Seanad Éireann - Volume 147 - 01 May, 1996

Discrimination against Psychiatric Patients: Motion.

An Cathaoirleach: There is a typographical error in line 1 of the motion — “section 2” should read “section 3”.

Mr. Finneran: I move:

That Seanad Éireann annuls the regulations made under section 3 of the Health Insurance Act, 1994, because:

[181] (1) they constitute a serious discrimination against the psychiatrically ill as other patients are not singled out for such a limit;

(2) the regulations give effect to a reduction of insurance cover for psychiatric patients from 180 days to 100 days a year; and

(3) the regulations fail to reflect the actual cost to subscribers of outpatient services.

Under section 3 (3) of the Health Insurance Act, 1994, there is a provision for the Seanad to annul regulations made under legislation within 21 sitting days after the regulations were laid before the Oireachtas. These regulation were laid before the Oireachtas on 28 March 1994.

The introduction of a 100 day limit on cover per calendar year constitutes a most serious discrimination against patients suffering from psychiatric illness because no other patients, that is, patients receiving care under the general medical service, are singled out for such a limit. Patients suffering from psychiatric illness must be treated no differently from patients suffering from physical illness. It is unbelievable that this Government is enacting legislation to effect this discrimination. These regulations represent a 45 per cent reduction in cover and are contrary to all the guidelines on psychiatric care that have been issued by the Department of Health in recent years.

The signing of these regulations is a clear attack on one of the most vulnerable sections of our community. It will, I believe, result in over 1,000 patients having to leave psychiatric hospitals each year before their in-patient treatment is complete. Other medical illness will continue to have 180 days insurance cover. This clearly discriminates against psychiatric illnesses such as depression, manic depression, schizophrenia, substance abuse and alcohol dependency, all of which have just as much a medical biological basis as, say, diabetes or heart disease.

[182] The Department of Health maintains that these regulations are necessary to enable other insurance companies to enter the Irish market. In these regulations the Minister has followed the requirements of insurance companies, who have always discriminated against people suffering from psychiatric illnesses requiring, say, travel insurance, mortgage protection policies, or critical illness insurance. It is one thing when insurance companies discriminate but it is another matter when the State discriminates in this way.

Turning to the regulations for outpatients health cost, a component of the core service is that the regulations seek to establish on a statutory basis a limited annual minimum benefit, the level of which is notional, twice removed from the reality of the actual cost of such services to the subscriber, and which is also subject to the withholding of a fixed annual amount of benefit.

In general insurance the purpose is to provide protection against unexpected costs, particularly those of a catastrophic nature. Subscribers to health insurance expect that the statutory regulations would at least safeguard this principle for them. However, the regulations, as now signed by the Minister, do not constitute an insurance arrangement formulated in the interests of the subscribing public. They leave the subscriber with an open liability at the end of each service at the level of the part of the actual cost not designated as allowable for benefit purposes and for which the regulations require that a minimum benefit be provided. There is no direct relationship with the risks experienced by the subscriber. In these regulations signed by the Minister, the insurer is fully protected from risk while the subscriber is fully exposed. This is surely anathema to the principle of insurance.

I call on Seanad Éireann to annual the regulations signed by the Minister for Health which fail to protect the civil rights of those who suffer from a psychiatric illness and to annual the same regulations because they put the subscriber [183] who needs care on an outpatient basis at risk rather than the insurer. I commend the motion to the House.

Mr. Daly: I second the motion proposed by my colleague. The Minister will be aware that we discussed this matter here in July 1995. We were very seriously concerned about the provisions the Minister had in mind at that time. At that time we asked the Minister to withhold making the regulations and to meet with representatives of various organisations involved in this area. At that time Aware had made very strong representations and the organisation is still in communication with us as are representatives of St. Patrick's Institution and St. John of God's, which are the private institutions providing top quality care.

In fairness to the Minister, he agreed to our wishes and he did look at the proposals at that time. In view of the motion before the House he had discussion and fairly detailed consultation between then and now, but we are still not satisfied with the level of cover proposed by the Minister. I will not go into the technicalities now, I do not wish to delay the House, but there is still the view that these proposals discriminate against psychiatrically ill patients.

The minimum cover of 100 days now proposed will still be inadequate and, compared to the 180 days allowed for other cover, it will be seen as discriminatory against a vulnerable section of the community, people who are in need of special care. As Senator Finneran said, the proposal is a 45 per cent reduction in the duration of cover compared to what exists at present. The Minister has not convinced me that this will not seriously affect people who have to go back on a number of occasions during a 12 month period. When he replied to previous questions on this issue he gave figures for admissions; a high percentage of people return a second or third time during the period and to provide the necessary [184] cover, 180 days is the minimum required.

It has also been suggested that where this cover will not be available or will be seriously curtailed, patients will be forced to go to the public service which, as the Minister is aware, is already under severe strain and barely able to survive. I will not go into that because it is not the issue before us but it will mean that many of those currently in receipt of care and attention in private institutions will be forced to go into public institutions that are under pressure. It is also recognised that the cost of in-patient service and attention in the public services is higher than in private hospitals; perhaps the Minister could clarify that.

The Minister has come some way towards meeting the views forcibly expressed by Members on all sides of the House when we debated this issue last July. He made a genuine effort to bridge the gap between what he originally proposed and what he proposes now. However, he must go another part of the way to meet the demands made. I have been convinced by the representations made by Aware, St. Patrick's Institution, St. John of God's and practitioners who deal with this on a day to day basis and must be in a position to give an objective analysis. I second Senator Finneran's motion and ask the Minister if, even at this late stage, he could examine the regulations to see if it is possible to bridge the gap between what is proposed and what is demanded.

Minister for Health (Mr. Noonan, Limerick East): I am pleased to have the opportunity to inform Members about the real and significant protections which the health insurance regulations constitute for the public. I do not think there is any doubt about the importance of the matter the House is being asked to consider in the motion before it. It is crucial, therefore, to understand the broad context within which we come to be discussing the regulation of the business of health insurance.

[185] This country's regulatory structure for health insurance was devised in the context of the measures adopted by the European Union to create a Single Market in insurance through its third non-life insurance directive. The central thrust and purpose of the directive is to bring about a free and competitive market. While it contains certain provisions particular to private health insurance, it is not a health services directive but rather relates to non-life insurance services generally.

In that context we must take a realistic approach to its implementation in terms of measures to admit competition to our market. We cannot, for instance, use it to copperfasten the dominance of the VHI or to require any insurer entering the market to perform as a VHI “clone”. To my knowledge everybody wants competition but there appears to be some reservations or lack of resolve when it comes to putting in place the measures to allow it to develop. The rules for competition have been set out in the regulations and I am gratified that already one major international health insurance undertaking, BUPA, has decided to enter the market on the grounds set out. I view this as a vital and positive development.

Through the efforts of my officials and myself, the EU Commission has accepted in principle this country's entitlement to regulate the private health insurance market. This involved considerable effort and persuasion on our part and took place against the background of a foreign insurance undertaking representing a contrary view to the Commission. This chapter is perhaps not yet closed as it has been recently reported that the Association of British Insurers may take up the issue of our entitlement to legislate for the conduct of the health insurance business. It is important, therefore, to understand that there is a fundamental international business dimension to our private health insurance framework.

As far as the Commission is concerned, competition and the performance of the marketplace are to be the [186] acid test. It must be satisfied, through the experience of the market operation, that the measures put in place are in proportion to achieving the objective of protecting community rating and do not constitute an unsustainable barrier to trade.

The regulations, which were made pursuant to the provisions of the Health Insurance Act, 1994, are intended to facilitate competition while protecting our core values of community rating, open enrolment and lifetime cover. The regulations include a statutorily guaranteed minimum level of cover in respect of a variety of hospital and consultant in-patient, day patient and out-patient services. Overall, the regulatory framework provides a high degree of protection to the members of the public in the context of opening up our private health insurance market to competition.

The motion I am addressing claims, inter alia, that the regulatory framework constitutes serious discrimination against the psychiatrically ill and gives effect to a reduction in insurance cover for psychiatric patients from 180 days to 100 days per year. In view of this I consider it instructive to look at what the market has provided up to recently as an express statutory entitlement to privately insured persons suffering from such illnesses. The answer is, nothing — at present no minimum cover is required for any insurer trading in this country, so rather than reducing cover we are introducing for the first time a requirement that minimum cover of 100 days will be provided for the psychiatrically ill. In the past the market was not obliged to provide for such cover on a statutory basis.

Until the regulations were brought into being, insured persons were entirely reliant on the customary practices of the VHI as the country's sole provider of private health insurance to the public in a restricted market. That market no longer exists by virtue of the EU's third non-life insurance directive. Under VHI legislation, the board may amend schemes of voluntary health insurance with the consent of the Minister [187] for Health. Under its rules the VHI Board may alter hospital benefits on the provision of specified notice to its members. What the VHI has provided and continues to provide to its members is cover of up to 180 days in-patient and/or day patient services a year. The utilisation of this could be entirely in respect of psychiatric illness or general illness but could also be a combination of both.

There are, however, other insurers in the market who provide indemnity cover within specific work/employee groups. I refer to the schemes operated by the ESB, prison officers and the Garda, who between them have about 80,000 lives covered. Under these schemes there are various arrangements relating to liability for benefit in respect of psychiatric illness. These range from cover for 42 days a year to 90 days in any three year period. Accordingly, varying insurance practices relating to psychiatric benefit already exist in our market and involve periods of indemnity considerably below 180 days in a year.

It is the general practice of major British insurers to limit and/or extensively qualify their exposure to liability for psychiatric in-patient benefit under their respective policies. Psychiatric benefit is not a common feature of UK health insurance and most insurers there do not cover it at all as part of their budget policies, which is the type of cover nearest to minimum benefit. Where insurers do provide cover of this kind they heavily qualify it by measures such as making payment of benefit subject to prior authorisation of hospital admissions; making payment on the basis of an agreed initial period of hospitalisation and making any extension of the period subject to further agreement; and excluding chronic or recurring disorders.

I believe it to be self-evident that the period of 100 days provided for in respect of the guaranteed minimum level of indemnity under the regulations is not only reasonable but substantial in [188] the context of our market being opened up to competition. In addition to this, I have a commitment that at an early date the regulations will provide for a minimum entitlement to 20 day-patient days services in respect of psychiatric treatment and care. That is, 100 days plus 20 day-patient days. As soon as the terms of that are sorted out, I will return with an amendment to the regulations before both Houses in order to provide for that.

These arrangements represent a considerable enhancement of the 40 days in-patient cover which was the original proposal on psychiatric cover. I was pleased to be able to respond positively to the concerns expressed by interested parties in the course of the extensive consultations held on the original proposals. I was very thankful for the debate which occurred here during the summer which drew to my attention the level of opposition to the 40 days cover. Prior to signing the regulations, I met with the authorities of the two major private psychiatric hospitals and was pleased to obtain their acceptance of the proposals. The two hospitals concerned are St. John of God's and St. Patrick's, which lobbied Members extensively on the 40 days issue.

I may add that the 100 days covers the vast majority of admissions to psychiatric hospitals. For example, the health research board's 1994 report on the activities of Irish psychiatric hospitals and units provides statistical information on discharges and lengths of stay in private psychiatric hospitals. Of a total of 4,209 discharges in that year, 3,781, or 92 per cent, recurred within three months. A guaranteed minimum level of cover in respect of 100 days in-patient services in a year, therefore, represents a very significant protection for the consumer, particularly in the context of the operation of a free market and insurance practice in the area of exposure to liability for such cover. In addition, there will be the minimum cover for day-patient services which I already mentioned.

[189] Where circumstances arise that an insured person requires treatment in excess of 100 days, later to be increased to 120 days, in a year, and where the insurance contract does not cater for this, it is open to him or her to avail of in-patient care in public psychiatric hospitals and public community based facilities. It is completely false to say, therefore, that persons who use up their insurance cover will have no access to psychiatric care. They will have such access in the same manner as the majority of the population has now.

The House may be interested to know that my Department is not aware of any other case, internationally, where providers of private health insurance contract to make available cover for a period of 100 days psychiatric in-patient service without pre certification and in an environment where the entire population is eligible for treatment under the public psychiatric service. I consider that regulations providing entitlement to a specified minimum level of indemnity cover in policies to be written by commercial insurance companies constitute a protection for the public. I further consider that, in relation to the approach taken by insurers to limiting exposure to the provision of psychiatric benefit, the minimum level set under regulation is substantial. Given the totally new context within which our private health insurance market is obliged to operate under our responsibilities as a member of the European Union, I do not subscribe to the view that this constitutes discrimination.

The concerns raised about the original proposals regarding the minimum period for treatment relating to alcohol, drug and other substance abuse have been met in the regulations. The original proposal has been enhanced from 40 days in a lifetime to 91 days in any continuous period of five years.

It is also contended in the matter under debate that the regulations fail to reflect the actual cost of outpatient services to subscribers. This suggests a fundamental misunderstanding of what the regulations are all about. The regulations [190] concerned are those relating to minimum benefits. They are concerned with core hospital and consultant services which all insurers must cater for, up to at least the level of indemnity specified, in any policies they wish to sell in our market.

Essentially, these regulations are a mainstay to community rating. They ensure that by requiring insurers to cover a range of benefits they are prohibited from specifically devising policies designed to “cherry pick” young healthy lives. Such policies could be made particularly financially attractive to the young and healthy by, for example, excluding the higher cost treatments relating to conditions associated with ageing to which the young do not consider themselves to be at risk.

The regulations relate outpatient services to hospital and consultant activities which are appropriate to the package of measures involved and reflect existing market practice. The regulations are not intended to prescribe every health service offered to the public by an insurance company. Any attempt to do this under regulation would constitute a completely disproportionate restriction on the freedom of insurers entering the market in terms of their scope for policy design. The recently announced decision of the major British insurer, BUPA, to enter our market on an establishment basis has served to highlight that, in the first instance, competition between insurers will be more on products than on premium prices. Prescribing a broad range of outpatient or community care services in excess of what is already generally available in the market would not be sustainable in terms of being objectively necessary to community rating.

The regulations provide for excesses and maximum payments to operate in respect of a specified range of out-patient services. It is a matter for individual insurers to determine under their policy conditions whether these will relate to actual expenditure or to eligible expenditure, as is the current practice of the VHI. This is, no doubt, one [191] of the factors the discerning purchaser of cover will take into account in deciding which company's policies best appeal to him or her. The protection given under the regulations regarding this matter is that, in respect of the services specified, the insurer cannot have an excess above £150 for an individual or £300 for a contract covering more than one person and cannot specify that total payments will be less than £650 or £1,300 respectively. To suggest that we should go beyond what is proposed to any significant extent is to seek to limit by use of legal compulsion the flexibility of insurers to negotiate arrangements with providers. I believe this principle is unacceptable and would not be tolerated by any other health service interests who would, rightfully, wish to be in a position to negotiate the arrangements and relationships they choose to have with others.

While I recognise the good faith and entitlement of interests to oppose regulations they regard as unacceptable, I am concerned that less than an accurate picture has been given about the measures taken in the regulations. In the interests of putting the record straight, I want to address the matters raised by the press release which Fianna Fáil issued on 12 April. The regulations do not put “a 100 day limit” on benefit for psychiatric in-patient services. On the contrary, they provide, for the first time, a statutory guarantee to a minimum of 100 days. Consequently, the claim that they constitute a 45 per cent reduction in cover is not correct.

Reference was made to the regulations increasing demand on the already overstretched public psychiatric service. This does not present an accurate picture of the situation or developments in relation to the provision of such services. Planning for the Future, the report on the development of the psychiatric services published in 1984, has been accepted as mental health policy by successive Governments. Its implementation has led to a shift in the delivery of mental health care from a [192] predominantly institutional setting to a community based one. It proposed a norm of 0.5 per 1,000 population in-patient places for short term and medium term psychiatric patients. While bed numbers have been reduced over the period, there has been a corresponding increase in the number of community residential places available. The level of bed provision still exceeds that set by Planning for the Future and remains very high by international standards. The organisational use of available resources is the issue to be addressed rather than the number of beds.

It has been stated that the regulations will seriously affect those suffering from substance abuse and alcohol dependence. Nothing, in fact, could be further from the truth, as the regulations give a statutory entitlement to 91 days in-patient treatment for such conditions in any continuous period of five years. This is exactly the same cover currently generally available in our health insurance market and provided by the VHI.

The sweeping claim made that the regulations, which provide for 100 days indemnity as a minimum, could result in people with serious disorders getting short term crisis treatment does not stand up to scrutiny against the recorded fact that discharges in respect of 92 per cent of in-patient stays occurred within 90 days. This also fails to recognise that everyone is eligible for treatment under the public system. I regret such inaccurate and unfounded claims have been made, as these must cause unnecessary concern and anxiety to members of the public.

In summary, I suggest to the House that it reject the motion on the grounds that the health insurance regulations meet our obligation to provide for competition; safeguard our core values of community rating, open enrolment and lifetime cover; and constitute a significant protection to the public in an open, competitive market. I recommend the regulations to the House.

Mr. Norris: I thank the Minister for his clear lucid exposition of the situation and for making available some of his [193] advisers for a briefing with some Members of the House today. I was there for part of the briefing — I did not stay for the entire briefing because I was at another briefing on the Refugee Bill but it certainly altered my mind. It is easy for the public to get the impression that the psychiatrically ill are being done down in some way. This perception would be unfortunate and nobody would wish to support such proposals.

However, having reflected on the matter and having read the motion, it seems to me that if it were to be passed it might have serious legal implications. It appears that the regulations under section 2 would fall completely, leaving us with a lacuna. Nobody wants this; the people would not be protected to the extent they will be protected under these regulations.

The Minister referred to the two principal psychiatric organisations — St. John of God's Hospital and St. Patrick's Hospital. I received a letter from Professor Anthony Clare on this matter. I would like to read part of it into the record of the House because he would be an interested party. The Minister has indicated that we discussed aspects of this matter before when Professor Clare and others lobbied extensively. As a result of this lobbying the Minister has met, at least partially, the concerns expressed. Professor Clare says:

The Minister for Health, Mr. Noonan, together with officials from his department, met with representatives from both hospitals, as he promised to do, when the final details of the regulations as agreed with the Trade Directorate in Brussels were drawn up. These regulations stipulate a statutory minimum level of cover for psychiatric disorders of 100 in-patient days per year.

The Minister made clear that the motion fails to appreciate the difference between a minimum cover and capping cover. There is no suggestion that that the VHI would be precluded from continuing to offer its 180 day cover. In a [194] competitive market it is likely it would do so because it would indicate a considerable advantage over the kind of scheme offered by BUPA. In the open market it is likely that the VHI will not regard this as a maximum ceiling — which it clearly is not — but, appropriately, as minimum, and will continue to offer the better service.

Professor Clare continues:

In addition, the cover currently provided by the Voluntary Health Insurance Board for patients suffering from alcohol and/or drug abuse of 90 days per five years is to remain as a statutory minimum cover for these conditions. An innovation in the regulations is the stated minimum provision of 20 days per year for psychiatric day care, which is to be provided by the health insurers for insured people suffering from psychiatric disorders.

Of course, the representative of both St. Patrick's and St. John of God's Hospitals regret that the minimum cover guaranteed under the regulations is not the 180 days as provided for by the VHI and we have expressed our views to the Minister.

That is understandable. After all, St. Patrick's Hospital was founded by the great dean of St. Patrick's Cathedral, Jonathan Swift and one of his most significant contributions was to dissolve the artificial boundaries that existed in the 18th century between medical physical illness and psychiatric illness and to allow a situation to develop where psychiatric illness was regarded as an illness and not as possession by demons or bad behaviour where people could be tortured and exposed to public ridicule in, for example, the Bedlam Hospital. Of course, they would go for parity of the physical and the psychiatric.

Professor Clare continues:

However, we do recognise the difficulty encountered by the Minister and his officials in his discussions with a Trade Directorate, primarily interested in insurance rather than health and [195] familiar with a health insurance scene across Europe, and particularly in the United Kingdom.

The Minister referred to this in passing but did not put all the figures on the record. I have before me a table of cover under budget policies for the nine principal insuring agencies in Britain. Various issues are covered, including the provision of psychiatric care. Of the nine surveyed, six make no provision whatever, one makes restricted provision and only two provide cover. This is important because this situation does not merely cover the medical area. It also covers the question of the competition regulations of the EU.

If we were promoting only those systems that were identical to our own, the Europeans would object to what we were doing on the grounds that we were not creating a proper market. Indeed, I understand from press reports that, in a characteristically mean minded approach, the Association of British Insurers have already attempted to sneak to Brussels. According to one newspaper, the ABI believes that the regulations which will be imposed on any new rentals are too restrictive and anti-competitive. The requirement to offer open enrolment lifetime cover and the use of a system of community rating allowing people of all ages to pay the same premia for the same level of cover attracted the most damning criticism. If it attracts the most damning criticism from the Association of British Insurers it should attract the most resounding praise from the Irish consumer.

The Minister correctly selected those three elements as the core values that we are seeking in this country. We do not want cherry-picking by big British unions. I commend him for ensuring that this will not occur.

Returning to Professor Clare's letter, he states in what I consider to be the most important and significant paragraph:

The requirement that all Health Insurers working in Ireland must provide, [196] in compliance with the Health Insurance Regulations, 100 days in-patient cover as a statutory minimum, is a major advance on the original proposals of 40 days, particularly in the light of the fact that some insurers in Europe fail to provide any psychiatric cover whatsoever.

We very much welcome the introduction of a statutory minimum cover for consultant-led psychiatric day care — 20 days per year — which should help us develop a day-care approach within insurance-based psychiatry to match the excellent quality in-patient care currently reimbursed and provided. Indeed, we very much hope that we will, in the future, be able to extend the level of day-care in agreement with the Department and insurers.

If we have the support of the two principal institutions providing this kind of care in Ireland, how can Fianna Fáil assume it has greater expertise than those who operate——

Mrs. McGennis: We have; it is obvious.

Mr. Norris: That is remarkably close to delusions of grandeur. I should be careful of it because the Senator may find herself requiring 100 days' treatment or confinement which the VHI would, no doubt, be glad to provide.

The Minister has also indicated that the ESB medical provident fund, the Prison Officers medical aid society and St. Paul's Medical Aid Society, who are in the open market with approximately 80,000 members, provide less than the minimum cover, which, I repeat, is not a ceiling or a cap but is a minimum, and represents an advance. I have been converted, I have seen the light and I am grateful to the Minister for his assistance.

Mrs. McGennis: Shame on the Senator.

Mr. Neville: If passed, this motion will have grave implications for the health [197] insurance business in Ireland. There will be an inevitable challenge to the regulations in Brussels which will result in opening up the area in a non-regulated fashion. Our system of community based health insurance will be prohibitive and a non-regulated insurance service will ensue. Companies will enter the market and cherry-pick aiming packages at the lower risk categories. Higher risk categories will be heavily loaded and it will no longer be possible for the aged to be insured, despite years of payment of insurance. Health insurance will cease to be for life and restrictions will be introduced by some companies to lower their premia. For example, they will not cover hip replacements, heart by-passes and other expensive medical interventions. If this motion is passed, who will suffer most? The elderly and the vulnerable. Families will no longer have cover for certain illnesses, especially those born with genetic problems.

The issue arises as a result of the EU directive on competition in the non-life insurance area which insists on open competition throughout the EU. That was important in framing the Health Insurance Act, 1994, which provided that as far as possible our community rating insurance system which prohibits discrimination on grounds of age, sex or state of health, was maintained. It facilitates open enrolment and lifetime cover for all under 65 years of age. It provides that cover must have certain elements, such as in-patient, day patient, convalescent, maternity and substance abuse cover. The initial proposal, that the regulations should cover a minimum of 40 days, was, after intense negotiations by the Minister in Brussels, increased to 100 days with an acceptance of a further 20 days for day care. This will be introduced by regulation in the near future.

In increasing the minimum level of cover from 40 days to 120 days, the Minister has extended the limit to its ultimate. If the regulations go beyond that limit they will seriously jeopardise the principle of regulation and open the situation to a free for all, which is the [198] case in other countries. Britain and other European countries provide restricted or no cover for psychiatric illnesses. BUPA, for example, provides psychiatric cover on a restricted basis which requires express prior authorisation by the company in respect of in-patient admissions. The cover will not in any case exceed 90 days in-patient care per year and will not extend to chronic or recurring disorders.

Under present regulations, that would not be accepted in this country. BUPA will have to cover 100 days in addition to 20 days outpatient care. The private patient's plan, which provides psychiatric cover by means of its discreet psychiatric benefits protection scheme, can be purchased as part of most of its insurance plan. Payment of benefit is subject to express prior authorisation and payment is made on the basis of an agreed initial period of hospitalisation in each case. Extension of this period is subject to medical certification and agreement by the insurer. The scheme does not specify in-patient entitlements in a subscription year and appears to operate on a case by case basis.

Norwich Union in the UK does not provide any cover for psychiatric illness. The Western Provident Association appears to have a limit of 28 days in-patient care. None of these companies provides benefit in respect of treatment arising from the abuse of alcohol, drugs or other substances. If we give these companies a stronger card in Europe and they seek to apply their systems in free market competition, what will be the response of the European Union? If we pass this motion we will give those companies a stronger card than they already have. Senator Norris's quote from the UK's insurance journal highlights the fact that the Association of British Insurers intends to challenge our present regulations in Brussels. Will we strengthen their hand by extending what they view as unacceptable regulations, which the Minister had to fight hard to achieve?

The association will be delighted if this motion is passed as it will have an [199] extra card in its efforts to deregulate the situation in Ireland. It is interesting to note that just 12 per cent of people in the UK are covered by health insurance in comparison to 35 per cent in this country. In the UK 70 per cent of those insured are insured through employment schemes. As a result most people drop out on retirement at 65 years of age. In Ireland, however, people have cover once they have enrolled before the age of 65 years and the cover applies up to the time of death. That is not the case under the deregulated system in the UK.

Brussels has accepted the insurance system in Ireland and the regulations introduced by the Minister. They are likely to stand if challenged. However, if we pass this motion we will make the situation risky. It is interesting to note that the three organisations mentioned by Senator Norris which operate in addition to the VHI in this country do not give similar cover to the VHI for psychiatric or substance abuse care. The ESB staff's medical provident fund covers to a maximum of 45 days within a fund year. It covers 90 per cent of hospital charges for further hospitalisation within the fund year and within the fund's limit. The prison officers' medical aid society offers cover for 90 day in-patient treatment plus 90 out-patient consultations in any three year period. Evidence of attendance at after-care programmes must be provided and each case is subject to committee examination. St. Paul's Garda medical society covers 42 days of in-patient psychiatric treatment in any year at a maximum of £84 per day. It covers 42 days treatment for substance abuse in a five year period.

Fianna Fáil should look at the implications of this motion for the excellent medical insurance cover that has been built up by the VHI and which has been maintained by the Minister in the context of the open market. We are now part of Europe and the Irish people accepted the Maastricht Treaty so we must respond to the open market.

[200] Mr. Farrell: This is an interesting debate. For many years we have tried to prove and we have now succeeded in proving that psychiatric illness is an ordinary illness that is curable. We closed down the old mental hospitals and there are new units in the modern general hospitals for psychiatric patients. However, every other patient who enters the general hospital is given 180 days cover. How are these two facts to be reconciled? It is either an incurable disease which cannot be insured or it is an illness like any other. I believe it is an illness and should be treated on a par with other illnesses. There should be no such thing as special concessions.

The previous speaker tried to instil fear in the Members. The days of instilling fear are long gone. Psychiatric illness should be treated equally. We have heard about other insurance companies but they have private arrangements with the staff concerned. That has nothing to do with statutory regulations. Private staff arrangements exist in many bodies but that issue does not arise in this context. The Senator should spare his breath to cool his porridge. The arrangements of private insurance companies have nothing to do with statutory regulations.

Mr. Neville: There will be a rush of insurance companies cherry picking in the market and the old and vulnerable will suffer. Fianna Fáil made much play on that possibility in a previous election.

Mr. Farrell: As an old saying goes, the cock that crowed that tune last would have a long red comb by now. We have been hearing about cherry picking for a long time. It is time we got rid of that cliché. We are told that other countries do not have our system. So what? Mozambique does not have a water supply. Can we ignore that?

Mr. Neville: We joined Europe.

Mr. Farrell: Let us teach Europe; it has already accepted a lot of that which [201] we see as standard. It is time we taught it more.

Mrs. Taylor-Quinn: That is the point. Praise the Minister for what he has done.

Mr. Farrell: We should let them know that we are considerate and that our psychiatric patients get the same treatment as other patients.

Mr. Neville: Psychiatric patients in the UK have not got the same——

Acting Chairman (Mr. Dardis): Senator Farrell without interruption. Let us leave the cross talk until later.

Mr. Finneran: Let us not talk about the UK psychiatric services.

Mr. Neville: It is the British companies that are coming in.

Mr. Finneran: Recent court cases do not say much for our services.

Mr. Farrell: We do not mind a little cross-fire — it makes for entertainment and helps us get across our points more forcibly.

Mr. Finneran: Senator Quinn would know about that.

Mr. Farrell: People seeking treatment for alcohol or drug use will only have 90 days cover in a five year period. A detoxification programme for a drug addict will last two or three weeks. In addition they would need 90 days in Aiséirí or a similar facility. An entitlement to 90 days treatment in five years is not a serious approach to helping a weak section of our community. There should be more cover for such problems. I hope I am interpreting this provision incorrectly; perhaps the Minister would clarify the matter.

None of the insurance companies seems able to satisfy the consultants who require an extra payment on top of the insurance. Normally when one pays [202] insurance one gets full cover; for example, if one pays an excess charge for motor cover the insurance is cheaper. However, with the VHI one could have to pay in addition to the cover. In the past patients were sent to the North for hip operations. A system will have to be devised for health insurance which gives the rates for common operations. It is wrong that someone who has been paying VHI cover all their life has to pay extra when they have an operation.

This motion should be supported. We should view mental illness as we view other illnesses. Imposing this limit on psychiatric treatment is an indication that psychiatric patients do not deserve the same respect or treatment as other patients. They do and we should treat them accordingly.

Mr. Maloney: I have spent the majority of my working life in the field of psychiatric care. In July last year I spoke in the House on the motion which called on the Minister for Health to defer the signing of the draft regulation pursuant to the Health (Insurance) Act, 1994. I said at the time that the regulation as drafted would have serious implications for the welfare of psychiatric patients and for the future of public and private psychiatric services.

The main point of contention in the draft regulations was the reduction of the entitlement of 180 days in-patient treatment to 40 days. This was a definite case of discrimination as it was only psychiatry and the psychiatrically ill who were being singled out in terms of time allowed for in-patient treatment. No other medical speciality was being subjected to these constraints. In many representations I received from people working in the psychiatric service, private and public, great concern was expressed about the time regulations.

The psychiatric speciality has always been discriminated against in the health services. It has never received the recognition or funding to which it was entitled. From the years I spent working in this field I know this discrimination [203] was always a source of extreme frustration, to say the least. As a member of the Labour Party I do not believe that any person should be discriminated against in any way.

The purpose of the draft regulations was to enable other insurance companies to enter the Irish market and, while competition is ordinarily healthy, it was the cause of discrimination against those it intended to serve in this case. The Minister took on board the criticisms of the draft regulations aired in this House. He was able to enter into discussions and correspondence with the EU Commission about our private insurance regulatory framework and put in place the regulations under section 3 of the Health (Insurance) Act, 1994, which are the subject of this motion.

The motion before the House is unfortunate. Having listened to the criticisms last year, the Minister undertook to revise the draft regulations. Speakers on the other side of the House mentioned that, under the proposed new regulations, VHI cover will reduce from the present 180 days to a minimum of 40 days psychiatric in-patient a year. This is not the case. I advise people to join the VHI and they will still be entitled to 180 days' cover.

It was also remarked that we had received letters from many people, including the directors of psychiatric hospitals. They were described as competent and caring doctors who are concerned their hospitals will have to increase costs to the patients. The letter I got from Dr. Anthony Clare read:

I am writing to thank you most sincerely for the support that you have given to myself and my colleagues working in St. Patrick's and St. John of God's in our fight to ensure a fair deal for psychiatry in the regulations governing health insurances in Ireland. Without your active participation and energetic support, we would never have achieved the significant improvement in basic minimum cover for psychiatric illnesses [204] which is now stated in the regulations covering health insurance in Ireland. My colleagues at both hospitals and myself are extremely grateful to you.

He went on to compliment the Minister in regard to the matter.

It should be remembered that the Minister and his officials were severely restricted in their room for manoeuvre as they were dealing with the EU Commission which was primarily concerned with insurance rather than health. The discussion took place in a European context where some insurers failed to provide any psychiatric cover whatever. Given the pressure the Minister was under, the requirement that all health insurers working in Ireland must provide, in compliance with the health insurance regulations, 100 days in-patient cover as a statutory minimum is a major advance on the original proposal of 40 days. This reverses the in-built discrimination of last year's draft regulations and this was what we asked the Minister to do at the time.

In addition, he stated that he is committed to the introduction at an early date of cover under the minimum benefit regulations for day care services in relation to psychiatric illnesses. The Minister has also increased the minimum level of indemnity for charges in the psychiatric hospitals from £35 per day to the lesser of £65 or 60 per cent, and the insurance cover for substance abuse from 40 days over a lifetime to 91 days in any continuous period of five years, a welcome move. These regulations constitute a balanced and effective basis for regulating a competitive market in private health insurance in accordance with the protection of the common good and with the thrust of the third non-life insurance directive in relation to competition.

The quality of service for the patient must always be our paramount concern. In reviewing the original regulation I believe the Minister is of the same view and I commend him and his officials for adopting that view. He should not take [205] my word for it. Dr. Anthony Clare has recognised his achievements and has said the measures contained in the present regulations put into force by the Minister provide a significant protection for the general public in the context of a competitive private health insurance market. He has accepted the Minister's package on that basis.

In the light of what was contained in the original draft regulations, which came before us last year, the Minister has delivered on what he promised, that is, eradicating the discrimination incorporated in those draft regulations. It is unfortunate that Members saw fit to undermine his achievements by tabling such a motion. He has ensured that those who are in need are in a position to receive the best possible care and that they are not discriminated against as a result of a concentration on issues outside health care. For these reasons, he deserves our commendations. I do not support the motion.

Dr. Henry: Like other Members, I would have preferred no reduction in the health care for psychiatrically ill patients provided by the VHI or any other insurance company It is important to remember we had a reduction some years ago. I remember when a psychiatric patient was given one year's cover and that was reduced to 180 days. Naturally, the reduction in the number of days covered is a cause of concern for patients and doctors. As the Minister said, it is important to remember this is the minimum number of days to be covered. If a health insurer wants to continue with a higher level of cover, they are entitled to do so. The Minister said 92 per cent of patients are discharged from hospital within this length of time, but patients may worry that they may be in the 8 per cent of cases or that they may be readmitted within a year. It is worrying for doctors because they will be under pressure as regards early discharge; this is never useful. This practice already exists in the physical health care area and it is depressing to [206] see it happening in the mental health care area.

It is particularly unfortunate that a few months ago in the North-Western Health Board area a successful prosecution was brought by a family who felt their father had been discharged prematurely from a psychiatric hospital — he was a public patient. He suffered from depression and committed suicide a number of days after being discharged. The doctor's clinical judgment was called into account. To my dismay costs were awarded against the family. I am sure the psychiatrist and those involved made the best judgment they could as regards clinical care. Who is to say the length of time a person's stay in hospital will effect such a grim outcome as a person committing suicide? Coming hard on the heels of such a judgment, I am anxious that there will not be such pressure put on those providing private health care to discharge people from hospital. I hope the report by the inspector of mental hospitals, which will shortly be in the public arena, will give comprehensive guidelines as regards good clinical practice in such cases. Doctors are in an invidious position where they feel their clinical judgment could end in a court case.

As Senator Farrell and others said, it is disquieting to see the distinction being made between physical and mental illnesses. We have being trying to bring mental illness into the main arena of illnesses to show that it is the same as any other. Indeed, depression is the most common illness in the world and it is the most important one to address when dealing with health matters.

Since health care insurers in many other jurisdictions do not cover mental health care, it is understandable that it is referred to in these regulations but it might have been better if only health care had been mentioned. If other insurers could have specifically excluded mental health care, we might be in a worse situation.

When these insurance bodies begin to operate here, it is important that the Minister makes it clear to the public [207] that mental health care may not be covered by some of them. We have already seen the regulations from BUPA. People may believe that it is more closely aligned to the VHI than is the case. Fianna Fáil has rightly criticised the level of outpatient care the VHI offers. Until ten years ago it concentrated on acute hospital care. It is important to note that BUPA, according to the information it has sent to date, will only focus on outpatient care.

A good thing from the view point of psychiatric patients is that there has been a trend towards treating them on an outpatient basis. For that reason, I welcome the provision of 20 days consultant cover which has been brought in with the new regulations. That did not exist before and there was a temptation to admit patients to hospital when it might not have been essential.

The most important aspect of this debate is how we will deal with the possibility of managed health care policies which may take over private health care. Are we looking far enough into the future in this regard? We are debating this issue because of competitiveness in the marketplace. Money and competition must be taken into account. This debate is about insurance rather than health.

What can we expect from managed health care which is in vogue in America and in some European countries? A battle which must be fought relates to pre-certification where a doctor must get permission from the insurance company before they can admit a patient to hospital. This happens with BUPA, a number of health insurance companies on the continent and with almost all insurance companies in the United States. That would be a major change if introduced here. Money and health care will be very important because the insurers will insist it is spent wisely. There will be a great cascade downwards of care from acute hospital care to sub-acute care to home care. The outpatients situation will need to be looked it very carefully.

[208] Firms who pay part of their employees VHI cover — or all of it if one is in Bord na Móna — will want the best value for their money. They will be able to look to different health care policies to see what they should get. Protocols may be given to doctors with regard to their role in health care. There will be little choice of doctor, and patients will be more restricted with regard to who can manage their cases.

I am glad Fianna Fáil raised this issue because it is at the centre of the debate we should have about whether managed health care will be introduced here and how we will deal with it. Will the Insurance Ombudsman be involved in overseeing health policies? Far too often we may find the public is not given sufficient information and in the small print there may be hidden difficulties for patients, which I hope the Insurance Ombudsman will deal with in the excellent way she has dealt with policies in other insurance fields.

Mrs. Taylor-Quinn: I welcome the opportunity to speak on this issue. Until recently I thought it had been completely and satisfactorily resolved and properly dealt with by the Minister and the Department. Some months ago there was a great deal of lobbying by families of psychiatric patients, various institutions and members of the medical profession in respect of the proposed reduction from 180 to 100 days. Following representations I received, I made various contacts with the Minister. Like Senator Maloney, I received a letter of appreciation and thanks from Dr. Anthony Clare. I assumed that if he was satisfied, so was everybody else.

It is important that the situation as it is be clearly put on record so that people who suffer from depression and psychiatric illness, about whom we are all concerned, are not in any way misled, stressed any further than they are already or frightened about their situation and future.

We should compliment the Minister and the Department for the fine work they have done, particularly in negotiations [209] with the European Commission, and for taking into account its attitudes to insurance, competition and free trade. They did a remarkable job in ensuring that the 180 day period will remain in respect of the VHI. Prior to this, there was no statutory protection or limit in respect of health insurance. Under these regulations there is for the first time a statutory limit. What happened up to now was a result of customary practice rather than statutory obligation. This is a major breakthrough because the consumer — in effect the patient — is protected to a far greater extent than he or she was heretofore.

Because of the opening up of the market, new insurance companies will enter it and possibly try to cream off its better end. Under statute they will be obliged to provide a minimum of 100 days care, whereas the VHI will provide 180 days care. I foresee companies being forced to increase the number of days care they provide in order to be able to compete with the VHI and this will be extremely good.

Senator Farrell expressed concern about addicts. It is important we realise that the original proposal was for 40 days care in a lifetime but this has been increased to 91 days in a continuous period of five years. The VHI gives this cover and will continue to do so in future.

Senator Henry spoke about pre-certification. I agree with her and I hope the pre-certification clause which exists in other countries will not be introduced here. The Minister and the Department should be complimented for bringing in these regulations without such a clause.

Everybody who spoke on this issue is extremely concerned about patients, particularly those suffering from psychiatric illness. We would all agree that people suffering from such illness are vulnerable and are in a fearful and stressful state. They are the last patients we would wish to see under further stress. It is important that the facts are repeated and that any unnecessary stress people have suffered in the last few weeks is reduced. The Minister and [210] the Department should conduct a publicity campaign to further educate people about what is and is not available.

At all times a public psychiatric service is available to everybody psychiatric hospitals throughout the State. This compares favourably with what is available in other European countries and in the United States. This is a good reflection on us as a community, a Government and a State. We all aspire to ensure that this continues in the future. If we cannot provide in a civilised, considerate and caring fashion for those who are most vulnerable and stressed, this is a poor reflection on us as a people.

I have every confidence that the Minister, the Minister of State and the Department will continue to endeavour to protect to the best of their ability those who are psychiatrically ill. They must be complimented for what they have done in recent negotiations with the EU Commission. It was a major success on their part to have secured 180 days for the VHI and a minimum of 100 days cover for new insurance companies entering the country. I hope the message will go out loudly and clearly to all concerned that this is the situation.

I ask the Opposition to be aware of and alert to the fact that we need to be considerate of the frustrations and worries of people who are psychiatrically ill. People in this Chamber or anywhere else should not do anything which would increase their anxieties and concerns. In light of this debate and the Minister's speech, the motion should be reconsidered by the Opposition. I hope they will withdraw it before the conclusion of the debate.

Mrs. McGennis: I congratulate the Minister on fighting a good battle to increase the period of care from 40 to 100 days. Unfortunately, however, we part company here. Senator Neville said these regulations will have grave consequences for insurers. However, I do not share this view, but I have grave doubts about the effect of these regulations [211] on the psychiatrically ill. Much comment has been made about the fact that the directors of the two leading psychiatric hospitals have accepted and welcomed them. If the hospitals are happy, I have to refer Members on the Government side to the letter from the users, patients and groups who support those who are psychiatrically ill, and specifically from Aware, a group set up to help those suffering from depression. They are far from happy. When the vote is called the Minister and the Government parties should consider those who have been or may be psychiatrically ill as a priority to insurers.

The Garda, prison officers and ESB schemes were referred to and I have personal knowledge of one such scheme. I wish to relate the effects on psychiatrically ill patients of inadequate insurance cover that some work schemes provide. After 40 days cover in the Garda scheme, for example, those in St. Patrick's or St. John of God are asked to leave when they are most vulnerable. They are beginning to recover; but in the majority of cases, as the Minister indicated, they are not well, according to the statistical information.

Constituents of mine have taken out credit union loans to remain in institutions like St. Patrick's and St. John of God. Thus, not only are they paying large contributions for private medical insurance which is inadequate, but they are also taking out bank and credit loans to pay for extra cover to stay in hospital.

Those affected are, in the main, women who want to get well and return home to look after their children. However, they are terrified of being discharged after 40 days. Reference has been made to the fact that there will be no change in the VHI and one will still receive 180-day cover, but that is wrong and misleading. After these regulations come into force, the VHI may decide to offer 100 days cover and nobody will be able to challenge that. What I have outlined as the experience of people in private schemes is awaiting those currently [212] with VHI cover. VHI subscribers should not be led to believe that the 180 day cover will remain permanently, because it may not.

Senator Norris questioned Fianna Fáil's wisdom vis-à-vis the two major psychiatric hospitals. We do not claim to have greater wisdom than anybody else, but the motion claims that these regulations are discriminatory. The basis of the motion is not that 180 days is better than 100, but that some people might require more than 180 days cover.

Prior to these regulations being signed by the Minister no distinction was made between someone who had open heart surgery, a broken leg, or who happened to be suffering from depression. A person's illness was treated until they got better. Now, for the first time the Government has singled out one group which I regard — although I may be wrong and the Government may not like me suggesting it — as being the most vulnerable in society. We are now about to write into legislation the fact that this group is not equal under the law and that they will not be treated in the same way as those who undergo open heart surgery or have broken their legs. In my opinion, such people will have a right to challenge these regulations legally because they are discriminatory and probably unconstitutional as well.

I am amazed at Senator Norris, who is recognised as being the champion of a specific group who have been, and probably still are, discriminated against. I have great admiration for the courageous stand he has taken and for his continuing representation of that group. A Fianna Fáil-Labour Government introduced legislation for the group he represented. However, I cannot fathom why, as far as Senator Norris is concerned, those who are psychiatrically ill are not entitled to the same support he gave to another group and that they should be discriminated against.

Even at this late stage Senator Norris should reconsider how he intends to vote on this motion. I appeal to him to support the Fianna Fáil motion, the [213] essence of which is that we will not support anything which discriminates and which decides that one group in society cannot have fair and equal treatment with another one. Senator Norris should back the motion which seeks to support a group which will otherwise be classed as second class citizens under the law.

Members on the Government side of the House may have quoted out of context the directors of two major psychiatric hospitals. I wish to read into the record what Aware said about these regulations:

The regulations stipulate that health insurance companies entering the Irish market would be obliged to provide 100 days cover for psychiatric in-patient care rather than 180 that is currently provided by the VHI... This is contrary to all the policies of the Department of Health for the integration of the psychiatric and general medical services... The wrong message from the Minister who has pledged his support to reduce the rate of suicide when it is known that premature discharge from psychiatric in-patient care is a major determinant in suicide.

It is interesting to note that the person who signed this letter is a doctor in St. Patrick's. I cannot understand why it is being suggested that those providing the services are happy. The letter continues:

Asking patients who are at a very vulnerable stage in their treatment to leave hospital, leave the medical and nursing service, with which they are familiar cannot be considered to be in anybody's interest.

Members should support the Fianna Fáil motion on the basis that these regulations cannot be in anybody's interest.

Mr. Sherlock: In the 1970s, psychiatric patients were covered 100 per cent for 365 days per year. That cover was reduced between 1977 and 1981.

Mr. Finneran: It certainly was not.

[214] Mr. Sherlock: It was reduced in that period. I welcome the improvement which the Minister, Deputy Noonan, has made to the draft regulations but I am not convinced they go far enough. I hope there will be an opportunity to revisit them in future. It is important to keep that in mind. As matters stand, psychiatric patients will still be discriminated against and they will be entitled to just 100 days in-patient cover, while patients with medical disorders will continue to have 180 days in-patient cover.

Previous speakers mentioned the integration of psychiatric and general medical services. I appreciate that a level playing field had to be created to enable companies to compete in the health insurance market. I also appreciate that our EU membership forces us to open up the health insurance market. However, I am extremely concerned that the EU should be in a position to effectively impose a two-tier health system on the public in the name of so-called deregulation.

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. We already have a two-tier health system in which one third of patients are privately insured and the rest must rely on an under-resourced and overstretched public health system.

Democratic Left has long argued for a universal system of health care free at the point of entry. I fear that these regulations may force private patients with serious psychiatric or substance abuse conditions to seek greater care within the public system, placing an even greater strain on our public facilities. That actually happened when the decision was taken previously. Patients in long stay private care had to find care elsewhere because they could not afford to pay, at the same time draining resources from our private facilities, which currently account for some 15 per cent of overall psychiatric in-patient provisions. In addition, these regulations reinforce the notion that people with psychiatric disorders are somehow [215] less ill than those with physical conditions and are less deserving of society's care and protection. That notion is unacceptable.

When the draft regulations were initially published, concerns were expressed by those involved in the care of the psychiatrically ill. I am glad that the Minister has responded to those concerns by making substantial improvements to the regulations and reducing the gap between the amount of in-patient cover afforded to medical and psychiatric patients. Given the constraints under which the Minister has had to operate with regard to EU competition demands, I accept that there was no further room for compromise. I hope it will be possible to revisit the regulations in the future.

In the interim, I urge the Minister to increase the provisions for public psychiatric facilities in order that private patients who have exhausted their cover can receive the care they need and deserve. I welcome the provision made by the Minister and I oppose the motion.

Mr. Lydon: I do not wish to make political points or attack the Minister in any way. He has done some good things but has not done enough. I speak on behalf of the patients I have cared for and treated since 1974, in one of the hospitals to which Members referred. I believe I have a good knowledge of how psychiatric patients or patients with mental or emotional illness feel when they see these regulations being promulgated. Senators Finneran and Maloney should also have a requisite knowledge in this regard. Many Members who have friends or relatives who suffer from psychiatric illness would be dismayed by the lack of cover provided.

To give the Minister the credit due to him, it is true that he has protected some provisions such as open enrolment in lifetime cover and statutory minimum level of cover for 100 in-patient days. That is good, as is the innovation of a stated minimum provision of 20 days.

[216] However, many speakers on the Government side of the House made play of the fact that Professor Anthony Clare agrees with these regulations. Professor Clare actually stated that:

The representatives of both St. Patrick's and St. John of God Hospitals regret that the minimum cover guaranteed under the regulations is not 180 days as provided for by the VHI and we have expressed our views to the Minister. We regret the introduction of a disparity between the cover provided for physical — 180 days — as against psychiatric disorders — 100 days.

Why is this happening? We are informed that it is because of the European Union or pressure from Brussels or large insurance companies. If that is so, how is it possible to make an arrangement to provide 180 days cover for physical illness and only 100 days for mental illness or psychiatric disorders? Why is it not the same for all patients?

If the Minister had two relatives, one suffering from a physical illness, the other from a mental disorder, the person with the mental disorder would be discharged without cover long before the person with the physical illness. I do not blame the Minister for this problem, which essentially is due to a mindset, not to rules or regulations. The basis of this mindset is that mental illness is in some way less terrible than physical illness. I have worked with people with psychiatric problems for over 20 years and I can state that mental illness is just as painful, as debilitating and, ultimately, as fatal as physical illness. There are many people with physical illness who have a good mental outlook. However, there are many people with a mental illness who suffer as a result of physical illness. The entire lives of such people are adversely affected because of their way of viewing the world.

I have seen extremely rich people — multimillionaires and people who own huge cars, estates and houses — cringing and crying in the corners of psychiatric wards. How can the Minister state [217] that those people do not feel hurt for 180 days? If cover can be provided for people with physical illness, it must also be provided for those with mental illness. This is not a party political issue. It involves a mindset which states that people suffering from one illness are less important than those suffering from another illness. I cannot accept this because it is not true. The Minister has done well up to a point, but he has not gone far enough. I am not making a political point against him.

It has been stated that this problem has been forced upon us by Europe. I am a European at heart and was a member, and vice-chairman, of the Council of the European Movement. To me, membership of the European Union means that I have a say in events and should not be dictated to by mandarins in Brussels. Words uttered by the Minister in Ireland are just as strong as those uttered by a Minister in Italy, France or Germany. How is it that Ireland always fares well in negotiations on the CAP and Structural Funds? It is because we enter such negotiations convinced that we can obtain the money we require. We negotiated fisheries quotas on the basis of the country's historical catch and made fools of ourselves and will never catch up. The issue under discussion represents a similar situation. If we relent now, we will never get back what we are giving away.

I ask the Minister to reconsider this matter, which involves people cringing in the corners of psychiatric wards who hear voices, are depressed or wish to kill themselves or someone else. Is the Minister stating that such people do not suffer as much as those with physical illness? Most people suffering from a physical illness regain their health more rapidly. If left alone, most physical illnesses, except the most severe, cure themselves. This is not the situation in the case of psychiatric illnesses. Psychiatric patients continue to suffer. It is to cater for those people that extra cover should be provided. However, even that provision of 180 days is too small. Some adolescents require care on a long-term [218] basis and the 180 day provision represents the bare minimum.

I give the Minister credit for his actions, but if he were Minister for Agriculture, Food and Forestry we would not be having this debate. The Minister for Agriculture, Food and Forestry and other Ministers fight in Brussels for what they believe in. The Minister for Health, Deputy Noonan, is as tough and intelligent an individual as one could meet. Members have seen him operate and know what he is like. If only he could believe that patients with psychiatric and mental illnesses suffer as much if not more than those with physical illness, the Minister would renegotiate the position. I request that he do so.

Mr. Quinn: I welcome the opportunity to contribute to this debate following the emotive plea from Senator Lydon, who has more experience of this matter than many Members. When I became familiar with the concerns expressed by Aware — the association helping to defeat depression. I reconsidered the statements made during a similar debate in the House on this subject on 19 July 1995. We all accept Senator Lydon's point that we must not belittle the psychiatric care required by people suffering from depression. It must be ensured that they receive as good a service as possible.

During the debate on 19 July 1995, the reason for the introduction of this entire area of legislation was to introduce “customer benefit, marketplace and competition”. I welcome this move because competition will improve the service given to those seeking to insure themselves against ill-health. The regulations appear to establish, particularly in terms of the adjustments which have been made, a great deal more than was originally planned. For example in the future, organisations offering health insurance on a private basis must provide a minimum of 100 days cover. At present, the ESB staff medical provident fund offers a maximum of 45 days, while the Prison Officers Medical Aid Society offers 90 days in three years. [219] Clearly, these are not as good as the minimum of 100 days which will be required. Another example is the St. Paul's Garda Medical Aid Society, which offers 42 days in five years. A minimum of 100 days is much better than those figures.

In Britain, the BUPA scheme offers much less. It has over 45 per cent of the market, but in no case does it exceed 90 days in patient care in a year. In Ireland, it must provide 100 days. PPP Healthcare in Britain, which has 27 per cent of the market, also offers far less than 100 days. The Norwich Union, which has 9 per cent of the market, does not provide any cover at all. If it comes to Ireland, it must provide 100 days. The Western Provident Association offers 28 days in five years. If it comes to Ireland, under the regulations it too will be obliged to provide 100 days cover.

At present the VHI offers 180 days and the valid concern expressed by Aware, other organisations and the motion is that, because it will be obliged to offer 100 days, it may reduce the 180 days to 100 days. In a competitive marketplace, where one is seeking to gain insurance cover and attract business, it is likely that the minimum requirement of 100 days will not become the maximum. If a prices board states one must not sell a product for more than a certain price, companies often decide that is the price they must not exceed, but they will compete in the market-place by offering a better price. In this area it is likely the VHI will see this gap in the market and ensure it attracts more business than competitors which will enter the marketplace.

In this context, is the requirement fair and likely to succeed? The adjustments made by the Minister in increasing the minimum from 40 to 100 days serves the purpose of creating a market which will demand attention from those considering taking out insurance. It will ensure there is a valid marketplace in which organisations will be forced to offer a minimum of 100 days, which they do not have to provide in Britain or elsewhere. [220] It is likely that existing Irish companies, such as the VHI, will continue to offer more than 100 days, and perhaps the maximum of 180 days. On this basis, I cannot support the motion and I must support the Government's effort to achieve its aims in the regulations.

Mrs. McGennis: To discriminate?

Mr. Quinn: I understand and sympathise with the concerns of Aware. I am also sympathetic to the objectives of those who are concerned about the regulations. However, if we are seeking to give customers the best value for money——

Mrs. McGennis: They are not customers; they are sick people.

Mrs. Quinn: They are not sick people but customers who are insuring themselves against the day they become sick. The regulations are valid and should be supported because it is the best deal we can secure.

Mrs. McGennis: It discriminates.

Ms Honan: I welcome the Minister and the opportunity to discuss the insurance regulations covering psychiatric patients. This is the third time I have contributed on this topic and I accept the Minister has substantially improved the level of cover for in patient hospital care for psychiatric patients by increasing it from 40 to 100 days since the issue was last addressed in the House in July. I also welcome the increase in insurance cover for substance abuse from 40 days over a lifetime to 90 days in any continuous period of five years.

In negotiating the regulations with the European Commission, I welcome that the Minister sought to protect our core values of community rating, open enrolment and lifetime cover. Everybody values these core aspects, which the VHI operates, and wants them maintained, given that the market will be open to competition. In common [221] with Senator Quinn, I agree that competition will be good for the industry. The British company, BUPA, has already moved into the Irish market. My problem is that the regulations still discriminate against the psychiatrically ill. It is the only sector which has been singled out in this way and these patients are being treated unfairly compared to any other sector of the population. As other Members said, they are discriminated against by insurance companies throughout Europe, and Ireland should take the lead in ending this practice. It has not existed in this country and we should not change to a system which discriminates against such patients.

The regulations, such as 100 days for in patient care for psychiatric patients, were set out by the Minister for Health and the Department and it is not right to infer that this action has been forced on us by the European Commission. The Commission adjudicated on whether the Irish Government had the right to introduce regulations under Directive 92/49 EEC. It did not comment on the details of the regulations. The last time this matter was discussed the House was given the impression that the Government and the Minister had no choice in this matter.

Mrs. McGennis: That is right.

Ms Honan: However, that is not the case. I am concerned that these changes will affect the future availability and quality of private psychiatric care in Ireland. The Minister does not propose to set minimum cover periods in any other area of treatment. By taking this action with regard to psychiatric illness, a certain group of patients will be discriminated against in a way which would be unthinkable if any other form of illness was involved. For example, a proposal to limit the number of days patients having by-pass or hip replacement operations could spend in hospital would be unacceptable. It is not acceptable in the area of psychiatric illness either.

[222] In Ireland insurance cover and benefits for patients with psychiatric illnesses have been more or less in line with general medicine. This had led to the development of different psychiatric services in Ireland than other countries and we should be proud of this fact. For example, in the United States President Clinton's task force on health has attempted to examine treating psychiatric illnesses in the same way as other illnesses. They seem to be moving towards the situation which pertains in Ireland, but we seem to be moving away from something we should value.

It is also ironic that the Minister for Equality and Law Reform intends to introduce equal status legislation before the end of the year. This will guarantee equal treatment in the provision of goods and services to everybody, irrespective of gender, disability, race, etc. It is odd that one arm of the Government is introducing legislation to give equality to everybody while the Minister for Health is introducing regulations which fly in the face of equality.

As other Members said, this matter involves a vulnerable group which does not tend to speak up for itself. Many of these patients and their families have been in contact with us and they are most concerned about this matter. I understand the Minister's difficulty in trying to protect our core values of community rating, open enrolment, lifetime cover etc. and also to regulate the activities of health insurance companies, but it is possible to do both of these without discriminating against a specific group of vulnerable people like psychiatric patients.

Mr. Finneran: I am extremely disappointed the Minister did not stay in the House for the whole debate. This is in itself a slight both on it and this serious issue. In his contribution the Minister made a few statements which I wish to comment upon, if not challenge.

On the matter of increasing the cover from 40 to 100 days, the 40 day figure was only a provisional one. We never reached this situation. It was never [223] realistic or on the cards for the Minister to claim that he negotiated this increase from 40 to 100 days; this is stretching credibility.

The Seanad's debate on this matter in July demonstrated to the Minister the opposition to any change in cover for psychiatric patients. It is disappointing that the Minister did not return to this House before he signed those regulations. This House told him at that time that it was unhappy with his approach to this matter. While the Minister took that on board, he did not come back to this House. He signed the regulations without returning and that is a pity. If he had listened to the full debate and then considered these regulations, he might have come to a different conclusion.

The Minister has also been somewhat economical with the truth with regard to the impact of the regulations. He suggested that 92 per cent of psychiatric discharges from private hospitals occurred within three months. He used this statistic to imply that the vast bulk of discharges were within the 100 day limit. However, if one examines the statistics more carefully, one will find that these figures only apply to the first time in a year that a patient might have been in a psychiatric hospital. It does not take into account any further periods spent in the hospital and the Minister did not address this at all.

Those of us with any experience in the psychiatric service know that remission takes place. Two, three or four admissions can take place inside a four week period, but it is a different case if it is taken cumulatively. If this is taken to its conclusion, people will be excluded from psychiatric care for periods [224] of the year. It is misleading for the Minister to use those statistics in that way; and, even at this late stage, I call on him to disclose how many patients will be affected by these changes. It will be many more than he admits.

On the provision for outpatients' benefits, the regulations as they stand put the subscriber to health insurance, and not the insurer, at risk. That point has been made clear in this debate. The provisions for outpatients are anti-consumer and should not be signed into law and I am amazed that any Minister would have done this.

Many speakers outlined the great difficulty any person would have in discriminating between one type of illness and another. Why anybody should have different cover because they have a mental, as opposed to a physical, illness is unbelievable and I find it hard to comprehend. I am amazed at the approach taken by the Independent Senators on this matter. They have stood up and fought for minorities through the years and have been the spokespersons for the downtrodden. However, it seems the weak and those in our community who cannot speak for themselves have been forgotten and there is nobody to speak for them. My party has put forward a credible performance on their behalf tonight. I still expect Members of this House to respond to the downtrodden and that we do not discriminate against those who have the misfortune to suffer from mental illness. They should be treated in the same way as anyone with other forms of physical disease. I recommend the motion to the House.

Question put.

The Seanad divided: Tá, 19; Níl, 27.

Bohan, Eddie.

Byrne, Seán.

Daly, Brendan.

Dardis, John.

[225]Honan, Cathy.

Kiely, Rory.

Lydon, Don.

McGennis, Marian.

McGowan, Paddy.

Mooney, Paschal.

Fahey, Frank.

Farrell, Willie.

Finneran, Michael.

Fitzgerald, Tom.

[226]Mulcahy, Michael.

Mullooly, Brian.

O'Brien, Francis.

Ormonde, Ann.

Wright, G.V.

Belton, Louis J.

Calnan, Michael.

Cashin, Bill.

Cosgrave, Liam.

Cotter, Bill.

D'Arcy, Michael.

Doyle, Joe.

Enright, Thomas W.

Farrelly, John V.

Gallagher, Ann.

Hayes, Brian.

Henry, Mary.

Kelly, Mary.

McAughtry, Sam.

McDonagh, Jarlath.

Magner, Pat.

Maloney, Seán

Neville, Daniel.

Norris, David.

O'Sullivan, Jan.

Quinn, Feargal.

Reynolds, Gerry.

Ross, Shane P.N.

Sherlock, Joe.

Taylor-Quinn, Madeleine.

Townsend, Jim.

Wall, Jack.

Tellers: Tá, Senators Fitzgerald and Ormonde; Níl, Senators Cosgrave and Magner.

Motion declared lost.

An Cathaoirleach: When is it proposed to sit again?

Mr. Manning: Tomorrow at 10.30 a.m.