Deputy O'Connell received permission to raise on the Adjournment the question of the proposed changes in the eligibility limits for medical cards following the removal of the food subsidies.
Adjournment Debate. - Medical Cards.
Is the Minister for Health not coming in?
I presume he is.
Could we wait until he comes in? It is not yet 8.30 p.m.
The question on the Adjournment should start the moment other business finishes. We will wait a minute for the Minister.
I would like the Minister's presence, not his gifts.
Tá sé ag teacht.
I sought permission to raise this matter on the Adjournment because I consider it to be quite an important issue. I asked the Minister today if he was aware of the increasing hardship caused to literally thousands of people in Ireland as a result of the abolition of the food subsidies which lowered their standard of living. No provision was made for this in the eligibility limits for medical cards. The Minister did not quite grasp the significance of my question. Indeed, I got the distinct impression that he was astray on the whole issue. I will try now to explain to him, perhaps in simpler language, exactly what is happening.
The guidelines for eligibility for medical cards are rather constrictive and very stringent. In the calculation of whether a person is entitled to a medical card, as little as 70p or 80p outside those guidelines can render a person, or indeed a whole family, ineligible. The Minister may argue—and I daresay he will—that the hardship clause can be invoked in respect of those people outside the limit of eligibility for a medical card. That is grand in the mind of the Minister but, unfortunately, in the application of these guidelines that does not prevail. Certainly it does not prevail in the Eastern Health Board area, the largest area in the country, where people with an income of 70p or 80p above the limit are denied a medical card.
The hardship caused these people is incalculable. They must pay £3 to £5 for a surgery visit and up to £7 for a doctor's call to their house. This is especially true with regard to poorer families, families with a large number of children who, more than anyone, experience the greatest degree of hardship. As we know, in many large families there is constant sickness because of malnutrition, overcrowding and taking into account also that infectious illnesses are inclined to spread from one member of a family to another. I am not talking about drugs here. I am talking about family doctor visits, when a family can spend as much as £10 per week out of a normal working man's wage on medical care. That is a considerable amount to spend on medical care; and these are people just barely outside the limits of eligibility for a medical card.
The limits are unrealistic having regard to today's cost of living and the expenses that are not necessarily taken into account in the consumer price index. I do not think doctor's visits are included in that, and that is a very important item in any household. The stringent application of these guidelines is bad enough. But perhaps I may be permitted to digress for a moment to say it is a sham and farce to say that the chief executive officers meet and decide these guidelines. I know this for a positive fact, and no Minister for Health is going to stand up in this House and say with truth that the eight chief executive officers meet and decide the guidelines for eligibility for a medical card. I say that is a downright lie because I know it for a positive fact. The Minister for Health—not the present Minister—but a Minister for Health does this purposely to take the "flak" from him. He says that the chief executive officers go through the process of deciding what will be the limits. They do not; it is decided in the Department of Health. I know this for a positive fact, so I can say that without fear of contradiction.
It is wrong.
I am saying now and I am staking my reputation on it because I have had it checked and rechecked——
I am sorry the Deputy is wrong.
I am saying now——
If the Minister says something is not correct, his statement must be accepted, and that is that.
Then his predecessor's adviser is wrong, because that is the person from whom I got the information.
He misinformed the Deputy. I am sorry, but he did.
The chief executive officers go through the formality and that is all.
The Deputy said they did not meet.
Oh, they meet; I never doubted that.
An Leas Cheann-Comhairle
We should not make any charges against any person in the civil service, advisers or otherwise.
In case there is any misunderstanding about what I said, the chief executive officers do not decide this. They go through the formality but the decision is made by the Department of Health. That is what I am saying.
That is not correct.
The guidelines decided on 1 January this year for eligibility for medical cards afford a single person living alone £28 per week or, if it be a husband, wife and four children, £56.50 per week, and that is gross income before tax is paid. There is allowance given for outgoings such as rent, mortgage repayments in excess of £4 per week. They will allow also exceptional expenses necessarily incurred in travelling to and from work where this creates undue hardship. Could anything be more ambiguous than that, because the normal travelling expenses a man incurs travelling to and from work are not taken into consideration in deciding whether or not he is eligible.
Did the Deputy say that reasonable expenses travelling to and from work are not allowable?
I said the normal expenses are not, only when they create undue hardship. I will read it from the guidelines for eligibility for medical card as issued by the Eastern Health Board, Report No 1, 1979, which says exceptional expenses necessarily incurred in travelling to and from work where these create undue hardship. Therefore, it must be established that there is undue hardship and that the expenses are necessarily incurred. It is not a case of normal expenses; one must prove that they create undue hardship. I am trying to explain what kind of income entitles a person to a medical card. For example, a husband, wife and four dependant children with £56.50 gross per week get a medical card. Having regard to their expenses, I feel that is inadequate and places so many people just above that limit in considerable financial difficulty.
That is bad enough but it bears no relation to the realities of today's cost of living. These guidelines will not be revised until 1 January 1980. That has been established by the Minister. He says it would be impractical to revise the guidelines at frequent intervals to take account of movements in the consumer price index. I do not know how impractical it would be if these eight great men were to meet just twice a year instead of once. If the Minister says they go through this process of deciding the income limits for eligibility for a medical card, why could not they do it twice a year instead of once?
I did not say anything about twice a year. I said at frequent intervals. I would not regard twice a year as being frequent.
No, I am saying twice a year. I am asking that it be revised to twice a year to take account of movement in the consumer price index in the preceding six months. Indeed, it was done up to a few years ago.
It was done on one occasion, twice in the one year, because there was rampant inflation under the Coalition Government.
But my point today is this. Since the guidelines were established the food subsidies were abolished. I am saying that as a result a different situation prevails today than when those guidelines were decided. It is a completely different ball game now. As a result there has been a drop in people's living standards. Their money is not buying as much as it did before the food subsidies were abolished. That is simple and clear and I do not think the Minister would argue that point with me. The new guidelines did not take this into consideration. I am not arguing with the Minister. I am saying merely that perhaps he overlooked it. I am endeavouring to bring it to his attention and asking him if he would give me a promise that these guidelines would be revised because a special situation has developed that was not taken into consideration when these eight men met to decide the guidelines that would come into effect on 1 January last. As the Minister knows, if they go through this process and if they say and do what the Minister says they do, it is obvious that they met in November. Indeed, they could have met in October. What is apparent to me and is apparent to the number of people who have been deprived of a medical card as a result of this—and there are thousands involved—is the drop in the number of people receiving medical cards. That has been established. There is an announcement to that affect.
A special situation has arisen here. It is not the normal type of situation and the Minister should be flexible enough to admit that it has happened. That is all I am asking the Minister to do. It is an unusual situation in that the food subsidies were not taken into consideration. In normal circumstances we cannot correct it until 1 January 1980. That is a long time to wait. The Minister should take into account the large number of people who have been deprived of a medical card and who for 12 months will suffer hardship as a result. This is an intolerable situation and the Minister has an obligation to do something about it. As he said today, he will be providing some recompense for some people in the social welfare field. But there are those just outside the medical card range and they are already suffering hardship. They are borderline cases and there are quite a few thousand of them in the country. I feel it would not be asking too much of the Minister to establish new guidelines to operate from 1 April and arrange for this to be done at six-monthly intervals thereafter. The Minister would not be bowing to any vested interest in doing that. The Government were able to bow to the farmers, so surely it would be a nice gesture on the part of the Minister and the Government if they were, for a change, to show a little concern for the underprivileged and the disadvantaged in our society.
I support Deputy O'Connell in bringing this very important matter to the notice of the Minister for Health.
I should like to deal with another aspect of this, and that is the situation of small farmers, particularly in the west. I should like to bring to the Minister's notice that not alone has the small farmer suffered from the abolition of food subsidies but will also suffer from 1 April because of changes in the multiplier system. It is not clear to me how small farmers are assessed for medical cards. I would suggest that the Minister bring in something along the lines of the multiplier, as he is doing at present for assistance, in order to make them eligible for medical cards. The Minister knows as well as I do that small farmers, with perhaps three or four cows and three or four calves, and who are married, are at present not eligible. Nobody has defined how a person living on a small farm is assessed for eligibility for a medical card. Is the number of hens taken into consideration or the number of bog acres he has, or is it based on the number of pigs he has? The position is that there is no guideline so far as the small farmers are concerned. I would appreciate if the Minister could tell this House exactly how the CEOs assess the income of these people.
Deputy O'Connell raised a number of points. First of all, I want to deal with the question of the information he has apparently received about the determination of the guidelines. I want to state categorically that the guidelines are decided by the CEOs meeting together and it is their decision. I do not know what happened in the time of my predecessor, but I believe it was the same in those days because statutorily this is a function of the CEOs. The chief executive officer of the health board is the person on whom this function is placed by statute. CEOs came together in pursuance of that statutory obligation and settle the guidelines.
By coincidence I had a prearranged meeting with the CEOs today to discuss other matters but I availed of the opportunity to discuss this aspect with them.
Hear, hear.
I specifically discussed with them something often said in this House: that the hardship provisions in the Health Act with regard to medical cards are not realistic and that they are never applied. The CEOs assured me today that they are. There is a very positive approach to the hardship provisions and they exercise the discretion which is given to them by the Health Act in so far as cases of exceptional hardship are concerned.
Let us come for a moment to the food subsidies. I said, by way of reply in the Dáil, that it would be quite impractical to change the guidelines and to operate and implement adjusted guidelines at frequent intervals. I meant frequent intervals. The guidelines were changed on 1 January. If we were to change them again now, that would be a frequent interval. I do not think it would be impractical to change the guidelines twice in one year, but that is about as much as we can do. Let us not forget that it is not just a question of taking a decision to change the level of income; it is a question of giving out more medical cards. It is a major administrative operation to review the issue of medical cards to the 40 per cent of our population who are covered by medical cards, so it is not something we can do every month. It was done once because inflation was up at around 20 per cent and over 20 per cent and the situation was so acute that it was deemed necessary by the CEOs, in the pursuance of their statutory duty, to revise the guidelines twice in the one year.
The effect of the removal of the food subsidies on the guidelines, if we were to give full effect to them at this stage, would be very small. I have had a calculation done and, in the case of a married couple for instance, if we were to increase the guidelines by the extent of the change in food prices by the removal of food subsidies, it would increase that £40.50 to £40.78—that is, 28p. From my discussions with the CEOs on this matter I know that an amount of 20p or 30p would be involved already in rounding up the figures.
Can the Minister give the figure in respect of a husband, wife and four children?
In the case of a husband and wife the increase would be 28p and it would be 3p in the case of each child. In deciding on the levels, the CEOs, having made their calculations, would round up the figures at the various levels. A figure may have been calculated at, say, £40.10 or £40.20 but may be round up to £40.50. Therefore, I do not think that there is established a case for changing the guidelines and all that involves in respect of these rather small increases—and they are small when measured.
The food subsidies' impact is not really related to medical cards in the way suggested by Deputy O'Connell. It is related more to social welfare benefit and income levels. The food subsidies real impact is on social welfare recipients and on lower-paid workers. The right way of correcting any disadvantage and any hardship which might be caused by the changes in relation to the food subsidies would be through those mechanisms and to that extent I suggest we have done reasonably well. I misunderstood what Deputy O'Connell was saying today. I thought that one of his arguments was that we were increasing social welfare benefits to counteract the removal of food subsidies and that those increased levels of social welfare benefits would take people outside the guidelines. I am assured by the CEOs that this will not happen. They tell me that in 70 per cent of the cases income is not taken into account, that 70 per cent of cases are on the basis of categories or groups.
But what about the other 30 per cent?
They told me that they could not visualise in any of their jurisdictions any case in which an increase in social welfare benefit would deprive someone of a medical card.
What is the position in relation to the 30 per cent?
They are included. The vast majority would not be affected by the guidelines because these are on the basis of categories such as single people and so on. The CEOs assured me that, from their intimate knowledge of the workings of the scheme, they could not visualise a situation in which an increase in social welfare benefits would affect medical card holders to the extent of depriving them of their medical cards. But the matter having been brought to their attention they are now alerted to it and will take it into account in their administration of the scheme.
I also discussed fully with the CEOs the question of hardship and they assured me that they operate the hardship clause in many cases. I stressed the need for the operation of this clause. It is available and should be availed of where necessary.
Is the Minister aware that 70p more than the guideline will have the effect of depriving people of medical cards?
I am not so aware, but if the Deputy is aware that this is happening I can only tell him that it should not happen.
Would the Minister be prepared to phone the health boards tomorrow on this matter?
Today, as I was meeting the CEOs about a totally different matter, I raised this question and we ranged over the whole area of medical cards. They are fully aware of my anxiety to ensure that in any borderline case the benefit of the doubt is given to the individual.
Up to what amount?
One cannot be inflexible in these matters.
Would there be flexibility to the extent of, say, £2?
Perhaps that would be going too far, but the Deputy must not cross-question me in this way.
Deputy O'Connell has had his opportunity and he must not take from the Minister's time.
The CEOs and I understand each other on this matter. They assure me that they are prepared and willing to operate the hardship clause where this appears necessary. They know that in marginal cases the benefit of the doubt should be given to the individual.
I shall let the Minister have details of some cases I am aware of.
The CEOs asked that the guidelines should not be revised again because of the comparatively small implications of the change in food subsidies.
But small amounts are important to the people concerned. I shall inundate the Minister's Department with such cases.
If there were a major change in the cost of living index there would be an unanswerable case for a change in the guidelines once, or even twice in the year if necessary, but to do more than that would create a lot of confusion in the administration of the system.
The Dáil adjourned at 9.00 p.m. until 10.30 a.m. on Thursday, 1 March 1979.