COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 14 Nov 2013

Chapter 22 - Eligibility for Medical Cards

Dr. Ambrose McLoughlin (Secretary General, Department of Health) and Mr. Tony O'Brien (Director General, Health Service Executive) called and examined.

Deputy Kieran O'Donnell took the Chair.

Vice Chairman

I welcome everyone. Before we begin, I remind members and witnesses to turn off their mobile telephones, as the interference from them affects the sound quality and transmission of the meeting.

I advise witnesses that they are protected by absolute privilege in respect of the evidence they are to give to this committee. If they are directed by the committee to cease giving evidence in respect of a particular matter and they continue to do so, they are entitled thereafter to only a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a Member of either House, a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

Members are reminded of provisions within Standing Order 163 that the committee shall also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies.

I welcome Dr. Ambrose McLoughlin, Secretary General of the Department of Health. I ask him to introduce his official.

Dr. Ambrose McLoughlin

My official is Mr. Paul Barron.

Vice Chairman

I welcome Mr. Tony O'Brien, director general of the HSE. I ask him to introduce his officials.

Mr. Tony O'Brien

They are Mr. Tom Byrne, chief financial officer, Mr. John Hennessy, national director of primary care, and Mr. Patrick Burke, assistant national director of the Primary Care Reimbursement Service, PCRS.

Vice Chairman

I also welcome the representative from the Department of Public Expenditure and Reform. He might introduce himself.

Mr. Tom Heffernan

I am Tom Heffernan from the sectoral policy division for health in that Department.

Vice Chairman

I welcome all of the witnesses to this important session of the committee. I now call on the Comptroller and Auditor General to introduce the accounts.

Mr. Seamus McCarthy

The medical card scheme was established under the Health Act 1970. The scheme currently helps in providing medical support to an estimated 43% of the population.

The cost of the scheme in 2012 was €1.7 billion, accounting for approximately 12.5% of the Health Service Executive's total expenditure. The scheme's costs increased from €937 million in 2003 to €1.7 billion in 2012, an increase of 85%. The number of cards in issue increased by more than 70% in that period and the estimated average cost of a card increased by about one fifth.

Eligibility for a medical card is, in the main, determined by a means test based on the applicant's income, taking account of certain relevant household outgoings. The HSE also has discretion to award a card if not doing so would result in undue hardship. Medical cards are normally valid for three or four years. Subject to continuing eligibility, cards are renewed upon expiration. Eligibility is determined either by way of a full case review by the HSE or through self-assessment by the card holder.

Our examination was carried out to assess the adequacy of controls over the initial award of cards and the process of review of cards in issue. The level of ineligible card holding was also examined. Shortcomings were identified in the application of controls in 8% of a sample of 2012 medical cards approved. In 4% of cases, medical cards had been approved in circumstances where the available evidence suggested that the applicant had not satisfied eligibility criteria. In the other cases, no documentation or inadequate documentation of outgoings had been provided. Additional guidance and staff training, as well as more formal supervisory reviews of medical card approvals, should ensure that prescribed controls are applied.

Approximately 5% of new cards are awarded on discretionary grounds, taking account of the individual's economic and social circumstances and the level of illness and related costs. A review of cards awarded on a discretionary basis identified opportunities for improving the information supplied by general practitioners, GPs, to allow the HSE to assess the individual's normal medical costs.

Administration of medical card scheme processing was centralised in June 2011. A significant backlog in the processing of applications and renewal notices had emerged by the end of 2011. The HSE introduced a number of initiatives to deal with the backlog and to prevent further backlogs from occurring. This included extending the self-assessment basis for the renewal of cards, allowing GPs to amend the medical card database in certain circumstances and extending eligibility for one year for some categories of card holders due for renewal in 2012.

In 2012, the HSE issued approximately 366,000 renewal notices. In 70% of cases, the applicant was asked only to confirm that the relevant circumstances had not changed. In the remaining cases, a full review of eligibility, comparable with an initial application, was conducted.

Overall, 10.7% of card holders had not responded to the renewal notices by May 2013 and their medical cards had lapsed as a result. A further 1.9% of cards were not renewed because it was found the card holders had died. Of the remainder, more than 94% had their eligibility confirmed as before or were awarded full medical cards instead of their previous GP visit cards. Some 1.7% had their eligibility reduced from a full medical card to a GP visit card and 4% were deemed not to have eligibility for either form of card.

During 2012, the HSE also reviewed 40,000 cards where card holders had not accessed medical services for periods of 12 months or more. Eligibility was removed in just under 40% of these cases. While these cases had not recently resulted in payments for prescriptions or other items, capitation payments to their GPs would have been incurred.

Overall, the available evidence suggests there is a material level of ineligibility of card holding in the medical card system. However, the financial implication of that ineligibility has not been established. In 2012, the HSE engaged consultants to review excess payments within the medical card scheme. They estimated that excess expenditure could be in the range of €65 million to €210 million per year. However, that review was limited in scope as it was conducted on the basis of a review of reports, rather than a detailed analysis of the database. The review concluded that a more reliable estimate would require detailed analysis of the medical card database.

The HSE has not yet developed an estimate of the level of excess payments in the medical card system. Based on our examination findings, I have recommended that the HSE initiate a cyclical programme of reviews of eligibility in respect of random samples of card holders. This would allow a reliable baseline estimate of the scale of excess payments to be identified. Tracking changes in the levels of excess payments would allow the HSE to evaluate the effectiveness of its overall control strategy and to identify the key drivers of excess payments.

Vice Chairman

I now ask Dr. McLoughlin to make his opening statement.

Dr. Ambrose McLoughlin

I thank the committee for the invitation to assist in the examination of Chapter 22 - eligibility for medical cards. I welcome the opportunity to bring clarity to the legal position regarding such eligibility. As Secretary General of the Department of Health, I strongly endorse the recommendations pertaining to eligibility outlined in the Comptroller and Auditor General's report.

I will begin with some factual information regarding medical cards. It may be useful for Deputies to know that, as of 1 October, 1,864,509 medical cards were issued by the HSE. This represented an increase of more than 60% in the number of medical cards, or 700,000 individuals, since the end of 2005. More than 40% of the national population hold medical cards compared with 27% at the end of 2005. Between 2004 and 2012, when medical card coverage rose from 27.7% to 40.4% of the population, unemployment rates increased from 4.3% to 14.4%.

This indicates a high correlation between these two variables. Therefore, as the economic position improves, resulting in more people returning to employment, we should expect to see a marked decrease in the number of medical cards issued.

As Deputies may be aware, the legislation governing the medical card scheme, section 45 of the Health Act 1970, as amended, allows for persons who are unable, without undue hardship, to arrange a general practitioner's service for themselves or their family to qualify for a medical card. Under this legislation, the determination of eligibility for a medical card is the responsibility of the Health Service Executive. Section 45 requires the HSE to have regard to the overall financial circumstances of a person and his or her spouse or partner in view of their reasonable expenditure. The HSE gives effect to the legislation and the Government's policy through its medical card national assessment guidelines. Where a person's income is in excess of the thresholds set out in the national assessment guidelines, the HSE uses its discretion to grant a medical card to a person who is unable, without undue hardship, to arrange a GP service. In doing so, it is obliged to have regard to the financial position and expenditure of the individual and his or her dependants.

To dispel any misconception that there still might be, I want to clarify that, in line with the legislation I have just outlined, there has never been an automatic entitlement to a medical card on the basis of having a specific illness or condition such as cancer. While there may be criticism of that approach, the correct interpretation is very clear from a reading of the legislation which has been in place for a considerable period of time.

There is an additional arrangement available to persons aged 70 years and over to establish their eligibility for a medical card. Persons over 70 years of age can also qualify for a medical card on the basis of a gross income test. Under the legislation, individuals aged over 70 years with a gross income not exceeding €600 per week qualify for a medical card. Couples over 70 years of age with an income not exceeding €1,200 per week also qualify for a medical card.

Medical card processing was centralised at the HSE Primary Care Reimbursement Service, PCRS, in July 2011. This system facilitates standardised, homogeneous and equitable assessment of all applications, irrespective of the origin or nature of the application. In previous years there was a decentralised process which led to inequities throughout the country. Medical cards may have been awarded on a discretionary basis in some geographical areas and not in others because of the lack of a centralised and standardised approach. This resulted in having regional and local areas in which there were high numbers of medical cards above what one might have expected. The assessment procedures used to determine eligibility for medical cards and GP visit cards has not changed, rather, through the centralised processing of applications where discretion is exercised, it is now applied equitably and consistently based on standard operating procedures, with medical officers assessing medical evidence for cost and necessary expense. The HSE has in place a process whereby a team of medical doctors, unrelated to the patient, assess his or her situation and grant or decline a discretionary medical card on a medical basis. Previously, different approaches may have been used in different parts of the country, resulting in an inequitable distribution of discretionary medical cards. With this standardised process there is fair and equitable treatment for all. This ensures the scheme operates to enable those who suffer financial hardship as a result of a medical condition to receive the benefit of a medical card.

For the record, persons in receipt of a medical card may also be entitled to the following additional benefits: exemption from paying the health portion of social insurance, PRSI; free transport to school for children who live three miles or more from the nearest school; exemption from State examination fees in public second level schools and financial assistance with buying school books. Under section 49(1) of the Health Act 1970, as amended, there is an obligation on medical card holders to advise the HSE if there is a change in their circumstances that could affect entitlement to a medical card. This provision, allied with data sharing legislation which came into effect in March 2013, allows the sharing of personal data between the Revenue Commissioners, the Department of Social Protection and the HSE which will result in a higher level of compliance and an overall reduction in the amount of medical cards issued.

The scheme has been in existence since the 1970s and benefited millions of citizens. I would like members to note this point. I assure Deputies that there has been no change in the past year to the qualifying criteria for discretionary medical cards. Notwithstanding the need to secure savings under the medical card scheme, it is important to note that nobody who under the legislation is entitled to a medical card will lose it or be refused one. I thank members for their time. I am happy to answer questions they may have.

Vice Chairman

I thank Dr. Ambrose. May the committee publish his statement?

Dr. Ambrose McLoughlin

Yes.

Vice Chairman

I now invite Mr. Tony O'Brien, CEO of the HSE, to make his opening statement.

Mr. Tony O'Brien

I, too, welcome the invitation to attend this meeting, in advance of which a report on medical cards was submitted to the committee. I am also aware that members of the committee have received the briefing material which has been the subject of briefings in the Oireachtas this week. I will, therefore, be brief in my opening statement.

Eligibility for a medical card or a GP visit card is determined on the basis of an assessment of financial means. If an applicant's means are above the financial thresholds set out in the national guidelines, the HSE examines for any indication of circumstances, medical or social, which might result in undue financial hardship. Eligibility may be granted on a discretionary basis if these circumstances are such that a person cannot access general practitioner or other medical services without undue financial hardship. There can be a significant crossover between social and medical circumstances and applications do not fall discretely into these specific categories. The process whereby the application of discretion may be considered includes a review by HSE medical officers led by a principal medical officer.

Almost 2 million people are covered by either a medical card or a GP visit card. This means that 43% of the population have medical cards or GP visit cards, with the number of people with eligibility having increased by 74% since January 2005. The HSE continues to make significant progress in the reconfiguration of this key component of national health infrastructure. The medical card centralisation project which commenced in 2011 has been successfully delivered. Medical card processing is now carried out, with single national governance, at a central office location, compared with 100 locations in the past. Customer service processes, assessment of applications and reviews, correspondence and the application of discretion are now operated in a consistent and equitable manner across the country.

Turnaround performance in processing medical card applications is reported online each week. This reporting confirms that the HSE continues to surpass the turnaround rate of 90% processed at 15 days. For example, as of 14 October, more than 96% of complete applications had been processed in 15 days. It is important to stress that eligibility for a medical card is founded on the undue financial hardship test. The HSE must operate within the legal parameters as set out in the Act, while also responding to the financial, medical and social circumstances and complexities faced by individuals who apply for a medical card. In parallel with a focus on service provision and improvements in customer service and efficiency, the HSE is also focused on its public accountability role in the overall management of the medical card scheme. New legislation passed in March created the legal basis for the sharing of records with Revenue and the Department of Social Protection. This will allow for further improvements in the management of the medical card system and offers an additional assurance that medical card eligibility continues to be provided for people appropriately in line with the national assessment guidelines for eligibility.

The availability to the HSE of data indicating changes in a medical card holder's circumstances such as change in employment status, income levels and a change in eligibility for Department of Social Protection schemes will inform the HSE in focusing reviews on subsets of the register to identify clients who may no longer be eligible. The introduction of these additional controls will strengthen the risk management framework for the scheme. I assure members that the assessment arrangements are designed to ensure people who are eligible for either a medical card or a GP visit card receive it quickly and efficiently and equally to ensure those who are not eligible to receive or retain a medical card do not.

Each month the HSE analyses the medical card register to identify those medical card-GP visit cards which are scheduled for review within three months. We have increased this timeline to four months in respect of those clients who were granted eligibility on the basis of discretion in order to allow an additional month to ensure all pertinent medical and other data are provided for inclusion in the assessment process. All customers scheduled for review are notified and a process of either full reviews or self-assessments is conducted.

The HSE will continue the focus on medical card probity into 2014. In the nine months between January and September this year, we initiated 428,682 medical card reviews, and we plan to more than double this level of review activity in 2014. Since the guidelines have been substantially reduced for those 70 years and older, we are required to review the means of over 350,000 individuals in this cohort completely, with the exception of those reviewed in 2013 and where income levels are already held on file by the HSE. We estimate that approximately 10% of the individuals concerned will be provided with GP visit eligibility in place of full eligibility.

Since centralisation, 106,828 individuals whose medical cards have been inactive have been contacted requesting residence confirmation. As of 1 October, 68,333 individuals, or 64%, had confirmed residence and eligibility was removed for 38,495 people, or 36% of the cohort. The Comptroller and Auditor General commenced an examination of the medical card system in June 2013 and completed it in September 2013. The audit report produced six recommendations and these have been fully agreed by the HSE for implementation.

This concludes my opening statement on medical cards but I should mention, with the Vice Chairman's permission, that with regard to the section 38 audit that has been discussed, we have been in a position to provide the report to the committee and in due course we look forward to discussing it.

Vice Chairman

Thank you. May we publish the statement?

Mr. Tony O'Brien

Yes.

Vice Chairman

I wish to deal with a number of issues specific to medical cards. As Deputies on the ground, we know a major issue for constituents is the discretionary medical card. Having read the material provided, it can be said about people with discretionary medical cards without fear of contradiction that they are seriously ill, as they would not have qualified for the discretionary medical card otherwise. In other words, these people got discretionary medical cards on medical grounds because of a serious illness. Based on the information provided, since the start of the year 45,000 medical cards have been withdrawn, and of those 10,400 were discretionary. Is that analysis correct? This is based on a publication provided by Dr. McLoughlin which gives the total number of medical cards. The review indicated 45,000 medical cards were withdrawn, with 9,981 not reviewed, 3,992 people deceased, 35,733 people who did not reply, and 5,803 cards which expired before the review was over. The period is January to September this year. On 1 January this year there were 63,136 discretionary medical cards in place and as of 1 October this year, there were 52,733. The reduction is in the order of 10,393, or 16%. The number of discretionary cards at the end of September comprised approximately 0.3% of overall medical cards. Is it correct that of the 45,000 medical cards which were withdrawn, 10,393 relate to discretionary cards?

Mr. John Hennessy

The numbers taken in this case are snapshots at a point in time. There were 63,000 at one point and 52,000 at the next. There is much movement in the system in the period and the numbers change weekly. A number of medical card holders who were on discretionary cards may have moved to other medical cards.

Vice Chairman

It is very simple for us. For the general public looking at this, and particularly those on discretionary medical cards, it is apparent that these were given on the basis of a serious medical condition. I am basing my assumptions on the HSE figures. At the start of January there were 63,136 and at the end of September there 52,733, which is a change of 10,393. Is that correct?

Mr. John Hennessy

It is correct. What is not clear from those numbers is the number who may have migrated to ordinary medical cards or GP visit cards.

Mr. Patrick Burke

We do not have the material in front of us but we did an absolutely forensic reconciliation.

Vice Chairman

This was provided to the committee by the Department of Health. The numbers are on the screen.

Mr. Patrick Burke

To put it in context, we did a forensic reconciliation. On 1 March 2011, there were 97,121 eligibilities registered on the medical card register as being granted under discretion. To explain, the director general indicated before that there is only one medical card. On occasion, if a family faced hardship or an emergency we can issue-----

Vice Chairman

No-----

Mr. Patrick Burke

We need to explain the context.

Vice Chairman

I have limited time and I understand from where the witnesses are coming.

Mr. Patrick Burke

I can provide the numbers without context.

Vice Chairman

I am making a different point, which is very simple. Of the 10,393 people, 6,282 got GP visit cards, with an increase in GP visit cards as there is a direct correlation between a reduction in medical cards and their change to GP visit cards. Of the 45,000 withdrawn medical cards, a quarter came from discretionary medical cards, but those cards only make up 0.3% of the total number of medical cards. People with discretionary medical cards have them for medical reasons. The basis of the medical card system from day one was to provide medical care for people with medical conditions who could not afford treatment. I am worried that there are people on discretionary medical cards with defined serious medical conditions, whereas a large cohort of the overall number of medical card holders may not use their cards. Is it correct that 10,000 cards were withdrawn?

Mr. Patrick Burke

No. One cannot draw that inference from the numbers without understanding the context. The two points concern the overall numbers and granting of eligibility on illness grounds. The Secretary General has dealt with that and we can go through it again. Let me deal with the numbers.

There were 97,000 clients recorded as having discretion and as of 1 October, 38,238 were recorded as having discretion. Following a review, 41,779 of those clients had a medical card on the basis of an assessment of their means. There is a balance of 17,059, and of those who do not eligibility, 2,361 were deceased; we received no response from 6,265 people despite multiple requests; 2,109 did not provide information that we needed to maintain a verification of circumstances; and 6,324 were judged not eligible when assessed the guidelines. We analysed those 6,324 cases.

Of these, 50% were more than 200% above the guideline figures, while 92% were more than 50% above them.

Vice Chairman

Therefore, 50% were more than 200% above the guideline figures.

Mr. Patrick Burke

Yes. Of the clients who did not have eligibility confirmed following an assessment of their means against the guidelines and taking into account medical or other circumstances involved, 50% of the 6,324 were more than 200% above the guideline figures, while 92% were more than 50% above them. The point I am making is that we reconcile the numbers flagged on a database simply to manage and control the data. Where we issued a medical card but exercised some level of discretion, we put a flag beside that registration. As we review them and some of the clients, when assessed and taking their means into account, receive a medical card, we no longer maintain that flag. That does not mean that their medical card is gone. They have eligibility and a medical card.

Vice Chairman

Mr. Burke is saying there are approximately 6,700 discretionary medical cards for which people did not qualify on means grounds.

Mr. Patrick Burke

Yes, on an assessment of their means. As of 1 March, according to the data on the register, there were 97,121 clients with a flag of eligibility granted on the basis of discretion.

Vice Chairman

Mr. Burke is missing the point. Will he give me the precise figure? Is it 6,324?

Mr. Patrick Burke

The precise figures are that 97,121 were recorded on the register flagged as discretionary. A total of 38,283 on 1 October still had a medical card on the basis of discretion. A total of 41,779 are on the register, but they are not flagged as having eligibility on the basis of discretion but on the basis of an assessment of their means against the guidelines. The balancing figure is 17,059 which I have broken down as follows: 2,361 deceased; 6,265 from which there has been no response despite repeated questions; 2,109 did not provide the material we needed to conduct an assessment, while 6,324 were not eligible when assessed against the guidelines.

Vice Chairman

My point is that those 6,324 people have a serious medical condition. In the cases that have come across my desk many of them are disabled children or children with Down's syndrome. They would have had medical cards since birth or from the first year of their lives. I am talking about the system; this is not personal. It is an important issue. Let us say a person has Down's syndrome and he or she is offered a long-term illness card under the mental handicap heading, a term that must be changed as it has been used since 1970. It is outdated and I have major problems with it. Let us consider the conditions that invariably occur with a child who has Down's syndrome. Up to 90% of such children have asthma, 70% to 80% suffer from hearing loss, while 80% to 90% will have heart conditions, yet when they receive the long-term illness card, they are not covered for any of these. Does that make sense, given all the time it takes to administer these 6,324 applications for people who are seriously ill, have had medical cards for the past ten years and are a vulnerable group? We are dealing with their parents who are under extraordinary pressure. In some cases, they do not have the time to put together what is needed for an application, but if they are offered a long-term illness card, it will not cover virtually all of the conditions from which their child is suffering. Along with this, when a review was carried out of a cohort of 428,682 and 9% of these, nearly 36,000, did not reply, is it value for money to chase down the discretionary medical card scheme for this small cohort of 6,324 people? They account for a minute percentage of the GMS cards issued. There are up to 1.9 million cards issued; perhaps, therefore, it would be better value to carry out a review of these categories. The point is that this is a group of people who received medical cards because there was a serious illness from the start. I am trying to see the logic of it and whether there is a need to change the system to deal with this issue. It all dates back to 1970. Will Mr. O'Brien address that issue? Does he understand our motivation?

Mr. Tony O'Brien

I do. The underlying point concerns the grounds on which a medical card of any type can be granted are set out in the legislation which does not provide that the existence of a medical condition alone qualifies a person to receive a medical card. The medical condition is a factor in the assessment of financial hardship against the guidelines. It is entirely possible that a person's medical circumstances will not change, but their eligibility for a medical card does.

Vice Chairman

Invariably, in the cases coming to our clinics in our constituencies the medical conditions have deteriorated. If one has a child with cystic fibrosis, for example, in many cases his or her asthma has got worse and the condition has progressed. I also see it happening with disabled children. I am talking about that cohort whose medical conditions have not improved.

Mr. Tony O'Brien

Forgive me, I did not say their medical conditions had improved, disimproved or changed. I said that under the 1970 Act the fact that they had a medical condition did not, in and of itself, qualify them to receive a medical card. The medical card test is one of undue financial hardship and the costs associated with the medical condition clearly factor into the arithmetical assessment of their eligibility. The Comptroller and Auditor General, the Secretary General and I have laid this out. If it is the view of the committee that it would be better for people in these circumstances to qualify on the basis of medical conditions alone, that could only be given effect by a change in the legislation, not by a change in the administration of the scheme by the HSE. The HSE would not have a legal right to operate the scheme on the basis described.

Vice Chairman

When the discretionary medical cards were granted, it was invariably for serious medical conditions from the start. If people were granted a discretionary medical card, up to ten years ago in some cases, and the medical condition of their child, whether the child is disabled or has Down's syndrome, has progressively worsened, how can Mr. O'Brien explain to them that the criteria for assessment have not changed?

Mr. Tony O'Brien

I will ask my colleague, Mr. Hennessy, to comment.

Mr. John Hennessy

That is precisely the situation we are in in a number of cases. The Vice Chairman might be familiar with some of them. Nobody would argue with the central point he is making. The scheme is in place to protect the people who need medical cards most. That is what we try to achieve at all times. However, all medical card holders are subject to review, from which nobody is exempt. It is also a fact-----

Vice Chairman

On that point, how many of the discretionary medical cards - Mr. Buckley has said 97,121 discretionary medical cards have been issued - have been subject to review? How many of the other approximately 1.9 million medical cards have been subject to review?

Mr. John Hennessy

The review is undertaken on a risk assessed basis. People receive medical cards with a review date which is related in some way to their circumstances.

Vice Chairman

I am asking this on an analytical point. How many of the discretionary medical cards were reviewed?

Mr. John Hennessy

I will try to get the precise number. Let me give an example to illustrate what I am saying. People, families or households, receive the benefit of a medical card at the early stages of cancer treatment, for example. In newly diagnosed cancer cases it can be a very expensive and traumatic time for a household, but that changes.

Vice Chairman

I understand. I wish to ask a simple question in the limited time available and in layman's terms. The general public look in at us from outside and have the general view that all discretionary medical cards have been subject to review.

Mr. John Hennessy

That is not the case.

Vice Chairman

The rest of the cohort, a far lower proportion of general medical cards, have been subject to review.

Mr. John Hennessy

That is not the case. It is a fact that all medical card holders are subject to review. It is also a fact that circumstances do change.

Vice Chairman

How many of the 97,121 discretionary medical cards have been subject to review?

Mr. John Hennessy

We will see if we can answer the question precisely. I wish to make two other points. In the course of reviews some medical cards are withdrawn. We all know that some people migrate to ordinary medical cards and that others migrate to other support schemes such as the long-term illness scheme. That is a factor that is taken into account by those who assess medical hardship. In the past month we have introduced a further safety net measure for people who have held discretionary medical cards in the past to make sure we know the up-to-date medical circumstances before final decisions are taken. On the central point the Vice Chairman has made, we endeavour at all times to support the people who need help the most. That is the way it works.

Vice Chairman

The job of the Committee of Public Accounts is to examine the procedures performed by the organisations that come before us. Would it give better value for money for the taxpayer and, more particularly, people who are seriously ill if more energy was directed, for instance, at the issues under general review? How many medical cards under general review are in the names of people who are deceased? Are there medical cards that are part of the general cohort which are not being used? A lot of the HSE's time and ours, as public representatives, but, more particularly, that of people who have seriously ill children is taken up in dealing with the discretionary medical card issue. How many of the 97,000 discretionary medical cards have been subject to review? How many of the general cohort of 1.9 million medical cards have been subject to review?

Mr. John Hennessy

I will answer.

Mr. Tony O'Brien

We will get the precise information to answer the question on discretionary medical cards. As I said in the my opening statement, in the first nine months of the year reviews have been initiated of 428,682 medical card holders. Does Mr. Burke have a precise figure?

Mr. Patrick Burke

I do not have a precise figure for discretionary medical cards, but I can confirm that what the director general has said is correct. In 2012 we reviewed 360,000 medical cards; this year, as at 1 September, we had initiated 428,000 reviews and by the end of the year we will have initiated nearly 600,000. That means that there are over 900,000 medical cards in respect of which a review has been initiated. We have a target of 1 million for next year. In terms of the figure of 36 months, we intend to cover the entire deal.

Vice Chairman

Does that represent about 50%?

Mr. Patrick Burke

Yes. Let me finish by saying every time a medical card or eligibility is granted, it is granted for a window of time, three months in advance of the end of which the client is advised and the review commences. There is a review date. In a sense, no particular group has been targeted or identified in any way. I will outline the only random act we have undertaken. It was done in line with what the Comptroller and Auditor General had recommended. This year we initiated a process whereby a random sample was used to establish a baseline to determine how the scheme was being managed. To answer to the Vice Chairman's question, during a three and a half year window the entire database will be reviewed.

Vice Chairman

That is fine.

Mr. Patrick Burke

We will undertake the reviews as they are scheduled to be undertaken.

Vice Chairman

It is still reasonable for me to ask the following question. How many discretionary medical cards have been reviewed?

Mr. Patrick Burke

I do not know. I can get the specific answer for the Vice Chairman, but I do not have it with me.

Vice Chairman

Please provide the information. I ask the HSE to examine the issue again regarding the cohort of persons who are seriously ill. When will its service plan be provided for the Minister for Health?

Mr. Tony O'Brien

We have asked the Minister for Health to consider granting us a further ten day extension and, if granted, that would take us to 25 November.

Vice Chairman

Will Mr. O'Brien tell me why the deadline has been put back on at least two occasions?

Mr. Tony O'Brien

It has been put back once.

Vice Chairman

The next deferral will be the second.

Mr. Tony O'Brien

Yes.

Vice Chairman

Will Mr. O'Brien explain the reason for the deferral?

Mr. Tony O'Brien

The reasons I have stated in my request to the Minister are that the process of formulating the proposed service plan for 2014 is significantly more complex than it was on previous occasions and that the extra time will enable us to provide a more robust and effective service plan.

Vice Chairman

Let me speak about what has been published and the measures involved. A total net saving of €666 million was published as part of the budget, with a medical card probity saving of €113 million. I ask Mr. O'Brien to indicate his view of the figure, the average cost per medical card and the number of medical card holders that will be affected by the measure. Please give us a flavour of the areas where the service plan will involve reference pricing and various other measures. What does "probity" mean?

Mr. Tony O'Brien

"Probity" is a broad terms that relates to ensuring medical cards are issued in full compliance with the legislation and guidelines and also to ensuring medical cards not in compliance are no longer in force. That is the broad and accepted definition. It is important to stress that the figure of €113 million referenced by the Vice Chairman will not have an impact on eligibility. It is an estimate for the potential reduction in overall costs in one of the categories listed in the annual Estimates volume that could arise as a result of active measures designed to ensure the probity of the medical card scheme. As I said in my opening remarks, just as our function is to ensure there are no medical cards in force for which people are not eligible, it is equally our function - the communications strategy in place is has been designed this way - to ensure those who are eligible receive medical cards. The figure of €113 million does not change the eligibility criteria. It will lead us to a continuation and extension of the fair process in place to ensure by way of a review people will continue to be eligible; that if they are eligible, they will have the medical card to which they are entitled and if they are not so entitled, they will not. The consequence is that we will reviewing very substantial numbers. We have indicated that we expect to review in the region of 1 million medical card holders in 2014. What that will produce will only be determined by the review process. Therefore, it would not be wise, prudent or in the general interest to speculate on the outcome of individual reviews. I know there has been a tendency in the media to float various figures, but that it is likely to cause fear and alarm. The reality is that if people continue to be eligible, they will continue to hold their medical card or their GP visit card, as appropriate.

Deputy Mary Lou McDonald

I welcome the witnesses. I wish to pick up on the last statement made by Mr. O'Brien. The difficulty, of course, is that the HSE has cited budget savings of €113 million arising from medical card "probity" as he put it. I do not think it is consistent for him, on the one hand, to say we must wait and see what the outcome of the medical card reviews will be and, on the other, to have a stated target saving of €113 million. It is his figure, the Department's figure and the Minister's figure that has caused considerable public alarm. How did the HSE land on the figure of €113 million? The Comptroller and Auditor General referred to the HSE's research that indicated a range of possible savings through probity measures and the HSE has settled on the figure of €113 million. Will Mr. O'Brien explain in a succinct manner the logic behind the calculation?

Mr. Tony O'Brien

The total figure is €133 million. There is a separate probity figure in the AEV of €20 million.

Deputy Mary Lou McDonald

Okay. Please explain the logic behind the figure.

Mr. Tony O'Brien

The figure of €113 million was decided on by the Government and published in the annual Estimates volume.

Deputy Mary Lou McDonald

I am aware of that. I am asking Mr. O'Brien from whence the figure arises. Does he know?

Mr. Tony O'Brien

It was not proposed by the HSE.

Deputy Mary Lou McDonald

Can the Department shed any light on it?

Dr. Ambrose McLoughlin

The figure arises from a Government decision within the range suggested by PricewaterhouseCoopers in a report on medical card probity.

Deputy Mary Lou McDonald

I have acknowledged the report, but is it the case that there are no firmer grounds than a Government decision and that the figure falls within a speculative range?

Dr. Ambrose McLoughlin

We operate on the basis of developing a service plan. As Mr. O'Brien has stated, we have exhaustively gone through every aspect of expenditure in some detail to arrive at the service plan numbers, but the Deputy must understand that at this point I cannot be more specific.

Deputy Mary Lou McDonald

Right. Savings of €113 million or €133 million are being speculated about. Notwithstanding the report, which is a projection and not a perfect science, this is the target for the cuts to medical cards in addition to what has already taken place.

Mr. Tony O'Brien

I would say that it is not a target for cuts. It is an estimate of what might be obtained as the result of a probity exercise. It does not change eligibility and it does not come, precooked, with a target for the number of people who should lose eligibility, because eligibility does not change.

Deputy Mary Lou McDonald

Setting a target, or having a figure like that handed down, is the very definition of precooking an outcome. Mr. Hennessy, Dr. McLoughlin and Mr. O'Brien have been at pains to emphasise that there is no change in the qualifying criteria for a medical card, and specifically a discretionary medical card. The witnesses cited section 45 of the Health Act 1970 and have underscored the fact that legislation is what determines whether a card is awarded. I have no argument with that.

Moving from the general to the specific, a specific individual is a five-year-old child called Katie Connolly from Douglas in Cork. She has Down's syndrome and has been turned down on assessment for renewal of her medical card, which she had since birth as decided in line with section 45 of the Health Act 1970. She has Down's syndrome, asthma and a heart condition that must be monitored every two years. She has recently been diagnosed with juvenile arthritis. Her family always understood that on a simple crude means test they would not qualify for a card, but Katie had a medical card as adjudicated by the authorities in line with section 45 of the Health Act 1970. She now no longer has the card and she has no GP visit card.

In this specific case in which a child was judged as qualifying for a full medical card and is now judged not to qualify for any medical card, the legislation has not changed, the child's condition has not changed and the family's means have not changed. Those elements are constants in the scenario. Notwithstanding what he has said, Mr. O'Brien is dancing on the head of a pin and the one thing that has changed is the policy in respect of how eligibility is interpreted. How does Katie, aged five, find herself with no medical card? I would like to know that.

Dr. Ambrose McLoughlin

I would like to make it absolutely clear that there has been no policy change from my Department in respect to this matter. We are caught by the legal situation. In the earlier discussion, the Chairman raised issues that are now prudent and proper for the committee to take forward. The Government must make decisions on whether it wants to provide medical cards to people who have illness, as distinct from having regard to what is in the law at the present time. We must be clear about that. We are dealing with legislation and my Department must operate within the policy framework set by the Government, but there is no direction from my Department other than to facilitate people who need medical cards on hardship grounds-----

Deputy Mary Lou McDonald

Dr. McLoughlin-----

Dr. Ambrose McLoughlin

Can I finish, please? It is important for us to understand and bear in mind-----

Deputy Mary Lou McDonald

Can Dr. McLoughlin please do me the courtesy of addressing my questions? We are being called for a vote.

Dr. Ambrose McLoughlin

Through the Chair-----

Deputy Mary Lou McDonald

No; I am leading the questions. If Dr. McLoughlin would demonstrate a level of courtesy, I would appreciate it. The fact of the matter is that this case is representative of many and the child, in accordance with the established law, was adjudged to merit a full medical card under the Health Act 1970. Under the same legislation, the view now is that she does not qualify. The child has not changed, the family circumstances have not changed and the law has not changed, so based on what Dr. McLoughlin is telling me, either the child had illegally obtained or been granted a medical card, or there has been a policy change and Dr. McLoughlin and his colleagues in the HSE are moving heaven and earth to try to disguise or conceal the fact.

Vice Chairman

Deputy McDonald can continue, as we will keep going until after the vote. At whom is the question directed?

Deputy Mary Lou McDonald

In the first instance, Dr. McLoughlin, because he has been the most vigorous proponent of the idea that there has been no policy change. This position leaves the parents of Katie Connolly somewhat gobsmacked.

Dr. Ambrose McLoughlin

I will allow my colleagues from the HSE to deal with the specific case, but I want to make it clear that there has been no policy change.

Vice Chairman

Dr. McLoughlin might direct his response to Deputy McDonald.

Dr. Ambrose McLoughlin

I have already indicated that there is a view, represented politically by a number of politicians, that we should move to eligibility on the basis of medical status and assessment. That is not provided for under the current legislation. If the political system wants to do that, it is a matter for the system. I am simply reiterating that has been no change in policy in respect of discretionary medical cards and I want to assure the public that anyone who feels entitled to a medical card should contact the HSE.

Deputy Mary Lou McDonald

I do not wish to be confrontational at this hour of the day, but that is so patently not true. The law has not changed. The law has been in existence since 1970. Katie Connolly is five years old, which puts her date of birth in 2008. She was granted the medical card with due regard and in accordance with that legislation. The judgment was that, given the seriousness, complexity and lifetime nature of the child's medical condition, and notwithstanding the parents' income, the child warranted a full medical card. However, she now finds herself with no medical card cover at all. She does not even have a GP-only card. The legislation has not changed, the family and the child have not changed and the only variable in the scenario is policy. With the greatest of respect to Dr. McLoughlin, I do not accept the assertion to the contrary. It would make the committee appear utterly foolish if we were to accept that line. It is not true.

Moving from the particular to the general, if we were minded to do a forensic trawl of the 6,324 cases in which people who had previously enjoyed a discretionary card were found not to be eligible, we would most likely find that the same scenario arises. People with serious illnesses of a long-term nature were granted medical cards under the legislation by the same authorities now find themselves with no medical card cover. I am not asking Dr. McLoughlin to defend this. He does not make the policy calls; the Minister does. However, Dr. McLoughlin should not come before the committee and tell us black is white.

Please do not insult us by doing that. There has clearly been a change in policy because one does not find a change in legislation or in the circumstances of the individuals concerned.

Mr. John Hennessy

Hopefully, I can try to explain and clarify the position on that. If it is okay, I will not discuss the particular family, even though we are in discussions with the family and with a number of others who are in similar circumstances. We are happy to do that and, thankfully, the number is quite small but they are there and there is no point in denying that. Essentially, the question is about what has changed and how people qualified-----

Vice Chairman

How were they granted a medical card?

Mr. John Hennessy

-----but do not qualify now when there does not appear to be any significant change, certainly in medical circumstances even though there can be changes in financial circumstances which need to be taken into account. That relates to an earlier point that all cards are subject to review. All cases are subject to review and there are actually changes in circumstances that are taken into account by deciding officers and by the medical officers who are examining the cases on a case-by-case basis.

What has changed? In the pre-PCRS time, we had a lot of local schemes being administered, by and large, on a stand-alone basis, for which we came in for very heavy criticism from the political system and the Ombudsman at the time. There was a sense of bewilderment at how somebody could get a medical card in Cork but not in Kilkenny or in Donegal, but not in Wexford. We had to deal with that, which we did, in a way that established a standard consistent system of application with a single rule set and a process for assessing hardship in a consistent manner with standard operating procedures - essentially, all of the good practices one would expect in a statutory national scheme from a public body. We now have that in place.

The consequences of that change are throwing up the type of cases to which the Deputy referred. As I said, thankfully, the number is quite small. We are working with each of those to try to provide supports around them. One of the things that became very clear to me from talking to the medical officers is that they actually take into account the fact people qualify for other services, such as the long-term illness card, and supports under the Disability Act, which can be quite significant, in some instances, for people, irrespective of whether they have a medical card.

Deputy Mary Lou McDonald

I appreciate the process was centralised. God knows we had many a session here around the backlogs and delays but, fortunately, that appears to be resolved. I also appreciate that it makes rational sense to have standardised procedures and to have a standard and a transparent approach. I am not gainsaying any of that. What I am simply saying is that people - 6,324 - who are ill and in difficult circumstances who were granted medical cards on a discretionary basis now find themselves without them. I would really be interested - I know it would laborious - to read chapter and verse, almost case-by-case, about those people. As the Vice Chairman said, in our front line politics and in our constituencies - this is happening right across the State - all of us have the experience of people coming forward with serious long-term illnesses who had discretionary medical cards but who no longer have them and who have no card at all. I think I have made the point - I will not labour it - sufficiently clear to Dr. McLoughlin that I put that down, as I think any sensible person would, to a change in policy. I do not think one can arrive at any other reasonable conclusion.

In respect of children with Down's syndrome, is there a figure for those children who would have had a medical card but who no longer have one? Does Mr. Hennessy have that kind of data?

Mr. John Hennessy

I do not think we have a precise figure on that. We will see what we can get the Deputy on that.

Deputy Mary Lou McDonald

I would be interested to see that.

Mr. John Hennessy

The point I would make on that again is that, thankfully, the number of people affected in the way the Deputy described is not anything like 6,000 but we are working to-----

Deputy Mary Lou McDonald

How does Mr. Hennessy know that?

Mr. John Hennessy

We have been contacted in the past three to four weeks by a significant number but it is not anything like 6,000.

Deputy Mary Lou McDonald

Okay but just a word to the wise. Just because the HSE has not been contacted does not necessarily mean the experience is not out there.

Mr. John Hennessy

I appreciate the point.

Deputy Mary Lou McDonald

We, as politicians, know that.

Mr. John Hennessy

Okay. The other point I want to make on that is that we are happy to work with those families and to provide whatever supports we can within the law and within the schemes available to us to support them during this period of time but what we cannot do-----

Deputy Mary Lou McDonald

What does that mean?

Mr. John Hennessy

I mean other entitlements to which families are able to access aside from a medical card. We cannot compound something that was wrong at one point by doing another wrong now.

Deputy Mary Lou McDonald

So it was wrong that Katie had a medical card.

Mr. John Hennessy

I will not comment on that particular case but it may have-----

Deputy Mary Lou McDonald

Mr. Hennessy has commented on it that it was wrong Katie Connolly had a medical card.

Mr. Tony O'Brien

With respect, my colleague specifically said at the outset of his remarks that he was not going to comment on that case and any comment he made thereafter should not be taken as a comment on that case.

Deputy Mary Lou McDonald

All right. Let me rephrase it. It was wrong that these 6,324 people, among whom we can count Katie, had medical cards.

Mr. John Hennessy

I am not saying that. That is not what I am saying at all. They may well have been entitled and eligible at a point in time but when it came up for review, the situation was that they were found not to be eligible but that does not mean that they are being abandoned entirely. We have other supports which we want to make sure families avail of.

Deputy Mary Lou McDonald

I would say to Mr. Hennessy very directly that the support they want is their medical card back. That is what they want. I am not for a minute playing down the other fine supports and services which are there. These people want their medical cards back. I certainly do not want to put words in Mr. Hennessy's mouth but he began to say that we cannot compound something that was wrong by continuing it. There is a need for a change in policy based on medical need. That is my view and I appreciate it is for us to pursue that in the political arena but I think it is very disturbing that we have a situation, when there has been no obvious change in the law and in people's circumstances, that one day, people are eligible for a card but the next day, they are not. I am sure all the witnesses will appreciate the kind of real distress-----

Mr. John Hennessy

Of course, we do.

Deputy Mary Lou McDonald

-----that causes people and their families because they all live in the same world we do. We are reeling off numbers here, naturally because the HSE is a big organisation which deals with a big budget and large numbers. These are not numbers; this is real stuff that is happening to people.

Mr. John Hennessy

The ultimate change that was made was a centralised system to process this-----

Deputy Mary Lou McDonald

I am aware of that.

Mr. John Hennessy

-----which now delivers a service in a fair, equitable and consistent manner and that, unfortunately, was not the case before, not making any judgments about people's entitlements at a different point in time. It is a fact that circumstances change. That is the point of reviewing cards.

Deputy Mary Lou McDonald

We are not going to have a meeting of minds on this and I think I have made my position clear. I refer to the language of probity and efficiency and centralising things for reasons that are entirely reasonable. When the consequence of that is thousands of casualties - I consider them to be casualties of that - we have to look at it again. Let me repeat that nothing has changed legislatively in terms of people's medical circumstances, but what has changed is policy. That is down to the Minister.

Vice Chairman

Deputy McDonald, you might come to a conclusion because we need to suspend for half an hour.

Deputy Mary Lou McDonald

I want to ask a short question which relates to the service plan. It has been indicated that it will be published on 25 November.

Mr. Tony O'Brien

No. What happens with the service plan-----

Deputy Mary Lou McDonald

It will be completed.

Mr. Tony O'Brien

-----is that it is submitted to the Minister.

Deputy Mary Lou McDonald

On 25 November.

Mr. Tony O'Brien

Once he has approved it, it will be published.

Deputy Mary Lou McDonald

In respect of the four CEOs of the hospitals who wrote to Mr. O'Brien recently, there was an indication that there would be consultation or communication between those persons and the HSE. Can I take it that is under way?

Mr. Tony O'Brien

There has already been communication between the HSE and each of those hospitals.

Deputy Mary Lou McDonald

Is there an ongoing process of dialogue in respect of the funding of those hospitals?

Mr. Tony O'Brien

There is, in fact, a continuous process.

Every month in fact, with or without letters to RTE, there are meetings around performance and risk issues with every hospital and that is the normal place in which concerns are raised.

Deputy Mary Lou McDonald

On the specific issue in the letter to RTE, is there dialogue and discussion on that matter?

Mr. Tony O'Brien

The national director of acute hospitals has been in contact and will continue to be in contact with each of those hospitals.

Deputy Mary Lou McDonald

Okay, that was as clear as mud. I thank Mr. O'Brien.

Mr. Tony O'Brien

A direct answer to a direct question I thought.

Deputy Mary Lou McDonald

Mr. O'Brien is being cagey.

Sitting suspended at 11.40 a.m. until 12.15 p.m.

Chairman

We will resume our meeting. Deputy Harris is next.

Deputy Simon Harris

Thank you Chairman. I thank Mr. O'Brien, Dr. Mc Loughlin and their teams for their patience during what was quite a lengthy suspension. We will now switch our attention from bailout exits to medical cards. The conversation we have had so far this morning has been helpful and constructive. The figures Mr. Burke provided on the review of discretionary medical cards and how that breaks down, with a high level of detail, were very useful by way of providing a context.

I ask the witnesses to outline the communication plan that is now in place with regard to medical cards. When the HSE makes any announcement about changes to income limits or eligibility criteria, a fear sets in and that can be particularly acute in the context of the vulnerability of the people concerned. In that context, I know the HSE has put in place a communications plan and I ask the witnesses to outline the content of that plan and to elaborate on how it is progressing. Has there been much contact with the public?

Mr. John Hennessy

Thank you Deputy Harris. We took action on our communications strategy in acknowledgement of the considerable amount of controversy and genuine anxiety and concern the announcement of the review provoked. The intention of our response was to explain, to clarify and to improve people's understanding of the operation of the medical card scheme in order to alleviate some of their anxiety and concern. In terms of the elements of the communications plan, Mr. Burke and his colleagues in the Primary Care Reimbursement Service, PCRS, introduced an additional control, particularly for people who already held discretionary cards. That is an important measure which allows us to capture the most up-to-date information on the circumstances of all cases before final decisions are taken. That control is now in place.

The second element of the communications strategy involved public advertisements, an enhanced helpline and website enhancements, including a new video. I would encourage all Deputies to look at the video on our website if they get a chance. It is not lengthy, at approximately eight minutes, but is quite informative. We are working on a frequently-asked questions leaflet for medical cards which will be ready in about two weeks and will go to all local offices, GP surgeries and hospitals as well as being circulated to public representatives. We have embarked on a range of meetings and briefing sessions with voluntary and advocacy groups. We have also embarked on a number of briefings in the political system through the local health fora.

The third element of the communications plan involved a re-working of our written communications. We came in for some criticism for the tone and language used in some of our written communications with the public. A review of the notification letters, in particular, is underway. The language is being personalised and we are enhancing the information that is provided for applicants, particularly with regard to the range of entitlements to services that people have which do not require a medical card. That might help to reassure people that losing their medical card is not necessarily a catastrophic event, given that a range of other services and entitlements is still available to them.

The final element concerns the issue of discretion. We are trying to explain that discretion is still available but that it is now being applied in a consistent, fair and equitable manner. Medical officers are involved in the process and carry out individual, case-by-case assessments. They pick up the phone and speak to the applicant's GP or consultant, as necessary. Obviously, the ultimate objective is to ensure the people who need a card get one but the scheme operates within the confines of the statute and the resources available to us.

Deputy Simon Harris

I thank Mr. Hennessy for that helpful response. I wish to focus on the question of consistency because this committee is not so much concerned with policy but with the implementation of that policy in a correct manner.

Therefore the expenditure of taxpayers funds is correct. Every member of the delegation who has spoken today has alluded to an inconsistency or a previous inconsistency in terms of how medical cards were issued in the past. I note the Comptroller and Auditor General in points 22.6 to 22.8, inclusive, of the report on eligibility for medical cards refers to an inconsistency between regions and that eligibility for medical cards was not consistent. Can we call a spade a spade and clarify what this means? Is it the luck of the draw? If one lived in County Limerick and had a certain condition, one might have been granted a medical card on the grounds of discretion, whereas in County Donegal, discretion may have been applied separately.

Mr. Tony O'Brien

Variation existed at the regional and even at the micro-regional level. We must remember, of course, that it is not that long since health services were provided by a multiplicity of health boards. In respect of discretionary items, the Health Act 1970 confers that discretion on the chief executive officers of those health boards and although they came together to develop an uniform statement of discretion, it was implemented in over one hundred different places by a hundred different sets of people, many of whom did not know the other hundred. It was inevitable that there would be inconsistent application of an apparently consistent policy.

Deputy Simon Harris

Discretion being a somewhat subjective concept in and of itself, if more than 100 different people are applying it.

Mr. Tony O'Brien

The discretion itself was consistently described but it appears applied inconsistently.

Deputy Simon Harris

Okay, it is useful to have that stated. Mr. O'Brien, as the director general of the HSE with Mr. Burke the head of the medical card section, is saying that discretion is being applied on a consistent and uniform basis, regardless of postal address. The criteria and same level of checks and balances apply whereas in the past that was not necessarily the case.

Mr. Tony O'Brien

That is correct, Deputy.

Deputy Simon Harris

Thank you. I wish to raise the issue of deceased medical card holders. I looked recently at the figures in relation to this issue and I was concerned to see a level, although lower than in the past, whereby the medical cards of the deceased were continuing to run up costs for the taxpayer. Mr. Burke supplied the figures. Of the 17,059 medical cards, 2,361 belonged to deceased people. As far back as 2003, the then Comptroller and Auditor General had referred to the costs of medical cards being paid for people who had been deceased for up to 14 years. Will he outline the present position?

Mr. Patrick Burke

When we centralised the processing of medical cards it gave us the opportunity to apply a central national approach to the task. We are linked electronically to the death events publication service. A number of times each month, we get a data feed from the death events publication service and this is integrated into our systems. On the notification of death, eligibility ceases for a medical card. In the event of the family being slow in advising the death events publication service and we have paid capitation for a number of months, that is automatically recouped. There are no overpayments for deceased medical card holders.

The Deputy referred to historic cases that related to the previous system, in which the death of a person with a medical card was not communicated to the medical card service of the HSE. We calculated the over-payment to GPs forensically, and I think, from memory, we recouped that two years ago. We tightened up the legacy issue. Now eligibility ceases on death and in the event of an overpayment, that is automatically recouped.

Deputy Simon Harris

That is very helpful. Those figures of 2,361, if funds were paid out, they have been recouped.

Mr. Patrick Burke

Absolutely. In fact, what I gave the committee was a reconciliation over a window of time, 1 March 2011. I was reconciling the number of people who held eligibility vis a vis now. As those individuals passed away, they were taken from the register. There were no overpayments.

Deputy Simon Harris

That makes sense. I am concerned that much of the discussion on probity - this word that has now entered the lexicon - the probity focus has been on medical cards being taken from people who currently hold them. From what I have read and heard from the HSE and the Department of Health, there must be concern about over-payments made to GPs, pharmacists and other. I have heard the Minister for Health publicly refer to claims for payments submitted by GPs and in some cases the HSE reaches a much lower agreed settlement figure with the GP involved. Could Mr. Burke give me a feel for that?

Mr. Patrick Burke

The payments to GPs are by and large capitation bids. This means that once one controls the register, notices of births and deaths and reviews on eligibility, one is controlling that aspect of the service. Capitation is like a salary that is paid to GPs, but the HSE has control over it. There are additional payments for annual, sick, maternity, paternity and study leave to GPs but they must provide the name and ID of a Locum to avail of it. Certain subsidies are given for GP practice secretaries and nurses but they must provide, P35s and PPS numbers of the persons employed. All of that expenditure is controlled. Some time ago we identified trends in the GP out of hours service or special services with which we were not happy. We challenged the GP community and in cases where we were not satisfied with a trend, we did not make a payment. It was not a question of making a payment and looking to claim it back. We unilaterally did not make a payment. We negotiated with the GPs on the ambiguities that constitute a claim in an out of hours setting, and after a mediated process we have agreed with GPs and advised them on the explicit definition. In the cases in which we had challenged the GPs and had not made the payments, we asked them to make a case on the validity of the claim as part of the mediated process. In some cases we offered settlements. If we were satisfied that the claims for out of hours services were valid and could verify them, we made a payment. Where we were not, we made a settlement, and in the cases with which we were not happy, we made no payment at all. During the past two to three years, when we have not been happy with a claim presented to us we simply do not pay.

Deputy Simon Harris

I have a final question on the issue of medical cards before I raise a few other points. There seems to be a very high level of "non response" when the HSE writes to an individual seeking information. The Comptroller and Auditor General has referred to it in his report and it has been alluded to in the figures presented to us today. Am I correct in saying that a cohort of people who receive the letter, and have not left the country do not respond? I am trying to get into the mindset of such people and the reason that they do not respond. Does the content of the letter make people too fearful? Has the HSE conducted research into the reasons for the high level of non response to the letters?

Mr. Patrick Burke

In any given month, we could also have 10,000 new applications as well as having to conduct 60,000 reviews of medical card eligibility. As part of the review process, a person with a medical card may now become eligible only for a GP visit card. People may appeal decisions and be granted a medical card on appeal. There is an absolute melting pot of activity in any particular month.

When we write to individuals, the person may have decided that he or she is no longer eligible and does not respond to the communication. We had a separate exercise in which we wrote to individuals who were not using their card and if they did not respond and did not confirm residency, we took them off the register. On our database we have 2 million people between medical card and GP visit card holders. Another 1.5 million people are registered under the long-term illness scheme, drugs payment scheme, Health (Amendment) Act. In total the central register would have 3.5 million plus unique clients. Even though access and touch off the service happens quite a lot, the address could be wrong. Incorrect addresses could be an element of the reason for non response. To safeguard the individual, we agreed with the Irish Medical Organisation and GPs, that if we had written to a client twice and if our address was wrong, when the client approached the GP, the GP could then move their eligibility for three moths to give them the opportunity to talk to the HSE. We put that measure in as a safety blanket. In the melting pot of transactional activity, there is churn, when people are fit and well they do not realise their card has expired and when they turn up at the GP, the GP realising he is not getting capitation urges them to get in touch with the HSE system and we assess their eligibility.

Deputy Simon Harris

That is helpful.

Mr. Tony O'Brien

Let me answer the question asked about probity among service providers. Mr. Burke has mentioned some of the processes relating to GPs. We also have inspectorates for pharmacy and dental services. They carry out reviews and audits. Sanctions are available to us. There will be outcomes from the investigations under way. Probity does apply on that side of the line.

Mr. Patrick Burke

In terms of materiality, I have spoken extensively about what we have done in the GP area. The same applies to the pharmacy area, as Mr. O'Brien said. In the past three or four years we have conducted almost 300 individual inspections with the Pharmaceutical Society of Ireland and the Irish Medicines Board. We all carry separate powers and strengths when we carry out our blitz of pharmacies. We examine their financial circumstances, for example. There has been that level of investigation in the sector. In the past few years we have inspected a significant percentage of the country's approximately 1,700 pharmacies.

Deputy Simon Harris

With the indulgence of the Chairman, I would like to mention two issues in respect of which I would like the HSE to be put on notice.

Chairman

That is fine.

Deputy Simon Harris

The first is disability funding. There is a real problem when Governments and Government Deputies make pronouncements in good faith. For example, it was announced that there would be a reduction to service providers of 1.2% in 2013. Service providers up and down the country have told us that they took a reduction of approximately 2%. The precise figure they mention tends to vary. In the case of one organisation, a 1.2% drop would have meant a reduction of €234,000, whereas a 2% drop would have meant a reduction of €390,000. It is obvious that this makes a real difference in the provision of front-line services for people with disabilities. In our own day-to-day interactions with these groups we have all seen the impact this has had. I congratulate Mr. Byrne on his appointment and wish him well in his role as chief financial officer. Why does 1.2% not always mean 1.2%? Have service providers which were told they would be taking a cut of 1.2% had to take a greater cut?

Mr. Tony O'Brien

I might respond to that question.

Deputy Simon Harris

Please do.

Mr. Tony O'Brien

In service plans such as the service plan for this year there is a difference between direct allocations which are clearly aligned with different sectors and indirect allocations. Savings measures derived from the Haddington Road agreement are being applied across the board. Savings measures can be applied as a result of value for money reports, in addition to headline reductions. In the service plans we propose to the Minister this year we will seek to be absolutely clear about the manner in which each of these things applies to each sector in order that it is fully and transparently described.

Deputy Simon Harris

That is important.

Mr. Tony O'Brien

When a headline figure is extracted, it is discussed and observed and people overlook the other things. We will seek to ensure that cannot happen this year.

Deputy Simon Harris

The problems that arose in the case of the difference between a 1.2% cut and a 2% cut were encountered by the disability organisations and service providers in advance of the Haddington Road agreement. That brings me to my next difficulty. I will give an example of what is happening in many organisations around the country. I think I gave notice of my wish to discuss this case. A service provider in my constituency, Sunbeam House Services, which is bound by the Haddington Road agreement was told to make a submission on what its savings would be under the agreement. It made a submission stating its savings would be approximately €77,000. I fully accept that it would be irresponsible of me, as a member of the Committee of Public Accounts, and irresponsible of the chief financial officer not to challenge all figures. The HSE actually reduced the budget of the service provider in question by €189,461, rather than €77,000. The difference between the two figures - a mammoth €112,000 - had a massive impact on services, including the suspension of transport services. Owing to the Rosetta system, reductions were not possible in some areas because these categories were not eligible. To its credit, the HSE came back and returned some of the money, but why was it taken in the first place? I expect organisations that know they are covered under the Haddington Road agreement to make the savings and they expect to make them. The vast difference between €77,000 and €180,000 placed many vulnerable persons in a really difficult position.

Mr. Tom Byrne

As the Deputy is probably aware, for us there was a cut of €150 million in the initial stages of the Haddington Road agreement. We were obliged to issue that cut into the system. Having obeyed the requirement to issue the figures, I made a decision within the HSE to draw €147 million of that figure back to hold centrally when I realised that the effects of time-related savings across the board enabled me to do so. It was not feasible. I am aware of the situation at Sunshine Home. We received from all parties details of the allocations they considered they could take and reviewed them across the board. I believe those discussions continued to a satisfactory conclusion between both parties, but it was unfortunate. We were, however, obliged to issue a figure. We decided to take it and hold it centrally.

Deputy Simon Harris

That brings us back to the previous discussion between the Departments of Public Expenditure and Reform and Health about what the HSE could actually achieve under the Haddington Road agreement. The extra bit was divided across a range of sectors, in the first instance, before it was decided that it should be taken centrally.

Mr. Tom Byrne

It was in review of the fact that an element of the €150 million was time-related. One cannot issue €150 million across the system and expect an immediate payback on it. As the Deputy said, negotiations on rosters, etc., need to be carried out. I made a decision at the time that it was appropriate for this to be done and that is what happened. As I have said, we agreed to a successful conclusion to the negotiations with Sunshine House on the savings it could deliver and those it can deliver in the future.

Deputy Simon Harris

I will direct my final point at Mr. O'Brien in the first instance. The HSE has carried out an extensive audit of another disability services provider in my constituency, St. Catherine's Association. This matter has appeared on the front page of a national newspaper on at least two occasions. I am concerned about a couple of aspects of the issue. The HSE seems to have carried out a very extensive audit of how public moneys were spent in this service provider which does a great deal of extremely good work in my constituency. How has an audit report that has not been seen by me or people whose children go to St. Catherine's ended up in the national media? I do not believe it has been published. Given that the audit seems to have appeared in such a comprehensive manner in the national media, I respectfully suggest the HSE look into who is leaking this document and the rationale behind that action. As it has been reported on so significantly, I suggest the HSE publish the audit.

I do not necessarily expect Mr. O'Brien to be able to respond directly to my final point, but I ask him to look into it. In the scenario I have raised the HSE has been providing funding for a service provider for a number of years. The HSE is not suggesting the funding was misappropriated - it is suggesting it was not spent in the manner in which it was meant to be spent. It was spent on services for children with disabilities. I would like to know, from the HSE's control point of view, how it took so many years for it to come across this. Will Mr. O'Brien come back to me with an explanation for how it took so many years for the HSE to discover this issue and carry out an audit? It is doing a huge disservice to the massive amount of work being done to sustain this service provider - the HSE is doing good work at local level to keep the show on the road - that this comprehensive audit report has appeared, in effect, in a national newspaper. I am concerned about the leaking of this document.

Mr. Tony O'Brien

I will ask my colleague Mr. Byrne to speak on these matters. I share the Deputy's concern about the apparent publication of sections of a report. We are slightly constrained in how far we can go in this regard at a public forum. There are processes that may need to be followed and they may be prejudiced, if I can use that term. I ask Mr. Byrne to provide such information as it is reasonable to provide in these circumstances.

Mr. Tom Byrne

As Mr. O'Brien said, the problem is that it would prejudicial at this stage to discuss the findings of the report. The relevant authorities were informed of the findings at the time. It was not a comprehensive audit - it was actually a finance and governance review. We provide funding for over 2,000 charities and disability services throughout the country. Ours is one of a number of Government agencies that provide such funding. The Department of Education and Skills also provides it. We rely heavily, as any organisation would, on the accounts we receive annually from organisations of this nature. In this case, we are talking about an independent limited liability company with its own board of directors and chairman and its own independent auditors. We review the statutory accounts which are signed by auditors as being true and fair.

Over a number of years we received that. I could explain here but I will write back to the committee formally in detail. An issue did arise a number of years ago in relation to this. As Mr. Tony O'Brien has said, as a health service, we try to work with everyone. We are very conscious of the 200 plus children with whom this charity deals. If the company accounts are signed off and supplied to us we will go by those and review those. We have meetings on a monthly basis with our regional managers of all of these service providers. To a large extent one would be inclined to say that the matter, when it arose, arose through the fact that the Revenue Commissioners advised us that a note of attachment was coming through. That was the first notification we had that there was an issue. We took it up with the board which is being addressed. Again, I would be circumspect in discussing further as to what has happened. Our governance review is what the Deputy is referring to. I know the new external auditors have carried out their own 78 page audit of the board of Sunshine Home-----

Deputy Simon Harris

St. Catherine's.

Mr. Tom Byrne

-----which has also been provided. At this stage we have taken it to the relevant authorities to review the report. It is probably inappropriate to discuss it any more at this stage.

Deputy Simon Harris

I thank Mr. Byrne.

Chairman

I call Deputy Nash.

Deputy Gerald Nash

I wish to raise a couple of points but will not detain the witnesses too long as much of the ground has been covered. In regard to the awarding of cards on a discretionary basis and the role of a medical officer in deciding on an appeal, I am interested to find out a little more about this new process. Perhaps the witnesses would talk me through how the process works. What is the function of the medical officer? Is there any oversight in terms of the medical offer who makes the decision or recommendation?

Mr. Patrick Burke

When an individual submits an application our first task is to do a financial assessment in cases where there is an issue. When a person has been assessed against the guidelines he or she may wish to bring health, social or other material. In quite a number of cases we can see very quickly whether the card should be granted or whether discretion should apply. There are circumstances where we want or need medical officers to review the case. We have a team of medical officers spread locally across the country, headed up by a principal medical officer. In circumstances where an applicant provides us with material about some health or social circumstance and they cross over, all that material on file is passed to the medical officer. They meet on a regular basis. They will say themselves that in nine cases out of ten they can make their decision very quickly by looking at the circumstances. They are medical doctors and they know the health services and the schemes and how health services are delivered.

Deputy Gerald Nash

And the cost associated with caring for a relative.

Mr. Patrick Burke

Absolutely. As well as that they know the services, the schemes in place and how health services are delivered. They are able to identify if the client can be supported and, if so, in what way. They conduct that assessment. If there are situations they find difficult they come together as a group twice a week to discuss those individual cases. On foot of those individual assessments or case conferences they make a recommendation to the deciding officer who will look at their recommendation.

Deputy Gerald Nash

It is very important that is communicated to the wider public because there is a view abroad that some kind of omnipotent medical officer is sitting in a back room in the HSE making a decision on the future care or the ability of a family to care for an ill or disabled loved one. That is a view that is out there. I am not saying it is correct but it is a view that has been communicated to me by constituents who have found themselves in difficult circumstances and are in the process of appealing decisions. One of the other issues that arises in that context is the apparent inability of some constituents of mine to access information records in terms of how that decision was made. I know of a number of examples where individuals are pursuing freedom of information requests to try to access that material. Would it be a more transparent process and in the interests of the HSE and citizens if they had access to that information in a much more open fashion? That is an issue that is hanging over this process. Clearly, if one is the parent of an ill or disabled child and one's medical card is withdrawn, one has to deal with that particular trauma and fight the system to try to get as much information as possible in order to come to some kind of an understanding as to how that decision was arrived at? Do the witnesses have any comments on that?

Mr. John Hennessy

I will start on that issue and Mr. Patrick Burke will contribute as necessary. It is a good point and transparency is obviously important in the operation of the scheme. The group of 12 medical officers, overseen by a principal medical officer, 13 in total, operate to a standard operating procedure. We will have a look at the issue. It is important that we put that into the public domain in order that there is good transparency and knowledge about how the process works and the way it works. The individual medical officers also liaise closely with the patient's GP and consultant, as necessary, if there is an issue of clarity that they may wish to bring to the decision making process. We will certainly look at the issue of transparency and bringing that into the public domain in a better manner than is currently the case.

Mr. Patrick Burke

To the extent that it can be, given that there are medical circumstances. We will share that with the client whenever we can. It might be important to put on the record that we can have applications where an individual applicant may have a life-threatening condition, for example, motor neurone disease. We have had a number of examples where a medical officer will always look at that. If one has net income in excess of €10,000 per week or €6,000 per week or €4,000 then the decision of the medical officer and the team will be that individual, difficult as their individual circumstances are, can access general practitioner services without financial hardship.

Deputy Gerald Nash

That is in keeping with the legislation.

Mr. Patrick Burke

In other words, in quite a number of the cases they will look at circumstances where the net income after allowing for any medical expenses and what not are many multiples of the guidelines. In those instances, as they assess it, they can arrive quickly at a decision. It is only where the net income is closer to the demarcation line that there will be that case conference conversation.

Mr. Tony O'Brien

Every person who applies and who is not successful will receive a financial statement. Given that it ultimately comes back to a financial calculation they receive a financial statement which sets out the information that has been taken into account and shows the calculations. There is that level of transparency. Clearly it should never be necessary for a person to resort to FOI in order to get that kind of information. Also it may be useful for public representatives to be aware that when they are presented with people who have an issue with the outcome of their determination that their attention might be brought to the statement they receive. Sometimes we find that people make a case that is not about the financial assessment but about their view of what the medical card system should be as opposed to what it currently is.

Deputy Gerald Nash

In relation to recoupment from GPs, I am quite satisfied that a robust system is in place to recoup overpayments from GPs or situations where they have been claiming in error, in some cases, for patients who are deceased or no longer eligible or no longer resident in the country. If it ever proves difficult for the HSE to recoup outstanding moneys from GPs what kind of sanctions does the HSE impose on that GP, if any?

Mr. Patrick Burke

Chairman, that is a difficult question to answer because where we were owed money we took it back.

Mr. Tony O'Brien

There is never a difficulty. All providers are paid at least a month in arrears. To the extent that money may be owed it is always significantly less than we owe then. Therefore, there is a let off essentially, so there is not a difficulty with reclaim.

Deputy Gerald Nash

I am satisfied with that.

Mr. Patrick Burke

If we have a concern about a claim we do not pay until we are satisfied.

Deputy Gerald Nash

Clearly there is a very substantial body of work going on in respect of probity around eligibility and so on. A point was made earlier and in some other associated documents we have received in relation to 106,828 individuals being contacted to establish residence.

Does "residence" generally infer residency in this State?

Mr. John Hennessy

Yes.

Deputy Gerald Nash

Is the HSE in a position to estimate the number of individuals who are eligible for or in receipt of medical cards, given the high level of inward migration we have had, who are no longer resident in the State?

Mr. Patrick Burke

When we centralised, we had an opportunity to link in and strengthen the controls around administration. Therefore, we now link in death events automatically. We also identify any individuals on the register who may have been granted eligibility for an extended length of time and we have reviewed all of those. Where we found somebody was on the register, but found no activity over a period with a general practitioner, pharmacist, dentist, optician or whatever - there is extensive data at the back of the register in the context of reimbursement - we wrote to those people to establish whether they are still resident. If on foot of a number of pieces of correspondence the person did not make contact, we ended his or her eligibility. We have a safety blanket in the process so that if one of those individuals is fit and well and goes to the GP, he or she can be reinstated. Does this answer the question?

Mr. John Hennessy

It is probably difficult to be very precise on that question. When cards are reviewed for renewal, the number of cards not extended for renewal tend to fall under three main headings. One group relates to patients who have died and these cards are dealt with now by recovery, back to the day the patient died. Some clients decide not to renew, for various reasons. Perhaps they have returned to work or their circumstances have changed. The third group relates to people who are refused on means grounds. Within the middle group, the non-renewal group, some of these may have left the State or gone abroad. Therefore, it is difficult to be precise. With the amount of outward migration, I imagine significant numbers fall into this group.

Deputy Gerald Nash

Obviously the HSE is not in a position to drill down into those figures to establish the number of people-----

Mr. John Hennessy

We conduct a certain amount of risk assessment at the award stage. Clients whose circumstances may be subject or liable to change in the short term would not be granted a card that lasts for three years, but for less time so that we can pick up on the changed circumstances.

Mr. Tony O'Brien

What we can say is that where verification occurred as a result of inactivity, some 38,495 cases led to eligibility being removed in circumstances where we could not establish residence. However, we cannot say much beyond that.

Deputy Gerald Nash

Thank you.

Deputy Áine Collins

I welcome the witnesses and thank them for giving their time to discuss the issue of medical cards and the wider areas of health. To be clear on the issue of discretionary cards, significant media attention has focused on this area and serious concerns have been expressed in our constituency offices. Many people fear losing these cards. What has changed to cause this reaction? I think I know the answer, but I want the HSE to clarify this.

Mr. Tony O'Brien

The immediate reaction is that this is a simple response to the fact that some medical cards held by patients, whether granted on a discretionary basis or otherwise, are being withdrawn following review. The response to this is understandable and there seems to be a general view that the medical card scheme should operate on the basis that where certain medical conditions exist, medical cards should be granted. However, as we explained earlier, that is not the way the medical card scheme operates.

The guidelines on how we apply discretion have not changed, but over the years there have been some changes to the primary qualification process for medical cards. This obviously has an impact on the discretionary guidelines above that. However, the primary change has been that the centralised process, the consistent application of the guidelines and an active process of review have led to a situation where a significant number of medical cards held previously are no longer held. Individuals have significant concerns about the impact on them and have expressed those concerns and society in general and the media are reflecting the concern that results from that.

Deputy Áine Collins

Thank you. Mr. O'Brien spoke about the increase in the number of medical cards, an increase of 75% from January 2005 to 2012. Would it be possible to have a breakdown on the increase for each calendar year?

Mr. Tony O'Brien

Yes, we can send it on.

Mr. Patrick Burke

We can get it at short notice. It will reach the Deputy today.

Deputy Áine Collins

That would be great. I want to link that to the unemployment and other social changes that happened in that time. Significant changes occurred during that period.

I was interested to hear what the HSE had to say about what happens where people on a medical card have died and appreciate there is a link now with the registry of deaths. I imagine a significant number of those people on medical cards are also in receipt of some sort of benefit, whether a pension, social welfare and so on. Would it be possible to link that to social welfare also?

Mr. Tony O'Brien

We are already connected with the Department of Social Protection, but my understanding is that it relies on the same primary source, the Death Event Publication Service, DEPS, which records and communicates the registration of a death. There can be an interval between the death and registration, because there is no compulsion regarding a particular timeline for that. The DEPS is the primary source used by all State agencies to ensure the veracity of population type registers - whether for screening, benefits or GP visit cards. It is used as the central repository of that information.

Deputy Áine Collins

My understanding is that from the point of view of social welfare or pensions, widows or the family receive the pension until six weeks after the death. Those in receipt of welfare must sign on within four weeks. Would it be worth looking at this to see how the margin could be narrowed?

Mr. Patrick Burke

General practitioners who sign the death certificate can also record the death on the database. We can pick up on deaths not notified to us and we are also notified of some deaths by individual families. There are various avenues people can use to inform us of deaths.

Mr. Tony O'Brien

The fact it may take six or eight weeks to inform us is immaterial, because that period does not result in a cost to the State.

Deputy Áine Collins

I appreciate that, but in light of what has happened in the past, we must try to ensure it does not happen again. The medical card system has been centralised, but is there a new IT system in place to manage it? What IT system is used? I presume the database can be used for modelling to extract various real time information.

Mr. Patrick Burke

The answer to that is "Yes". The results of that modelling are demonstrated weekly on medicalcard.ie, where we openly and transparently produce our activity levels. That is one output from the modelling.

Deputy Áine Collins

What is the administrative cost of delivering medical cards? Has the cost increased or decreased in comparison to what it was? Now that the process is centralised, have the costs changed? Are more staff involved? I appreciate there has been an increase in the number of medical cards, but what does it cost to administer and manage the system?

Mr. Patrick Burke

Medical cards are centralised through the central reimbursement service. Therefore, as well as determining eligibility, we also have the reimbursement function to the 6,500 contractors who provide 80 million transaction items in the primary care field. The total card of the medical card and primary care scheme is approximately €2.4 billion. That is our global figure, but there are economies of scale as we centralise medical cards because we are using part of the machinery and systems that are in place for reimbursement. Our operating costs for 2012, as a percentage of our total spend, were approximately 1.13% of that. In 2011, the cost was 1.02%. If we draw a comparison-----

Deputy Áine Collins

A percentage of the €2 million?

Mr. Patrick Burke

Of the €2.4 billion. In other words, the cost of administering the service in its entirety was 1.13% of that in 2012 and 1.02% in 2011. In comparison, comparable reimbursement entities such as Blue Cross, Kaiser or VHI have operating costs from 7% to 10%. The figure of 1.13% is the overall cost of the administration of the reimbursement and assessment of eligibility.

As Mr. O'Brien said earlier, we had an operation which was distributed nationally, involving 450 or more individuals and whatever governance was over each of those.

We have now centralised it and there are approximately 150 people there. The efficiencies in head count allowed the HSE run down its staffing or HR. Centralisation enabled us to allow some who had previously been involved in that process to become involved in other frontline processes and others to exit the administration.

Mr. John Hennessy

Let me reinforce that point. It made very good business sense to centralise from the point of view of the cost of operating local offices in each of the health boards to administer medical cards. The saving was in excess of 100 wholetime equivalents who were redeployed into other areas. Aside from the benefits of a single system and standard operating procedures, rights of appeal and consistency, it resulted in a significant reduction in overhead costs.

Deputy Áine Collins

Overall it has worked. There is better efficiency, greater fairness of eligibility and it has reduced cost.

Mr. John Hennessy

There are problems still to be ironed out but in general it would be regarded as a success story in terms of business processing, cost and overheads.

Mr. Patrick Burke

It improves customer service too. If we go back some years, this committee and other fora dealt with the fact that there were huge waiting times and that there were different standards across the country. We published the fact that between 95% and 97% of applications are dealt with monthly. Our focus is on making the customer service better and dealing with that tail of 3% as quickly as we can. There is a huge customer service perspective as well.

Deputy Áine Collins

Good. In respect of administration and costs in the HSE there has been a 10% reduction in staff, an 8% increase in population and €3 billion has been taken out of the budget. What percentage of that 10% of staff were frontline as opposed to administration staff? Is that information available? If not, could the witnesses forward it to me?

Mr. Tony O'Brien

It is not available here but we can provide it.

Deputy Áine Collins

Thank you. There seems to be a big cost issue here in the area of prescription drugs, compared with other parts of Europe. I know that there was some work to be done in this area. How is that work progressing or is an update available?

Mr. Patrick Burke

Over the past four years various policy initiatives from the Department of Health and operated by the HSE have reduced the cost somewhere in the order of €1 billion. Reductions in the overall cost of the drugs that we supply to our 2 million customers, or 3.8 million if we take the other schemes into account, have been in the order of €1 billion. That has resulted from new and changing supply arrangements with the industry, the proprietary manufacturers and the generic industry. It has come from efforts to reduce individual prices and negotiations with individual companies. It has been pushed further with the introduction of the legislation this year to push out reference pricing and where there is a generic equivalent the total drugs bill is approximately €400 million. We aim to take €50 million out of half of it by the middle of next year. That will push on next year and the year after.

Deputy Áine Collins

On a personal note, I have a child with a long-term illness who requires a drug called Creon. When we go on holidays we have had to buy it because we forgot to bring it with us. The State provides the drug here. We paid, I think, €8 in Portugal. I have sometimes bought it here because things happen when one is moving around, and it cost €28, for the same quantity of the drug, approximately 100 capsules. That happened in the past two years. There is obviously some work still to be done.

Mr. Tony O'Brien

We have just moved, following legislation, to a reference pricing environment. The first drug has been subject to reference pricing as a result of which it is priced at 70% less than previously. That is a first step. We intend to do significantly more of that on a progressive basis. It is interesting to note that, despite reducing the price for a particular manufacturer in effect by 70% it is still sufficiently interested in the market to put full page advertisements in the newspapers to encourage people to continue taking its product at the 30% rate. We think that there is significant scope in that area and that is why we are aiming for a €50 million budget cut in that area for the coming year.

Deputy Áine Collins

Is that for the coming year?

Mr. Tony O'Brien

Yes.

Dr. Ambrose McLoughlin

The Minister was particularly keen to see a medicines management programme established. It is the first time in the history of the State that we have invited experts to work with GPs, other medical practitioners and other prescribers, to prescribe the most cost-effective option for a patient. I believe that in the next year or two we will see significant benefits accruing from this change. I particularly want to thank Professor Michael Barry from the pharmacoeconomics unit in Trinity College who is leading this initiative.

At the end of the day we want to ensure that patients get the most appropriate and the right medicine, in the right dose at the right time. This medicines management programme is particularly important in achieving our objectives.

Deputy Áine Collins

Good. I welcome that. I have a question for Mr. Byrne whom I congratulate on his new position. I see that there is a request to the Department of Public Expenditure and Reform in respect of a new financial management system within the HSE. What will it cost? What will be its benefit? Will there be real-time information? The public struggles to get accurate information on costings and so on and they seem to change. Will this be part of a new, connected health initiative?

Mr. Tom Byrne

We all look to everything to be a panacea for all problems. Something that is often missed in discussion of the accounts of the HSE is that we receive a clean audit annually. It was part of my comment, and the Comptroller and Auditor General has commented, that the accounts systems are not fit for purpose. I would say that refers to the purpose for which they are intended in the future. We have a disparate system, formerly four health boards, a number of systems, applications and products, SAP, systems across the country and we do not have a common chart of accounts. It will not be an easy task to develop the new financial model as I know coming from a base of some experience in this area. It will start with very simple facts, a common chart of accounts and rolling out an integrated system of finance across the health service. We do not know the costs involved at this stage. The initial tender has gone out. PA Consulting has been appointed to carry out the work on delivering the business case which we would hope to have ready in quarter one for issue to tender for support and delivery of this system.

I come to this with some past experience. It is not an easy task but it is absolutely essential for the health service. It will start with the simple fact of systemising the accounts and bringing them all to one truth, as we like to say. It is a difficult move because there are approximately 15 different systems across the country. In response to your comment about administration staff, it is important as well to take into consideration the back office issues, 60% of my finance team produce information and that should be down at 20% or 30%. That is necessary because with the systems we have we report in different formats, by region, care group etc. The process has started. We are working with PA Consulting to develop the business case to go to tender for delivery of this.

Deputy Áine Collins

What is the timescale?

Mr. Tom Byrne

I imagine this will be a three-year project but we will commence it in quarter one. That is the initial target.

Deputy Áine Collins

I welcome that. It is long overdue to judge by what we see in regard to accuracy and so on.

On a separate issue, in my constituency there is an area where service providers whose budget was cut have to manage an increase in salary. That means in real terms they are cut by 3% or 4% because they have to comply with the Haddington Road or Croke Park agreements, or whatever the case may be. This is having a huge effect on the ground. I have come across a real problem in respect of personal assistance for pre-school providers and have gone around the block on it. I thought the Department of Social Protection looked after this, or the Department of Children and Youth Affairs but I understand that the HSE does. To get a personal assistant depends on what county I am in and who the provider is. I know of three cases where four-year-olds who have serious physical disabilities are not being granted personal assistants.

Yet, if they lived in another part of the country, there would be no problem. By centralising the issuing of medical cards and discretionary medical cards at least we will have a fairer system. This is a huge issue. For these parents and these children next year is no good to them. While the HSE and the service-provider might be fighting over budgets and politics might be involved, that is no good to these four year-olds. I am struggling to get an answer to this and it is being raised as a Topical Issue matter in the Chamber today. There seems to be no one in charge or from what I can see, there seems to be no standardisation. I ask the witnesses to come back to me as a matter of urgency if they do not have an answer today.

Mr. Tony O'Brien

I cannot give the Deputy a detailed answer with regard to that particular case, but I can say that for the first time in the health system we now have a national director for social care which includes disability. I will ask my colleague, Pat Healy, to make contact with the Deputy to establish the situation to which she refers.

Deputy Áine Collins

I have already been in contact with the directorate in Cork and the manager of the department. The issue has been going back and forth since last September and we have not got any further.

Chairman

I ask Mr. O'Brien to give the committee a note on this matter.

Mr. Tony O'Brien

Yes, I will do that.

Deputy Áine Collins

Thank you, Chairman. I would appreciate that.

Chairman

I call Deputy Shane Ross.

Deputy Shane Ross

With your permission, Chairman, I will give way to my comrade Deputy Dowds because he is in a hurry to go to the Chamber.

Deputy Robert Dowds

I am due to speak on the Local Government Bill in the Chamber. I have one question about discretionary medical cards. I note that approximately 5.5% of medical cards are awarded on a discretionary basis. Mr. O'Brien gave some explanation as to how the HSE decides on discretionary cards. This issue was raised at my party's parliamentary party meeting and there was considerable anger expressed by certain Deputies over the fact that those decisions on discretionary medical cards were not made locally because at a local level people can be much more aware of the actual situation of the individuals and families concerned. A further note of anger which I want to convey to the witnesses is that when dealing with the office in Finglas which makes the decisions, it is not possible to deal with the same person when discussing an ongoing case. It would be much more satisfactory if the process is being administered centrally that at least one was able to deal with the same person on any subsequent discussion. This is part of the same issue. Could such decisions be made at local level? If they have to be made at central level, could one at least be able to deal with the same person rather than have to deal with different people all the time? One of the problems of centralising everything is that the patient is faceless. That is one of the biggest problems with public service and the Civil Service, that if one is not dealing with people on a face-to-face basis, it is very easy to forget that they are human beings.

Mr. John Hennessy

I will answer that question and Mr. Patrick Burke will also contribute. We have been listening very carefully to the feedback over the past number of weeks about the controversy about medical cards. One of the important messages coming through is that while there are significant strengths in a centralised system, with help lines and customer service, it still poses a difficulty for a significant number of people who would prefer to deal face-to-face with the health service. For that reason and as part of our current initiative we intend to strengthen the information and support available at local health centres and to provide an opportunity for people to be able to walk in and to discuss any problem with the application or with the application of discretion. That point is acknowledged and has been taken on board that we need a better blend between the advantages of a centralised system and the level of support, information and assistance available at local health centres. We will be working to ensure that balance is better.

Deputy Robert Dowds

Is it possible to provide a timescale?

Mr. John Hennessy

It will not take an undue amount of time in that we have a good infrastructure of local health centres. We want to ensure that a consistent approach is adopted across the entire country on this matter. There will be a need for a degree of training for staff. I will not say it will be weeks because it may take some months.

Deputy Robert Dowds

I ask Mr. Hennessy to send me a note, please, because it would be useful for clarification. I also ask Mr. Burke to send me a note about the central office.

Mr. John Hennessy

I am happy to do so.

Mr. Patrick Burke

One of the weaknesses in the distributed system was that we had circumstances where an individual could handle an application from cradle to grave. We are trying to ensure that we have a single system in place so that the patient should be getting the same answer irrespective of who is dealing with them. We have a new head of customer service and a new customer service department and this section can escalate particular issues if required. As Mr. Hennessy said, we have a wider communications plan to continually make people aware of what other schemes are in place and what they need to do when filling out paperwork. We also aim to provide a standard customer service to everyone. I am not sure that it will be possible for the same individual to deal with the same query every day. We should be able to deal with any patient or client who comes to us in a consistent and standardised way. Our training will be aimed at such an outcome.

Deputy Robert Dowds

These frustrations are expressed by Deputies and I can imagine it is much more difficult for ordinary members of the public. I ask if the HSE would try to allow for a situation where one can deal with the same person about the same case - I do not mean always dealing with that person for all cases.

Mr. Patrick Burke

I agree there must be balance. However, it must be recognised that in the past 12 months the HSE has handled nearly half a million calls and the vast majority are dealt with satisfactorily and closed off.

Deputy Robert Dowds

I am talking about difficult cases.

Mr. Patrick Burke

I accept that point.

Deputy Robert Dowds

If Mr. Burke accepts the point, does that mean he will ensure that one can talk to the same person about the same difficult case?

Mr. Patrick Burke

I have already said that difficult cases will be escalated through our customer service department and dealt with by named individuals.

Chairman

That is the best that can be done, Deputy Dowds.

Deputy Shane Ross

I was absent for much of the meeting. I apologise if my questions have already been asked by other members. I was struck with the extraordinary increase of 74% since 2005. The HSE marched everyone up to the top of the hill and gave them these cards and now it is telling them that the number of medical cards must be reduced. Is that a difficult decision for the HSE?

Mr. Tony O'Brien

We are not saying we have to reduce the number; we are saying we have to ensure that all those who have a card or are going to retain the card continue to be eligible for it.

Deputy Shane Ross

Is it not the case that this will reduce the number?

Mr. Tony O'Brien

It will produce a number but we do not have a target number. The Deputy's question almost implies that we had a specific target. What we are doing is applying the rules that exist. Clearly it is a difficulty, more so for the individuals than it is for us, if a card which a person has come to depend on is removed by reason of his or her loss of eligibility for it.

Deputy Shane Ross

I understand that point. The figure of 74% is staggering. I apologise if Mr. O'Brien has answered this question earlier. What percentage of applications are refused?

Mr. Patrick Burke

I do not have that information with me but I can find out.

Deputy Shane Ross

That information is extremely important. Can the witnesses provide any idea?

Mr. John Hennessy

I can give the Deputy an indication of how many are refused on renewal. That number is between 2% and 3%. They are refused on means grounds-----

Deputy Shane Ross

Between 2% and 3% only are refused?

Mr. John Hennessy

Yes.

Deputy Shane Ross

Is that on renewal or on first application?

Mr. John Hennessy

That is a refusal of renewal on means grounds. Quite a number of others lose their cards for various other reasons such as they do not choose to renew, they have left the area or circumstances have changed and they decide not to proceed. The cards are cancelled for those reasons.

That is probably around the number one would expect in that for a large number of medical card holders circumstances do not change.

Deputy Shane Ross

What percentage are refused on their initial applications?

Mr. John Hennessy

We deal with approximately 120,000 new applications per annum. We will have to get that figure.

Deputy Shane Ross

Do the delegates have no idea? They have given me a renewal figure of approximately 2% or 3%.

Mr. Patrick Burke

There are multiple channels for people to apply. An individual can fill in an application form and send it in, it is assessed and they are deemed ineligible. I can find that number out.

Deputy Shane Ross

Do the delegates not have that number here? It is so important. Have they no idea?

Mr. John Hennessy

It would be higher than 3% but we can get a number for Deputy Ross.

Deputy Shane Ross

It is staggering that they do not have it. How many are passed and how many are not is very important in the administration of how this works. Nobody can tell me that. Neither the Department of Health, the Department of Public Expenditure and Reform nor the HSE can tell me what percentage are refused.

Mr. Tony O'Brien

We can tell Deputy Ross, we just cannot tell him now.

Deputy Shane Ross

Yes, but there are seven delegates here. I thought one of them would have the answer.

Mr. Tony O'Brien

Well, we do not. We can get it today.

Deputy Shane Ross

What percentage of refusals are appealed?

Mr. John Hennessy

Approximately 30%.

Deputy Shane Ross

How many of those get through on appeal?

Mr. John Hennessy

I have an idea but I would prefer to be precise. A significant number of appeals are successful.

Deputy Shane Ross

The majority?

Mr. John Hennessy

No, less than half.

Deputy Shane Ross

So we know 30% of refusals are appealed but an unknown number are successful.

Mr. John Hennessy

I have a figure in my head of approximately 20% of appeals being successful but I would prefer to give a more precise answer.

Deputy Shane Ross

Okay.

Mr. Patrick Burke

Somebody who appeals may bring more material to the appeal and that has to be reassessed so we need to be careful as we work through that.

Deputy Shane Ross

Fair enough. If the delegates could let us have the information on refusals promptly it would be useful.

Mr. John Hennessy

Sure.

Deputy Shane Ross

Politicians are involved in many of these representations to the Department. Do the witnesses know anything about how successful these representations from politicians are?

Mr. Patrick Burke

They are not successful in the sense that there is a process by which we assess eligibility and on foot of that assessment a person is eligible or not. A politician can ask about the progress of that assessment but there is no other influence on the assessment process.

Deputy Shane Ross

So improper pressure is never put on the HSE?

Mr. Patrick Burke

No.

Deputy Shane Ross

So a politician is just a filter, filling in the forms.

Mr. Patrick Burke

Absolutely, an advocate.

Deputy Shane Ross

Do the witnesses find that satisfactory.

Mr. Tony O'Brien

When counterposed against the alternative, that a person who would not otherwise be eligible becomes eligible because of a political representation. That would be unsatisfactory.

Deputy Shane Ross

So the witnesses think politicians representing people on medical card eligibility is okay?

Mr. Patrick Burke

They do no more than GPs and pharmacists do. We receive advocacy from the Irish Motor Neurone Disease Association, the Irish Cancer Society and individuals' relatives. Once an individual has made an application there is a concern about how quickly that will be dealt with. We receive representations from a number of areas asking about the status of applications. In the older system there were circumstances where an application was treated cradle to grave by one individual locally and they could be approached by anybody making representations. In the current system duties are separated. We have different people at post level and review level. We have data captured and put into a central engine. No one individual would have oversight of an application process from cradle to grave. Separate to that we have a call centre, customer support and a dedicated Oireachtas line. We receive representations from Oireachtas Members via that line and they ask about the status of applications, what an unsuccessful applicant should do next, whether they have missed something. They could be trying to help the individual.

Deputy Shane Ross

I think I heard a witness say the HSE would review 1 million cards. Is that not bureaucracy gone crackers? How many people will be involved in that?

Mr. Tony O'Brien

Approximately 200 people in total.

Deputy Shane Ross

There will be 200 personnel involved in reviewing medical cards full time?

Mr. Tony O'Brien

No, in the totality of the PCRS.

Deputy Shane Ross

How many people will be involved full time? Will it be 1 million reviews in a year?

Mr. Patrick Burke

Deputy Ross should bear in mind that we had a medical card assessment of eligibility in 100 locations with approximately 450 people. As we have centralised that we have provided the platform where we receive electronic feeds of data from Revenue. We also have access to social protection data. We are joining up government. As we go forward and talk about being able to conduct 1 million reviews next year, quite an amount of those will be reviews on the basis of information we have. We do not intend to review and ask 1 million people to provide us with chapter and verse. A risk assessment is done on the basis of the information flows we receive. As that system moves forward over the next number of years exactly the same will happen as our links with the Department of Social Welfare develop. We should be in a situation where we can provide an applicant with his or her health eligibility on foot of one assessment without asking that individual to provide information.

While the 1 million reviews would seem a challenge, over the past two years we have conducted more than 900,000 reviews. We are answering questions raised in this forum by the Comptroller and Auditor General. When we confer eligibility we confer a medical credit card. While it may be free for the individual who uses it, it incurs a cost to the taxpayer, and that cost could be €1,000 or €100,000. In exactly the same way as we want to ensure everyone who is eligible for a medical card receives one, we should be able on an annual or biannual basis be able to confirm that the person has eligibility to use a medical credit card at the taxpayer's expense.

Deputy Shane Ross

I understand all that. Could I return to the question? The HSE is a very large organisation which, apparently, dedicates a large number of staff to reviews of medical cards. Would that be fair?

Mr. John Hennessy

I am not sure that is quite fair in that we have fewer people working on this now than we had three years ago. One of the benefits of that central system is that it gives us capacity use automation and technology to do more with fewer people. The overall objective to which Mr. Burke refers is to maintain the accuracy of the GMS register. That is what we endeavour to do.

Deputy Shane Ross

I know what the Department is doing. How many person hours are involved per year? What does this massive exercise cost the HSE?

Mr. Patrick Burke

I have already made the point that as well as assessing eligibility-----

Deputy Shane Ross

I know, but what is the cost of it all?

Mr. Patrick Burke

The cost is approximately 1.02%.

Deputy Shane Ross

How much is that?

Mr. Patrick Burke

That is a percentage of €2.4 billion.

Deputy Shane Ross

How much?

Mr. Patrick Burke

We will do the arithmetic in a moment.

Mr. John Hennessy

We went from approximately 400 people processing medical cards to just over 200, who do it in a much more efficient-----

Deputy Shane Ross

I have had all that. What is the cost?

Mr. Patrick Burke

Approximately €20 million out of the-----

Deputy Shane Ross

It costs €20 million to review these?

Mr. Patrick Burke

No, it costs €20 million-----

Mr. Tony O'Brien

The total cost of the PCRS, which is the entity that contracts with service providers, issues the medical cards, and transacts all the reimbursements of €2.4 billion per year, is €20 million.

Mr. Patrick Burke

We process 80 million transaction items of service. The primary care contractors we have contracted with provide services to those 3.8 million clients.

The total cost of that service in terms of assessing people's eligibility for free or co-funded health services, managing the contracts with premier care contractors and reimbursing contractors for services provided is approximately €22 million or €23 million. That is out of an overall budget of €2.4 billion, so it is 1%.

Deputy Shane Ross

Is that per annum?

Mr. Patrick Burke

Correct.

Deputy Shane Ross

Has the amount varied during the past five or six years? Has it increased?

Mr. Patrick Burke

It has been in that space. The percentages during that period were 1.13%, 1.02%, 0.81%-----

Deputy Shane Ross

And a couple of hundred staff are employed to work on it full time.

Mr. Patrick Burke

The total complement for the function is 328.

Deputy Shane Ross

So those 328 people work on medical cards on a full-time basis.

Mr. Patrick Burke

No; they work on a full-time basis on assessing eligibility for medical cards and on reimbursing the 6,500 doctors, pharmacists, dentists and opticians for the 70 million items of service they provide to 3.8 million members of the population on an annual basis.

Mr. John Hennessy

The medical card scheme is one of 12 run by the PCRS.

Deputy Shane Ross

Okay, and a couple of hundred staff are employed to operate it. I did not realise there was an obligation on people to surrender their medical cards if their circumstances change.

Mr. Patrick Burke

Yes.

Mr. Tony O'Brien

There is a provision in the 1970 Act which governs that.

Deputy Shane Ross

Is it an offence not to surrender one's card if one's circumstances change?

Mr. Tony O'Brien

It is.

Deputy Shane Ross

How many people voluntarily surrender their medical cards under the provisions of the 1970 Act?

Mr. Patrick Burke

When the universal entitlement to a medical card for those over 70 ceased at the end of 2009, we wrote to all those involved. As I recall, some 12,000 people voluntarily surrendered their cards. Since then, small numbers have surrendered their cards. On foot of the correspondence we sent out in 2009, some 12,000 voluntarily surrendered their cards. In the interim, individuals have written to us and indicated that they believed they were no longer over the limit, but the numbers in this regard have been small.

Deputy Shane Ross

What action does the PCRS take in respect of people who have gone over the limit and who have not surrendered their medical cards?

Mr. Patrick Burke

When we confer eligibility on a person, he or she will remain eligible until his or her case is reviewed. We can review at any point in time or on a designated date. A person will remain eligible until his or her review date. When someone is found no longer to be eligible, his or her eligibility ceases.

Deputy Shane Ross

What is the position if a person has not voluntarily surrendered his or her card despite the fact that he or she exceeded the income threshold? Is the person committing an offence?

Mr. Tony O'Brien

The person would certainly be in breach of the 1970 legislation if he or she retained the card with criminal intent.

Deputy Shane Ross

Has anyone been prosecuted under that legislation?

Mr. Tony O'Brien

Not that we are aware of.

Deputy Shane Ross

Does the PCRS not report people who have exceeded the limit and who have not voluntarily surrendered their cards? What action does it take?

Mr. Patrick Burke

Could I do this-----

Deputy Shane Ross

Does Mr. Burke see where I am coming from?

Mr. Patrick Burke

Yes. When we centralised the processing of medical cards, we did so with the intention of having a more efficient, standardised system. We would have preferred to standardise the entire operation in the first instance, centralise it thereafter, deal with our clients and then introduce probity and controls. Unfortunately, there was such resistance to centralisation from every quarter that we decided to centralise first and standardise and apply probity as we proceeded. We all know the result of that, namely, that we were obliged to deal with the backlog that arose in the latter part of 2011 and early in 2012. As we move forward with the centralised operation, we have already built in links with the Revenue Commissioners and we are establishing them with the Department of Social Protection and general practitioners. The new system is much more amenable to control. As we communicate with our clients, we are seeking to ensure that they know what is expected of them. At the same time, we will start to develop a challenge to anyone who is identified as providing incorrect information or anything of that nature. A small number are referred to our solicitors in order to answer questions. The answer to the Deputy's question about whether anyone has been prosecuted is "No". This is a work in progress as we centralise the operation and begin to use its strengths.

Deputy Shane Ross

The PCRS identified a large number of people who went over the income limit over a period. It did so as a result of the reviews it carried out. The PCRS identified the individuals to whom I refer and informed them that they were no longer entitled to medical cards. Is that correct?

Mr. Patrick Burke

Yes.

Deputy Shane Ross

The people in question have been committing an offence.

Mr. John Hennessy

That is a fine point in the context of the legislation. Traditionally, the review process and the review date have been used as the control mechanism. The test for knowingly providing false information in order to claim an entitlement with criminal intent is a much higher test than that which would normally be employed here. In terms of a change in circumstances being picked up on renewal - perhaps due to a cardholder returning to work, for example - strictly speaking and under the provisions of the legislation, his or her card should have been returned. This tends not to happen too often.

Deputy Shane Ross

I know.

Mr. John Hennessy

Obviously, our systems pick it up as quickly as possible on renewal.

Deputy Shane Ross

But nothing happens after that. So the law is actually ignored.

Mr. John Hennessy

I would not say it is ignored. The test for criminal intent in terms of somebody knowingly making a false declaration, for example, in order to receive a State service would be much higher in nature.

Deputy Shane Ross

I cannot see the point of that. We all want those whose cases are worthy to receive their medical cards. Ninety-nine percent of those to whom I refer have worthy cases. Any of us in possession of a medical card whose income rose above the threshold might retain it in the hope that nobody would notice. That is probably quite natural. When someone is identified as having retained his or her card despite having exceeded the income limit, he or she is not charged with having committing a criminal offence under the law. I do not know whether the law is right or wrong in this regard, but nothing is being done. Is the PCRS not under an obligation to do something in respect of those who hold on to medical cards to which they are not entitled once it discovers that this is the case?

Mr. Tony O'Brien

If we had clear evidence that someone had set out, deliberately and with criminal intent, to falsely obtain a medical card by misrepresenting his or her means in the first instance and then retained it, we would have an obligation to do something about it. We are coming from a context in which we have a cultural issue to deal with.

Deputy Shane Ross

Sorry; what does the PCRS have to deal with?

Mr. Tony O'Brien

A cultural issue. It is manifestly clear that there is a commonly held belief that discretionary medical cards have been granted, should be granted or are granted in the context of the mere existence of a medical condition. This is a widely held perception which is only really being challenged now in terms of the public understanding of it. Indeed, this perception has been reflected to some extent during these proceedings. It also seems clear that there is a widely held misconception to the effect that because these cards - like credit cards - include an expiry date, once one qualified when one applied, one has an entitlement up to that expiry date. By means of the centralisation, standardisation and communications processes, we are clarifying what constitutes true eligibility. We were asked earlier about the cost-benefit balance and the amount of resources we invest. In circumstances in which we genuinely do not believe - unless a barn-door case appears - that there is any prospect of being able to prove that someone set out, with criminal intent, to falsely obtain a medical card, we do not take action. The resources we would be obliged to allocate in order to follow up every instance in which a person is identified as having held a medical card when it was clear that they should not have had one would be completely disproportionate to the benefit. Our resources are much better deployed in ensuring that medical cards are held appropriately. Where they are not so held, it is probably because someone has exceeded the threshold probably without even realising it. At that point, we end their eligibility.

As we move forward with the process and reach a point at which we expect that people should have a better understanding and at which we have communicated with them clearly, we will be seeking to do two things in circumstances in which we can prove retrospectively that someone has falsely obtained a medical card. The first of these is to ensure that the matter is referred to the appropriate authorities with regard to the offence committed, in respect of which there is a small fine. The second is that in the context of the greater amount of money involved - namely, the cost to the public purse through capitation fees, free entitlement to medications, etc. - in providing that medical card, we might well be in a position to consider taking civil action to recover that cost.

We do not believe that we have got to that point yet.

Deputy Shane Ross

Since the Act of 1974 - was that the year of the Act?

Mr. Tony O'Brien

It was 1970.

Deputy Shane Ross

Since the 1970 Act, the organisation has not done anything to anybody or has not referred the Act to anybody who was failed to volunteer in this respect.

Mr. Tony O'Brien

Would Mr. Patrick Burke like to take that question?

Mr. Patrick Burke

In fairness, if the Deputy wants to go back to 1970, he will find across those decades that there were times when individual health boards challenged individuals and referred things to the appropriate authorities. It would be unfair to-----

Deputy Shane Ross

Mr. Burke thinks they did.

Mr. Patrick Burke

Yes. I am satisfied that-----

Deputy Shane Ross

Has that happened recently in Mr. Burke's time in the organisation when many more medical cards have been issued?

Mr. Patrick Burke

No. I have said-----

Deputy Shane Ross

Okay. Mr. Burke might remind me of the number of cases of people who failed to hand up their medical card when they exceeded the income threshold.

Mr. John Hennessy

We will take that one away and put precise figures around it. I am aware that cases have been referred to the appropriate authorities.

Deputy Shane Ross

Can Mr. Hennessy give me figures on that?

Mr. John Hennessy

We will try to be more precise about that in terms of finding a number for the Deputy. It is probably fair to say that there is an awareness within our system of the issue to which the Deputy is alluding. We are refining the review process in fairly precise ways, with links to other State agencies, to sharpen the focus of reviewing. Links with the Department of Social Protection and Revenue are key to that. There is an awareness of the issue. Part of the plan for the PCRS includes a control unit that will focus on the problem of probity in its widest sense. That is not only in regard to applicants but with regard to the entire system from a probity point of view.

Deputy Shane Ross

Mr. Hennessy will see my point. There is no deterrent whatsoever. There is no incentive whatsoever for people to hand in their medical cards. There is no reason they should do so. There is none whatsoever. They are never prosecuted; nothing ever happens. If the officers catch them, they will hand it back. It is a one-way bet for them, is it not?

Mr. John Hennessy

I am not sure about that. There is a fine in place. It was originally £50 under the 1970 Health Act.

Deputy Shane Ross

It is never imposed.

Mr. John Hennessy

The review process tends to be the more productive one for us. The director general mentioned that our focus is on the accuracy of the GMS register. That ensures the people who need to be on it are on it and the people who are not entitled to be on it are removed. That, in essence, is what we are trying to do.

Deputy Shane Ross

I have one more question or perhaps one and a half. I want to ask about St. Michael's House but perhaps I could communicate with the witnesses about that after the meeting or at some other time. Would someone take a call from me about it?

Mr. Tony O'Brien

Of course.

Deputy Shane Ross

I thank the witnesses. That would be very useful.

Chairman

Was that the half question?

Deputy Shane Ross

That was the half question and the next one is the quarter one. Looking across, a number of men are seated behind the witnesses. Could the witnesses tell us who they are?

Dr. Ambrose McLoughlin

Mr. Howard is from the parliamentary affairs office.

Deputy Shane Ross

Yes.

Dr. Ambrose McLoughlin

Mr. Hempenstall is from the parliamentary affairs unit.

Mr. Tony O'Brien

Mr. Mitchell heads the parliamentary affairs unit.

Deputy Shane Ross

Of all the organisation.

Mr. Tony O'Brien

Of the HSE.

Deputy Shane Ross

I thought it would be useful to know who they are. Do the witnesses see something strange about the fact they are all men? Is health a no-go area for women?

Dr. Ambrose McLoughlin

Not at all. A majority of those on the management advisory committee of the Department of Health are women.

Deputy Shane Ross

It is just a coincidence there are ten men present today.

Chairman

You might vary it in future for Deputy Ross.

(Interruptions).

Mr. Tony O'Brien

In general, as the Chairman would understand, when Accounting Officers decide who they should bring, they bring the people with the relevant management experience for the particular subject. If we were dealing with a different subject, the Deputy would see a different composition.

Deputy Shane Ross

It is just a coincidence that this time-----

Mr. Tony O'Brien

It is a pure coincidence.

Deputy Shane Ross

That is fine. I am not a raving feminist but I see something uniform about all the witnesses.

Chairman

Dr. McLoughlin is the chairman of the HSE. He might give us his titles as he has a few of them.

Dr. Ambrose McLoughlin

No, I am the Secretary General of the Department of Health. I stepped down at the end of July from being chair of the HSE. A new directorate is in place as part of the reform programme.

Chairman

No, but Dr. McLoughlin was Secretary General.

Dr. Ambrose McLoughlin

Yes.

Chairman

What is Dr. McLoughlin's position from 1 January?

Dr. Ambrose McLoughlin

From 1 January the position will be that the director general will be the Accounting Officer. The Minister has indicated that he will be bringing legislation to transfer the Vote before the House. That legislation is ready and it will be published shortly, but it will be 1 January 2015 before the Vote will return to the Department and I will become the Accounting Officer for it.

Chairman

When will Dr. McLoughlin become the Accounting Officer?

Dr. Ambrose McLoughlin

On 1 January 2015.

Chairman

Mr. O'Brien will remain in place until then.

Dr. Ambrose McLoughlin

We need to work through a process of transfer. Since I came to the Department of Health we have been involved in significant reform of the financial management and control system. We want to ensure we dovetail that with new appropriate governance systems to ensure that when the Vote comes back to the Department of Health, the necessary support and expertise is in the Department to ensure we can do the job properly.

Chairman

Alongside the work Mr. O'Brien is undertaking, in terms of Dr. McLoughlin's role as Secretary General and bearing in mind that he will be the Accounting Officer in 2015, has he established from his point of view, looking in at the HSE from the Department and taking into consideration the plans for the future, the systems required to bring about greater efficiencies, transparency and accountability to this House? Can we expect considerable change or a gradual change over a period of years?

Dr. Ambrose McLoughlin

I decided as Secretary General to bring in Mark Ogden to undertake a review of the financial control systems in the health service in June 2012. That was followed up by intensive work involving a reform board, which was chaired by Tony O'Brien and on which I sit. This is to look at the total financial control and management system of the health system in all its aspects. The first significant change in that was the appointment of the chief financial officer, Thomas Byrne, to take over responsibility for the totality of the HSE budget. My Department has been actively and fully involved in the design of the new reform system which will ensure the appropriate controls and governance are in the Department of Health, the Health Service Executive and other agencies for which the Department will be accountable.

In respect of the Department, I have commissioned a reform of the Department of Health and there will be announcements in due course about the shape of that. I have been actively involved as Secretary General in the reform programme in ensuring the Department of Health has oversight of, say, the new hospital grouping structures and is actively and directly involved in, for example, the arrangements in respect of the children's hospital and other developments. I can assure the Chairman that we are very actively involved and I would be happy to give him details of that as he sees fit.

Chairman

Was "Ogden" the name Dr. McLoughlin mentioned?

Dr. Ambrose McLoughlin

The Ogden report. Mr. Mark Ogden was brought in.

Chairman

When was that report finished?

Dr. Ambrose McLoughlin

It was finished in June-July of 2012.

Chairman

What was the cost of that report?

Dr. Ambrose McLoughlin

It involved a minimal cost. It was done by an expert literally on a pro bono basis and he got nominal thousands for it. I sought the assistance of colleagues in the United Kingdom who had expertise in financial controls, so I brought him in to assist in the process.

Chairman

In relation to Mr. Byrne, were you recruited from outside?

Mr. Thomas Byrne

Yes. I was recruited from the private sector.

Chairman

The private sector.

Mr. Thomas Byrne

Yes.

Chairman

Is Mr. Byrne familiar with the application made to the Department of Public Expenditure and Reform in relation to the IT system?

Mr. Thomas Byrne

Yes, I am.

Chairman

My understanding from a meeting we had with the HSE in April was that this application was made around then. We are now heading into November and December and is it the case, Mr. O'Brien, that another ten days has been granted to do the plan?

Mr. Thomas Byrne

We have applied for that but, to my knowledge, it has not yet been granted.

Chairman

No, but the plan is being done and another number of days has been applied for. Is it ten days? Have you applied for ten days?

Mr. Thomas Byrne

We have applied for ten days but I do not know if they have yet been granted.

Chairman

In term of the expenditure for next year, there are 15 different cost centres and an application has been made to the Department. I questioned Mr. Watt when he was before the committee the last day and we asked for a response. It took him a considerable length of time to get together a paragraph to explain that there is a business plan being put together. Why has it taken all that time to get to the point where the Department of Public Expenditure and Reform has encouraged the HSE to introduce a single business coding system and so on and still it is not dealt with? The members find it frustrating that they cannot get answers on the analysis of various issues or problems that might arise and we are told it is down to the computer system, the 15 different centres and yet, as a big business, the HSE made an application to the Department of Public Expenditure and Reform sometime early this year and it is still not dealt with.

What is the reason for the delay when the people in the HSE accounts section - I do not say it is Mr. Byrne, but other people who were in place before him - assured us that a system had been identified which was not so much off-the-shelf but could be purchased and put into effect immediately?

Mr. Tony O'Brien

Some improvements are currently being made in terms of the SAP discussion we had earlier.

Chairman

I am asking specifically about this application.

Mr. Tony O'Brien

We established the financial reform board, which Dr. McLoughlin referenced, which includes representatives from the HSE, the Department of Health and the Department of Public Expenditure and Reform, DPER. That was supported with some external expertise and with Mr. Byrne once he was appointed. The purpose of that was to agree on a consensus basis the nature of the system we should be seeking from a business point of view, bearing in mind that the health system is about to go through substantial organisational change. In order to seek to ensure the best possible passage for our business case when it goes into DPER we felt it appropriate to have that level of discussion. The board concluded its considerations at the turn of September into October. Presentations were made to the relevant Ministers in the Department of Health to ensure that it aligned with their expectations of what would be required in the future and it was agreed at that point by the board that following the consultation the business case would be developed for formal submission to DPER, which is what is currently happening.

Chairman

Was the application this year not a formal submission?

Mr. Tony O'Brien

It was not the formal business case. It related to agreeing a process that would lead to a formal business case, which hopefully will gain the active support of DPER so that we can then procure it.

Chairman

As the manager of the HSE, what is the earliest date Mr. O'Brien would expect a decision to be made? We are tired of listening to the Department tell us that they do not have the systems in place. It is important for the HSE that the systems are in place.

Mr. Tony O'Brien

We expect to conclude the business case in early January and to then engage with and formally submit it to the chief information officer at the Department of Public Expenditure and Reform, which is the appropriate process. As one would expect, they will seek to interrogate and validate to ensure that they are satisfied that what we are seeking meets the business objectives and in accordance with their own processes they will then approve it in due course. We will then have to procure the system in accordance with public procurement requirements. As the chief financial officer has said, fully moving over to that system is probably a three-year project.

Chairman

Before I turn to the communications section, could Dr. McLoughlin indicate whether he will answer parliamentary questions when he becomes Accounting Officer in 2015 or will he refer them to the HSE?

Dr. Ambrose McLoughlin

I will answer the questions. Of course I will. I will be very happy to assist the Chairman. It will not be a problem.

Chairman

What about the parliamentary questions of the rest of my colleagues as well?

Dr. Ambrose McLoughlin

Of course, I would be delighted to respond.

Chairman

When we table parliamentary questions they are referred to the HSE.

Dr. Ambrose McLoughlin

We will deal with them in an appropriate way. If you are asking, Chairman, whether as Accounting Officer I will personally answer questions from the Chairman-----

Chairman

No, I refer to the system of parliamentary questions in the House. Currently, questions to the Department are referred to the HSE. One has to wait a long time before one gets some answers, in particular to urgent questions. The norm for parliamentary questions is that they are answered within three or four days. Will Dr. McLoughlin adopt such an approach or is that a policy matter?

Dr. Ambrose McLoughlin

To be clear, I will ensure the most effective response system is in place as it relates to the Vote and my role as Accounting Officer. If the questions are appropriate to the Department and its Minister of course I will advise the Minister and I will deal with the questions expeditiously. If the questions relate to service matters, of course we will have to engage with the HSE or other service providers on the matter.

Chairman

Will Dr. McLoughlin insist on the HSE delivering the information to him in a prompt fashion? I am trying to get a feel for the direction Dr. McLoughlin will take.

Dr. Ambrose McLoughlin

Mr. O'Brien and I work very closely together. All of the time we are trying to improve communications between the Department of Health, the HSE and the Oireachtas. We will do everything we can to ensure a quick and speedy response. We probably need to look at the communications systems on the ground between Deputies, Senators, the HSE and service providers. I came from another era when one had regular meetings and contacts with Deputies, Senators, county councillors and other local authority members. We were always in a position to help them. We should examine whether we could improve the communication across the political system with the health system in the coming years.

Chairman

On the communication about the medical card system, Dr. McLoughlin said 200 staff are involved in the processing of medical cards. Does that include the communications area? Dr. McLoughlin referred to a helpline and additional staff numbers for information campaigns. Are they over and above the 200 staff?

Mr. Tony O'Brien

The call centre itself operates on an outsourced basis not by directly employed personnel.

Chairman

When people ring to inquire about the medical card system are they ringing a call centre?

Mr. Tony O'Brien

Yes.

Chairman

The staff are appropriately trained for the purpose. What is the cost of the call centre?

Mr. Patrick Burke

I do not have the information but I can get it.

Chairman

The HSE has 200 staff employed on the processing of medical cards but there is an additional cost for the outsourcing of the communications element of the work.

Mr. Tony O'Brien

Other elements of communication are not outsourced. For example, the materials that are currently being produced are produced in-house.

Chairman

Could the HSE provide a note on the information in terms of cost and how the system operates?

Mr. Patrick Burke

It is still within the 1% of the overall cost for providing the service that I mentioned earlier.

Chairman

How many people have been trained to work in the call centre?

Mr. Patrick Burke

You will appreciate, Chairman, that when one has a call centre one might expand it and contract it as the need arises. We designed responses to particular levels of query. There could be a question such as where one gets a medical card. That is a level one question that could be answered or a person could be pointed to a website. As one goes deeper and someone starts to talk about their specific case that is something we would handle internally.

Chairman

I appreciate what Mr. Burke is explaining but how many people did the HSE train, regardless of the level of queries, for the call centre? That is what I want to know. What was the cost of the training and of running the call centre? They are important issues. I also want to know how much of the cost of the communication network, outsourced or not, has been factored into the budget for 2014. Mr. Burke said that some local health offices would be geared up to handle aspects of the medical card queries so we will have a local element back again. Has that been costed and how many staff will be in place? Could we have the cost of training, the cost of staff and where they might be located in the context of 2014?

Mr. John Hennessy

We could put a very concise report together for the Chairman on the information he seeks. The cost of the immediate communications exercise that has been taking place over the past three weeks is €150,000.

Chairman

For what?

Mr. John Hennessy

For the communication campaign that has been running for the past three weeks. The vast bulk of that has been absorbed by the cost of newspaper advertising. We consider that to be reasonable value given the level of concern and anxiety that existed and in the context of the overall cost of the GMS scheme at more than €2 billion.

Training for call centre staff is a continuous process. A training programme was already under way for those staff to accommodate the changes announced in the budget this year and to deal with the calls from the public concerning that. We were able to enhance that to deal with the anxiety and concern that was triggered by the controversy in the media in recent weeks. There are good reports on the activity of the call centre in terms of the type of calls, number of calls, algorithms used to deal with the calls and in particular the performance response times.

Chairman

Could we have all of the information?

Mr. John Hennessy

We can certainly share that with the committee.

As regards the training for our front-line staff in particular, we will be absorbing that within the organisation using people with expertise within the organisation and the structures already in place to roll that out in a consistent manner to our own front-line staff in local health centres.

Chairman

Regarding the medical cards, I welcome that the Health Service Executive is getting all these systems in place to analyse how it spends that much money on the medical cards and that in future it will be able to give us much more information. I welcome also that it is getting control of the vast bulk of the applications but if I filled the Gallery this morning with people who had their medical cards taken from them or who found out their medical cards were taken from them, they would not believe what they were hearing from Mr. Hennessy. There are cases which I do not want to go through one by one but rather I will give Mr. Hennessy two extreme examples, and they represent quite a number of people who have turned up at my clinic, and I am sure is the case elsewhere. The son of a 91 year old woman went to the chemist to get the medication and was told he could not have it because the medical card has been cut off. I have raised this with the HSE already.

The second case involved a woman undergoing cancer treatment for a second time who applied for a medical card but was turned down. The reason I raise that particular case is because Mr. Hennessy has done something else in regard to the medical cards. When someone applies for a medical card and is refused, he or she is entitled to a review or an appeal or may go for a review and automatically go to appeal subsequently. I have seen letters issued from the HSE telling people who asked for a review or an appeal that because they have offered no new evidence they will not be granted the review or appeal. That is quite different from what I have experienced with the system previously because in any decision the wrong decision may have been made.

I have attended meetings with general practitioners who have complained bitterly that they are being forced to write letter after letter to the HSE in support of an applicant who is entitled to the medical card but who for some reason is not getting their message across. Consultants who are now being asked for letters by patients to support their application are becoming annoyed that they are being drawn into a whole bureaucracy that they simply not cannot afford to manage in their day's work.

Has the HSE consulted with the GPs on this issue, the changes to the medical cards for children under five or GP cards because their complaints are that they are stressed by much of what is being imposed on them? I would like Mr. Hennessy's views on the review and appeal system. For those patients who are waiting for an application, a review or an appeal there should be a process in place whereby the card is kept open until such time as they are refused and are outside the system following a review or an appeal.

Mr. John Hennessy

I will reply briefly on that and I might ask Mr. Burke to take us through the detail on the process as well. I do not think it would be fair to talk to the particular examples but I can tell the Chairman with certainty that nobody is cut off without repeated notice and without getting the reasons that decision has been taken, and they are outlined in a schedule that accompanies the letter notifying the person; I think the general practitioner is notified as well.

Regarding rights of review and appeal, I am somewhat baffled by the letters the Chairman is citing but I would be happy to view them off-line with him because there is a standard right of review and a standard right of appeal, in a consistent manner, that accompanies all the correspondence. If there is some aberrant letter out there denying applicants or the public the right of review and appeal, I would be very interested in seeing it.

Chairman

It is not just one.

Mr. John Hennessy

Okay.

Mr. Patrick Burke

I will deal with the GPs and I might go over some ground again. As the director general has said, there is one medical card. As we assess an individual we may have to exercise discretion. In some circumstances we will have to involve our medical officers to look at medical or other circumstances that are being brought to bear. As our medical officers across the country looked at material presented to us on foot of an application we found absolute differences with people making applications. In terms of what we did, in some cases applicants would get a letter from their GP. We sought to standardise that. We engaged over a period of a year talking to general practice and the Irish Medical Organisation, IMO, about how we would have a standard form on which GP to GP could communication and set out tritely the type of information our medical officers would have to allow them assess eligibility. I have already said it was difficult to get that agreement from general practice because in some cases where an individual is looking for a medical card they may well be losing the private patient. We have pushed the point that we simply want general practitioners to help an individual work through their application.

We have sat down with GPs. We have put forward, as agreed by our medical panel, a standard form that could be communicated, not near administration but GP to GP, setting out the medical circumstances we want as an aid to the applicant in pursuing their application and having whatever discretion needed to be brought to bear. Those are the circumstances in that regard.

Regarding the schedule, we agree a schedule with an applicant. An applicant makes an application to us. We provide back a detail of what we believe to be their outgoings and their income, and we try to agree that schedule. I mentioned already that we have issued close to 1 million of those. In conversations with other TDs yesterday they made the point about making it more granular. We are making it more granular but it might be no harm if I read into the record the first or second paragraph of the letter that will go out to people today. This is where an individual has not been successful. It states:

Thank you for your recent application for a Medical Card/GP Visit Card.

I am enclosing a statement detailing your income and outgoings based on the information you have provided. This shows that your application is over the financial threshold set out ... This means that you and your dependants ... are not eligible for a Medical Card ... If you believe the statement is incorrect, please supply information to allow us to check this for you.

Your current Medical Card ... will continue until ...

We want to ensure that you continue to hold your Medical Card/GP Visit Card if you are eligible. To do this, we want to check with you if you have information that you did not send us that could make a difference.

Additional information you can provide

We wish to give you the opportunity to send additional relevant information ... The types of medical and or financial information we welcome include:

- A letter or report from the relevant GP or medical consultant.

I am skipping words, Chairman. I am simply trying to-----

Chairman

That is the letter that is going out now.

Mr. Patrick Burke

Yes. I can give the Chairman a copy.

Chairman

It is more helpful than what was there.

Mr. Patrick Burke

I can read the one that went out previously. It is the one that is on the production line, and it is not 100 miles away from that but I can get copies of that for the committee. They are there, and they are on the record.

As we work forward with it - it is a work in progress - we are, as Mr. Hennessy has already said, making sure that that communication is better and better. It is an ongoing exercise.

Chairman

I will finish on this because Deputies want to contribute. Regarding what Mr. McLoughlin said earlier about informing and educating people and upskilling the people in the call centres, it might be no harm if we were brought into the loop because we are the ones at the coalface dealing with some of the legitimate cases that are not being acknowledged for one reason or another in the HSE's medical card application system. While I have found many of the people we deal with very helpful, and some of them are here, we need to know much more in terms of the manner in which it is conducting its business to allow us at least relate to those making the applications.

I would also ask the witnesses to bear in mind the fact that many people to whom they are sending these letters, application forms, renewal forms and the random audit forms are elderly and do not have a clue what to do with them in some cases. They are going to citizens advice centres. They are coming to our clinics. Deputy Ross asked if we can influence them. All we are doing is offering them information and guidance but it is unfair to some that they are now allowed a good deal of time to submit the information and deal with it because they are elderly, sick or are waiting for a consultant's or a doctor's report in some cases.

Deputy John Deasy

As the witnesses have been in attendance for a long time, I will be brief. An article appeared a few weeks ago in a national newspaper about general practitioners claiming treatment fees for dead medical card holders. It referred to family doctors having claimed more than €1.5 million in taxpayers' money for treating medical card holders who were dead or who do not exist. According to the article, the aforementioned figure in overpayments was identified by the Health Service Executive, HSE, last year but not a cent has been repaid and a deadline of 31 October was set for doctors who received the overpayments. While this matter was touched on briefly earlier in this meeting, I wish to delve into a little further, because I tabled a parliamentary question on it to which, in fairness, I should note I received a reply within three days.

Chairman

The HSE was looking after it.

Deputy John Deasy

Can someone respond to that article? I am aware that in the meantime, for example, it has been denied that this is the case in The Medical Independent, in a certain fashion. The witnesses should tell me whether this is a problem and whether money is outstanding.

Mr. Patrick Burke

Absolutely. I would not read whoever wrote that again.

Deputy John Deasy

Right.

Mr. Patrick Burke

It is absolutely wrong.

Deputy John Deasy

It is stated in The Medical Independent that "no payments were made to GPs for deceased payments". I am simply clarifying this matter.

Mr. Patrick Burke

To clarify absolutely and as was discussed earlier, since we centralised, we have had an electronic link with the death events publication service. We are notified immediately of all deaths and eligibility ceases. If the notification is delayed and we have overpaid the GP, for argument's sake in the event that an individual passes away in April but the death events publication service does not tell us until September, we immediately recoup any gap in that regard. It is done automatically and there are no overpayments. That is one point.

Deputy John Deasy

Okay.

Mr. Patrick Burke

In the older system-----

Deputy John Deasy

Mr. Burke is saying that no moneys are outstanding in respect of overpayments.

Mr. Patrick Burke

There are no overpayments and there are no moneys outstanding because in the older system and with the Comptroller and Auditor General - I am unsure where one should leave the credit in this circumstance - we identified a number of overpayments going back over a number of years, in which individuals had passed away and their eligibility ceased long after the event and it was not recouped. We conducted a forensic examination of that, which came to a different sum than that mentioned and we recouped every cent. Consequently, there are no legacy overpayments.

Deputy John Deasy

Okay.

Mr. Patrick Burke

At the same time, GPs made arguments that they were entitled to some births and that their view of the contract from 1989 was that one balanced out the other. In fact, they were not too far off the pace but we dealt with both births and deaths. There are no overpayments, no legacy overpayments, no overpayments outstanding today and none to be collected.

Deputy John Deasy

Okay. In the reply to the parliamentary question I tabled, it was stated:

GPs can update the database to reflect the death of patients on their GP list. In 2012, GPs made 4,400 such amendments and in all of these cases payments to the GP are ceased immediately.

Mr. Patrick Burke

Correct.

Deputy John Deasy

Mr. Burke is telling me the HSE has got back all overpayments to GPs in respect of deceased medical card holders and that it has not found payments that have not been made in respect of deceased medical card holders.

Mr. Patrick Burke

Correct.

Deputy John Deasy

Does the HSE consider the system to be clean at this point?

Mr. Patrick Burke

Yes.

Deputy John Deasy

It deserved-----

Mr. Patrick Burke

In fairness, GPs step in when they know of a death. They have the functionality to register the death on the system to stop the calculation.

Deputy John Deasy

This issue deserved clarification today because an article appeared a few weeks ago in a national newspaper stating that this was occurring. Regardless of that, when I read The Medical Independent, it still was not clear to me. When I tabled a parliamentary question in the Dáil, I thought the issue deserved a response. However, Mr. Burke now has clarified it and that is fair enough.

Chairman

That brings us to the end of the meeting. Is it agreed to dispose of Chapter 22 of the 2012 report of the Comptroller and Auditor General? Agreed. I thank the witnesses for their attendance.

The witnesses withdrew.

The committee adjourned at 2.15 p.m. until 10 a.m. on Thursday, 21 November 2013.