I will call on the Deputies who tabled questions to the Minister for Health and Children in the order in which they submitted their questions to my office.
Private Notice Questions. - Medical Card Cover.
asked the Minister for Health and Children to make a statement on his decision to deny people on low income the medical card.
asked the Minister for Health and Children if he will make a statement on his decision to deny those on low income the medical card.
asked the Minister for Health and Children if he will make a statement on his decision to deny those on low income the medical card.
(Dublin West) asked the Minister for Health and Children if he will make a statement on his delay in the implementation of the extension of medical card cover to many low income and vulnerable people.
asked the Minister for Health and Children if his attention has been drawn to the grave concern expressed by the Society of Saint Vincent de Paul and others regarding serious implications for people on low incomes of the announcement by the Minister for Health and Children that there will be no increase in income eligibility for medical cards for 2002; if the Government will urgently review this decision and if he will make a statement on the matter.
asked the Minister for Health and Children to address the issues raised by his announcement that there will be a delay in extending the medical card entitlement to the most vulnerable people in our society and the need for this decision to be immediately reviewed and reversed.
The issue of eligibility was considered in the context of the new national health strategy launched by the Government earlier this week. The strategy outlines a number of measures designed to improve eligibility for health services which the Government has committed itself to introducing over a number of years. Among the measures proposed is an increase in access to medical cards. In addition to the recent extension of eligibility to all persons aged 70 years and over the strategy includes a commitment that significant improvements will be made in the income guidelines in order to increase the number of persons on low incomes who are eligible for a medical card and to give priority to families with children and particularly children with a disability. The estimated cost of giving medical cards to all is about £800 million.
Our first priority is the reduction of waiting lists, services for people with disabilities and for older people and also to ensure that those who had eligibility can actually gain access to the services to which they are entitled. In the broader context, the strategy emphasises fairness and the objective of reducing health inequalities in our society. A whole series of initiatives are outlined to clarify and expand the existing arrangements for eligibility for health services. Shorter waiting times for public patients is prioritised as a fundamental issue of equity. There will be expansion of bed numbers and the introduction of a treatment purchase fund. In addition there are clear commitments to targeting vulnerable and disadvantaged groups including continued investment in services for people with disabilities and older people. There will be initiatives to improve the health of Travellers, homeless people, drug mis-users, asylum seekers, refugees and prisoners.
Implementation of the national anti-poverty targets relating to health have been agreed with the working party and are contained in the health strategy. Access to primary care services is of crucial concern to the Government as is shown in the new primary care model that was so well received yesterday. There are many services that are now not as available as we would like and this model seeks to address the problem by putting in place co-ordinated, integrated one-stop-shops for services that will be of particular benefit to older people and medical card holders.
The first step will be the further development of 24 hour, seven day GP co-operatives. This will be supported by the immediate establishment of a primary care task force to help drive the roll-out of the new model. The emphasis will be on putting together primary care teams which can effectively meet the needs of patients and clients. Patients will have the option of enrolling with these teams and with an individual general practitioner, if they so wish. They will also be able to self-refer to any member of the team. I believe this model offers the way forward in terms of primary care and it will change utterly the way in which we deliver primary care services and will also be hugely important in helping to streamline the delivery of patients and clients to more specialised services both within and beyond the community setting.
The Government's record on improving services to older people in particular is second to none. This morning reference was made to the issue of social inclusion and social equity. Last July the medical card was extended to everybody over the age of 70. This extension is wholly consistent with the Government's policy towards improving the position of the elderly generally in society. It is a logical consequence of the three year phased doubling of income limits initiated in March 1999. In addition to that, the Government has stood over unprecedented increases in rates of payment for people relying on social welfare. This is much greater than anything the parties opposite ever even attempted.
At £850 million, the package of social welfare improvements for 2001 is the biggest ever, and more than double the previous year's welfare package. The significant social welfare improvements which we have made amount to over £1.8 billion since the Government came to office. The value of the child benefit scheme, for example, is an effective mechanism for the provision of child income support and that is reflected in the substantial investment which the Government has made in the scheme. Before we came to office expenditure on child care was £397 million annually. Our first three budgets increased this to £575 million, an increase of more than 40%. Last year's increase of £25 and £30 per month in respect of child benefit rates represents a further full year investment in the scheme of approximately £330 million. Some 530,000 families with more than one million children will have benefited directly from the increases.
In 2002 the Government's priorities for improving the health system will be the provision of 650 additional acute hospital beds, addressing waiting lists through a new treatment purchase fund in addition to existing funding in the Estimates. We will also commence implementation of the new model of primary care, ongoing services for people with a disability and services for older people.
The Government's record in relation to people on low income is excellent and I am proud to be part of it. The national anti-poverty strategy is the Government's major vehicle for addressing the needs of people in poverty who are experiencing social exclusion. Although health and health targets were not included in the original anti-poverty strategy published in 1997, my Department has been involved in setting and reviewing annual work plans for the national anti-poverty strategy. Recently the Government gave a commitment in the PPF to review the strategy across all Departments and to develop NAPS targets in the health area within an associated monitoring and implementation framework. In late 2000 the Department established a working group on NAPS and health which included the social partners and the Combat Poverty Agency and sought the assistance of the Institute of Public Health with the research and consultation aspects of the exercise.
Will the Chairman tell me how much time I have left?
The Minister has until 4.45 p.m. Other Members have questions to ask during that time.
We have questions to ask.
I would say the Minister has about 12 weeks.
Acting Chairman
The debate has to finish at 4.45 p.m.
With respect, I came from a committee to this debate. I do not intend to read the entire reply. I will take questions.
The Minister is not even answering the question.
A Deputy
Let us get on with the real business.
This is real business as well.
Is the Minister entering it for the Booker prize?
Does the Minister agree that the means announcement made yesterday, two days after the launch with grandiose fanfare of the so-called health strategy called Quality and Fairness, nails the lie to that title as it implies that the so-called Government health strategy is one of inequality and unfairness? Will the Minister tell the House why, in his announced figure of £10 billion to be spent on the health service over the next ten years, he could not find some money to increase the income limit for medical cards for the poorest? Is the Minister aware that in the ESRI research for males aged 55 and over, the death rate among poorer people is three times higher than it is for those who are better off because they cannot afford to go to the doctor?
Is the Minister aware that individuals with an income of over £5,200 must continue to pay every time they visit their GP and that a couple with two children must pay if their income exceeds £9,386? Is the Minister aware that in a recent survey of male patients in their 50s conducted by Professor Tom O'Dowd of TCD, 25% of patients reported that either they or a member of their family put off going to the doctor because of cost? How can the Minister square that with a health strategy that is supposed to be about quality and fairness? The Minister has extended apartheid from the secondary system into the primary care area and that is outrageous.
I reject totally the assertions made by Deputy Mitchell. There is a political and electoral imperative on the Opposition parties to do everything they possibly can to undermine the health strategy. They appear to be willing to do this by whatever means they can.
That is a scandalous statement.
(Interruptions.)
Anyone who has witnessed the performance of Deputy Mitchell over recent days can only come to that conclusion.
That is unworthy of the Minister.
I did not interrupt Deputy Mitchell when he made his charge and I would appreciate if I could have the opportunity to make my point. Equity runs through everything in the health service—
There is an equality imperative.
Yes, there is, but it is right across the health service. People have to make choices and Ministers have to make choices in any one year in terms of how they prioritise and how they endeavour to tackle inequalities.
The people who cannot afford the hospital beds have no choice.
Having done much research on the health strategy, in terms of whatever previous Government's attempted to do and so on, the key point is that of access to beds in public hospitals. The prioritisation of the largest expansion ever in public hospital bed capacity will take place in 2002 because I have made that a priority. I have also prioritised issues pertaining to disabilities. The Opposition's record on disabilities in real terms of action and resources is shameful and dis graceful. They have some neck to come into the House and lecture me or anybody on this side of the House about disabilities or anything else.
(Interruptions.)
Acting Chairman
I will allow Members to ask questions.
I do not think the Minister wants to listen.
I do not want to be accused of hogging time but I want to know, because the Acting Chairman interrupted me in full flight, if I have one minute to reply to every question?
Acting Chairman
Yes, there is one minute to reply and one minute to ask each question.
I thank the Acting Chairman.
Last week I was presented with the case of a family of six children where the father earned £300 per week. Two children needed to visit the doctor at a cost of £30 each and there was a cost for prescriptions on top of that. Does the Minister think it right that this family does not qualify for a medical card? Is the Minister living in the real world? I told these people I would try to appeal the case next year when the new guidelines came in and now I find out that the guidelines will not be changed.
Last year the Minister provided that the over 70s would receive medical cards and I welcome that, but now families are being targeted and they cannot get medical cards. This is an outrageous state of affairs and it is time the Minister stopped the PR in his Department. All we heard for the past week was PR on the radio and television and the media was taken in by it. The people are waiting for the Government to do something about this matter. I challenge the Minister to allow people to answer him in terms of his strategy. The answer will result in the Minister sitting elsewhere rather than where he is now.
Does the Minister agree that the health of the poor is being compromised because they cannot access treatment to primary care as they cannot afford it? Will the Minister agree that we should not accept under any circumstances that 250,000 people face financial barriers to the first point of contact with the health services, as outlined by the Irish Medical Organisation yesterday?
Surely it is an indictment of the Minister and the health services that this is the case. Does he agree that people are seeking care in hospitals as a result of not being able to gain access to primary care because their condition deteriorates to a level where they have no choice but to do so? That these people need and receive care in hospitals rather than at primary level has created some of the difficulties behind the crisis in our hospitals.
(Dublin West): Does the Minister understand the angst suffered by many individuals and families in this State over the low threshold required for medical card qualification? Many people on marginal incomes and with great medical needs do not qualify. Is the Government's act of putting increased eligibility on the long finger a sign of things to come for the Minister's new health programme?
There are many people who hoped, despite past disappointments, that the programme might mean a brighter future for them with better and more comprehensive health care for which more people would be eligible. Are they justified in thinking that, on the very first test within two days of the announcement of the programme, they are seeing chinks in the armour of this scheme? Are they right in thinking that the rowing back on this much needed reform points to the fact that the Minister's new health programme will suffer the same fate and that, far from being achieved in the next five to ten years, it will become a pipe dream. I will leave it there. I need a bit of a medical care myself at the moment.
Acting Chairman
Does the Minister wish to reply to Deputy Ring? I have the other three speakers for supplementary questions, or will we take them together?
I would like to hear the Minister's reply.
Acting Chairman
The Minister to reply to the first three supplementary questions.
In relation to Deputy Ring's point, the Government is committed, as am I, to widening the eligibility thresholds for medical cards patients. No Government has invested more in the health service right across the board than this one.
That is not happening.
In relation to Deputy Neville's point, there was a range of services prior to 1997 that was scandalously neglected, none more so than—
The Minister did a mean thing.
The Minister should answer the question.
I am answering the question. It is an issue of prioritisation. There are equity issues in every area of the health service. We cannot narrow it down to one area. They are present in every area, none more so than in mental health which has been one of the great scandals of the past 30 years and over which Members of the Opposition presided for many years. The first substantial investment to be made into mental health services – to take people out of those horrible buildings – was made in the last three to four years, particularly in the last year.
Is there any chance the Minister would answer the question?
I made those choices again last year. We went for the over 70s and the broad income last year because older people need to see a GP more than younger people. That was my position. Others disagreed, but I argue that people with a greater medical need have to be factored in.
The Chief Medical Officer does not agree.
That is not what the Minister said.
With respect, no-one knew where the Deputy stood on it because he was attacking it when it suited him, he voted for it when it suited and then he came out saying he wanted to do it for over 65s.
(Interruptions.)
The Minister is misleading the House.
We are committed to widening eligibility for medical cards but we are equally committed to greater access for poor people across the full range of health services including public hospitals and better mental health services.
In relation to Deputy Joe Higgins's remarks, I am fully aware of the difficulties people face. There are strong provisions, even in the case that Deputy Ring raised. Discretionary powers are available to chief executive officers to whom people must have recourse. There is a significant number of discretionary medical cards given out every year acknowledging that there are people with chronic medical conditions who require on-going medication.
I am sure the Minister is aware that the Society of St. Vincent de Paul has described the Government's prioritisation measures as "obscene". Would he not accept that the most extreme inequity in the health service is where poor families cannot afford to see their family doctor? Does he accept that his approach means that money will go into medical practices and the development of primary care, as a matter of his choice, rather than ensuring the working poor have a chance of getting a medical card? He must be aware that the medical card system is largely restricted to people on social welfare and that people on low incomes cannot afford to bring their children to the doctor without it having a major impact on their weekly household budget. For example, a working man earning £324 gross per week would need to have ten children before he would qualify for a medical card.
The Minister has levelled a charge of political opportunism at the Opposition. Would he make the same charge about the Irish Medical Organisation and the Society of St. Vincent de Paul and is he aware of what they have said about his proposal? The IMO has accused him of bringing in an unacceptable measure that will undermine the health strategy's guiding principles of equity, access and fairness. It estimates that 250,000 people cannot afford treatment. Does he agree with that assessment or are they guilty of political opportunism too?
Similarly, the Society of St. Vincent de Paul said they were "shocked and incredulous at this obscene decision". It gives examples of people who will be bypassed. Would the Minister agree that, having launched the strategy with such razzmatazz, it has fallen at the first hurdle? He has failed to provide the equity and fairness that everyone in this House, at least on this side, wants.
The Minister will recall that I raised a matter on the Adjournment about a situation where a young boy with a hole in his heart required an operation. At that time his family were being refused a medical card and did not subsequently get one. They had to travel to England to have the operation carried out. Is he aware that I wrote a letter, to which he replied, which raised the matter of a family where both spouses had long-term illnesses? The husband has a tumour and the wife a serious heart problem. They are married with two children, both working to pay their way – ordinary people, paying their mortgages – and they were advised by the health board that one of them should stop work so that they would qualify for a medical card. Those people have to drive to Dublin continuously for treatment and yet they are being refused a medical card.
The Minister replied in his letter that they should re-apply. They did so a number of times but still got no card. I can see no reason people who are seriously ill are refused medical cards because of their incomes. When they are seriously ill they should be entitled to a medical card.
Is the Minister further aware that a person, living alone, who is under 66 has an income limit of £100 and that a single person under 66 living with his or her family is entitled to £89 per week? We are all aware that on £89 per week all one can do is keep body and soul together. Surely the level of eligibility should be widened. I ask the Minister whether he has lost touch with reality and the people because the people I meet are unable to pay their doctor. People are unable to pay the doctor the necessary fee in order to send them to hospital. The Minister should look at this. We are not making this a political issue. I would raise it regardless of what side of the House I was on because to deprive people on low incomes of medical cards is a national outrage.
Is the Minister aware of the disparity in access to health care given that under the current arrangements the public sector is substantially subsiding the private sector to the disadvantage of those who do not have health insurance? It is unfair that the private sector contributes less than 10%, yet there is preferential access to health care for 40% of the population with health insurance. People who are paying are getting very little.
Will the Minister address the specific question he has avoided? It relates to the number of vulnerable people on very low incomes by any standard, who cannot get a medical card and who were led to believe by the Minister's proposals in recent days that they would be included. Is it not condemning his own proposals to the level of aspiration when it comes to the tangibles that real live families on low incomes, who badly need access to their family doctor, are deprived of even being able to consult their family doctor because they cannot afford the fees? Is that not the kind of tangible that matters rather than glossy presentations on aspirations for what might happen in three, five, seven or ten years' time?
The real tangible for many people within the next few months or next year will be more beds in public hospitals. The real tangible for people with disabilities will be a guarantee of more residential places, more day care places and more respite places. This is the first Government that has prioritised any real disability, despite what the Deputy says. I would say to those who presided here prior to 1997 that nothing was done in terms of any substantial provision of additional places for people with disabilities.
That is not true.
These people had to take their place in the queue.
The Minister is still looking after the rich.
Other Governments made other choices.
(Interruptions.)
Acting Chairman
The Minister without interruption.
The Minister for Finance, Deputy McCreevy, and my predecessor, Deputy Cowen, started the process in regard to disability. This has resulted in an unprecedented provision of places and prioritisation for people with disabilities. I continued the process last year and this year and it will be continued in 2002. That is tangible under the health strategy. I would like to do a lot more but there are limits to what can be achieved in 2002. There are limits across the board.
The Minister promised us.
I am being upfront and honest on this matter; likewise in regard to the issue of mental health. On Deputy Enright's point relating to people who are not entitled to a medical card, the discretionary facility should facilitate that a medical card be given in those situations.
The Minister is the boss.
I am not the boss.
I wrote to the Minister and he did not do it.
The House devolved the authority to the health boards who have the discretion to make medical cards available. Given the circumstances the Deputy outlined, I have no doubt that there should be utilisation of the discretionary clause. There was an agreement last year with the IMO to provide extra funding because of the numbers of discretionary cards in the system. The IMO complained bitterly about the numbers saying they needed recompense, which we provided for last year.
The drugs payment scheme facilitates those who are chronically ill or are on a lot of medication and who do not qualify for a medical card. When the 1999 drugs payment scheme was introduced, it replaced the old drug expenditure recoupment by patients from health boards. No individual family need pay more than £42 per month for approved prescribed drugs. The take-up of the scheme has progressed dramatically as was pointed out yesterday because this Government has marketed the scheme more than its predecessors.
People cannot afford to go to their doctor.
A person on £89 a week is not entitled to a medical card.
In the year ending May 2001, the following increases took place. The number of people registered under the drug payment scheme increased by 250,000 to a total of 950,000. That is an increase per month of 43% and a total cost increase of 35%. Because of the new methodology in regard to forms, the chemist and so on, people who never applied in the past are now registering under the scheme. All those entitled have not yet registered. The numbers of people on different levels of income who are being assisted in meeting their medication costs far exceeds anything contemplated in the past.
Under the agreement between the Government and the IMO, up to 40% of the population can be covered for medical cards. Forty per cent of the population is currently approximately 1.6 million people, of which 1.1 million are covered. However, 450,000 people could be covered under the existing agreement with the IMO if the Minister raised these absurdly low levels which are making poorer people sicker. These are the people who will occupy the beds and it has nothing to do with staffing. It has to do with the disagreement the Minister had with the Minister for Finance, Deputy McCreevy.
Acting Chairman
The Deputy must allow the Minister to reply to the final supplementary.
The agreement to which the Deputy refers is that it may not exceed 40% without renegotiating the contract with the IMO.
That is correct.
It is because the Minister has frozen the limits.
The figure has declined to 31% because there are an extra 300,000 people working who were not working in 1997 because of the Government's economic performance.
Written Answers follow Adjournment Debate.