this afternoon and, on an issue such as this, it would be roundly defeated. In the Minister's own interests it would be advisable to see if he can reach agreement with the various representative bodies before these regulations are laid before the House. During those 21 days they will be challenged if they remain in their present state.

I do not wish to go over ground covered by other speakers, but the people who will be affected most by these new regulations will be psychiatric patients and their families. Everyone knows the burden upon families in some such cases. We all have experience of dealing with people suffering from depression and related illnesses, and we are aware of the trauma this causes for [1279] families. While we have some understanding of the points of view put forward by the institutions, my concern is for the patients and their families. They are looking to this debate to see some sign of the Department changing its view.

The draft regulations as they have been drawn up will be seriously detrimental to and will discriminate against a sector of people who had adequate cover up to now. We must examine this situation carefully as this directive which had the intention of benefiting the community will, in reality, have a negative effect.

We do not comply totally with many of the directives that emanate from the EU. In many cases we have sought derogations and time to enable us meet the requirements of directives. The Oireachtas Library is full of EU directives which have not been fully implemented, in many cases for good reason. There are good reasons why this directive should not be fully implemented along the lines of the regulations being drafted at present.

I appeal to the Minister to talk to the organisations involved, such as Aware. We have had representations from Doctors Larkin, Clare, McKeon and others attached to the institutions involved. I have had numerous representations from individual patients who are upset and worried. Every Member of the House has had representations from patients who are grievously worried. We should not upset this category of patients further. I ask the Minister of State to persuade the Minister to discuss this matter with the interested parties before the draft regulations are laid before the House. If they are left in their present form they will be rejected.

Mr. Maloney: I welcome the opportunity to discuss this motion which states:

That Seanad Éireann calls on the Minister for Health to defer the signing of the Draft Regulations pursuant [1280] to the Health Insurance Act, 1994, to allow new negotiations to take place with hospitals and health insurers, in view of the very serious implications that these regulations would have for public and private psychiatric patients and services.

People who avail of the psychiatric services have been stigmatised for far too long. This appears to be another attack on behalf of the insurance companies. I would not like to think we would consider money before people. I agree with the motion and I am glad the matter has been raised. As they stand, the regulations would have serious implications for the welfare of psychiatric patients and for the future of the public and private psychiatric services.

Up to the present people in need of psychiatric treatment and who are insured with the VHI have been entitled to 180 days in-patient treatment in each year. People suffering from alcohol dependency and other forms of substance abuse have been entitled to 90 days in-patient treatment every five years. According to the proposals as outlined in the draft regulations, companies who wish to offer health insurance in Ireland need only provide a minimum of 40 days in-patient treatment per year, and for alcohol and other substance abusers only 40 days in-patient treatment in a subscriber's lifetime.

These proposed minimum cover areas are likely to become the norm and, as someone who worked in the psychiatric field for many years, that would be of concern to me. Many people who suffer from psychiatric illnesses recover quickly with treatment, but successful treatment can take much longer for others.

This provision will attack the way of life of people who live in rural areas. Many people from rural areas feel embarrassed going to the local psychiatric hospital and to save embarrassment to themselves and their families they take out VHI cover which allows them to go to St. John of God Hospital or elsewhere for treatment. This is [1281] understandable because of the stigma that has been attached to people going to psychiatric hospitals. This provision will attack an element of rural life.

Psychiatry does not call upon highly expensive diagnostic and therapeutic technologies but relies on some highly effective treatment methods by a well trained and highly motivated psychiatric staff. It is only psychiatry and the psychiatrically ill who are being singled out for discrimination in terms of time allowed for in-patient treatment. No such time constraints are imposed in any other medical speciality.

In many representations made to me by private hospitals, ordinary people and people working in the public and private psychiatric services, it was put to me that they are extremely worried about these regulations. When one looks at the recommendations concerning people suffering from substance abuse the position is serious. At present the VHI allows 90 days every five years and the draft regulations propose to allow 40 days only within a lifetime. The incidence of alcohol and other substance abuse is not reducing; if anything, it is getting worse.

The introduction of a 40-day limit constitutes a more serious discrimination against psychiatric patients and no other group is singled out for such a limit. It will mean that people receiving private psychiatric treatment will now have to go to the already overstrained public psychiatric services. It will include sufferers of all psychiatric illnesses, whether it is schizophrenia, psychiatric disorders associated with ageing and other physical diseases or manic depression.

In certain cases people can recover in a short time. However, if one speaks to psychiatric nurses, behavioural psychotherapists or addiction counsellors they will say that in many cases it can take people anything up to 6 months to recover — this is supported by the percentages outlined by the Minister. What are we to do in such a situation? The [1282] staff are already working in fairly overcrowded conditions. There are staff shortages in psychiatric hospitals and we must do what we can to help them. The constraints imposed under the draft regulations outlined by the Minister of State will cause serious problems for patients and staff in the psychiatric services.

The Minister of State has the power, with a stroke of pen, to make the changes which are required to look after those who are psychiatrically ill, and not to bow to the whims of the European insurance companies who seem to be making the running. People should come before money and the insurers have a duty to provide care for the people who are paying for it. These regulations would make a bad situation worse. I ask the Minister of State to seriously reconsider the decision to sign these regulations into law on 30 July.

It smacks of another attack on people suffering from psychiatric illnesses. As I said earlier, I worked in that sector and I saw how life treated these people. They have always been discriminated against within the health services. Psychiatric services have never received the recognition or money to which they are entitled. I hope the White Paper on the Mental Treatment Act, due soon, will go some way towards alleviating and highlighting some of the discrimination against those with psychiatric illnesses. We should not discriminate against such people in any way.

I know the regulations are being brought in to enable other insurance companies to enter the Irish market. However, competition should not mean discrimination. The greatest quality of care for all patients should be our priority.

The Health Insurance Act, as the Minister of State outlined, provides for the appointment of an assessor whose role is to review the minimum benefit regulations. I call on the Minister of State to move for the appointment of the assessor before these regulations are signed into law. We agree with the motion. We should move to appoint the [1283] assessor and no decision should be taken to sign the regulations into law by 30 July. I commend the motion to the House.

Dr. Henry: With his experience in the psychiatric services, Senator Maloney has expressed how we all feel. It is great that someone which such experience in this area can address the House. I know the Minister of State has great difficulties with competition law within the European Union. However, we have a great tradition of trying to put health before other concerns and that is most important.

As the Minister pointed out, only a small proportion of those with psychiatric illnesses are in hospital for such a length of time — those with schizophrenia, severe psychoses, severe depression and so on. We must try to put them in context and realise that early discharge of these people is disastrous for them, and can be disastrous for the community. I do not want to appear hysterical about this but there have been cases in the very recent past of people who could not get admittance to psychiatric hospitals being involved in murder here and in England. It is essential that there is never a compunction on people with serious psychiatric diseases to leave hospital. That is very serious not only for themselves but for those around them. There have been great community service improvements in psychiatric care which is laudable and that is what we all want. However, this is very difficult for patients with very serious illnesses, and these are the people we are really talking about.

If we are serious about tackling our appalling drugs problem, it is not enough to interrogate people for seven days. We most also improve our seriously deficient treatment centres for patients who are drug dependent. I would loathe to see the Minister of State being in a position where he had to cut back on those facilities while we have such a serious problem. The drug situation is multi-faceted; we must [1284] tackle it from every angle because it is no good dealing with just one part of it.

Mr. Sherlock: I am glad of the opportunity to contribute to this debate. I am very concerned that the European Union should be in a position to effectively impose a two tier health system on the Irish public in the context of so-called deregulation. That is exactly what these regulations, if signed, will mean. Health care is being treated by the European Union like any other commodity or service which must be deregulated at all costs in the name of the market.

What these draft regulations will mean is very simple. As has been mentioned, health insurance companies will continue to provide 180 days in-patient cover per year for physical conditions but they will be forced to provide just 40 days cover per year for psychiatric conditions. They will have to provide just 40 days cover during a subscriber's lifetime for substance abuse treatment.

The Minister of State said that concern has been expressed at the arrival of profit motivated commercial companies in this country. If these regulations are not brought into force these commercial bodies will have no place because people will not want to do business with them. The regulations must not be signed or enforced. A person in their twenties taking out private health insurance can expect to live another 50 years, during which time they are guaranteed just 40 days of in-patient cover for conditions involving substance abuse — less than one day per year.

We already have a two tier health system where one-third of patients are privately insured and the rest must rely on the under-resourced and over stretched public health system. Democratic Left has long argued for a universal system of health care which is free at the point of entry. However, we must legislate for the world as we see it and not as we would wish to see it. The inevitable result of these regulations will be that private patients with serious psychiatric or substance abuse conditions will be [1285] forced to seek care in the public system, placing even greater strain on our public facilities.

In the 1980s, the VHI cover for long stay patients in psychiatric hospitals was one year — later reduced to 180 days. In Cork city patients had to leave a private psychiatric nursing home because they could not afford to pay. This will now happen on a very large scale at a time when the Department and the health boards are seeking to have psychiatric patients treated in the community — that system is not working but that argument is for another day. There will be great demand for places by patients who will have to leave hospitals, placing even greater strain on public facilities while draining resources from our private facilities which currently account for 15 per cent of overall psychiatric patient provision.

These regulations reinforce an ancient prejudice which I had hoped we had discarded, along with all the other shibboleths which used to pervade our society. They reinforce the notion that those with psychiatric disorders are less ill than those with physical conditions and less deserving of society's care and protection. That notion is unacceptable to me. I hope the Minister will reconsider before he signs these regulations into law.

Mrs. McGennis: I welcome the Minister. I thank the Leader for agreeing to take the Fianna Fáil motion on this matter. I am loathe to criticise the Minister of State's officials because the Minister for Health, Deputy Noonan, rapped my knuckles for seeming to do so in relation to another issue. However, the Minister of State should speak to the official responsible for writing his speech because it shows an underlying lack of appreciation or understanding about this issue.

I refer to the language used in the speech. For example, it states that:

The minimum benefit levels have been set at the lowest level so as not to be perceived as presenting a barrier [1286] to trade while at the same time giving a protection to consumers.

...On arriving at 40 days as a minimum figure, we had to try to strike a balance between protecting the consumer and ensuring that we were not placing a barrier to trade to insurers who wished to enter the market.

...It is essential that the minimum benefit regulations do not adversely constrain the development of a competitive market in private health insurance in Ireland. We must leave insurers with sufficient flexibility to develop imaginative, innovative packages of health cover in the interest of the customer.

No Member has referred to consumers during this debate. Everybody, without exception, has spoken about people who are ill. We are discussing patients not consumers or customers, as Senator Quinn referred to them. These are people who are ill and require hospital care. That is the first point of change which the Minister of State needs to address.

As many speakers have stated, the regulations are discriminatory. I am awaiting the Minister for Equality and Law Reform's equal status legislation. These regulations are discriminatory and would be in conflict with any equal status legislation. If the Government proceed with signing these regulations we will attempt to amend the equal status legislation to overturn this kind of discrimination.

The Minister of State's speech said that this has been forced upon us by Europe because:

The EU Commission would not accept a regulatory framework which would require insurers to offer benefit which simply repeated the 180 days hospital cover available from the dominant insurer.

If those companies wish to enter the marketplace and trade on a commercial basis then we should dictate the terms. This is the basis on which our private [1287] health insurers are providing cover. There is no reason that we should reduce the kind of cover we are providing to attract outside competitors. I could understand why a level was being set if the VHI was not able to provide the level of cover it does.

The Minister's speech also states that he will be appointing a minimum benefits assessor. He goes on to state that “The regulations can be changed to incorporate the recommendations made to the Minister by the assessor.”. If that is the case, why is the Minister of State setting his face against accepting what we are saying? Why does he insist on signing these regulations? If they have to be put in place — because we are obliged to do so and the EU will not allow us to simply repeat the 180 days cover — how can the Minister of State insist that the regulations can be changed to incorporate the recommendations made to the Minister? If they can be changed, they should not be introduced at the level the Minister has suggested.

The Minister of State refers to a victory he secured by not having to accept treatment plans. Is the Minister aware that one private insurer in the Republic has required such treatment plans prior to offering insurance cover? Senator Finneran and Senator Maloney, who both work in the area of psychiatric medicine, have made a clear case on this issue. A further point of which Senator Maloney may not be aware is that the 90 days cover for alcohol and substance abuse is vital and necessary. By my reading of the Minister of State's speech, the 40 day in-patient treatment is not per annum or per five years but for the entire period for which cover is provided. That represents 40 days in the life of somebody suffering from alcohol, drug or substance abuse. Senator Sherlock referred to the fact that mental health was stigmatised in the past. We are taking a step back into the Dark Ages. These regulations cast it in stone that people who suffer any kind of [1288] psychiatric or substance abuse problem will be stigmatised.

Mr. Enright: I am happy that the Government has decided to accept this motion where the Seanad calls on the Minister for Health to defer the signing of the draft regulations.

Mr. Wright: We want to know if it has been accepted. It is not clear from the speech.

Mr. Roche: It is not accepted in the speech.

Mr. Enright: I hope the motion will be accepted. These regulations are far-reaching and need to be given further consideration and analysis. I hope this will happen because it will have many implications for the future.

Until now, people in need of in-patient psychiatric treatment who were insured with the VHI were entitled to 180 days in-patient treatment per annum. People who suffered from alcohol, drug or similar problems were also entitled to 90 days in-patient treatment every five years. The new regulations propose that companies, including the VHI, who wish to offer health insurance in Ireland should provide 40 days cover for in-patient treatment per year but, as Senator McGennis pointed out, 40 days in-patient treatment is provided, in the subscriber's lifetime, for people who suffer from alcohol or drug abuse.

I have met many people who suffered serious psychiatric problems and different forms of ill health in the past. It is a great tragedy to meet people who have suffered with psychiatric problems. Friends of mine who suffered with such problems found they were unable to cope on returning home to their families. People suffering from psychiatric problems can upset the entire household which may have extensive repercussions.

I hope there is a delay in signing the regulations. People entering into contracts with insurance companies are [1289] entitled to obtain cover for different risks. We should ensure that the VHI maintains the insurance cover it provides at present. Many suicides in this country are related to psychiatric problems and the victims might not have killed themselves had they received treatment in time. Similarly, if people have to leave hospital prior to their treatment being completed, they may take such drastic action. This is a serious matter and I am certain the Minister will be sympathetic to the motion. When we speak about health, we must recognise that the patient is the important person. While we have difficulties with health services in Ireland, we can be proud of the fact that they are as good, if not better, than health services throughout the world.

If I have a heart problem I am entitled to treatment for 180 days whereas if I have a psychiatric problem my treatment is limited to 40 days. I cannot see why a person with a heart problem should be treated differently to a person with a psychiatric problem. They both have serious illnesses and need care, treatment and attention. It would be wrong to discriminate between one type of illness and another.

I was worried when I heard about opening up the market. Tougher systems are being introduced and the market is becoming leaner but it is also becoming meaner. There is a great deal of talk about competitiveness. This may be helpful in ways but it has an impact on patients and I have great reservations about it.

Over the last few days I have received more telephone calls and letters about this issue than about any other problems or difficulties which have arisen from legislation over the years and I do not think this has been a co-ordinated effort. I hope the Minister will accept the motion.

Mr. Norris: The case for this motion has been well made and I hope the Minister will accept it. I will vote for it if it is put to a vote and I would take pleasure in doing so.

[1290] Senator Enright said he received telephone calls and messages about this issue to an unusual degree and so have I. I received a telephone call about two hours ago from a woman who gave me details of her situation. I asked her if I could place that situation on the record of the House and she said I could. I told her I would do so without naming her. She said she would be happy to be named but I indicated it is not in the tradition of the House to name any person. The strength of feeling of this family is shown by the fact that it is prepared to be named in public on such a matter.

Since 1969 this woman's husband has suffered from manic depression; he has had seven hospitalisations. Under the present programme, because there is not a restriction of 40 days care, he can have continuity of care from the psychiatric services. This family is afraid that if the Government pursues the line it appears it wishes to pursue, he will be forced into public care and the continuity of care which has been vital to his mental and psychological wellbeing will not be sustained.

This woman gave me her full name and said she and her entire family are members of the VHI, although they are not in good circumstances. They are members, not for snobby reasons but because they regard membership as vital to their wellbeing. She said she would pay VHI subscriptions before she would put the dinner on the table. She is asking for equal treatment for those with disability.

We have a Minister for Equality and Law Reform. One of the forms of equality we should look at is equality between patients who suffer from mental and physical illness. It is an extraordinary way to celebrate the 250th anniversary of the foundation of St. Patrick's Hospital by the great Jonathan Swift, Dean of St. Patrick's Cathedral, by attempting to reduce the amount of cover available for patients with psychiatric illnesses. Swift's great contribution to the 18th century was to make it clear that he, at least, regarded mental illness, [1291] or what was then known as lunacy or madness, as an illness parallel to physical diseases of the body. I call on the Minister to ensure those suffering from mental illness are treated in the same fashion as those with physical illness.

There is a suggestion that people may be pushed out into care in the community. We have seen this happen in Great Britain and the United States with frightening repercussions. People are put into the community before they are in a position to take care of themselves and this has serious social consequences. Anybody who visits the major cities of the UK and the US can see this fallout in action.

There are a number of problems involved — Alzheimer's disease, Huntingdon's chorea and schizophrenia. I received a telephone call this morning from a young woman who suffers from schizophrenia. She was extremely concerned at what the implications of Government policy might be for her.

I understand — and I am concerned about this — that the Minister refused to meet the representatives of the consultants. Is this the case? If so, why? At this juncture is the Minister prepared to meet these representatives?

I believe the present policy, if unamended, will lead to unacceptable pressure on carers, relatives and others who have to support a person with psychiatric illness. I strongly urge the Minister to take on board this prudent motion.

Mr. Roche: At this stage the Government, through the Minister, must be clearly aware that it faces an uprising. I compliment speakers from the other side who put forward the most cogent reasons for accepting the motion. I am at a loss because it is clear from the Minister of State's speech that he is not accepting it. These regulations are a barbaric discrimination against people who should not be the subject of discrimination. I compliment Senator Finneran and Senator Daly for pressing this issue and Senator Maloney for his clear [1292] exposition as to why these regulations are repugnant, discriminatory, barbaric and unacceptable.

Will we have a debate and accept the motion, after which the Government will sign these regulations or, in accepting the motion, will the Government defer signing them? It is not clear from the Minister of State's speech that they will be deferred. It is clear from my reading of it that the Minister will sign the regulations despite what has been said in the House.

I have no doubt that the minimum of 40 days will become a maximum. Speakers, including some from the Government parties, have made this point. Market forces will determine that 40 days will be the minimum. When this issue arose in the US, President Clinton would not allow a minimum of 40 days to be stated and the regulations there provide for a minimum of 90 days.

These regulations will result in repugnant discrimination. If a person breaks his or her leg and there are complications, they are entitled to VHI cover for a full 180 days. However, if a person suffers from a psychiatric illness, he or she will only be covered for the minimum of 40 days. There is no medical, ethical or defensible reason put forward for this 40 day minimum other than the extraordinary suggestion that market conditions should determine the minimum time. Compassion and medical practice should determine it. The existing figure of 180 days, which is not availed of in the majority of cases, is a humane figure and is determined by medical practice.

Nothing in the Minister's speech argues the case against 180 days. However, there are a series of serious contradictions in it. I draw exception to the Minister saying “Over 70 per cent of all discharges from psychiatric hospitals occur within 40 days.”. That may be the case and Senators with professional experience have accepted that, but what of the other 30 per cent? They will be shoved back into the community or onto the State services by these regulations. Senator Maloney said there are good [1293] reasons people would want to avoid that stigma. If there is a stigma people can only avoid it by having the choice available through medical insurance. Senator Norris said this is why people put themselves to the pin of their collars to afford medical insurance. The Minister is a humane person, although I do not know about the person who wrote his speech. I am sure the Minister cares for the other 30 per cent.

The Minister's speech contains statements which directly contradict each other. It says “If this is not demonstrated to the satisfaction of Brussels, then much of our legislation on private health insurance may be seen by them as invalid.”. That is conjecture. There is no evidence that that is the case. There is no argument I know of in European law that we should introduce lesser reasons. The only argument about restraint in trade that can be put forward in European law, as the Minister and his officials know, is that of unfairly discriminating. If the 180 days rule applies to Irish insurers, it also applies to every insurer and cannot be regarded as a constraint on trade. I challenge any official in the Department to produce a scintilla of evidence that any case has ever gone under European competition law on the basis of unfair discrimination when the recipient nation, in this case Ireland, has a set of regulations because once they apply across the board to all companies in the field, it cannot be argued, as is done in this specious argument, as being unfairly discriminatory.

I wish I had further time to read a letter circulated by AWARE into the record. The Minister must clarify that he will not sign these regulations because that is the wish of all Members who have spoken so far. I commend all Members for their clarity and wish the Minister had exercised the same.

Miss Ormonde: Everything has been said at this stage and I can only reiterate some of the points made by my colleagues. I especially compliment Senator Finneran for spearheading this motion. It is good to hear from all sides [1294] an admission that there is blatant discrimination against the most vulnerable in our society. The Minister's presentation is the most clinical I have come across and has nothing to do with the motion.

The Minister's contribution says “Departmental officials have consulted widely with a wide range of interest groups”. I would love to see the officials the Department consulted because the people to whom I have spoken were not consulted. All we want is to allow consultation to take place. Interested groups like the St. John of God's Hospital, St. Patrick's Hospital, AWARE, the Alzheimer Society of Ireland and others have approached me and told me this legislation discriminates against the ordinary person. I ask the Minister to return this legislation and I support the calls not to sign it into law.

I will not delay the House any further. I fully support this worthy motion and I hope the Minister will have second thoughts on it.

Mr. Cassidy: Everything has already been said on this issue. The Minister has refused to see deputations from St. Patrick's Hospital and St. John of God Hospital, which cater for a high percentage of mental illness cases. The Minister is definitely not speaking for any Member of this House in doing this. It is a retrograde step. In this age of communication and technology, the Minister would not see them for even a few minutes to discuss the matter.

Mr. Finneran: I thank all who contributed in a positive way to this debate. Providing cover for our psychiatric patients has caught everybody's attention. The Minister must now consider the views of this House. I am not clear of his intention from his speech and it would help if he could clarify it. I appreciate the Minister of State is deputising for the Minister for Health and in those circumstances, I am not sure how far his brief would extend. I know he is interested in the matter and [1295] it would help us if this matter was clarified. If the 40 day minimum is allowed, the norm will become 40 days.

The Minister has to comply with section 3 of the Act and put the draft regulations before the House in 21 days. If they are the same as those mentioned in his speech, I will introduce a motion to annul them. The wishes of this House will have been ignored if the Minister signs those regulations.

I ask the Minister, if at all possible, to clarify this matter for us so that this House can adjourn feeling confident that he has taken on board the serious reservations everybody has experienced about these draft regulations. He should defer signing these regulations and negotiations should take place with the different groups. The discrimination to give psychiatric patients less cover than those with other illnesses should be removed so that we will treat our citizens equally.

Mr. Wright: Will the Minister clarify the situation? It would help the House.

An Cathaoirleach: This is not normal procedure. The Minister has spoken.

Mr. Wright: On a point of order, I am sure that if the Minister would like to clarify his position on the motion and a deferment of signing these regulations, all Senators would agree to it.

An Cathaoirleach: This is not normal practice, but I will let the Minister speak briefly.

Mr. Wright: I accept that.

Mr. Daly: This is not a normal situation.

Mr. O'Shea: Thank you for facilitating me to respond, a Chathaoirligh. I have not been in this House since your elevation to this post and I wish you the best in your new position.

[1296] Basically, 30 July was set as a target date for signing the regulations. The consultation process will not be exhausted until next week. Two institutions in Dublin were mentioned — St. Patrick's and St. John of God. People from those institutions on two occasions met officials from the Department.

Mr. Roche: The Minister for Health, Deputy Noonan, refused to meet them.

Mr. O'Shea: Representatives of the Schizophrenia Association will be met tomorrow. There is nothing sacrosanct about 30 July. It is a target date and the consultation process has not yet been exhausted.

Question put and agreed to.