Health (Amendment) Bill 2005: Second Stage.

Minister of State at the Department of Health and Children (Mr. S. Power)

I move: "That the Bill be now read a Second Time."

I am pleased to introduce the Bill, which provides for the amendment of the Health Act 1970 to address two substantive matters: the provision of a legal framework for the charging of patients for the maintenance element of inpatient services in publicly funded long-term care residential units and the introduction of doctor visit medical cards. The Government has introduced the legislation to establish a sound legal basis for the policy of requiring a contribution towards shelter and maintenance of people with full eligibility in the long-term stay institutions.

Succeessive Governments have supported and implemented this policy. The Supreme Court recently confirmed it is constitutionally sound for the Oireachtas to legislate for this policy. The issue is finally being put beyond legal doubt after almost 29 years. We are also proposing the introduction of a doctor visit medical card as announced at the publication of the 2005 Estimates. This fulfils a key Government commitment to ensure people on low incomes have access to general practitioner services and advice. It is most efficient to address both issues in the same Bill.

The decision of the Supreme Court on 16 February 2005 in the matter of Article 26 of the Constitution and the Health (Amendment) (No. 2) Bill 2004 has brought clarity and finality to the issue of long stay charges. It has also paved the way for the introduction of this Bill to provide the legal basis for charging for inpatient services in publicly funded long stay institutions. We had a full debate in the House on the Supreme Court decision two weeks ago. The court found the Bill's provisions for prospective charging of inpatients were not repugnant to the Constitution. There is no constitutional prohibition on implementing a charge into the future for public long stay inpatient services.

The Government accepts fully that the Supreme Court found the retrospective provisions of that Bill on making lawful the imposition and payment of such charges in the past to be unconstitutional, in so far as this concerns the property rights of citizens. We are concerned with the implementation of policy going forward. I do not believe the House needs to revisit the debate we had two weeks ago on the Supreme Court decision. The debate should focus on the Bill's provisions and look forward to the clarity and benefits they will bring.

The principle that it is fair and reasonable that most people should make a contribution to the cost of their long stay care is a significant and long standing feature of our system of publicly funded long-term care. This has been restated and reinforced in the health strategy, Quality and Fairness — A Health System for You. It is recognised that quality care is expensive and the bulk of the cost of providing a high standard of quality care should be borne by the Exchequer. It is estimated the charges imposed on those in public nursing homes represent approximately 10% of the overall cost of care. It, therefore, represents a modest contribution towards the total cost of treatment and maintenance.

The services provided to people in long stay care are a valuable part of the health services. It is essential that these services should be protected and maintained. The charges in question are embraced by the concept of a co-payment, which is common throughout the health service. This is consistent with the overall principle that where individuals can contribute a modest amount to the cost of their care, it is reasonable that they do so. Other examples include the inpatient overnight hospital levy. In the latter case, the charge is €55 per night subject to a maximum of €550 in any 12 consecutive months. Those availing of private or semi-private accommodation in public hospitals are also charged.

I refer to future services for older people specifically. It has been the policy of successive Governments to endeavour to help older people maintain themselves in the community while at the same time providing for residential care which is not prohibitively expensive. The policy of the Government on the development and delivery of services for older people is to maintain them in dignity and independence at home for as long as possible in accordance with their wishes, as expressed in many research studies. People are much happier in their own homes and they recover more quickly from illness in their own environment and we will continue to allow that to happen in so far as that is possible.

The roles of all community care services are, therefore, vital to the implementation of this policy. The charges provided for in the legislation will assist in providing funds to help in the implementation of these overall policy objectives in the future. On foot of advice sought by the Tánaiste from the Office of the Attorney General, the Department of Health and Children issued a letter on 9 December 2004 to the chief executive officers of the health boards and Eastern Regional Health Authority asking them to stop making such charges immediately, pending the introduction of amending legislation. It is estimated that this is costing approximately €2 million per week. Accordingly, a statutory framework that puts the long-standing policy on a sound and statutory legal footing and safeguards the income generated from this source is vital. The provisions of the Health (Amendment) Bill 2005 will secure this source of income. Let us remember that this income is applied exclusively towards health services. It does not revert to the general Exchequer. It is part and parcel of health funding and has been so for decades past.

On 18 November 2004, in conjunction with the publication of the 2005 Estimates, the Tánaiste announced the Government's intention to introduce a doctor-visit medical card for 200,000 people. This was the most efficient way to help the most people to access primary care. It is in line with the commitment contained in the health strategy to ensure that the allocation of medical cards is on the basis of prioritising groups most in need. This is one of a package of developments that we have announced regarding the medical card scheme. The others involve adjustments to the income guidelines in respect of standard medical cards which will enable 30,000 additional people to obtain such a medical card in the current year. The new income guidelines have been in force since January 2005. Those guidelines reflect the 7.5% increase on the 2004 figures, as announced in November 2004, and include substantial increases in respect of dependent children.

Parents of children with illnesses that persist from year to year can be assured that they will not have to reapply for a medical card each year, thus alleviating the anxiety of wondering if their medical card will continue. It is intended that this arrangement should apply to a small number of children with very serious illnesses, where a review would normally result in automatic renewal of the medical card. As I stated, the Government is providing extra resources for additional medical cards in a way which benefits as many people on lower incomes as possible.

Concern has been expressed by several people and groups, including general practitioners, that some parents have been deterred from attending their family doctor, or from bringing their children to the doctor, by the cost involved. People should not be discouraged from visiting their family doctor, and especially from bringing their children to the doctor, because of cost. For this reason, the Government has decided to introduce a new medical card which will enable 200,000 people on low incomes to visit their GP free of charge. This measure will remove for individuals and families any concern about the cost of bringing their child to a doctor or attending themselves. People will be able to get the advice and reassurance that they need from their GP and, if necessary, be referred to other health services in either the community or the acute sector as necessary.

It is important to remember that not all concerns or medical conditions with which people attend their doctor necessitate the prescription of medication, so in many cases no cost need arise in that regard. For those who require prescription medication, under the drugs payment scheme no one need pay in excess of €85 in prescription drug costs in a calendar month.

The Health Service Executive is preparing for the introduction of the doctor-visit medical cards and is drawing up appropriate operational guidelines to enable applications to be assessed on a standardised basis across the country. Once that legislation has been enacted, the HSE will be able to begin promoting the scheme and inviting formal applications with a view to the first doctor-visit medical cards being issued during April.

I am pleased that the Irish Medical Organisation has welcomed the initiative and I look forward to its co-operation in the introduction of these new medical cards in the interests of the families and individuals concerned. I understand that the Health Service Executive has written to the IMO, inviting it to discuss the administrative and operational arrangements regarding the implementation of the doctor-visit card. The additional funding of €60 million provided in the current year should allow up to 200,000 doctor-visit medical cards to be issued. The Health Service Executive intends initially to set the income threshold for the doctor-visit cards at 25% higher than applies for the standard medical card. That threshold may be reviewed in light of experience to ensure that the desired numbers of cards are being issued to those intended to benefit under the initiative.

The introduction of the new doctor-visit cards should also be seen in the context of the broader modernisation agenda under way for the medical card schemes. A medical card review project was set up under the former Health Boards Executive in April 2002 to assist the health boards in the promotion of good administrative practice regarding the management of the medical card scheme and the achievement of high standards for their customers. Nine sub-projects were established undertaking the following: the management and control of the GMS register; administrative processes and standards; modernisation and development of the appeals system; modernisation and simplification of application and review forms; the development of customer satisfaction measurements; examination of IT system integration options with health boards and the GMS payments board; researching and clarifying guidelines in interpretation of legislation; developing a training strategy; and developing training in the principles of good decision-making.

The work of those sub-projects was accepted by the board of the Health Boards Executive. It is now being progressed, under the auspices of the Health Service Executive, by a national steering group set up to oversee implementation of the outputs of the Health Boards Executive process. The work of the project will modernise the operation of the medical card and related schemes to make them more customer-friendly, administratively streamlined, fair, accountable and IT-enabled.

I now propose to outline the scope and principal provisions of the Bill. For the purposes of clarity I will deal first with long-stay charges and then with doctor-visit medical cards. The Bill is designed to eliminate the anomalies that have arisen under the current legislation for raising charges for long-term care in publicly funded long-term care institutions. In addition, the Bill and regulations will promote consistency in the application of charges, with greater clarity for those receiving services and the public generally, as well as promoting administrative efficiency and transparency throughout the system.

Section 4 of the Bill provides for an amendment to section 53 of the Health Act 1970 which deals with the legal basis for the imposition of charges as follows. It replaces the existing enabling provision in subsection (2), which provides the Minister with discretionary power to make regulations by a provision, something that requires the Minister to make regulations to impose charges regarding all persons, that is, those with full and limited eligibility. As matters stand, section 53 of the Health Act 1970 provides power to make regulations to impose charges on those who have limited eligibility only. It inserts a new subsection (3) which specifies categories of person exempted from charges imposed under subsection (2). Such categories include all persons under 18, those detained involuntarily under the Mental Health Acts, those in receipt of medically acute care in hospitals and those pursuant to section 2 of the Health (Amendment) Act 1996 who, in the opinion of the Health Service Executive, have contracted hepatitis C directly or indirectly from the use of human immunoglobulin anti-D or the receipt within the State of another blood product or a blood transfusion.

We intend to insert a new subsection (4), which empowers the Health Service Executive to reduce or waive a charge on financial hardship grounds, and a new subsection (5) to make it clear that any current regulations in force under section 53 remain in force. The regulations in question are those which impose a hospital levy of €55 a day, subject to a maximum payment in any 12 months of €550. Those charges will continue not to apply to people with full eligibility — medical card-holders, including all over-70s — and a series of other exemptions, such as women in respect of motherhood.

We are also inserting a new subsection (6) to provide that the charges shall apply for inpatient services only after a period of 30 days or periods aggregating 30 days within the previous 12 months. The new subsection (6) also limits the weekly charge to an amount that does not exceed 80% of the maximum of the weekly rate of old age non-contributory pension. We will insert a new subsection (7) to clarify that the period of 30 days referred to in subsection (6) begins to run immediately the person concerned is provided with inpatient services. We also intend to insert a new subsection (8) to provide that the charge shall be in respect of the maintenance aspect of inpatient services.

I would now like to outline for the House the Bill's provisions regarding doctor-visit medical cards. Section 1 amends section 45 of the Health Act 1970 in two respects. In both cases the amendment is to ensure an alignment of the legal principles governing the award of the standard medical card and those contained in the provision to be included in section 58 of the Act in respect of the doctor-visit card.

The amendment to be inserted by section 1(a) makes it explicit that the judgment as to whether a person meets the criterion of “undue hardship” specified in section 45(1)(a) of the Health Act 1970 is made by the Health Service Executive.

The amendment to be made by section 1(b) replaces the existing section 45(2) of the Health Act 1970 with a wording which makes it clear that decisions on eligibility by the Health Service Executive must be made not just by reference to a person’s means but also to what constitutes reasonable expenditure on the person’s behalf. This is in line with existing practice in the Health Service Executive whereby costs associated with such matters as a person’s employment, reasonable housing provision and the care needs of children or dependants, as well as nutrition and clothing needs, are taken into account in determining whether a person faces undue hardship in meeting the costs of GP services.

By amending the law in this regard we are making it a legal requirement that a person's reasonable expenditure needs are taken into account in the application of section 45(1)(a) of the Health Act 1970. In both cases these provisions reflect what is already the practice of the HSE regarding the assessment of individuals for medical cards. These amendments, therefore, will not affect the processes and practices already in place as regards the award of the standard medical card.

Section 2 amends section 47 of the Health Act 1970 by adding a reference to section 58 with the existing reference to sections 45 and 46. This is to ensure that the relevant appeals provisions extend to the scheme for doctor-visit medical cards.

Section 3 amends section 47A of the Health Act 1970 to include the doctor-visit medical card scheme in respect of the Minister's power to issue guidelines to assist in decisions regardless of whether a person is ordinarily resident in the State. Guidelines issued to the health boards in this regard in 1992 and remain in force.

Section 5 replaces the existing section 58 of the Health Act 1970, which deals with the making available of general practitioner services without charge, with a new provision. The new subsection (1) will require the Health Service Executive to make available general practitioner services without charge not only to persons with full eligibility but also to persons with limited eligibility for whom, in the opinion of the executive, it would be unduly burdensome to arrange these services for themselves and their dependants. This provides the legal basis for the granting of medical cards, the scope of which is confined to patients' attendance at a general practitioner.

Subsection (2) of the new section 58 specifies the same general requirement regarding the making of decisions by the Health Service Executive in respect of doctor-visit medical cards as is being inserted regarding decisions on eligibility, that is, they must be made not just by reference to a person's means but also to what constitutes reasonable expenditure on the person's behalf.

Subsection (3) maintains the existing requirement that there be a choice of doctor for persons obtaining general practitioner services under section 58 and ensures that this applies to holders of doctor-visit medical cards as well as holders of the standard medical card.

As the House will see, in respect of charges for long-stay care this legislation will bring clarity to an area which, it is now clear, has not been operating on a sound basis for nearly 30 years. This is a genuine move to provide that charges for long-term care that are imposed have a sound legal basis. The legislation will also ensure that the income flow from charges imposed to date is secured and that it will continue to support the provision of quality services to those in long-term care. It has been accepted that these charges, as contributions to the cost of care, are fair and reasonable.

With regard to new medical cards, Government policy is, as stated in the programme for Government, to extend eligibility for medical cards for people most in need rather than to achieve coverage of a certain percentage of the population or to issue a specific number of medical cards.

The introduction of doctor-visit medical cards will enable up to 200,000 additional people from lower income households to go to their doctor free of charge. This will help to overcome barriers to accessing GP services for many individuals and families who are above the standard medical card income guidelines. I commend the Bill to the House.

Dr. Twomey

I welcome the Minister of State to the House to speak on the Bill. We would have preferred to see the Tánaiste here but it is good to see a Fianna Fáil Minister in the House talking about the health services because the Minister's colleague who held his position before the reshuffle has been as silent as a Trappist monk on this issue. He has still not made a statement — he was a great man for issuing statements — on his role in this issue. That is disappointing considering that Fianna Fáil is the largest party in this House and should show more concern not only for the health services in general but also two issues we are talking about, namely, legalising nursing home charges and doctor only medical cards. However, a huge number of problems remain outstanding about which the Minister of State, the Tánaiste, Deputy Harney, or any member of Government do not appear to show much concern. Those problems are just as important to people as the two issues we are debating today.

Of concern to me and some of the people I have been talking to is the reduction in the number of public only nursing home type beds in the health care system. Some people are of the view that what the Minister is trying to do in this legislation is force people into using private nursing homes, not because of eligibility criteria but because there are no public nursing home beds in certain areas, and the numbers available are constantly decreasing.

That was brought home to me in my constituency where a new hospital to replace what was basically a workhouse, St. John's Hospital, Enniscorthy, is proceeding at an extremely slow pace. Phase one, currently being built, will not replace the current full complement of the hospital. St. John's is one of the few hospitals remaining in the country which is basically a former workhouse, a throw-back from two centuries ago. It is used now to look after the elderly in County Wexford.

Yesterday, I spent most of the day in County Kerry where two issues were brought to my attention. A promise was made to the people of Kenmare that €2 million would be provided to put an extension on to the district hospital in the town. That money has not been provided and there is no commitment to make it available. The people have not got a straight answer from anybody regarding that money.

I visited Dingle also where a local landowner made a very generous gesture in giving approximately five acres of land to the health board on which it could build a new district hospital for the people of that peninsula. Again, no commitment was forthcoming and there has been no indication of when the funding will be made available to build a hospital.

The district hospital in Dingle is also a former workhouse. One can go up to the third floor of that hospital — thank God it is no longer used for patients — and see the original lay-out of the workhouse as it was in 1840. One can see where the straw would be brushed out of the wards when the bedding was changed once every six weeks when it was used as a working house. Now, over 150 years later, we are talking about imposing nursing home charges on people who are being treated almost like the way animals were treated. It is disgraceful that we are talking about imposing nursing home charges when we should examine how we can look after the elderly in our society.

I do not want the Minister to implement a policy which will force patients into private nursing homes, not because the care in private nursing homes is substandard, although that issue has been raised a few times in this House regarding certain institutions, but in terms of the cost to patients. That is something of which the Minister has not taken much notice. These nursing home charges have now been made legal but the Minister should examine the overall level of cost to patients.

That is an issue we have raised in the House since the legislation was passed before Christmas. It was raised at Question Time and again two weeks ago. Subvention payments, which patients are entitled to if they have to go into private nursing homes, average €150 per week. There has been no increase in that payment since 2001. For all the fine words we have heard in the House, a basic entitlement for elderly patients has not improved since 2001. Where does that leave patients if they need to obtain additional funding to enable them to enter nursing homes?

As the Minister of State is aware, one will not come across too many private nursing home beds that cost €150 per week. The people to whom I refer must seek enhanced subvention payments. Such payments are described by some as being at the discretion of the CEOs of the respective health boards. Patients are beginning to feel, however, that they are at the mercy of health board officials rather than their payments being at the discretion of those individuals. This is as a result of the difficulties they encounter in obtaining enhanced payments that are realistic in nature. I will provide an example of this later. The vast majority of patients in private nursing homes are paying in excess of €500 per week to retain their places there. That is a huge burden on the individuals involved and on their families.

We discussed this issue on Question Time two weeks ago. I referred to a patient in County Wexford with whom I am familiar who sold her house a number of years ago and used the proceeds to fund her stay in a nursing home. Her money was beginning to run out when she raised the issue with me last November. I tried to make contact with the local health board and with officials throughout the region on her behalf. The best response we received was the woman in question would receive an enhanced payment of €80 per week. This was despite the fact that she paid approximately €600 per week for her nursing home place. When I raised the matter on Question Time, the health board miraculously arrived at a solution last week and the woman will be given a bed in a public nursing home.

What happened in the case to which I refer is disgraceful for a number of reasons. I would hate to think that the woman in question's continued long-term nursing home care had anything to do with political intervention. One of the major problems with our health service is that too many of the services it offers are at the discretion of people who should not possess that type of power in the first instance. The position as regards people's entitlements should be much clearer. I refer here not only to medical cards but to long-term care in institutions. Some of the provisions in the legislation will exacerbate the problems that exist or will, at least, return us to the bad old days when politicians had more to say about people's health care than did their doctors.

Concerns about the care of patients with dementia and Alzheimer's disease have been raised on numerous occasions. The Government is implementing a policy relating to the care of those with dementia. This was supposed to be put in place within seven years, commencing in 2002. I have not seen any major progress being made in respect of that policy, despite the fact that concerns about the two issues to which I refer are becoming more widespread. There is a major cost involved for families that try to pay for services on a private basis. Dementia and Alzheimer's patients are categorised as high dependency and require additional nursing care. This means, therefore, that there is an extra cost involved.

The Government is making extremely slow progress in respect of this matter. Most of the patients have seen nothing in terms of points four, five and six of the Tánaiste's magic ten-point plan to resolve the accident and emergency crisis. A great deal was made about the provision of 100 long-term residential beds, step-down facilities and respite facilities. Most of the patients to whom we are referring will see little benefit from the provisions in the plan. The Government needs to wake up to reality and deliver a much better service to elderly patients. All it is doing in this legislation is legalising a cock-up it made three to four years ago. The Government knew much more about this matter than has emerged to date and I am anxious to see what the Travers report will have to say in that regard.

The Minister of State referred earlier to the health strategy, which was the bible for Fianna Fáil during the most recent general election. National goal No. 2 of the strategy states "New legislation to provide for clear statutory provisions on entitlement will be introduced." The target date for this was 2002. No action has been taken on this goal in the past three years. It is easy to see why that is the case. When someone decided to examine the legislation, did they recognise that there was a problem vis-à-vis nursing home charges and a huge number of other issues on which the Government has not delivered?

While what is happening in terms of the provision of health services might be seen as the continuation of a form of political patronage into the 21st century, in some respects it might also be seen as evidence of the Government's incompetence. Perhaps the Government behaves as it does because it is afraid to make any difficult decisions for fear that this will cost it votes. Services are being denied to patients and there is, therefore, clear guidelines and legislation. I refer here to the legislation promised since 2002, which must to be delivered. The Minister of State referred to a nine-point plan and the fact that a number of sub-groups are considering this matter at present. How long will those sub-groups continue to meet before we see real action in terms of people's entitlements?

It is sad that the Tánaiste is not present because I would like to ask her where she stands in terms of a policy to fund the care of the elderly in the future. There is major uncertainty and insecurity in respect of this matter at present. We have broached this subject on a number of occasions in the Dáil in recent months but, again, no clear answers have been offered in respect of it. The Minister of State made an important point on a recent Question Time when he stated that if a person's house is worth in excess of €75,000, this would be taken into consideration as means when he or she is seeking subvention payments in respect of private nursing home care. He stated earlier that he does not understand why a person who owns a house worth more than €1 million should receive support from the State. Where does the Minister of State stand as regards the grey area in terms of houses worth between €75,000 and €1 million? At what point does the Government believe someone's private house should be considered as part of his or her means?

The Tánaiste got into a hell of an amount of hot water when, at a conference in 2003, she stated that a person's private home should be considered as means when he or she is seeking a nursing home subvention. The Government has completely fudged this issue since 2002. Another of its objectives in the health strategy was that, by the end of 2002, it would publish a policy on funding of the care of the elderly into the future. I understand that a number of submissions on that matter were made to the Department of Health and Children and that a policy was drawn up but that, for some reason, the Government has not seen fit to publish it. Even though the position is being regularised and we are making it legal to take money from elderly patients in nursing homes, the Government has done nothing to inform those who are 55 years or older who may wish to avail of these services in the future exactly what will be their entitlements.

It is the responsibility of Government to make decisions and I am surprised this Administration is sitting on the issue and making no progress on it. I am of the opinion that a large number of members of the Cabinet — both Fianna Fáil and Progressive Democrats Ministers — want to take family homes from elderly people to pay for their long-term care but that for some reason they are hedging their bets and refusing to make a decision on the matter. That failure to make a decision is probably holding back a number of other initiatives and this should be made clear to the people. Funding for care of the elderly into the future will become a massive issue within the next decade. It is time for action and not hedging one's bets. The Government must come clean on this matter in the near future.

I wish now to deal with the issue of doctor-only medical cards. I am disappointed with the Government's handling of this issue. I promoted the granting of such cards before the Tánaiste announced their creation in the Estimates. I stated that we should immediately introduce a system involving such medical cards because I have seen the difficulties that arise in general practice. A number of patients do not receive the services to which they are entitled because of the cost involved in delivering them. Some mothers will not bring their children to see a doctor because of that cost. The solution to it was that people could get a professional opinion that would help to relieve the anxiety as to whether they were genuinely sick or it was just a viral illness that did not require further treatment. We are now approaching the month of March and not one doctor-only medical card has been issued. Not only that, 10,000 standard medical cards have been withdrawn since the announcement was made in the Estimates that 30,000 more were promised. That is not a proper reflection on the Minister's commitment to the health services and especially to the people concerned.

The Minister of State pointed out in his speech that the Department was going to deliver medical cards to patients on grounds of need rather than on the basis of percentage of the population. That is the Fine Gael position, as the Minister of State knows. We feel it they should be extended to 40% of the population. It is going to be done on the basis of what people should receive. However, nothing has been delivered and instead medical cards have been taken away since the announcement was made. It should never have been introduced as the permanent solution to this problem, merely as a temporary solution.

The Minister has now introduced a third tier to the health care services. This will work out badly in the long term for the patients involved. My concern is how the medical card scheme is administered in tandem with the provision of health care to people who are dependent on the State. For instance, full eligibility is based on financial hardship but allows a certain discretion on medical grounds by a health board chief executive officer. A percentage of medical cards are supposed to be issued on a discretionary basis by the CEO based on the medical needs of patients rather than financial criteria. I welcome those initiatives and support them, but they still have the potential for abuse. However, there has not been much abuse of this kind within general practice, although doctors know that some people with medical cards are not entitled to them. It may be that such people did not fill in the forms honestly, but one cannot be 100% certain whether such cards are issued on the basis of who they know rather than what they need.

However, the doctor-only medical card uses the term "unduly burdensome", which is a lesser test than financial hardship. Going back to the health strategy, the Minister promised to reduce the ambiguity over entitlement to services. This term, "unduly burdensome", may be interpreted in a number of different ways by health board officials in different regions. That means the problems we had with the old health boards, where services were different throughout the country, will continue. Some people in a given area were able to get enhanced subventions of up to €500 a week while in other places they could only get up to €300. It is a distortion of what people throughout the country may get. There is no level playing field when terms such as that are introduced. More problems are being introduced with this legislation than are being dealt with.

It is vital that entitlement to any public service is clear-cut. That is where the legislation from 2002 is coming from. We must get rid of any semblance of grace and favour from the public service system, whether it is health care or public authority housing. Grace and favour means that people are more dependent on the politician or public officials than on the laws of the land and what they are legally entitled to. This legislation makes no great improvement on that. I detect a discretionary element creeping in which is more or less going back to putting people at the mercy of officials.

It might be worthwhile to offer a short history lesson on this issue. The Tánaiste likes to go back to 1970 when she talks about the issue of nursing home charges. Prior to 1970, the dispensary system was in operation where a doctor was hired in a local parish and patients considered too poor to pay were allowed to go to the dispensary medical practitioner. Patients got access to the dispensary doctor by getting either a green or a red ticket from the local politician. The green ticket entitled them to go to the doctor in the surgery whereas the red ticket entitled them to house calls. The reason the system was got rid of was that it was wide open to abuse and political cronyism, where people who were connected got the red ticket for house calls but those who were not only got the green and were told to go the surgery. So much of what is now being done goes back to that old system of basic abuse. I wish the Minister, in going to the trouble of doing all this, had cleared up that system to a greater degree.

Some of the points scoring against the Opposition indicated in the Minister of State's speech suggests that children with illnesses will not have to renew their medical cards. I have recently encountered a constituent with an adult family member who has intellectual disabilities and is entitled to a medical card. That medical card used to last for about two years at a time and the family is now getting renewal forms every six months for it, even though the person concerned is an adult with intellectual disabilities and there will be no change in personal circumstances in the next six or 12 months or even two years. Doctors see this system creeping into general practice as well where cards are being given for shorter periods. Perhaps the health boards hope that in some cases patients will not renew their cards, will not have the ability to do so or will be too intimidated.

Such issues regarding primary and elderly care are constantly being raised in this House. The Minister of State's speech appears to indicate that much is being done in this regard but in fact it is very little.

This legislation seems to have been thoroughly vetted from a legal viewpoint so that a referral to the Supreme Court will not be warranted and we will not be debating it again in the House in two months' time. Perhaps the reason the Minister of State is present is because the Tánaiste does not want to have to face into this again. Section 1(b) of the Bill, which amends section 45 of the Health Act 1970, states in respect of a spouse: “including the means of the spouse, if any, of that person, in addition to the person’s own means”. Perhaps the Minister of State should ask a constitutional lawyer to have a look at that because it might be considered to be an unconstitutional attack on marriage. Perhaps the Minister of State could clarify this in case he has to return to the House in two months and start all over again with a third version of this Bill.

Ms McManus

I welcome the Minister of State. I am astonished that he and not the Tánaiste is taking the Bill. I do not see this as a matter of sorrow, as Deputy Twomey does. Rather, it engenders in me a certain suspicion. The Minister developed a reputation over the years for shouldering responsibility and telling it as it is, yet it is noteworthy that she is absent. At a time when a Bill is being introduced in the House relating to two issues central to Government policy, it is remarkable that the Cabinet Minister responsible is absent.

This Bill deals with two unrelated matters. It provides for charges to be levied for nursing home care in line with the Supreme Court judgment on the Bill recently struck down. It also provides for the new general practitioner-only medical cards. While they are unrelated, the two issues are linked. In 2001, when the Government drew up legislation to extend medical cards to the over-70s, the anomaly regarding charges being levied against those in public nursing homes came into sharp focus. This was the moment when the fudge that had prevailed should have been faced up to. That point was made by the Supreme Court and begs the question why the Government parties, Fianna Fáil and the Progressive Democrats, did not deal properly with issue then. It was the Government's decision to change the law on medical cards, which has proven to be extremely wasteful and costly for taxpayers. It was a decision made for opportunistic electoral purposes.

Now that she is presiding over this fiasco, the Minister is desperately trying to wrap the mantle of 11 Governments around her for protection. She referred back to the McInerney case in 1976 in her attempt to spread the blame. She also referred to senior counsel opinion provided by Ronan Keane in 1978, but there is no published record as to what that opinion states. She has an obligation to publish that opinion so that we can see what precisely is the basis of the argument used in her damage limitation exercise. If there are matters arising from that opinion which are in the public interest, I strongly urge her to publish it now.

She also needs to tell the House when and why exactly she changed her view on the nature of the problem. In her speech of 16 February 2005, she stated:

In my statement to the House last December I stated that the charges had been levied in good faith. The Taoiseach made similar statements, both of us on advice and on the basis of the information available to us at that time. The Supreme Court decision today does not make a judgement whether the charges were made in good faith or bad faith, but in the light of the Supreme Court judgement and in the light of information that came to light in preparing for the hearings at the court, I would not now characterise the levying of these charges in the way I did in December. For example, legal advice was provided in 1978 by then Senior Counsel Keane and McCann that the basis of charges was not sound.

This statement has very serious implications. If a public official or office holder purports to exercise those powers, having received legal advice that such an exercise would be contrary to the law, he or she leaves himself or herself personally open to accusation of malfeasance in public office. One can only presume that the Minister for Health and Children had chosen her words carefully, so her words open up the scenario that cast doubt on the competence, integrity and liability in the civil courts of public officials and public office holders.

It is important that the Minister clarify the time she changed her view and the information that led her to arrive at such a potentially damning conclusion. We do not need to wait for publication of the Travers report since she made these statements in the House and should be able to reveal the basis for them in this House. I hope that she does this by the end of Second Stage. Despite her commitment to publish the Travers report swiftly and her indications that the report would be on her desk yesterday, we now know there is a delay in bringing it to Cabinet. The Taoiseach's reply this morning did not engender confidence that this report would quickly be in the public arena. Will we have to wait until after the by-elections before the public can have the full information to which it is entitled? It certainly seems that the process is being delayed unduly, which is not acceptable to anyone from the Opposition and does nothing to enhance the Minister's already bruised reputation.

We know that the issue of charges and their legality were clarified with the introduction of the over-70s medical card scheme. In 2002, the South Eastern Health Board sent an 80 page legal opinion to the Department relating to long stay care and the legality or otherwise of the charges. We know it was also circulated to other health boards, but we do not know what was in that legal opinion. I have sought that the legal opinion received by the SEHB be published, but again the Minister has refused to do so. It appears that she prefers to drip feed selected items of information as it suits her, to put some gloss on her own deplorable record of trying to legalise retrospectively unlawful charges against vulnerable people. Again I ask her to publish this legal opinion and, with the Keane opinion, to open it to public scrutiny.

She has published the minutes of a very high level management advisory committee and CEO meeting which was attended by three Ministers, Deputies Martin, Tim O'Malley and Callely, as well as senior departmental figures and health board CEOs. It is interesting that the Minister who was not at that meeting is here today for this debate. The issue of long stay charges was the third item on the agenda and a clear decision was made to refer this matter to the Attorney General to have an assessment of the need for a stand-alone Bill. The then Minister for Health and Children, Deputy Martin, stated that he was not present for that particular part of the meeting, yet it is simply incredible that he did not read the minutes of that meeting nor understand the importance of the matters involved.

It beggars belief that the then Minister for Health and Children, Deputy Martin, can maintain such a position. He has serious questions to answer and he should come into the House to answer questions on his entire role in this fiasco. He cannot wash his hands in the manner of Pontius Pilate, no matter how hard he tries to do so. The Minister of State with responsibility for older people was in attendance all the way through the meeting, as was the Minister of State with responsibility for mental health. What have they to say for themselves? How do they explain their negligence on an issue that was the subject of a central discussion at a meeting at the highest level of their Department? Deputy O'Donnell defended the Minister in this House, claiming that Ministers were being kept in the dark and that this was the problem. That may be part of the problem, but it is very clear from this meeting that Ministers were not kept in the dark and that the issue was discussed in their presence.

During her speech on the original Health (Amendment) Bill 2004, which has since been struck down, the current Minister for Health and Children stated:

Arising from that meeting a small group was convened within the Department to prepare a position paper on the legal issues surrounding charges for long stays in public institutions. This position paper was drawn up at the end of January 2004, as was a letter to the Office of the Attorney General requesting legal advice that would have been signed by the Secretary General. Unfortunately, this letter was not sent at that time.

Was any Minister involved in any way with this special group? Was there involvement in any way by the senior Minister in respect of the letter to the Attorney General not being sent? We are having a debate on these issues and asking legitimate questions, yet we do not have the essential information that this House needs to ensure proper scrutiny of the Government record. The Travers report is delayed and that fact can be used as a handy shield for the current Minister for Health and Children, but there is nothing to stop her from fully answering the questions posed today that need to be answered. It might redeem her in the eyes of some, at a time when she needs it.

In the most recent opinion poll, one third of the population now thinks that the health service has deteriorated under her watch. This is a remarkable come-down for a Minister who promised so much on taking office. She stated: "The one thing I want for the country I love is to have a health service that is accessible to every citizen regardless of their wealth." She went on to speak about a world-class health service. We now find that six months later, one third of the population is convinced that during her term of office, the health service has deteriorated.

All we have seen from the Minister has been the administrative change in the establishment of the Health Service Executive. In a tremendous rush before Christmas and following a disgracefully guillotined debate it was established on 1 January. Now that it is in existence, I can compare it only to a headless chicken running to stand still. It is without direction, leadership or a chief executive officer. As we saw in recent days, the body the Minister vaunted as the great hope to manage the health service cannot even organise and manage a phone helpline. Hundreds of people could not get past a voicemail message to obtain the information they needed on the hospital charges debacle. I recall my constituency colleague, Deputy Roche, making great mileage out of the ending of the voicemail culture in the public service. I wonder what his criticism would be of his Cabinet colleague's failure to ensure the successful operation of a helpline.

It is important that we receive answers on the Travers report. The Minister for Health and Children, Harney commissioned the report was commissioned and undertook that it would be completed quickly and published. This morning, my party Leader asked the Taoiseach to indicate when the report would be published, but the latter refused to answer the question. He evaded it and failed to indicate a timeframe, saying it was already in the public arena, which it is not. It should be. It is important to ensure that publication of the report does not depend on what is in it, but on the public's right to know. While the Minister herself has described the fiasco as the result of systemic maladministration, she has not explained in detail precisely what she means. She is noted for shooting her mouth off on occasion as we saw in the impact such behaviour had in the context of a tribunal issue. When a Minister uses such language, she has a duty to explain precisely what she means and should not leave her words to hang in the air and cloud an issue in a malign way.

Somebody must clarify what people qualified for public nursing home care but did not receive it, as indicated by the ombudsman. Perhaps the Minister of State, Deputy Seán Power, has the answer. The people in question entered private nursing homes and were forced to pay for the care they received. We must hear a Government view on whether they have rights, including the right to compensation.

As Deputy Twomey pointed out, there are significant issues to address, which have nothing to do with charges and everything to do with long-stay care. There is a shortage of public nursing home beds. Quite apart from future needs, we lack the capacity to deal with today's demands. The Government promised to fast-track the delivery of 850 community long-stay nursing home beds through public private partnerships. Years after the promise, not one bed exists on a drawing board let alone in a completed facility. It is an indication of the lack of planning and strategising that has characterised the Government's policy on care of the elderly and it is a matter of great concern.

As we are all aware, the population is ageing. While we are fortunate that our population has a younger profile than those of many other member states, I would have thought it provided us with the opportunity to get things right ahead of time rather than to lay the foundations for a future crisis. Nursing home residents and their spouses are being pauperised as subventions are not enough to cover the costs of nursing home care. Some cannot manage to pay for care without losing everything, while others cannot pay even after losing everything due to their low incomes as pensioners. The Government must deal with a set of strategic issues in this context.

While everybody understands and accepts the principle that the State should meet a portion of the costs facing people in public nursing care, the parliament for older people has pointed out that the proportion of a person's pension left for pocket money may be too low. When one itemises the costs for newspapers, haircuts, presents for relations and cigarettes, it becomes apparent that the proposal to limit pocket money at a low level requires review. I hope we receive more information on the way in which the compensation scheme will operate. In the case of the drugs refund scheme under which moneys were illegally deducted from people's funds, it was enormously difficult to access the sums owed. The onus was placed on individuals to make their cases to the Department instead of on the Department as the body that made the mistake. If the system of compensation is difficult to understand and places the onus on people to prove their cases, it will be unfair. Enough unfairness has been levelled against vulnerable people like those in long-term care.

We are finally seeing legislation on the general practitioner only, yellow-pack medical cards. It is important to place the proposal in the context of the difference between the Government's promise and reality. The Government promised 200,000 new medical cards, not 200,000 yellow-pack cards. The original promise implied access to a great many services including drugs provision as per the entitlements under the security of medical card cover. It is important to note that since the Minister announced in November or December that she would provide 30,000 new medical cards, between 10,000 and 11,000 people have lost their cover. It is indicative of the difference between the Ministers' promises and reality as experienced by patients who find it difficult to pay their bills.

Opposition Members often complain that they do not have the resources required to make their cases. I am delighted we are to be provided with researchers in the near future. I pay tribute to the small, dedicated Labour Party staff who do a great deal of work to ensure that we have a sound basis on which to make our arguments in the House. Labour Party staff did excellent work in tracking the Government's record on medical cards as opposed to the spin. We produced a document recently, entitled A Cruel Deception, which tracks the story of the loss of medical cards during the term of office of a Government which promised to increase the number issued.

It is worth looking at what the Government has said. The national health strategy stated there would be significant improvements in income guidelines to increase the number of persons on low incomes eligible for a medical card and to give priority to families with children, particularly those with disability. The 2002 Fianna Fáil manifesto stated the party would extend medical card eligibility to more than 200,000 extra people with a clear priority given to families with children.

These are the promises, but since 1994 the percentage of the population covered by medical cards has plummeted. Some 36% of the population was covered in 1994, but by 2004 that figure was down to 25.7%. The GP's contract allows for up to 40% of the population. We are a very rich country and we can afford to provide medical cards for people on low incomes who cannot get to see their family doctor and pay the drug bills to keep their families well.

This is a cheap "Lidl style" medical card. Money is being diverted elsewhere by the Government into less important causes. What can be more important than a family having the security of a medical card? They could have that without legislative change. They could have it immediately without new deals with doctors, or awful deals such as that struck with regard to the over-70s. It should be straightforward; it is all there.

The only thing required is a Government to commit the money and live up to its promises. However, that is what we do not have. We have a Minister who claims she is now delivering 200,000 new "yellow pack" GP cards. Shame on her. People need the security of knowing they can access care when they need it. A family-only doctor card is better than nothing, but are we really that cheap in this country? Have we not developed in ways that we can afford to? Are we going backwards? One only needs look to the past. The former Fianna Fáil Minister, Erskine Childers, delivered and ensured there was fairness in the system. He created a way of ensuring people could access care, yet now when we are so much richer and more capable of providing for people we are doing proportionally less for them. That is deeply disappointing and adds to the cynicism people feel about the Government.

While the number of medical cards has plummeted, medical costs have also plummeted. Our document showed, for example, that there has been a 62% increase in health inflation since 1997. The industrial wage went up by only 51% and the increasing rate of inflation by 29.4%. Until the recent changes the increase in income threshold for medical cards was only 27.88%. One must look at the actual costs that people without medical cards must meet. Inflation in the health sector is up 62% since 1997; inflation in the cost of doctors' fees is up 75.6%; and inflation in the cost of hospital fees is up 108%. The drugs threshold has increased greatly. People simply cannot afford to care for themselves and their families.

We now have a cut-rate deal which may or may not work. The Minister promised 30,000 medical cards, but fewer people are now getting cover than when she took office. She is stating that this Bill will bring in 200,000 people under the "yellow pack" scheme, but there is no link between the Bill and the figure of 200,000. She may say that, but the evidence is not there. We must tease out this matter on Committee Stage.

Last night I attended a meeting of post-polio sufferers and the issue of medical cards and long-term illness cover came up. This issue was raised at the Joint Committee on Health and Children and there was all-party unanimity that post-polio sufferers and their support group need to be prioritised. These people are suffering the severe effects of polio later in life even though they contracted it years ago. There is only one generation; there will be no more. However, these people are still in our community and still experience great difficulties. I urge the Minister to ensure this small category of vulnerable people are properly provided for.

I thank the Secretary General for coming to the committee and I thank the Minister for providing €300,000 for this group. However, the protection of the medical card scheme and long-term illness cover would substantially improve their lives. That type of intervention would prolong the quality of life for those who suffer so much, and we should look after them.

Mr. Sargent

Ba mhaith liom mo chuid ama a roinnt leis na Teachtaí Connolly, Healy agus Ó Caoláin.

This legislation is in many ways an attempt to mop up, but the health service requires much more than mopping up. It is important that we have this debate to try to tease out some of the areas which have not been addressed in this legislation. I want to stay with the legislation because while an overall debate on the health service is necessary, it will not be justified simply by this legislation. Time must be set aside for it.

A number of my constituents are affected by the illegality of the Government's actions in terms of payments for nursing home care. Included in the number are young adults as well as the elderly. People with learning disabilities in particular are concerned that they are forgotten in the overall debate. I do not take from the enormous concern that exists among elderly patients and their relatives. However, we should perhaps give a more comprehensive breakdown because the headlines tend to focus on the issue of the elderly, and, while it is right that they do so, the whole picture must be seen and understood.

There have been enormous problems in the area of elderly care, as has been mentioned by other speakers. Deputy Twomey spoke earlier of the overall condition of nursing homes. In the past, for example, people requiring residential care fell between two stools, not only in terms of entitlements, enhanced entitlements or the bureaucracy involved in making applications, but also geographically. Enormous distress was caused when an ambulance did not arrive from the nearest location but from the centre of a health board area that was much further away. There was a lack of co-ordination in that regard but it is to be hoped that we have left that behind us now. It was a needless cause of distress to people in my area of Balbriggan which was closer to Drogheda than Dublin for ambulance services.

The overall issue of nursing home standards and the provision of public nursing home facilities in particular requires further debate. I would welcome such a debate if it could be arranged. The Minister of State, Deputy Seán Power, will be aware of the extent to which home help is being cut back because his brother, my friend and colleague, Councillor J.J. Power, has probably told him about it. That cutback has a knock-on effect and is part of the important debate that needs to take place concerning nursing home care. People who find it difficult to manage generally prefer to stay in their homes. The availability of a home help can make the difference between having a good quality of life or, sometimes, losing the will to live. Home helps represent exceptionally good value for money but they earn meagre pay. That problem needs to be addressed by providing proper remuneration for the work done. There is no comparison between the cost of providing home help and the cost of a nursing home place. The amount saved by not having to provide a nursing home place makes the provision of home help more than worthwhile. The Department should examine how it can satisfy the need for home helps thus avoiding the fall-back position of providing nursing home places, because that appears to be the only available option. The Minister of State is in a good position to address that matter, so I would like to hear his views on that question which is relevant to the general discussion on nursing homes.

In his opening remarks, the Minister of State referred to general practitioner-only medical cards. A trend is developing whereby people find they are unable to attend their GPs as often as they used to. They find there is only one option, which is the GP who happens to be available. The solution may involve discussions with the GPs themselves. Yesterday was work balance day, so GPs need to take this matter into account as well. When somebody cannot visit their own GP who is familiar with their case history, it represents a lowering of health care standards. Their local GP represents a better chance of providing holistic health care because he or she knows the patient and may know their family members as well. That is a help when it comes to treating hereditary diseases.

In dealing with the Bill on Committee Stage, I hope we can examine those issues, which are relevant. They may not fall directly within the terms of the legislation but, nonetheless, they represent an opportunity to raise expectations through upgrading the provision of services.

Tá díoma ar dhaoine atá ag fiosrú mar gheall ar na haisíoctaíochtaí altranais mar, de réir dealraimh, níl aon duine fostaithe ag an líne chabhrach náisiúnta chun déileáil le daoine trí Ghaeilge. Tar éis do dhaoine fiosrú a dhéanamh óáiteanna sa Ghaeltacht, no sa Ghalltacht, níl duine ar fáil le cúrsaí a phlé trí Ghaeilge. Is trua é sin agus seans go bhfuil sé míbhunreachtúil. Tá an Coimisinéir Teanga ag plé na ceiste ach tá sé go dona do dhaoine ón Ghaeltacht atá aosta agus atá a phlé cúrsaí trí Ghaeilge ó thús saoil amach nach bhfuil siad in ann déileáil leis an cheist seo trí Ghaeilge.

Mr. Connolly

I welcome the opportunity to speak on the Bill which provides for the introduction of GP-only medical cards as well as providing a basis for levying charges on elderly persons in nursing homes and full-time care. Nobody doubts that the provision of GP-only medical cards, or "yellow pack" cards as they are popularly known, is a step in the right direction. However, the Bill appears to have a few ominous, restrictive qualifications that will water down the provision of such cards.

I call for a moratorium for people who currently have medical cards. Some form of instruction should be issued not to withdraw medical cards from those who have them, although that appears to be the trend. It is most likely that the people whose medical cards might be withdrawn will automatically become entitled to the doctor-only cards. Until the Bill is enacted and the new cards become available, we should avoid pulling the plug by withdrawing medical cards from those who currently hold them.

The Bill's provisions contain some restrictive qualifications, particularly the phrase "[for whom] it would be unduly burdensome to arrange general practitioner medical and surgical services for themselves and their dependants". The matter is left to the discretion of the new Health Service Executive, with no income guidelines specified in the legislation. It seems there will be a decrease in the number of medical cards provided.

One of the benchmarks for community welfare officers is an income guideline. It may not be the best method and on many occasions we have criticised such income guidelines but at least they provided a benchmark. I am concerned that the withdrawal of medical cards will now be left to the discretion of the chief executive officer of the Health Service Executive. The provision of 200,000 GP-only medical cards to bring borderline cases in line with regular medical cards would seem to be little more than a pipe-dream divorced from reality. The number of medical cards is being reduced. We were promised 200,000 extra cards but they are not coming on stream; they are being withdrawn.

Apart from the lack of guidelines for the provision of medical cards, the insufficient number of GPs to cater for 200,000 GP-only cards will have to be addressed. There is a crisis, particularly in some rural areas that cannot attract newly qualified doctors. That issue must be addressed as well.

Holders of GP-only medical cards will have to pay up to €85 for prescription drugs and hospital services. The cost of visits to a GP is a serious deterrent for people on low incomes. The provision of GP-only cards recognises this and is a step in the right direction in that it will be more likely that such card holders will visit their doctors and, therefore, that their illnesses will be diagnosed earlier. The medical evidence is that early diagnosis and intervention can lead to a more successful result from treatment. Early intervention means that patients will not have to wait while their illnesses deteriorate or face increased medical costs as a result. If they remain untreated, such people can become emergency cases availing of hospital accident and emergency units. These issues must be examined.

Debate adjourned.

Sitting suspended at 1.30 p.m. and resumed at 2.30 p.m.

Dáil Éireann debate - Wednesday, 2 Mar 2005