Vol. 557 No. 6
6 Ms O. Mitchell asked the Minister for Health and Children when it is intended to extend medical card eligibility and, in particular, to ensure that families with young children will be covered by the scheme; and if he will make a statement on the matter. [22841/02]
36 Dr. Cowley asked the Minister for Health and Children his views on the present low income eligibility for medical cards which must be addressed immediately. [22804/02]
75 Caoimhghín Ó Caoláin asked the Minister for Health and Children his plans to extend entitlement to the medical card; if there is a timetable for implementation of this commitment; and if he will make a statement on the matter. [22796/02]
169 Ms O. Mitchell asked the Minister for Health and Children when it is intended to extend medical card eligibility; if families with young children will be covered by the scheme; and if he will make a statement on the matter. [23081/02]
I propose to take Questions Nos. 6, 36, 75 and 169 together.
As Deputies are aware, the health strategy includes a commitment that significant improvements will be made in the medical card income guidelines in order to increase the number of persons on low income who are eligible for a medical card and to give priority to families with children and particularly children with a disability. This should be viewed in the broader context of the strategy's emphasis on fairness and its stated objective of reducing health inequalities in our society. Due to the prevailing budgetary situation, I regret it will not be possible to meet this commitment for next year but the Government remains committed to the introduction of the necessary changes within its lifetime. As the Deputy may also be aware, the present GMS scheme costs have increased by over 29% which will cost €230 million extra for the present people availing of the scheme.
It should be remembered that health board chief executive officers have discretion in relation to the issuing of medical cards and also that a range of income sources are excluded by the health boards when assessing medical card eligibility. Many allowances such as carers' allowance, child benefit, domiciliary care allowance, family income supplement and foster care allowance are all disregarded when determining a person's eligibility. Given these factors and the discretionary powers of the chief executive officers, having an income that exceeds the guidelines does not mean that a person will not be eligible for a medical card, and a medical card may still be awarded if the chief executive officer considers that a person's medical needs or other circumstances would justify this.
The strategy includes a whole series of initiatives to clarify and expand the existing arrangements for eligibility for health services, including recommendations arising from the review of the medical card scheme carried out by the health board chief executive officers under the PPF which include: streamlining applications and improving the standardisation of the medical card applications process to ensure better fairness and transparency.
The health strategy emphasises fairness and the objective of reducing health inequalities in our society. A 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, with the 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, initiatives to improve the health of Travellers, homeless people, drug abusers, asylum seekers-refugees and prisoners and implementation of the NAPS targets relating to health also.
Additional informationIn July 2000 the medical card was extended to everybody over the age of 70. The extension of medical cards to the over 70s is wholly consistent with Government policy aimed at improving the position of the elderly. Access to primary care services is of crucial concern to this Government as is shown in the new primary care model. Primary care is the first port of call for the majority of people who use health services. It can meet 90-95% of all health and personal social service needs and is a vital public service. People want community-based, well integrated, round-the-clock services that are easy to reach. They want themselves, their family members and their communities put right at the centre of care delivery. The primary care strategy sets out a vision of the service we want to put in place building on our existing strengths, to develop a high quality, userfriendly primary care service to meet people's needs into the future. However, change will not be effected overnight. The strategy sets out an implementation plan, which recognises the breadth of the change which will be required in order to support the rolling-out of the new primary care model over the next decade.
As the new model is developed, a wider primary care network of other primary care professionals will also provide services for the population served by each primary care team. This will enable us to see, in a real and practical way, how the new model will operate in practice, the benefits which we hope will flow from this new way of working and to explore some of the implementation issues in a practical way. This is, of course, only one of the first steps along the way. The implementation period recognises that there are major structural changes which must occur in order for the new primary care model to be implemented. It is also necessary to ensure that the required numbers of health professionals are trained and retained in the system over the coming decade and beyond to meet anticipated needs.
Following an extensive consultation process with disadvantaged groups carried out under the auspices of the working group on NAPS and health, NAPS health targets have been included in Building an Inclusive Society: Review of the National Anti Poverty Strategy under the Programme for Prosperity and Fairness, published by the Government earlier this year. Key health targets are to reduce the gap in premature mortality and low birth weight between the highest and lowest socio-economic groups by 10% by 2007 and to reduce differences in life expectancy between Travellers and the rest of the population. Policy measures for implementing these targets as outlined in the framework document for the NAPS review and the report of the working group on NAPS and health, have been taken on board in the national health strategy.
One thousand people waiting for more than 12 months have now had operations under the national treatment purchase fund. By the end of the year 1,900 will have been treated. This will contribute significantly to reducing hospital waiting lists in the next 12 months.
If it is not possible to extend the medical card coverage to additional groups, will the Minister at least consider raising the eligibility level in line with growth and income levels in the economy? People would then not have to give up jobs to hold on to their medical cards. Is it not particularly cruel that people who had medical cards are losing them while those who expected medical cards are not getting them? At the same time the Minister is raising the threshold for the drug refund scheme. That subhead is being savaged, which is totally inconsistent with what is promised under the primary care strategy.
First, the commitment was to increase income thresholds to such a level that we were bringing in approximately 200,000 extra people. As I have said, the financial envelope I have this year does not allow me to do so. There would obviously be cost implications and the envelope I have allows me to do certain things. I prioritised the beds and acute hospitals services issues to ensure people have better access to treatment in our acute hospitals. I have prioritised cancer services with an additional €29 million and I have prioritised waiting lists through a combination of the mainstream waiting list initiative with €43 million and the treatment purchase fund, which will have approximately €30 million at its disposal. Approximately 7,000 additional patients are expected to be treated under this next year and those are people waiting longer than 12 months for a variety of treatments. That will significantly reduce waiting times for those people.
That is what I have done with the envelope at my disposal; unfortunately that is the position for 2003.
I have not had an opportunity to comment on the Estimates but in the spirit of the Government's defence, I ask the Minister to comment on the fact that in 1997 37% of the population had medical cards while in 2001 that figure had dropped to 31%. Will the Minister comment on the recent problem of overpayment involving 15,000 medical cards? Who does he feel was responsible?
On the first matter, the principal reason the number of people holding medical cards declined from 37% to 31% was the economic growth in the country and the fact that approximately 300,000 people secured employment between 1997 and now. Obviously if one secures employment one's income increases and the vast majority of people with medical cards who secured employment then exceeded the threshold. It is equally true that in the same period a significant additional number of people benefited from the DPS scheme compared to previously. The budget for that scheme has rocketed between 1999 and now. That is the main reason the percentage of people with medical cards declined – the dramatic economic growth and growth in employment meant people's income limits went up accordingly, thereby putting them over the threshold for eligibility.
Regarding medical cards, we will be entering negotiations with the relevant bodies, such as the IMO, but the bottom line from the exercise undertaken is that over 15,000 cards were invalid. Many of the holders were dead or had moved to other locations. Subsequent validation is taking place for those under 70. A serious situation that has been uncovered and I have heard various public pronouncements but to be fair – the Deputy himself is a GP – one would expect GPs would know if people on their list died.
How many died?
On the other hand, there are issues of computation and so on. The bottom line is that no matter who is blaming who, in essence, 15,000 people had ghost medical cards. That is what has emerged from the validation study.
Not all disabled children are getting medical cards. I know of one case I would like the Minister to re-examine – I have written to him about it before – involving a child with several handicaps who is being fed through a tube but because the child's parents earn a reasonable income, the child has no medical card.
Is the Minister suggesting a married couple with three children on €215 or €220 a week can afford €40 for a doctor's bill and €60 for medicine? That is an impossible situation. Also, parents in my constituency do not have a children's ward available to them and must carry the cost of travelling to Cavan, Drogheda or elsewhere with their children. That is an added burden for those families. The children's ward has been closed for some time. I am not trying to play that up but the situation is very serious for those on low pay. I accept that medical cards for 200,000 people may not be possible but the Minister must make sure that those who have medical cards do not continue to lose them as is happening at present.
I take the Deputy's comments on board. Regarding the individual cases, the chief executive officers of the health boards have discretion, in cases of hardship and where people have chronic or long-term illnesses, to award medical cards. In many instances they do.
In some they do not, unfortunately.
They cannot in many cases. It is not unlimited.
I did not say it was unlimited, but the numbers are so substantial that the Irish Medical Organisation saw fit to negotiate for a contribution from the State in respect of the additionality. The IMO has raised this issue from time to time. It is important that chief executive officers are allowed the flexibility to award medical cards, particularly in hardship cases such as those outlined by Deputy Crawford and in cases of chronic and long-term illness.
We have a variety of other support schemes. The long-term illness scheme, for example, assists people with a range of diseases and disabilities and is of assistance to families and children. The DPS is also of assistance to families and children. The 1999 amendment specifically allowed families to add the costs of individual members of the family as one cost in order that the refund kicks in when the total cost goes above the threshold.
Now that 200,000 people are having to face the harsh reality of not having a medical card or the protection it offers, will the Minister state clearly what is likely to happen to the drugs refund scheme? Does he envisage additional price increases or a heightening of the threshold? What will happen to those on very low incomes who are having to pay their family doctor's bills and are very fearful? Already they have faced an increase in the drugs refund scheme and now face another. Will the Minister elucidate on the matter?
While we all accept that doctors should know which of their patients have died, does the Minister accept that issues of accountability regarding how the system operates have been raised? It is the health boards which should have the information regarding numbers of patients. Does the Minister also accept responsibility for miscalculations? When the Department calculated the cost of the over 70s scheme, his assessment of the number of over 70s in the country was so out of line that that his figure turned out to be half the true figure.
The Department was responsible for overcharging patients when the change was made in the drugs refund scheme and the old system, when two schemes were in place, was abolished. Nevertheless, it is refusing to pay back what is owed to the people concerned. Will the Minister comment on this?
The threshold of the drugs payment scheme will be increased. I am looking at various options in an attempt to bring forward a regime that will protect those on low incomes. I will let Deputies know the details as soon as the process is completed. We are modelling a variety of options. There will be increases in the drugs payment scheme, which has increased dramatically in line with increases in the GMS. Some of the increase relates to the ingredient costs and some to the way we changed the administration of the scheme at pharmacy level in 1999. There has been a vast increase in the numbers availing of the scheme since.
I accept that there are accountability issues in terms of the number of ghost medical cards. That is the reason I brought in Deloitte & Touche four or five weeks ago to make a critical examination of the governance and accountability mechanisms in the general medical services scheme and payments made by the GMS board on behalf of health boards. Deloitte & Touche consultants will examine the roles and responsibilities of the Department, the Eastern Regional Health Authority, the health boards and the GMS payments board. They will examine the underlying reasons for increasing cost trends in the medical card scheme, validate the latest estimated outturn for 2002 and assess its implications going forward and make recommendations for the immediate resolution of any identified weaknesses and inadequacies.
The GMS scheme has been in place for 30 years. While it has changed, its fundamental governance has not. I accept that there is an accountability issue across the system which needs to be tightened up. With regard to the miscalculation of the number of over 70s, I do not estimate population trends.
That is what the Minister's Department did.
No, it did not. It worked in consultation with the Central Statistics Office in relation to the number of people aged over 70 years.
That was not the problem. The Department did not know how many people already had medical cards.
The strongest recommendation made by Deloitte & Touche in its audit of last year was the need for investment in IT systems. This and many other miscalculations of numbers of patients, and employees, in the health service indicate that it is essential that this investment is made. We must also invest in the provision of the single patient identifier card. If health boards, the GMS and doctors were all working off the same list and each patient had an identifier card, general practitioners would automatically know if a patient had moved from his or her practice or if a patient had died. Is this not the sort of investment we should be making in order that the blunders of recent months do not continue to occur?
I agree wholeheartedly with the Deputy. One of the greatest deficiencies of our health system is in information and the lack of comprehensive databases across the system, both in the administrative and clinical areas. There have been sigificant improvements, in terms of HIPE data in acute hospitals for example, and we are better off than we were ten years ago. Nevertheless, there is a fundamental lack of a robust database, which the Deloitte & Touche report identified. The national health strategy also identified this need during the consultation process. The Government is committed to the development of a national health information strategy for which we will be publishing the blueprint shortly. A central and essential part of the strategy is the unique patient identifier. More and more screening issues will arise in the future.
This is a safety issue, too.
We would benefit if we had an electronic patient record which could be accessed from primary to secondary and continuing care. There are data protection issues and legislation will be necessary. Public health should take precedence over other considerations and measures can be included to ensure civil liberties are safeguarded.
