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Dáil Éireann debate -
Wednesday, 11 May 2005

Vol. 602 No. 2

Other Questions.

I must remind the House that supplementary questions and answers are subject to a maximum of one minute.

Health Care Strategy.

Eamon Ryan

Question:

61 Mr. Eamon Ryan asked the Tánaiste and Minister for Health and Children the progress made to date in implementing the primary health care strategy; if a proper primary health care strategy will deal with up to 90% of illnesses; the costs for such a health care strategy; and if she will make a statement on the matter. [15372/05]

The strategy, Primary Care: A New Direction, sets out the Government's broad vision for the development of primary care as the central focus for the delivery of health and personal social care services in a modern health system. The strategy aims to shift the emphasis from the current over-reliance on acute hospital services so patients will have direct access to an integrated multidisciplinary team of general practitioners, nurses, health care assistants, home helps, occupational therapists and others. As the new primary care model is implemented, a wider network of other health and social care professionals will also provide services for the population served by each team.

The strategy provides a template for the development of primary care services over a period of ten to 15 years. The full implementation of the primary care strategy will require significant investment, over a sustained period, to expand capacity and enable primary care to become the cornerstone of our health system. Three broad approaches will be taken to enable this to happen, namely, revenue and capital investment by the State to deliver additional services; a structured role for the private sector in the development of facilities and possibly also the delivery of services; and the substantial reorganisation of the resources already in the health service.

The strategy provided an indication of the scale of resources potentially required. Those who formulated it estimated the capital cost of developing a primary care facility at some €2.5 million for each team, which is approximately €1.27 billion for the first 400 to 600 teams. The additional staffing costs involved, allowing for the availability of existing staff and taking account of the composition of typical core teams and the associated network professionals, were estimated to amount to approximately €615 million per annum for the first 400 to 600 teams. The strategy also estimated that up to €50 million in once-off costs and running costs of €12.7 million per annum would be required for ICT supports. However, as was indicated clearly in the strategy, the required investment could come from a range of sources, not solely from the Exchequer.

On implementation, one of the first steps has been to establish an initial group of ten primary care teams, with supplementary funding to enable existing staff resources within the public system to be augmented.

Among the enhanced and expanded range of services these teams are providing or developing are improved access to physiotherapy and occupational therapy, shared care arrangements with general hospitals and social work services focusing on general family support needs.

Additional information not given on the floor of the House.

The experience of the ten teams to date has shown that collaborative work among health professionals at local level supports both a shared understanding and service response to a range of health care issues, while also providing continuity of care for patients and their carers. This reflects the international consensus. It is now widely accepted that integrated team-based primary care represents the most appropriate, effective and user-friendly approach to service delivery, offering the potential to cater for 90% to 95% of all health service needs.

A significant element in the implementation of this strategy will be the reorganisation and reconfiguration of resources and services already within the health service. This reflects also one of the core principles underpinning the health service reform programme. The Health Service Executive must address this to provide a firm basis for the development of primary care teams and networks as the standard model of service delivery. I am aware that considerable work has already been undertaken by the former health boards over the past two years to map out the proposed numbers, locations and configuration of future primary care teams and the resource requirements associated therewith. The HSE must complete this task to provide a firm basis for the reorganisation of resources within primary care.

One of the most significant changes this process will require is that primary care professionals of different disciplines will have to develop strong and effective working relationships with each other, at team and network levels. The primary care model requires horizontal working and reporting across disciplines. The existing model of professional management in primary care services, in which reporting arrangements are often largely hierarchical, does not align well with the model of team-working set out in the strategy. The current contracts with general practitioners are also out of keeping with what is required of a modern, high-quality primary care service and will be the subject of detailed review in the context of the development of new contractual arrangements in respect of GPs' delivery of primary care.

I look forward to all professionals involved committing to embracing the new working arrangements I have described as a key part of the process of reforming and developing our health services.

As I have indicated, all of the investment needed to enable implementation of the primary care strategy need not involve the public sector. I am committed to developing policy in ways that will stimulate private sector investment in the development of both facilities and services. In light of the considerable private sector interest in the development of hospitals and long-term care services, I envisage much potential for such developments in primary care to complement investment by the State. I have asked the Department to consider how this agenda can be advanced in a way that will harness this undoubted potential within the non-State sector and so enable and support the delivery of integrated primary care services in line with national policy.

I thank the Minister for her reply. Does she agree that the document is excellent and acknowledges that we can deal with up to 90% of illnesses through primary care? This is an astonishing figure. However, is it not the case that the significant investment, about which the Minister has spoken, has not been forthcoming? Will she explain why the last meeting of the steering group considering primary care was cancelled? Was it cancelled because many people felt she had not stepped up to the plate — to use a phrase I heard from one of the members of the steering group — or made a commitment regarding the investment? The group wants the investment programme to be set out so it will know that circumstances will be much improved in three or four years.

The cost at the time of publication was €1.2 billion. Further costs were estimated to amount to a couple of hundred million euro per annum. We do not have these resources at present. We are increasing spending on health by 10.8%, or 8.5% in real terms. In the United Kingdom, the previous Government advocated a target of 6% growth in spending. It said it hoped to achieve it during its lifetime but has not yet done so. In both France and Germany, spending is increasing at a rate of 2%.

There is only so much one can do with the resources available. I hope that in the context of the contract renegotiated with primary care professionals, who are essentially the doctors who will lead the teams, and with the introduction of some tax incentives, we might be able to encourage greater private sector investment in primary care. There are issues concerning taxation to be cleared at EU level.

I recently met a number of GPs from Killarney who have adopted a very innovate approach. They are looking for relatively little from the State to build a state-of-the-art primary care centre in Kerry. This is the kind of model we need to replicate in other parts of the country. It is the only way we can achieve the kind of primary care strategy we all want to see implemented.

Does the Minister agree that if we had managed properly the overruns that accrued in respect of road building projects, we could have had an excellent primary care strategy?

Construction inflation was running at approximately 25% per annum some years ago because of the level of demand. That is always what happens when a sector overheats.

The country is spending €1 out of every €4 running the health service. This is not an inconsiderable amount. We have come an awfully long way, yet we all know of the deficiencies and gaps. It is a question of having a sense of priority and trying to obtain as much as we can for the money being spent. I accept there might be too great a focus on hospitals and that we should focus more on primary care. The primary providers of health care are doctors. Doctors at general practice level intervene more with patients than any other group of doctors. Some people see a consultant only once in a lifetime because they may not require further visits, but they see their general practitioners frequently. I accept that more and more resources must be directed towards primary care, coming from a very low base. However, we will not be able to obtain the sum I mentioned in the short term.

Safe Sex Promotion.

Pat Rabbitte

Question:

62 Mr. Rabbitte asked the Tánaiste and Minister for Health and Children if her attention has been drawn to concerns expressed regarding the reduction in funding for the promotion of contraception and safe sex among young people, especially in view of a recent increase in the number of teenage pregnancies; and if she will make a statement on the matter. [15336/05]

In response to the specific issues regarding unplanned pregnancy, the Crisis Pregnancy Agency was established by statutory instrument in 2001 and is funded by the Department. The Crisis Pregnancy Agency is a planning and co-ordinating body established to formulate and implement a strategy to address the issue of crisis pregnancy in Ireland. A core aim of the agency is to achieve reduction in the number of crisis pregnancies by the provision of education, advice and contraceptive services.

The first strategy to address the issue of crisis pregnancy was officially launched in November 2003 and provides a framework for understanding the causes and consequences of crisis pregnancy and presents a clear set of actions to address the complex and interacting factors that contribute to the experience of a crisis pregnancy. The Crisis Pregnancy Agency works on an ongoing basis with statutory and non-statutory agencies to ensure successful implementation of the strategy. Since its establishment, the agency has received a total of €26.996 million in funding.

To promote contraception and safe sex, the Crisis Pregnancy Agency funds the Think Contraception campaign. This campaign is aimed primarily at people between 18 and 30 and also promotes abstinence as an option in sexual health as well as all forms of contraception for those who are sexually active but do not wish to become pregnant. The Think Contraception campaign is the result of many months planning which involved the development of an evidence base to inform the campaign, a consultation process with relevant stakeholders and focus testing among the target group. The campaign aims to prevent unplanned pregnancy by reminding sexually active young adults to use contraception consistently. While primarily a television advertising campaign, support literature and a website have also been developed to further support the key messages. The leaflet has been widely circulated to all GPs, pharmacies and family planning clinics. These are locations where young adults can receive expert advice and information.

The Crisis Pregnancy Agency develops and runs additional promotional campaigns on pregnancy prevention on an ongoing basis to directly engage with sexually active young adults. The aim of these targeted campaigns is to heighten awareness among young adults of the probability of sexual risk-taking with alcohol consumption, specially while one is on holiday, away from home and in places of entertainment. It also aims to renew their knowledge on benefits of condom use and contraception awareness. The 2005 promotional campaign will begin in June of this year.

Additional information not given on the floor of the House.

In 2005, the funding allocated to the Crisis Pregnancy Agency's programme of prevention will be €825,000. In addition to the agency's direct promotional work, its funding programme is the largest single component of the annual budget. The programme funded 78 projects in 2004 and there is a no-policy-change commitment to disburse more than €3 million of funds in 2005. Within the overall programme of funding, a wide range of projects with a focus on crisis pregnancy prevention has been supported to the value of €736,000 nationally.

The Department also recognises its key role in supporting policy development and cross-Government working to address the issue of young people's health generally and in particular regarding promoting safer sex. In this regard, the Department works closely with the Department of Education and Science and other agencies and bodies to support young people in developing the appropriate knowledge, attitudes and personal skills to enable healthy relationships and sexuality.

In the school setting, the Department is working in partnership with the Department of Education and Science and the Health Service Executive to support schools in the introduction and delivery of social, personal and health education at both primary and post-primary levels. Relationships and sexuality education is an integral part of this curriculum and remains a key priority for this work with schools. Since the establishment of the support service in 2000, the Department has directly provided funding of more than €150,000 per annum to the service and this has been matched by substantial funding from the other partners.

In the out-of-school setting, the health promotion unit of the Department works in partnership with the youth affairs section of the Department of Education and Science and the National Youth Council of Ireland to implement the national youth health programme. The aim of the programme is to provide a broad-based, flexible health promotion and education support and training service to youth organisations and to all those working with young people in the non-formal education sector. Within the context of this programme, a training initiative entitled "Sense and Sexuality" is offered to youth workers. It addresses the issues of relationships, sexuality and sexual health with young people. In 2005 the programme will receive a funding allocation of more than €80,000.

The health promotion unit also runs a national public awareness advertising campaign to promote sexual health. The campaign is aimed at men and women in the age group 15 to 35 to increase awareness of safe sex and sexually transmitted infections. The overall goal is to increase safe sex practices, reducing the incidence of sexually transmitted infections transmission and unwanted pregnancies among young people. The campaign runs in third level colleges, places of entertainment, including pubs, clubs and discos, and youth venues and some health centres. This national programme has been running for several years and the health promotion unit is currently implementing a new and revised campaign, which has greatly increased the number of venues targeted. Since 2002 an information leaflet has been distributed as part of the campaign and currently the campaign is placed in 1,490 display points in 240 venues nationally. In 2005 almost €200,000 will be allocated for the development, expansion and continuation of this programme. The health promotion unit also produces a range of awareness raising leaflets on sexually transmitted infections and safe sex practices.

In all of the work carried out by the Department and the agencies it funds, the important role of parents in the development of healthy relationships and sexuality for young people is acknowledged and supported. To this end a key aspect of the strategy to address the issue of crisis pregnancy is to support parents in their role as the primary educators of their children on issues such as sexuality and relationships. In response to requests from parents and parent groups for help on how to begin talking to children about such a sensitive topic, the Crisis Pregnancy Agency developed a new resource called "You Can Talk To Me". This DVD and booklet aims to assist parents in communicating with their children — adolescents in junior cycle — about sexual health and relationships.

The rate of teenage fertility in Ireland has been relatively stable over the past 30 years. The number of teenage pregnancies per 1,000 females aged between 15 and 19 has ranged from 17.04 in 1970 to 25.66 in 2001. The teenage pregnancy rate shows a similar pattern to fertility rates since the 1980s. While the figure has been increasing since 1996, the current level is now the same as the 1980 level.

My Department's response to the issue of crisis and teenage pregnancy has been to work with all relevant stakeholders to develop a comprehensive and co-ordinated response and strategy. Total funding for the wide range of activity currently under way reflects a considerable increase in the allocation in recent years.

Nobody would argue that the Crisis Pregnancy Agency is not doing a very good job and therefore I will not comment further on this. However, I am concerned about the rather complacent approach the Minister of State has adopted to safe sex. One does not just get pregnant from sex, one can also get herpes, gonorrhoea, syphilis and hepatitis B, for example. More people are contracting STDs or STIs than ever before. The number has trebled since the late 1980s. Does the Minister not feel he should be ashamed that the budget for promoting safe sex among young people has decreased by 17%? What will he do about that? Young people have been targeted but people beyond child-bearing age also contract sexually transmitted diseases, yet there seems to be no effort to inform them about the risks in unprotected sex.

I do not agree we are complacent. We are aware of the difficulties that exist. We have taken action to highlight to young people the dangers of unprotected sex. We work with the Department of Education and Science in schools. Outside the school setting we engage with youth groups to provide education and promotional material. We run a national public awareness campaign to promote sexual health directed at men and women aged between 18 and 35 years. That campaign aims to increase awareness of safe sex and sexually transmitted infections.

Promotional campaigns are only part of the solution to the problem. There must be back-up too. A recent study of third level students showed that when in difficulty they are reluctant to come forward and seek advice. We are working with the colleges to ensure we have a team available on campus to deal with students in trouble.

We have run a national awareness campaign for the past six years for which we will provide over €200,000 this year. In 2000 the figure for that campaign was €106,000.

Is the Minister of State not aware that in every year during which the Department has run its campaign the level of sexually transmitted infections has risen? He has not answered the question why, if this issue is so important and deserving of campaigns, the budget was significantly reduced between 2003 and 2004. Why does the budget not increase to meet the needs created by this growing problem? It is a problem which affects young and old people, whom the Minister of State seems to ignore as being sexually inactive.

The Crisis Pregnancy Agency was established to deal with the problem of unplanned pregnancy. The agency's main aim was to reduce the number of crisis pregnancies through education, advice and the provision of contraceptive services. Since we established it in 2001 we have increased the revenue to the agency each year, amounting to a total of €27 million.

I am referring to the budget directed at young people.

There have been several campaigns and we have increased the budget for the national awareness campaign each year for the past six years.

The Minister of State is focusing on contraception but he should focus on education. It might surprise him to know that 13 and 14 year olds regularly engage in sexual activity. Three factors are involved here: many teenage girls suffer low-esteem and allow themselves to be coerced in sexual activity, there is a high rate of consumption of alcohol and drugs by teenagers and they are ignorant of sex education. In many cases they have no clue as to what is happening or what they are doing. That is because there is no proper sex education. The Government's sex education policy is fumbling around in the same way that teenagers fumble around when engaged in sexual activity. That is the area on which the Minister of State should focus. We will have moved in 15 years from having to provide sex education in secondary schools to providing it in primary schools if we do not tackle the issue. I would appreciate the Minister of State's opinion on that comment.

We are aware of the problem and have worked in partnership with the Department of Education and Science to support schools in the introduction of social, personal and health education. That scheme involves primary and post-primary schools. The relationships and sexuality education is a vital part of the curriculum and is a key priority of our work with schools.

I disagree with the Deputy that teenagers do not know what they are doing. Young people are more educated today than they have ever been. They are probably prepared to take more risks today than we were.

I must challenge that statement. Teenagers may know what they are doing, but they do not know how it works.

Several studies have identified alcohol as a major factor in many unwanted pregnancies and in the practice of unsafe sex.

Registration of Medical Practitioners.

Enda Kenny

Question:

63 Mr. Kenny asked the Tánaiste and Minister for Health and Children the protection and safeguards that exist for patients from discredited doctors; and if she will make a statement on the matter. [15427/05]

Under the Medical Practitioners Act 1978, the Medical Council was established as the body with responsibility for the registration of medical practitioners and the regulation of their activities. The function of the Medical Council is to protect the public through implementing appropriate controls on the medical profession.

Doctors practising within this State should be registered with the Medical Council. It is an offence under the Medical Practitioners Act for a doctor to represent himself or herself falsely as a registered medical practitioner when he or she is not registered. Registration is required to sign medical certificates and to issue prescriptions for certain categories of drugs. In addition, doctors are not entitled to recover in legal proceedings fees charged for the provision of medical or surgical advice or treatment given when they were not registered.

Where a concern arises about the professional activity of a registered medical practitioner, the Medical Council has the power to investigate the circumstances of the complaint and, if a prima facie case exists, to conduct an inquiry. Where a finding of professional misconduct or unfitness to practise is made against a doctor, the council has the authority to suspend, limit or revoke the registration of that individual.

The parliamentary counsel is drafting a new Medical Practitioners Act to update substantially the provisions of the 1978 legislation. Among the many changes I propose to introduce are a clear compulsory requirement for registration for all medical practitioners, changes to the fitness to practice process, the introduction of a mandatory scheme of competence assurance for all doctors practising independently and a much increased public profile for the council. I also intend to increase significantly the non-medical representation on the council to best ensure that public safety and protection is given the highest possible priority by the council as it develops in the future.

There is no point in rejigging the council unless it is backed up by a proper legislative position. The 1978 Act is totally inadequate today. In this House we have discussed the case of a medical practitioner who abused his position and the case of an alternative practitioner who in effect cost a person's life. Doctors and the Medical Council have called for a change to the Medical Practitioners Act because it does not work in today's world. For example, in regard to the distinction between doctors and alternative practitioners, no doctor can wilfully prescribe a placebo to a patient.

Under the Act, the Medical Council could strike off a doctor for prescribing a sugar pill. However, much of what alternative practitioners distribute is no more than a placebo. There is no regulation of the alternative health industry. The Tánaiste must introduce the necessary legislation not only for medical practitioners who are trained doctors and who, usually for financial reasons, prescribe dubious treatments, but also to regulate alternative practitioners.

The latter want to be regulated. Many of those who practise reiki or other alternative therapies such as acupuncture want regulation because they want to keep the cowboys out of their industry too. This is one area of society in which people call for greater regulation.

I agree with the Deputy. Until I took up this position I did not know that one could practise as a doctor without being registered. One cannot prescribe but it is possible to practise, which is incredible. I am not sure if I sent the heads of the Bill to the Deputies' offices.

No, the Tánaiste did not send them.

I apologise for that. The idea is to work with the Medical Council and others on legislation that will give the council the strongest possible powers. Its powers will allow it to be proactive rather than reactive when a complaint is received. Confidence assurance will be a great guarantee to the public and to patients because it means ongoing training and education. This is important in any profession but especially in the practice of medicine. The procedure of fitness to practise, which requires one to be a member of the council to sit on the inquiry, of which there are 40 to 50 per year, is a huge demand on the complement of people that makes up the council. This includes people in other professions and people who are very busy, so we need to provide more flexibility in this area.

It is not an either-or situation. We must strengthen the legislation governing medical practitioners and provide for the registration and regulation of alternatives. That can be done under the Health and Social Care Professionals Bill 2004 which is going through the Oireachtas. This will provide for the registration of several different health care professionals, but we need to go further to reassure the public that someone is competent and safe to give them assistance.

There should be a statutory registration for all people who consider themselves either acupuncturists, general practitioners or physiotherapists. Every GP must register with the Medical Council. If one does not do so, one cannot prescribe in this country. GPs pay more than €5,000 per year for insurance purposes in case they make a mistake. The alternative practitioner to whom Deputy Cowley referred does not have to pay anything. She does not have to pay a registration fee or indemnity insurance. This is not a nice situation in which to leave patients when so many use alternative practitioners. There should be regulations covering that. We would find that cowboys would disappear quickly if they had to have insurance and had to register.

On 26 May 2004 the former Minister for Health and Children, Deputy Micheál Martin stated that: "While the proposed amendments to the Medical Practitioners Act will relate to conventional medical practitioners, it must be acknowledged that the public will continue to use the services of alternative and complementary practitioners and alternative and complementary remedies." That suggests the legislation will not include these alternative practitioners who do not purport to be doctors but are natural healers, such as the lady to whom I referred earlier.

There is a need to regulate the treatments people use. Anyone can give out a placebo except a doctor. Doctor Paschal Carmody, with his dubious cancer treatment, was struck off the register but can still continue as an alternative practitioner and give placebos that doctors cannot give. There must be some measure to ensure that someone prescribing tablets is giving something that is evidence-based, that is, that it works, as opposed to tablets that purport to be something but which amount to nothing, such as in the case of homoeopaths. I have nothing against complementary practitioners but I have a problem with alternative practitioners who set themselves up as the alternative to traditional medicine and who endanger people's lives. The Medical Practitioners Act refers to mainstream medical practitioners. My concern is the alternative medical practitioners. Will the Tánaiste re-examine this situation?

The Medical Practitioners Act deals with the medical profession and will greatly strengthen and enhance the powers of the council. We want to maintain self-regulation in this and other areas of health care because it is more appropriate and does not involve the State carrying the cost of the regulatory regime. The Health and Social Care Professionals Bill will provide for a host of people to be brought under regulation but practitioners of alternative therapies might not easily be classified under a professional title.

There is a role for the Garda Síochána. We have strong laws regarding fraud. If people are told they will be cured of cancer on payment of €17,000 per treatment, as happened in some cases I came across last week, it is worthy of investigation from a criminal perspective. Many people are fooling very vulnerable citizens who have illnesses into paying large sums of money. Desperate people will do desperate things and these people are extraordinarily convincing. Very smart people can be fooled by them and the criminal law needs to take effect in this area.

Medical Cards.

Joe Costello

Question:

64 Mr. Costello asked the Tánaiste and Minister for Health and Children the number of medical cards issued in June 1997, June 2002, 30 September 2004 and the latest date for which figures are available; if the Government intends to honour the pledge in An Agreed Programme for Government to extend eligibility to another 200,000 people and the commitment provided in the publication of the Estimates for 2005 that 30,000 additional medical cards would be issued from 1 January 2005; the number of the promised 30,000 new medical cards that have been issued since 1 January 2005; and if she will make a statement on the matter. [15313/05]

The number of medical cards issued and number of persons covered by a medical card for the dates are as follows. In 1997 there were 1,244,459 medical cards, or 34.37% of the population of 3,621,035. In June 2002, 1,207,096 persons had medical cards, or 30.81% of the population of 3,917,336. In September 2004, 1,151,106 persons were covered by the medical card, or 29.39% of the population of 3,917,203. In April 2005 there were 1,145,331 medical cards, or 28.32% of the population of 4,043,800.

Generally, the reduction in recent years in the number of medical cards may be attributed to the increase in the number of people in employment and also the improved economic situation nationally. Additionally, during 2003 and 2004, health boards undertook a review of medical card databases in which approximately 104,000 medical card records were removed. Many of the deletions from the databases would have been due to normal reviews but a number would have been duplicate or expired records. These reviews have led to deletions of medical card records due to duplicate entries, change of address, cases where the medical card holder is deceased or ineligibility due to changed circumstances. The determination of eligibility of applications for medical cards is a matter by legislation for the chief officer of the relevant area of the Health Service Executive. In determining eligibility, the local area of the HSE will have regard to financial circumstances and medical needs of the applicant.

In November 2004, I announced revised medical card income guidelines which were increased by 7.5 % for determinations of full eligibility, together with significant increases in respect of dependants, with a view to extending the number of medical cards by 30,000 in 2005. These guidelines are in operation since January 2005. In addition, the doctor-only card was introduced and these patients' income can be up to 25% in excess of the income guidelines used for the traditional card. The legislation required has been enacted and it is intended that a further 200,000 persons will become eligible. Additional funding of €60 million to allow these measures be introduced in 2005 has been provided.

The implications of my decision to extend medical card coverage will become apparent as the year progresses. We are determined to reach the figures. In relation to the doctor-only cards, the Health Service Executive has put in place the necessary administrative arrangements for their introduction. A public information and advertising campaign will commence over the coming days. This will indicate the process to be followed by applicants to obtain application forms and to have their eligibility assessed by the HSE. In the first instance, the executive will consider an applicant's eligibility for a full medical card in case he or she may be entitled to one. A process of engagement with the contractor and staff representative bodies is ongoing.

Does the Minister for Health and Children not accept that this is a shameful record? As this country has become richer, the number of people able to avail of the medical card has declined consistently. This is not because more people are richer but because the ceiling has been kept so low by a Government that is not willing to address the great difficulty people on low incomes have in availing of health care, specifically visiting their doctor and obtaining medication. Is the Minister aware of the substantial increases in the cost of visiting a doctor and of drugs and hospital care? The second two are charges where the Government is responsible for major inflation. Yet, according to the figures the number, in real and percentage terms, of people on medical cards has dropped during the term of office of this Minister. How can she say she is introducing 30,000 new medical cards when the figures indicate a drop in the number of medical cards? Who is the Minister trying to fool? The figures relating to low income families are much worse than indicated because they include the rich over 70s.

I remind the Deputy of the one minute time limit.

Will the Minister be honest with the people in regard to the position with medical cards and explain how she can say she is giving 30,000 additional medical cards and stand over figures that show the number of medical cards have dropped during her time in office?

As people get richer it may well be that fewer qualify. The unemployment rate was 11.5% in 1997 and is now down to over 4%. This year we increased the threshold for the traditional medical card by 7.5% which is twice the rate of inflation. The income guidelines are way out. We have used the best data available which is the Revenue Commissioners' figures. Clearly people's incomes are much higher than the increases provided for. That is the reason we are looking at this matter. I am determined that the 30,000 extra medical cards will be issued and that we reach the 200,000 GP only visit cards target. We need to move to a position where disposable income is taken into account. For example, child care costs should be allowable when calculating a person's income for the purpose of receiving a medical card. It is a complicated system in that it allows so much for travel, mortgage or rent. Obviously I want to focus on families with children. It leads to much confusion and makes the data less applicable than it might otherwise be. For next year I would like to move towards a disposable income position and if we can do it for the remainder of this year I would welcome it. We have the €60 million for that purpose and I am determined it will be spent on providing access to lower income families, particularly those with children, to general practitioner or services at that level. If we have to revise the income guidelines because people's incomes have risen faster than anticipated that is what we will do.

I wish to ask one supplementary.

It is a simple matter. The income levels will have to increase to a realistic rate. That is what can and should be done.

A 7.5% increase is pretty good.

Will the Minister state that the Government of which she is a member that promised 200,000 new medical cards has broken its promise, that it is abandoning the commitment it made to the people and will not deliver the badly needed medical cards to 200,000 people?

The Tánaiste gave a guarantee to spend €60 million on this issue, €30 million of which was for the doctor only medical cards and €30 million for the 30,000 traditional medical cards, all of which was to commence on 1 April or thereabouts. Given the rate of progress no medical cards will be issued before the summer. How will she spend the €60 million? Will it be spent on advertising, telling people about something they will not get until all these issues are sorted out? None of the medical cards announced last November has been issued, traditional or otherwise. That is the problem. Whatever about breaking promises, there is a litany of broken promises since the general election in 2002. No medical cards have been issued, and we are now into the summer, and neither has there been an announcement in regard to capital projects for 2005. It should be made crystal clear when these medical cards will be issued. They are a big issue.

Many cards have been issued since the beginning of the year and many new people have cards. We are issuing cards.

The Minister is taking them away.

No. People's income is rising faster than anticipated and the data on which these decisions are based are not as up to date as we would wish and yet it is the best available. That is the reality. Incomes are rising faster than any of us realise. Given the limited resources one has to use income data to decide what one can do.

The idea of the GP only card is to allow the widest possible number of people, particularly families with children, access to their doctor. We are aware of the huge increase in drug costs and how little can be done if we include it in the traditional way. I felt there should be graduated benefits where some get all and others get a different rate. We are determined to issue those cards this year. That is the plan and it will happen.

Written answers follow Adjournment Debate.

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