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Dáil Éireann debate -
Tuesday, 8 Oct 2013

Vol. 816 No. 1

Discretionary Medical Cards: Motion [Private Members]

I move:

That Dáil Éireann:

notes that:

- the number of discretionary medical cards fell from 80,524 at the start of 2011 to 63,126 at the end of 2012;

- in the first seven months of 2013 there was a further reduction of 8,142 such cards to 54,984, a monthly average reduction of 1,163;

- the Health Service Executive, HSE, set a target for 2013 to reduce the number of discretionary medical cards;

- this deliberate targeting was approved by the Minister for Health in the 2013 HSE service plan; and

- the targeted reduction to 55,328 in 2013 has already been exceeded;

agrees that the discretionary medical card is essential for those with serious illnesses, the treatment of which can cause major financial hardship;

deplores the decision to deliberately target people in clinical need of such cards;

and calls on the Government to:

- discontinue the targeting of those with discretionary medical cards; and

- ensure that no one in clinical need is denied such cards where it can cause significant financial distress.

I wish to share time with Deputies Sean Fleming, John Browne, Barry Cowen and Niall Collins.

We have been raising the issue of discretionary medical cards for some time. We did so when the budget for this year yeas introduced last December. When, in the context of that budget, a policy of withdrawing and removing medical cards was announced, we highlighted the fact that this would create huge difficulties for many people. On each occasion on which I have raised this issue, the Minister of State, Deputy White, has consistently stated that there has been no change in policy or in the guidelines. However, a cursory glance at the number of discretionary medical cards in the system shows that there has been a concerted effort on the part of the HSE to withdraw such cards. I accept that there has been no change in the guidelines. People are normally awarded medical cards on the basis of their financial means. That is how the system works. People make applications, their financial means are assessed and, based on the relevant criteria, they will either be awarded medical cards or they will not. However, there is also a mechanism whereby discretionary medical cards are granted to individuals whose incomes exceed the limits relating to ordinary medical cards. A discretionary card is awarded in light of the costs a person may incur on foot of the nature of his or her illness. At one stage in excess of 8,000 discretionary medical cards were in the system. I do not know about the overall health profile of the nation. However, I am aware of one thing, namely, there is no way there are fewer sick people in this State than was the case a number of years ago. It is not feasible to suggest that people suddenly appear to be getting better very quickly , that they are not suffering with serious illnesses or that they do not have major needs.

The Minister of State continually states in reply to parliamentary questions that there is a system in place in respect of the awarding of discretionary medical cards. The latter is simply not the case. There is a concerted policy on the part of the HSE in respect of this matter. That policy primarily revolves around the need to rein in the budget. We all know one thing for certain, namely, that discretionary medical cards are used by people who are very sick. As a result of the fact that the individuals involved are so ill, the costs incurred by the State in respect of these cards will always be high. The primary reason for the award of a discretionary card relates to the fact that the people to whom they are given are very sick.

As already stated, I have been consistent in raising this matter in the Dáil and I have tabled numerous parliamentary questions in respect of it. I have in my possession a list of individuals who, despite what one might believe, had their discretionary medical cards revoked. In some instances people have undergone both review and appeals processes but their discretionary medical cards have not been reinstated. Almost all of the individuals on the list to which I refer have illnesses which cannot be cured. The first of them is a young boy of six years of age who has profound intellectual and physical disabilities, who is confined to a wheelchair, who does not have the use of his limbs, who is incontinent and who cannot communicate. The card relating to this boy was withdrawn as part of a review. Following a protracted row with the HSE, a discretionary card was awarded for a period of six months. This is in respect of a child with profound intellectual and physical disabilities and all of the other problems to which I refer. I cannot understand how the Minister of State can stand over a system under which the medical card of a child whose physical and intellectual circumstances will never improve could be revoked and then replaced, following a review, with a six-month discretionary card.

Those in government appear to be on a merry-go-round whereby they continually state that there has been no change in policy. There has to have been a change in policy. Such a change is quite evident from the figures provided in replies to all of the parliamentary questions we have tabled in respect of this matter. There is no doubt that the number of discretionary medical cards has been reduced dramatically. Another of those on the list to which I refer is a boy who will be three years old in December, who has Down's syndrome, who is profoundly deaf, who requires substantial daily care, who has serious medical needs and who has an intellectual disability. This child's medical card was also revoked. Is the Minister of State seriously saying that he can stand over this change in policy? There is no point in his even suggesting that there has not been a change. What is being done is underhanded and represents a sleight of hand. I say this because medical cards awarded on discretionary grounds are now being assessed in the context of the guidelines relating to cards awarded on the basis of people's financial means. Such cards will, of course, be revoked because they were granted on the grounds of medical need and not on financial grounds. This is why there are 20,000 fewer discretionary medical cards in the system than was previously the case.

Another of those on the list I possess is a man who has lung cancer, who was recently diagnosed as bipolar and who had half of his right lung removed in March. His medical card, which was granted to him three years ago, was withdrawn. I am highlighting this matter because I am of the view that the Minister of State does not want to stand over what is happening. He knows in his heart and soul that it is appalling that, under the current system, medical cards can be taken from children and adults such as those to whom I refer. I instanced specific cases because what the Minister of State is being told and what is happening on the ground are completely different. There is not one Deputy in the House who would concur with his view that there has not been a change in policy. In parliamentary questions and during debates on health, Members continually highlight the fact that discretionary medical cards are being taken from those who are most ill.

We await next week's budget with bated breath. The Government has been flagging the fact that it intends to provide free GP care for those under five years of age. We all welcome this but who is going to pay for it? Will it be the six year old and three year old boys or the man with lung cancer to whom I refer? I have a sneaky suspicion that they will have to pay for it. The Government's mandate is based on its commitment to introduce universal health insurance and free GP care for everybody. As matters stand, no one has free GP care and those who are extremely ill and who have the greatest need of health services are suffering most. The Government has stated that health care should be provided not based on one's ability to pay but rather on one's need. Those to whom I refer are the people who need it most.

Another man whose name appears on the list in my possession is over 70 years of age. This individual has terminal stage cancer, he is being fed by means of a percutaneous endoscopic gastrostomy, PEG, tube, he can no longer move or speak, he is confined to a special wheelchair, he has dementia and we was awarded a GP-only card. The Minister of State cannot, in all good conscience, state that there has not been a change in policy. There has been a fundamental shift in policy. The nature of that shift is very simple: the Government is withdrawing discretionary medical cards on a continual basis. The Minister of State is correct in stating that there has not been a change in the guidelines. This is because there have never been guidelines in respect of discretionary medical cards. These cards are awarded at the discretion of the relevant individuals. In other words, it is their responsibility to consider the circumstances and needs of individuals and then make the decision to either award or not award a card. It has been stated that there has not been a change in policy. Neither have the illness profiles of people with physical or intellectual disabilities or those with particular medical needs changed but they can no longer obtain medical cards on the discretionary basis on which they were previously awarded. Of course there has been a change in policy in respect of this issue.

We are calling on the Minister of State and the Government to do whatever it takes to reverse this sinister, nasty attack on the sickest and most vulnerable people in our society.

This motion is an indication that, on a continual basis, Members on both sides of the House are raising this issue. If the Minister of State, Deputy White, does not believe me, he should read the parliamentary questions day in, day out on discretionary medical cards being withdrawn and asking the Minister to intervene.

I raised this issue on Leaders' Questions as far back as last January. At the time, the Taoiseach told me to send him on the individual cases. I do not expect the Taoiseach to be involved in every case because, as he says, he is a very busy man. However, the reason I sent him on the cases is that it is unbelievable that Members opposite can defend this issue. I raised the case of a woman in the House who has had a double mastectomy and is on chemotherapy. Her medical card was taken from her but eventually she was given a GP card.

In all conscience, the Minister of State, Deputy White, must accept the veracity of this motion. The amendment to the motion is an insult to the thousands of people who are waiting for reviews, who are trying to receive discretionary medical cards and who are trying to put forward their medical and financial evidence but who must wait months on end for a decision. Unfortunately, in the vast majority of the cases, the decision is to take medical cards granted on a discretionary basis rather than to grant them.

I thank my colleague, Deputy Kelleher, for raising this important issue of discretionary medical cards which affects many thousands of families. The Minister of State, Deputy White, may say there has been no change in policy but the practice has been changed. I believe there has been a change in policy but it has probably not been written down.

It boils down to the fundamental issue that this Government is focused on cutting expenditure on the most vulnerable people in Irish society. The majority party in this Government has decided, as a matter of policy, that it will not ask those who can make a larger contribution to the running of the country to do so. It has said it will make cuts in respect of people relying on State services, whether people with disabilities, people looking for medical cards, people on social welfare or parents depending on child benefit, and the Labour Party is implementing that down the line. The Minister of State, Deputy White, is in the firing line for this issue which is basically as a result of Government policy to cut Government expenditure on those who need it most in order to protect the well off people who are the main voters of the larger coalition partner in Government. That is why we have most of the difficulties in these areas.

If one looks back over the motions over the past year or two years, most of them relate to cuts in expenditure which this Government has decided to implement, as a matter of choice, rather than increase taxation. It can longer blame the troika as it will be gone. The level of adjustment will be the Government's choice and the breakdown of that adjustment in the budget next week will be a choice between taxation and cuts in expenditure. If the Government follows the practice of the past two years, further regressive steps will be taken in that regard.

I have been struck by the number of people coming to my constituency office about this issue. Every Member will be able to list difficult cases and I will highlight one in a moment. The Taoiseach was asked about the reduction in the number of discretionary medical cards by my party leader, Deputy Martin, on Leaders' Question some time ago. There was a time when if a person had serious cancer, he or she got a medical card as a matter of course for one year or two years until he or she recovered. It may not have been written down as policy but that was the established practice in every part of the country. That practice has now changed. If one has serious cancer, one will be told to go to one's public hospital and one will not get a medical card as a matter of course. The discretionary medical cards have been withdrawn in those situations.

The Taoiseach was pursued on this matter and the frightening comment he made was that people will get discretionary medical cards where their condition is life-limiting. In other words, if the condition one has will make one die sooner rather than later, one will get a medical card but if it will make one very sick and distressed for the rest of one's life, although not shorten one's life, one will not get a medical card. The Taoiseach was specific in referring to cases where the condition was life-limiting. I have said to people that if they have cancer and get a medical card, some consultant must think they are on the way out because the Taoiseach made it very clear that they will only get one if their condition is life-limiting. That is what is behind what is going on. The Minister of State, Deputy White, should not take my word for it but should read what the Taoiseach said. It is fine for him to say there is no policy on this but the practice, as a result of Government decisions, demonstrates otherwise.

I have come across dozens of cases but I would like to highlight one case which came to public notice in County Laois recently. I have the permission of the person involved to use his name in this debate. Mr. Joe Barrett published this article in the Laois Nationalist, a local newspaper, on 1 October 2013. The Minister of State's Department, which scans the newspapers for nice photographs of Ministers when they visit constituencies, should have come across this article. The headline was: "You Couldn't Make This Up". That is how bad he thinks the story is. I will summarise his story which is one of several stories I could relay and is in the public arena.

He stated that after 30 years of receiving a medical card, he was refused one this year. He went on to state that there has been a lot of disquiet since Fine Gael and the Labour Party came into government and cut 24,000 discretionary medical cards and that people who qualified before will only get a card if they require urgent and ongoing medical treatment. The first he heard of it was when he got a GP card. He asked the HSE why he was getting a GP card as he had serious conditions. The Minister of State, Deputy White, cannot outsource this problem to the HSE because the Minister, Deputy Reilly, has abolished the board of the HSE and is taking direct political control of this area.

At that stage, Mr. Barrett decided it was necessary to outline his situation to the HSE. He said that 30 years ago, he underwent a kidney operation and not long after that, he was found to have diabetes. After that, he was diagnosed with high blood pressure and then qualified for a medical card. Fast forward a number of years, and he then suffered a heart attack. Two months later, he had two stents inserted in arteries in his heart and a month later, an artery that had already been stented had to be redone. In the same year, he underwent open heart surgery and received a triple heart bypass. Following that operation, he underwent a heart operation a year later when one of the grafts that was used in the bypass blocked and had to be stented. Over the years, he has been in and out of the hospital in Portlaoise and St. Vincent's hospital in Dublin.

This person was refused a medical card. He stated that in consultation with a cardiac surgeon, he chose not to undergo another cardiac procedure. Could one blame him? During those years, he has undergone six angioplasty procedures and over the years, he has been on various doses of and different medication. He is currently on a daily dose of 14 tablets. On top of that, he is in heart failure but has been refused a medical. Shame on the Minister for Health and the Department who will say there is no policy to review but the practice is otherwise.

Mr. Barrett went on to appeal the situation and wanted to know what medical assessor refused him. He asked for a copy of the file of the medical assessor who reached the decision but he was refused it. He was told he could apply to get his own medical information under freedom of information. Talk about trying to deal with a member of the public properly. He submitted an appeal but in the meantime, he is seeking review from the HSE as to why he was refused. He will then be told he can appeal again. In the meantime, he does not have a medical card despite those conditions. That household has several other conditions which would back up the need for a discretionary medical card. That is one example on the public record. One might say the man is not going to die so he does not require a discretionary medical card.

I have good personal regard for the Minister of State, Deputy White, who I believe is sincere. He has gone into a Department in which he wants to make progress but he must get on top of the situation where his Department is cutting back on discretionary medical cards for people who have these medical situations.

I highlight cancer cases, in particular, because years ago, people got discretionary medical cards as a matter of course for the year or two years for which they required them. I referred earlier to daily medication. The prescription fee has been trebled from 50 cent to €1.50 per item.

That is now costing many households up to €10 a month. They are having difficulty finding this additional cash. Regardless of whether the Minister classifies this as a policy or as a practice, the reality is that it is happening on his watch and he is responsible for it. People are suffering as a result of the deliberate policy of removing people from the system. A similar approach is being taken in the Department of Social Protection, where disability and invalidity payments are being withdrawn from people. The same policy is evident in the medical cards section of the Department of Health. People are having their medical cards taken from them and their cover is being reduced.

The journalist I mentioned concluded his article by saying Mr. Barrett wrote his appeal at 3 a.m. He does not know where it is going next. He is "worried sick" because he cannot cope with the stress he is under. He says that this worry is adding to "my cardiac conditions" and "starting to affect my family". The Minister's answer is to tell him he is not entitled to a medical card. It is shameful that the Department is acting in such a manner.

I compliment Deputy Kelleher on the motion he has proposed. The widespread and deliberate withdrawal of medical cards is causing huge anxiety and concern throughout the country. The number of discretionary medical cards fell from 80,000 at the start of 2011 to 63,000 in 2012. As Deputy Kelleher has pointed out, in the first seven months of this year the number of medical cards reduced by between 1,100 and 1,200 per month. I do not doubt that there is a cynical campaign to reduce the number of discretionary medical cards. It is clear from what public representatives across the country are hearing in their clinics that a widespread cull of discretionary medical cards is under way. I could mention many examples of this. I have never received as many representations about medical cards as I received during the first six months of this year. I am sure every other Deputy will say the same. Many people are losing their medical cards. In addition to the withdrawal of medical cards, there are delays in issuing medical cards. People are very concerned and annoyed about this. The Government is continuing to mislead the public by denying that any cuts are taking place in this area. Indeed, the Taoiseach has said in this House on many occasions that there have been no changes in the ground rules or the regulations. He has suggested that everybody who is entitled to a medical card should get one. Obviously, the Taoiseach is out of touch with what is really happening on the ground at HSE level.

Discretionary medical cards are issued on health grounds, on the basis of medical need. Under this Government, thousands of medical cards are being withdrawn because the recipients' incomes are above the threshold. When decisions on discretionary medical cards are being made, patients are assessed on the basis of the seriousness of their illnesses rather than on the basis of their incomes. The Taoiseach and the Minister for Health continuously claim that there has been no change in policy or in the medical card guidelines, but nothing could be further from the truth on the ground. Every public representative has seen evidence of a widescale programme of cuts that is hitting very sick children and vulnerable families that are under enormous pressure. As I have said, we have been inundated with representations from people whose medical cards have been revoked even though they have a clear and undeniable medical need. It is very concerning that families facing severe health and medical pressures are having to deal with the withdrawal of medical cards. As I said, the number of discretionary medical cards has decreased by more than 20,000 since 2010. This seems to give the impression that everyone who had a medical card has suddenly been cured and no longer needs the card, which shows the cynicism of this Government at present.

If the Minister does not want to believe what we are saying, I remind him that Emily O'Reilly recently said that cutbacks are being implemented by applying “the letter of the law” and removing the element of discretion that previously applied. According to the Irish Motor Neurone Disease Association, discretionary and emergency cards are not being given to people with the condition, which is terminal. I have given two examples of independent voices that support what we are saying. The Jack and Jill Foundation, which does tremendous work for children, provides direct funding to the families of children with brain damage to enable them to purchase home respite care. The foundation says that as a result of these recent changes in this area, it is impossible to get medical cards for children at present. The comments of these three independent groups about the withdrawal and removal of discretionary medical cards are at variance with what the Taoiseach and the Minister for Health are saying.

Deputy Sean Fleming spoke about the treatment of cancer patients, which is causing grave concern. Over the years, regardless of the Government that was in power or the Minister who held the health portfolio, medical cards were issued to cancer patients until such time as they no longer had the disease. Medical cards are no longer being allocated to cancer patients on medical grounds. Instead, all kinds of income and finance obstacles are being put in their way. The HSE has said that it issues medical cards within 24 hours, but I can refute that by referring to the example of a person whose family applied for a medical card three weeks ago. I have seen the letter sent by the consultant from the hospital where the person is being treated, which makes it clear that this is an end-of-life situation. Three weeks on, that person has not been issued with a medical card. I have been contacting the medical card section of the Department on a daily basis. In fairness to the official in the section that deals with Deputies' inquiries, he has been very helpful and supportive of my efforts to find out why this medical card has not been issued. All kinds of information, including insurance policies, proof of income and details of farm premium payments, has been sought from this person's family even though the consultant has said this is an end-of-life situation. It is obvious that medical cards are no longer being issued in such circumstances.

Medical card reviews are also causing consternation, particularly for older people. Old age pensioners who were issued medical cards with expiry dates of 2014, 2015 or 2016 have come into my clinic to tell me they have received letters from the medical cards section of the Department to tell them that a review is being carried out. I cannot get the HSE or the people who issue medical cards to explain why this is happening. They just say they were told to seek a review, even though the medical card holder expected to have the card until 2014, 2015 or 2016. I ask the Minister to find out why this is happening to old age pensioners whose circumstances have not changed. The Minister, Deputy Burton, keeps telling us she has not reduced the old age pension, which is fair enough, but she has not increased the pension either. It is not as if a pension increase has caused these people to fall outside the medical card limit. The Minister needs to give serious examination to these areas. The discretionary medical card system must be reintroduced. Old age pensioners whose circumstances have not changed should be left alone, rather than being pressurised. Old age pensioners should not have to send in their pension book numbers again when no changes have taken place.

We are spelling out clearly that we have major problems with the manner in which discretionary medical cards are being issued. As I mentioned, the same point has been made by the Irish Motor Neurone Disease Association and the Jack and Jill Foundation. Emily O'Reilly, who is the most independent person in this country, has been continuously saying that the HSE is withdrawing discretionary medical cards from patients who are seriously ill and suffering from cancer, stroke or heart problems. These people have enough issues to be dealing with - family circumstances etc. - without having to face the pressure of having to reapply for a medical card and worry that the application might not be allowed. I ask the Minister to give serious consideration to this situation. All of the issues we have raised tonight need to be clarified and changes need to be made to ensure the discretionary medical cards to which people are entitled will be re-issued as quickly as possible.

The motion refers to the fact that the number of discretionary medical cards fell from 80,524 at the start of 2011 to 63,000 at the end of 2012 and that, in the first seven months of this year, there was a further reduction of 8,100, which is a monthly average reduction of 1,163. This takes place against a background of obvious increases in eligibility and suitability on the part of many people in society by virtue of the situation in which we find ourselves. Although the situation has reached such a pitch, this is not the first time the matter has been brought to bear in the chamber with a view to addressing and resolving the issues in a manner more in line with what Members find in their constituency offices.

When I consult my office I hear about, and during my regular clinics I meet, a growing number of people who have been reviewed and subsequently lost medical cards. I therefore contacted a sample of those people today to ask their permission to refer to their case in the chamber. Although I have been given that permission - I will use my remaining time to talk about some of the cases - I will not use anyone's real name, but I will make the cases available to the Minister after the debate.

Helen has held a full medical card for a number of years as she suffers from severe rheumatoid arthritis and attends St Vincent's hospital regularly. Her application came up for renewal in April and was refused. We requested a review, but it was disallowed. We then requested an appeal and only yesterday we received word that she was granted a doctors only medical card. This lady is on medication that costs more than €100 a week, which she does not have the means to meet.

Timothy has always held a full medical card on medical grounds as he suffers from ADHD, attention deficit hyperactivity disorder, drug addiction, depression and a fracture to a vertebrae. As he held a card, his three children were also entitled to a card. His card came up for renewal in August, but his application was refused. The case is under review.

Anne has always held a full medical card on medical grounds as she suffers from osteopenia and severe rheumatoid arthritis. Her case came up for review in April. When her application was refused, it went to review but that, too, was refused, and it was later refused on appeal.

Breda has held a full medical card as she has a number of medical conditions and is awaiting surgery on her kidneys and bowel. Her card came up for renewal in August, and she was awarded only a doctor visit card. A review was requested and we await the outcome.

Audrey has always held a full medical card. She suffers from hypertension and is on long-term medication. She attends her general practitioner regularly. Her application came for review in April. It was refused. We requested a review of the decision, but the original decision was upheld. Her case is under appeal.

Kieran always held a full medical card on medical grounds as he suffers from COPD, chronic obstructive pulmonary disease, sleep apnea, heart disease and high blood pressure. His card came up for review in February. His application was refused, and we requested a review, which is ongoing.

Jack is aged nine. He has held a full medical card. He has multiple disabilities, including cerebral palsy and a hearing impairment. Jack's medical card came up for review in February and he was awarded a doctor visit card. We requested a review and the original decision was upheld. We therefore appealed the decision and that was again upheld.

The final case that I will mention in the short time that I have relates to a young lady whom I know. I wrote to the Minister and to the Department on 1 August:

I write further to representations from the above named [We will just say that her name is Jeanette] and further to a phone conversation this morning with [someone] in your section.

I've known Jeanette and her family all my life as she is from [my home town]. [She] was born without lower limbs and has been in a wheelchair all her life. This has not, or never, deterred her as she lived a very fulfilling life [and has continued to do so], excelling in sport and all aspects of community life.

Jeanette works in the HSE ... has always sought not to be an economic burden on the State. She has had and retains her own medical needs which surpass her means, now that she has dependents, namely her partner ... whom is unemployed and her miracle baby [now 12 months old]. [That baby unfortunately] is in constant need of specialist medical attention. All the relevant details pertaining to this case, economic and medical, are on the file.

I find it distressing that this application process has been so poorly dealt with, considering the amount of communication Jeanette has had with the relevant sections dealing with her application.

She was informed over the phone that the cards were granted only to be informed the opposite days later.

It is unbelievable that Jeanette should be forced to avail of my ... office in seeking to have the only decision possible in this case, arrived at.

I don't normally seek to personalise cases in this manner, but I am too well aware of the need in this instance and cannot 'for the life of me' understand how

a) This case has been dragged so long

b) That a medical assessor did not find in favour of this application.

[I asked that arrangements be made] for these cards to be issued or failing that [to make available to me] the full reasoning and methodology at a decision that medical cards are not necessary from a medical perspective.

I did not receive any explanation from the office in question on that decision and how it was arrived at and, unfortunately, the lady in question did not retain her medical card and is just in receipt of a doctor only visit card even though she has a great medical need and does not have the financial means to meet the demands on both her and her child .

As I said, those are only a sample of the cases that are prevalent in all our offices. The sample has grown greatly as the months pass. It is plain for me and my colleagues to see that these issues are not being dealt with in a manner in which we can stand over. I ask the Minister to take a personal interest in the cases that we will forward to him and to find out where the failings are in the relevant sections. Is it the case - I would have doubted very much that it would be the case - a direction has been given? It seems patently obvious that it might be the case.

I begin by making a few comments on the junior doctors dispute. It is very regrettable. We must consider the plight of junior doctors. Equally, we must consider the people whose procedures and operations were cancelled. I think that we would all agree that, for the betterment of everyone, it is incumbent on everybody to get together to resolve the matter. It is fair to say that junior doctors over the years have been failed by the State. They have also been failed by the IMO, their trade union and its old guard in particular. I know that the IMO's leadership has changed, which is refreshing and welcome - it is about time junior doctors had proper representation and leadership from their trade union.

The debate crystallises a number of points which I want to address briefly. Why are people cynical about politicians and the political profession that we are engaged in? It is because there is a complete disconnect between what happens to people on the ground and what they hear from official speak, which is regrettable. The fact is that the Government and the Department will say that there has been no policy change, but there is no getting away from the fact there has been a de facto policy change. We experience that change every day of the week; that is what people experience on the ground when they get notification that their medical card has been unilaterally cut off or withdrawn. The first time many of those people hear about it is when they are in their doctors clinic or surgery. There are a number of reasons for that and there may be fault on all sides, but that is not good enough. The situation is not good for the patient, the cardholder or the doctors. When people are sick, which is a stressful situation, the last thing they need to do, apart from trying to get themselves better, is worry about the status of their medical card. For the Minister to say that is not something that he or his Department is responsible for is not good enough and must be addressed.

My main concern - I will raise a specific case in the 60 seconds that I have left - is about the discretionary medical card for cancer patients.

I will give the Minister of State the details of the case when we are finished. I have permission from this lady, Anne, to raise her case. She rang me from her hospital bed on a number of occasions. She was diagnosed with breast cancer last February. She had chemotherapy and a mastectomy, is now undergoing radiotherapy in Limerick and bone treatment in Cork and is due a second round of chemotherapy in Cork in due course. It is regrettable and reprehensible that I must raise her case in Dáil Éireann, albeit with her permission, to try to further her case. I have been dealing with people from the primary care reimbursement service, PCRS. She is at the end of her tether. It is about a medical report and her GP has furnished a detailed medical report. She is literally at her wits end and her GP is telling her that the PCRS has been furnished with her medical status. This woman has cancer.

Apart from this case, the details of which I will give to the Minister of State, there are all the other cases of people throughout the country who have had their cards unilaterally withdrawn. When people are sick, they cannot work and earn money. Some of them might have illness cover but others do not and medical cards entitle them to other benefits, for example, school transport for their children and other knock-on benefits. It is putting pressure on people. The Minister of State has responsibility for medical cards. There has been a de facto change in policy and we need to be honest with ourselves and get away from the official spin which is being put out about this because the figures prove it. The evidence is there on the ground and in our clinics. The Minister of State needs to meet the challenge head on.

I understand the Minister of State with responsibility for primary care, Deputy White, is sharing time with the Minister for Health.

I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"notes that:

— there has been no change to the manner in which discretionary medical cards are awarded;

— there is no target set in the Health Service Executive, HSE, national service plan to reduce the number of discretionary medical cards;

— of the 24,000 reduction in discretionary medical cards from the start of 2011 to July 2013 almost 23,000 of these persons have been awarded medical cards on the basis of their financial means;

— the HSE has produced national assessment guidelines to provide a clear framework to assist in making reasonable, consistent and equitable decisions when assessing applicants;

— these guidelines facilitate the application of discretion by decision makers in responding to the needs of the applicant when additional or exceptional circumstances exist;

— the Health Act 1970, as amended, provides that persons who ‘are unable without undue-hardship to arrange general practitioner’ services for themselves and their family qualify for a medical card;

— in accordance with the Health Act 1970, as amended, the assessment for a medical card must ‘have regard to the overall financial situation’ of an applicant and dependants; and

— the centralisation of the processing of medical cards at a national level, rather than at a local level as was the case before mid-2011, facilitates the assessment of applicants for medical cards in a consistent and equitable manner;

commends the Minister for Health on directing the HSE to set up a clinical panel to assist in the processing of applications for discretionary medical cards, where there are difficult personal circumstances;

further notes that:

— between mid-March 2011 and end-August 2013, the number of individuals who had eligibility to a medical card increased by 214,244, some 13%, to 1,863,062; and

— the HSE is facing significant challenges in 2013 and in 2014 given the need to set expenditure levels within the parameters of the national recovery plan; and


— the significant reductions in financial and staffing resources which the health sector has experienced over the last three years; and

— the range of measures being actively progressed by the HSE to manage its financial resources to ensure that services are provided to persons entitled to receive them; and


— the Minister for Health and the Government on providing resources to meet the increase of over 200,000 medical cards since March 2011;

— the Minister on the passing of legislation to abolish restrictions on general practitioners wishing to become contractors under the medical card scheme;

— the Minister on the implementation of legislation to achieve savings under the medical card scheme through the use of generic drugs and reference pricing; and

— the Minister on the savings being made in the cost of drugs for the medical card scheme through negotiations with pharmaceutical drug suppliers."

Deputy Kelleher commenced his contribution by talking about what he described as a policy of withdrawal of discretionary medical cards. He made some reference to it having been announced in the budget last year. I wonder whether either this evening or tomorrow Deputy Kelleher could draw our attention to where it says in the Budget Statement that a policy of withdrawal of discretionary medical cards is being announced or introduced. The motion does not simply imply or suggest but baldly states that the HSE has set a "target" for 2013 to reduce the number of discretionary medical cards. It goes on to say that what it describes as "this deliberate targeting" was approved by the Minister for Health in the 2013 HSE service plan. I would respectfully ask Deputy Kelleher, through the Chair, to draw our attention to where he finds authority in the HSE service plan or budget statement last year for such an alleged targeting. In the absence of Deputy Kelleher doing so, I must put on the record of the House that I must and do reject the contention in the motion that there is a deliberate targeting of holders of discretionary medical cards. I must say that in the absence of any evidence that would bear out this very stark allegation, this contention is false and without foundation. I want to make it clear that there is no "target" to reduce discretionary medical cards in the HSE national service plan for 2013 and neither, I assure the House, is it Government policy.

The Deputies and the motion refer to the reducing number of cards awarded on a discretionary basis. Information from the HSE indicates that there has been a reduction of about 24,000 in the number of discretionary medical cards between the start of 2011 and July 2013. Of these, almost 23,000 have been awarded medical cards on the basis of their means assessment so that they have not, in fact, lost their medical cards. A total of 23,000 out of the 24,000 who no longer have medical cards on the basis of the discretionary approach have medical cards on the basis of their means assessment. Therefore, they retain the medical card. The number of people who hold medical cards on discretionary grounds has fallen in recent years largely because more people who previously were marginally over the normal qualifying limit became eligible for medical cards under the normal scales. I am not saying that this encompasses everybody about whom Deputy Kelleher is talking but it encompasses a huge number.

Contrary to the suggestion that we are targeting people who need our support, this Government has provided funding to ensure an additional 220,000 people are now covered by the General Medical Services scheme since it entered office. The suggestion that there is a tactic to reduce medical cards for budgetary purposes is fatally undermined by the fact that an additional 220,000 people are covered through the GMS scheme. This means that over 43% of the national population currently has access to GP services without any charges under the GMS scheme. That comprises 40.6% with the full medical card and 2.7% with GP visit cards.

I can confirm that there has been no change to the qualifying criteria for discretionary medical cards in the past year and that the scheme continues to operate in such a way that those who suffer genuine financial hardship as a result of a medical condition receive the benefit of a medical card, as they should. I acknowledge that the number of discretionary cards has fallen from the beginning of 2011 to July 2013. This is evident from the publicly available statistics but it has occurred for the reasons I have stated and not as a consequence of some kind of so-called mission on the part of the Government to extract medical cards from those who are entitled to them.

As the Deputies will be aware, under the provisions of the Health Act 1970, as amended, persons who are unable, without undue hardship, to arrange a general practitioner service for themselves or their family qualify for a medical card. In accordance with the legislation, the assessment for a medical card is determined primarily by reference to the means, including the income and expenditure, of the applicant and his or her partner and dependants. Under the legislation, the HSE is responsible for assessing an individual's entitlement to a medical card and a GP visit card. Specifically, section 45(1) provides that adult persons who, in the opinion of the HSE, are unable, without due hardship, to arrange general practitioner medical and surgical services for themselves and their dependents are deemed to be persons with full eligibility. Under Section 45(2), the HSE is obliged in deciding on an individual's eligibility to have regard to the person's overall financial situation, including the means of the spouse, if any, in view of the reasonable expenditure in respect of himself or herself and his or her dependants. The Deputies will also be aware that different criteria apply for assessment for eligibility for a medical card for those persons aged 70 years and over. Assessment is on a gross income basis, as provided for under section 45A of the 1970 Act.

Medical card processing is now carried out centrally with single national governance and a central office location replacing the 100 different locations that existed in the past. Customer service processes, assessment of applications and reviews, correspondence and the consideration of discretion are standardised and operated in a fair and equitable manner. The medical card scheme is now underpinned by a stronger foundation, which enables better governance, more transparency and efficient modern processes.

The PCRS of the HSE oversees the medical card scheme and has a target to process 90% of medical card applications within 15 working days. These turnaround times are now published online on a weekly basis at In practice, almost 95% of applications are processed within the 15 day target. Medical card applications are considered on the basis of an assessment of the applicant's means by reference to the HSE national assessment guidelines and national income guidelines. Where a person's income is within the income guidelines, a medical card or GP visit card will be granted for three years in most cases.

However, and this is the nub of the issue this evening, the HSE has discretion to grant a medical card where a person's income exceeds the income guidelines. The discretion must be exercised by the HSE but the fundamental provision in the 1970 Act is that a person is assessed on the basis of undue hardship in arranging a GP service, as well as his or her means. I will come back to this later on if I have time but a Member opposite referred to one of the cases that were raised by Members, all of which I am sure are absolutely genuine. The Member referred to a case where somebody had a medical card on medical grounds. There is no such thing in our system. Perhaps there should be and perhaps we should have a debate about it. I am quite happy to have a debate about it but the system that has obtained since 1970, over which the Deputy's party opposite presided for most of that period, certainly two thirds of it, does not and never has awarded a medical card to somebody on the basis of a medical condition.

There is no such thing as what one speaker referred to as a medical card on medical grounds. Nobody acting on behalf of the HSE has the authority of this House to grant a medical card other than on the basis of the 1970 Act. We might all have views on whether that Act should be amended but until such time as that occurs it remains the law. Nobody, including Ministers, can act outside the law. In fairness to Deputy Kelleher, he accepts this.

These are all difficult cases and no Member of this House would make light of the human circumstances described by Deputies during this debate. Deputy Seán Fleming referred to circumstances in which individuals with cancer always get medical cards. Is it being proposed that a person with cancer should automatically receive a medical card irrespective of his or her income or circumstances? I do not criticise anybody for making such a proposal but it would entail a fundamental change to our law. If that is what is being proposed, let us debate it.

Social and medical issues are taken into account when determining whether undue hardship exists for the individual concerned in accessing GP or other medical services. Discretion will be applied automatically during the processing of an application where additional information has been provided by the applicant which can be considered by staff or a medical officer, where appropriate. Once a full assessment of an application or a review is completed a letter issues to the applicant advising of the decision. If a review of an application is assessed as ineligible or eligible for a GP visit card only the letter informing the applicant of this decision will include an explanation of how the application was assessed and the details of the means assessment calculated on the application. Applicants will be advised that they can request a review of the HSE decision if they believe their financial or other circumstances have not been correctly assessed. They will also be requested to provide any additional relevant information or details of any change in circumstances since their original application. In addition, the letter will notify the applicant of the option to appeal the decision and the contact details of the appeals office.

Where applicants submit an application without any additional medical documentation and are refused, they will receive a letter giving a calculation of the guideline thresholds and where these have been exceeded. At this stage, they are informed of the option to furnish further medical documentation to support the application. If applicants finish medical evidence at either initial stage or following a refusal, and where discretion has been used, they are informed of the decision of the medical officer. Once again, the letter will notify the applicant of the option to appeal the decision and the contact details of the appeals office. Additional information that can be used for consideration on a discretionary basis, following receipt of a letter indicating an unsuccessful application, includes illness or medical circumstances which results in financial hardship; the cost of providing general medical and surgical services; the cost associated with the provision of medical, nursing and dental treatment; and the cost of medical aids and appliances.

At the direction of the Minister for Health, the HSE set up a panel of specialist medical professionals to assist in the processing of applications for discretionary medical cards where a person exceeds the income guidelines but is facing difficult personal circumstances, such as an illness. These community medical officers, CMOs, apply discretion within the guidelines to determine if the applicant is suffering from hardship, review and interpret medical information provided on a confidential basis and provide reassurance to the medical profession and the public regarding the safeguarding of patient-doctor confidentiality. They liaise with general practitioners, hospital consultants and other health professionals as appropriate so as to determine the health needs of the applicant and his or her family. They advise on the granting of discretionary medical cards to an applicant and his or her family on the basis of the guidelines. They also work closely with staff in the PCRS and contribute to the ongoing development and delivery of an equitable, efficient and streamlined medical card application process nationally.

Medical card eligibility provided either on the basis of means or where discretion is involved is identical and provides access to exactly the same set of health services. More people than ever before have medical card eligibility. It now stands at almost 41% of the population. Furthermore, over 43% of the national population currently has access to GP services without any fees under the general medical scheme.

Deputy Seán Fleming quoted the Taoiseach on the emergency medical card system. The HSE has a system in place for the provision of emergency medical cards awarded on a discretionary basis. The Taoiseach must have been referring to this system. These cards are provided to patients who are seriously ill and in urgent need of medical care that they cannot afford. Emergency medical cards are issued by the HSE within 24 hours of receipt of the required patient details and the letter of confirmation of the condition from a doctor or a medical consultant. Deputy Browne referred to an end of life situation in which an individual was waiting for an emergency medical card to be issued. That sort of situation should not arise. I can provide my colleagues with further details on emergency medical cards and the circumstances in which they should be issued.

The processes I have outlined for consideration for a medical card on a discretionary basis clearly demonstrate that every effort is made to assist, support and facilitate both new applicants and those under review. The opportunity to provide additional information in support of an application is afforded to an individual following refusal on means assessment basis and the avenue for appeal is also advised. I am aware suggestions have been made in the public domain in recent months that the criteria for awarding discretionary medical cards had changed. I emphasise that there has been no change to the qualifying criteria for discretionary medical cards in the last year.

Absolute nonsense.

Deputies will note that the former Ombudsman was recently reported in the newspapers as stating that her officials' examinations of complaints about the removal of discretionary medical cards revealed nothing substantial had changed in regard to the regulations that applied. We do, of course, need to ensure that those most in need can qualify for the service. We also have an obligation under the legislation to ensure that those whose situations have improved are not using a service to which they are no longer entitled. To this end, a critical element of probity in medical card scheme is the ongoing review of client eligibility by the HSE. Deputy Browne referred to persons who received letters in regard to a review even though there was no change in their circumstances. If a person's circumstances have not changed, there will be no change in his or her eligibility. There is no issue in that regard.

Why were people with valid medical cards subjected to reviews?

We have to request information in order to assess whether an individual's situation has changed. I do not think there is any improper or objectionable to the HSE writing people to ask for information in order to assess whether their position has changed.

Deputies have raised a number of individual cases. I accept they did so entirely in good faith. I encourage them to use the dedicated Oireachtas telephone line and e-mail service. I assure them we will do all we can with the system to ensure that cases like the ones referred to this evening are expedited and dealt with in a sensitive manner. If that system is not working and the problems are not being addressed properly, I would like to hear about my colleagues' experiences.

It is not blaming the officials. It is blaming Government policy that is directing the officials.

I would be quite happy to hear from Deputy Healy in respect of cases that are not being addressed in the manner that I am saying they are.

For all of these reasons, I commend the amendment to the House. There is no such thing as a medical card on medical grounds. Our system has never awarded medical cards on those grounds. Obviously, Deputies have an issue with the operation of discretion. To support their argument, they have cited the drop in the number of discretionary cards in the system. This is the main argument in support of the claim about targeting. I have demonstrated to the House that a substantial number of those persons who used to have medical cards on discretionary grounds continue to have medical cards, but on income grounds. Something in the order of 23,000 people of the 24,000 people who no longer have discretionary cards have remained in the system because they have been found to be entitled to medical cards on means grounds in the normal way.

For these reasons, there is no basis whatsoever to suggest a targeting of people with discretionary medical cards, as has been claimed in the motion and by Deputies. I commend the Government amendment to the House.

To pick up where the Minister of State left off, it is worth repeating that the number of people with access to free general practitioner, GP, care is the highest in the history of the State. Some 43% of the population has access to free GP care. Compared with when the Government took office, more than 250,000 additional people are eligible for free GP care. At the end of August, almost 2 million people held medical cards or GP visit cards. The number of discretionary medical cards has fallen. As the Minister of State demonstrated clearly, this is because almost 23,000 people who would have had discretionary medical cards now hold full medical cards. In this light, the Opposition motion has a hollow ring to it.

The Minister of State has clearly outlined to the House the legislative basis for awarding medical cards, particularly those medical cards that are awarded on a discretionary basis. His thorough description demonstrates how every effort is made to support applicants in applying for medical cards and, in particular, the efforts made to accommodate those who may be in excess of the income limits but who have difficult personal circumstances. These processes, in themselves, demonstrate how the Government is concerned with looking after people and with making every effort to ensure that those most in need can qualify for the service. This point is critical. The Deputies across the way would be the first to jump up and down at the Committee of Public Accounts and in this Chamber if they discovered that people who were not entitled to medical cards had them. It is important that our limited resources are focused on those who are entitled to and need services the most.

The number of people who hold medical cards on discretionary grounds has fallen in recent years, as more people who previously were marginally over the normal qualifying limit became eligible for medical cards under the normal qualifying scales. There has been no change to the qualifying criteria for discretionary medical cards in the past year and the scheme continues to operate in such a way that those who suffer genuine financial hardship as a result of a medical condition receive the benefit of a medical card. Indeed, I asked that a group of professionals be put in place to consider the issue of hardship because of particular medical needs as well as the normal other issues that can result in hardship for people.

The processing of medical cards at a national level, rather than at a local level as before mid-2011, ensures that all people are assessed in a similar and fair manner when applying for a medical card. The HSE set up a clinical panel to assist in the processing of applications for discretionary medical cards where income guidelines had been exceeded but difficult personal circumstances, such as an illness, existed. The HSE put in place a process whereby a medical doctor would consider the assessment for discretionary medical cards. In previous years, there was a decentralised process, which meant that there could be inequities throughout the country. This means that people may have been awarded discretionary medical cards in some parts of the country and not in others because of the lack of a centralised, standardised approach. This led to inequities and pockets in which there were high numbers of medical cards above what one might have expected.

A team of medical doctors unrelated to the patient assesses the situation and grants or declines a discretionary medical card on a medical basis. Previously, different approaches may have been used in different parts of the country. Now, the process is standardised and there is fair and equitable treatment for all.

The HSE takes a person's social and medical issues into account when determining whether there is undue hardship for a person in providing a health service for himself or herself or his or her dependants. The same supports are offered to new applicants and those under review. Discretionary emergency medical cards may also be awarded. The HSE has a system in place for the provision of emergency medical cards for patients who are seriously ill and in urgent need of medical care that they cannot afford. Emergency medical cards are issued by the HSE within 24 hours of receipt of the required patient details and the letter of confirmation of the condition from a doctor or a medical consultant.

The HSE issues all emergency cards on the basis that the patient is eligible for a medical card as a result of his or her means or undue hardship, and that the applicant will follow up with a full application within a number of weeks of receiving the emergency card. As a result, emergency medical cards are issued to a named individual with a limited eligibility period of six months.

The arrangement is slightly different for persons with terminal illnesses. Once the terminal illness is verified, a patient is given an emergency medical card for six months. There is no means test and the nature of the terminal illness is not a factor.

I am satisfied that, given the nature and urgency of the issue, the HSE has appropriate escalation routes to ensure that the person gets the card as quickly as possible. Furthermore, the HSE ensures that the system responds to the variety of circumstances and complexities faced by individuals in these circumstances.

Deputies will be aware that, under the provisions of the Health Act 1970, as amended, persons who are unable, without undue hardship, to arrange a GP service for themselves or their families qualify for medical cards. In accordance with this legislation, the assessment for a medical card is required to be determined primarily by reference to the means, including the income and expenditure, of the applicant and his or her partner and dependants. Furthermore, it is clear that every effort is made by the HSE within the framework of the legislation to support applicants in applying for medical cards. In particular, efforts are made to ensure that those who may be in excess of the income limits but who have difficult personal circumstances are catered for.

I am aware of how the diagnosis of a serious illness can invoke fear and insecurity for the person affected and his or her family and friends. Through the systems operating, every effort is made to provide the support needed to avoid further distress. I am also acutely aware of how, regrettably, certain misinformation or misconceptions reported in latter months on awarding discretionary cards have caused such concern.

The scheme provides GP and public health nurse services. I wish to commend those working in our primary care services on their sterling work. It is one of the most trusted parts of our health service. Satisfaction with the GP service in this country is second to none. Being able to see a GP within 24 hours must improve outcomes for our citizens. However, I would dearly love to see reliable outcome measures so that we might focus on the work that improves outcomes and focus less on some other areas of activity.

It is worth repeating that, since this Government took office, there has been no change to the qualifying criteria for discretionary medical cards in the past year. Furthermore, there was never a medical card for a specific condition, which is what seems to be implied here.

We never suggested there was a medical card for a specific condition.

Deputy Fleming said it.

The scheme continues to operate in such a way that those who suffer genuine financial hardship as a result of a medical condition receive the benefit of a medical card. As I have said, there are now more people covered by the medical card scheme - both for medical cards and GP visit cards - than at any other time in the history of the State. Deputy Kelleher may not have said so, but his colleague did. Even though I could see him, I did not see Deputy Kelleher so perhaps the latter did not hear him.

I commend the Government amendment to the House. I reassure people that the medical card scheme has not changed in terms of eligibility for discretionary medical cards, and there is no intention for it to do so.

I understand that Deputy Ó Caoláin is sharing time with Deputy McLellan. Is that agreed? Agreed.

It is hard to believe that this Government has actually promised in its programme to provide free GP care for all. Its actions have all been in the opposite direction. It has increased the cost of primary care for people on medical cards by increasing prescription fees and for non-medical card holders by raising the drug payment scheme threshold. As this motion points out, it has reduced the number of discretionary medical cards issued, which is an indisputable fact.

The Government repeatedly points out that the overall number of medical cards, issued on the basis of income, has increased. The Minister has just made that point. That is correct but it is not an indicator of the Government’s commitment to primary care. It is, rather, an indicator of the dismal economic failure of this and the previous Government in driving masses of people down to the low levels of income which qualify for a full medical card or a GP visit-only card.

I have repeatedly raised the issue of medical card restrictions with the Minister, Deputy Reilly, and his Ministers of State, Deputy White and Deputy Kathleen Lynch, both in this Chamber and in committee. I have also met and lobbied the central medical card administration in Finglas.

It speaks volumes about the lack of real planning and real substance in the Government’s plans for universal health care based on the private insurance model that they fell at the very first hurdle with regard to GP care. The proposal to begin the roll-out of free GP care for all people in the long-term illness scheme has been abandoned. Why was it proposed to proceed in that way in the first place? Why was false hope given to people on that scheme?

Let us be clear. Sinn Féin has long advocated GP care free at the point of delivery for all, funded by fair and reformed general taxation - the funding basis for the truly reformed universal health service that we advocate. We have long advocated also commencing free GP care for children. It now seems that the Government may be considering extending free GP care to children under five. We included that proposal in our alternative budget proposals published today and we hope the Government does indeed proceed in that way, as a first step. I take this opportunity to advise the Minister that Sinn Féin will fully support such an initiative or an even more inclusive measure, if that is to be presented in the coming week as a first step. We must at least agree that a start needs to be made.

The specific focus of this motion is the discretionary medical card. We asked the Minister for Health about this matter recently and urged him to ensure that all children diagnosed with cancer are granted, or allowed to retain, medical cards. This matter arose because it was reported to us, and, I am sure, to other Deputies, that whereas previously the granting of discretionary medical cards to children with cancer had been virtually automatic, in recent times some parents were experiencing refusal or delay. This was contrary to previous experience and legitimate expectation.

Last July, when I questioned him on this issue at the Committee on Health and Children, the Minister admitted that discretionary cards are no longer being granted to cancer patients in the same way as previously. The record shows this. I pointed to the irony that the Government is promising to extend free GP care to all while at the same time cutting medical cards for some of those who need them most.

Medical card assessments need to be carried out with appropriate discretion and compassion, and not simply on the basis of the very low income threshold for qualification. This is clearly a requirement where applicants have life-limiting conditions, including cancer. The HSE has claimed that there has been no change in criteria for discretionary medical cards but has also admitted that the number of people on discretionary medical cards has indeed decreased, as the figures cited in the motion demonstrate. It does not take much imagination to see the great distress all this causes to already traumatised parents of children with cancer.

That distress for parents will be compounded by a reading of the Minister’s reply to our recent Dáil question urging him to ensure that all children with cancer get medical cards. He pointed out that other than on the grounds of income and “undue hardship” there is no provision for the automatic granting of discretionary medical cards to children with cancer, unless they are terminally ill. That is a most cruel position. It is also illogical and medically highly questionable. In very many cases no one can tell whether a cancer will prove terminal or not. It depends on a number of critical factors, including how the patient responds to treatment. What parent wants to provide medical evidence that their child’s cancer is terminal, in order to qualify for a discretionary medical card that is valid for six months?

This only goes to show the inequities and in some cases the cruelties that arise when the principle of universal care on the basis of medical need and medical need alone is not adhered to. The reality is that the Minister - like the previous Minister, Mary Harney - is shredding our public health services with his regime of cuts and patients are suffering as a result. That is the real situation.

A budget over-run on health spending is predicted again this year. That is no surprise. We have had successive years of health cutbacks since 2007 with our public health system unable to cope. Cuts of €781 million in health were imposed by the Minister for the current year. When Fine Gael and Labour cut over €750 million out of health for 2012, on top of the €1 billion cut in 2011, we said it was unsustainable and would cause huge damage to the health services. These are cuts, not reforms of health service funding. They then cut a further €130 million in August 2012. At the end of 2012, the Minister had to ask the Dáil for an additional €360 million supplementary Estimate to prevent services collapsing before the end of the year. That is no way to fund and run our public health services.

As we made clear at our alternative budget launch today, we would discontinue the futile austerity policy. We would address the deficit by redistributing the burden away from those on low and middle incomes and taking a greater contribution from the highest earners and from wealth. This is the only approach that can prevent further cuts to health and other public services.

Look at what has happened to health over the summer. In July, we saw further restrictions on discretionary medical cards, the focus of this motion. We found out during the summer that hundreds of young people with severe disabilities, who have finished school, are to be denied the day services they need due to coalition Government cutbacks. Cutting the allocation from almost €10 million in 2012 to €4 million in 2013 can only be described as callous in the extreme. The Minister of State, Deputy Kathleen Lynch, signalled that the Government intends to bring in means testing for home care and other services for older people and people with disabilities. This was denied subsequently but in the language of the reply to me from the Minister, there is clearly wriggle room for means testing to be sneaked in by the back door.

We had the cuts to services for people with disabilities at Stewart’s Hospital in Palmerstown. We had the decision to close the 22-bed mental health unit at St. Brigid’s in Ballinasloe. We have had the cuts to services provided by St. Michael’s House, one of the largest providers of services to people with disabilities. Over 2,000 service users are dependent on St. Michael's House.

In a Dáil reply to me, the Minister stated that in 2012, some 121 HSE executives earned in excess of €100,000. Between them, total remuneration, including allowances and arrears, amounted to €14.6 million. He said that a high-level analysis of annualised payroll data from May 2013 indicates that at that time, the number of executives on annual remuneration in excess of €100,000 had risen to 129.

This is scandalous, particularly in light of the cuts imposed on health services, the impact of which is having a devastating affect on the lives of many thousands of vulnerable citizens on a daily basis. Front-line services, acute and community care, medical cards, disability and mental health services have all been cut while those at the top of the HSE are rewarded time and again.

The Minister, Deputy Reilly, has failed to deliver the level of savings possible from the State’s drugs bill. We estimate that an additional saving of more than €300 million is achievable in 2014. This is based on figures provided and confirmed by the Minister's Department. The Minister and his predecessors, back to Deputy Martin, have failed to address the recurring junior hospital doctors crisis resulting in the industrial action which took place at hospitals across the State today. This action was inevitable given the lengthy failure to implement the working time directive. It is long past time to implement the directive in full and to bring in the root and branch reform of hospital medical staffing and training that is required.

I support the motion as presented by Deputy Kelleher.

Anyone who knocked on doors over the summer months while canvassing or who held regular clinics will have met a substantial number of people who had either lost their medical card in recent weeks or who are likely to do so. Anecdotally, it was clear that there was a massive change in how medical cards, and in particular discretionary cards, were being allocated. The motion, which I am glad to support, underlines this fact. The cold statistics, which we all have, indicate a reduction in these cards from 80,524 at the start of 2011 to 63,126 at the end of 2012 and to 54,984 after the first seven months of this year, which is a huge decrease. Many people every month are losing discretionary medical cards. I dislike the word "discretionary" as it sounds like a luxury or something extra. It is anything but. For many families, it is essential to ensure that they or their loved ones get the treatment they deserve and quite plainly need.

To illustrate this point, I will give an example. Bryn Bailey is a young boy of six years of age from my constituency. When his card expired he was refused the discretionary medical card even though his circumstances were worse than when it was granted. Only on appeal and after ferocious lobbying by public representatives for four months did he even receive the six month emergency card, which is a mere stop gap. He was in intensive care in hospital when this emergency six month card was approved. He is still in hospital four weeks later. His parents will have to go through this process again when they should be left to concentrate on his care. Bryn's parents are not looking for cards for themselves but for Bryn who received the card initially on discretionary grounds. Young Bryn faces challenges in his young life we can only begin to imagine. Among other things, he suffers from epilepsy, spastic quadric paresis, mitochondriaI disorder, global developmental delay, hypertrophic cardiomyopathy, precocious puberty, chronic constipation, hypothermia, microcephaly and right renal calculi. He has no means of communication, no use of his arms or legs and is wheelchair dependent. His parents have had to make huge sacrifices to support and care for him. He requires 24 hour care seven days per week. His parents are his carers. They do absolutely everything, from feeding and bathing to physiotherapy for him. They had to move to a bungalow in 2011 in order to care for Bryn safely. The rent they receive from their old home does not cover the mortgage on this bungalow. They need to adapt their car so as to be able to lift Bryn in and out as he now weighs more than 32 kg. Bryn needs countless medications and equipment, which costs thousands of euro annually. His card would cover his frequent visits to the GP, outpatient and inpatient visits, procedures and his wheelchair, on which he will depend for the remainder of his life.

The application to the HSE is accompanied by dozens of letters from doctors, consultants, Bryn's school and so on, all of which contain the message, "Please give this young boy a medical card." Bryn is an incredible young man who is battling daily with many conditions. His parents are the type of parents we would all aspire to be, doing all that they can to help him. I defy anyone to tell me that he does not deserve a medical card; that he and his parents do not deserve that assistance, which would require very little effort from the authorities.

Bryn is not the only one in this situation. There are countless others like him and his family who are truly struggling and relied on the medical card. Now that it has been withdrawn they do not know what to do. The Government made a conscious decision to target these cards even though it was aware that many, indeed the bulk of those who would lose these cards, had received them on the basis of clinical evidence and a clinical need. This is needless bullying on the part of the Government of the sick and the vulnerable. It needs to halted now. People such as Bryn Bailey should not be deprived of their discretionary medical cards.

The next speaker is Deputy Seamus Healy, whom is sharing time with Deputy Pringle.

I support this motion in regard to discretionary medical cards. This is an issue about which I am deeply concerned. The withdrawal of medical cards from sick and elderly people is in my view an act of social vandalism. It is shameful in the extreme. It is an attack on the sick and the elderly, the most vulnerable in our society. The Labour Party should be ashamed of its involvement in this matter. Not only are Connolly and Larkin turning in their graves, so too are Brendan Corish and Frank Closkey. They would not have countenanced such an attack on sick and elderly people.

This Government must stop terrorising sick and elderly people across the country. This is what is happening. The Government's austerity policies are targeting sick and elderly people. It is targeting the medical cards of current medical card holders across the country. This policy is being implemented by the Health Service Executive on behalf of the Government. It is not possible to overstate the fact that sick and elderly people are traumatised and living in daily fear of losing their medical cards. The post man or woman, always a welcome sight for sick and elderly people, is now a source of anxiety lest he or she might bring the dreaded white envelope in which is a letter stating their card is under review and may be withdrawn.

Let us be clear about what is happening. Sick and elderly people are being targeted by this Government in order to protect banks, bondholders and the 10,000 top earners in this country who each earn €595,000 per annum. It has always been the position that people with serious medical conditions in need of urgent or ongoing medical care qualified for a discretionary medical card. This is still the stated policy of the Health Service Executive. However, it has now de facto changed and is not being implemented. Medical cards are being withdrawn. The fact is that many people with cancer and motor neuron disease are being denied medical cards or are having existing cards withdrawn. Another section of society affected is the elderly, including people from their sixties to their nineties whose cards are not due for review and are valid, having been assessed, approved and issued by the HSE, in some cases, up to 2020. These people are being punished by this Government to satisfy the greed of bankers and bondholders.

I support the motion. The Minister of State, Deputy Alex White, whose contribution I listened to on the monitor in my office, asked earlier where the evidence was that cards are being withdrawn. Page 15 of the Health Service Executive's service plan for 2013 states that policy changes have targeted the removal of 40,000 medical cards during 2013.

Not discretionary medical cards.

Some 40,000 medical cards will be withdrawn in 2013 under HSE policy. This policy change includes a reduction in the allowance for travel to work and a reduction in the allowance for medical costs. The number of discretionary medical cards issued this year has decreased by more than 12,000. These 12,000 obviously form part of the 40,000 target.

Some 100,000 new medical cards will issue this year.

The plan provides for 100,000 new cards but 40,000 people who currently hold medical cards will not have them renewed at the end of this year. This policy is being implemented by the HSE on behalf of the Government. Most of the people involved are people who hold discretionary medical cards. Every Deputy in this House could give the Minister instances of people whose discretionary medical cards have been withdrawn.

I too could give many examples of patients recovering from cancer whose discretionary medical cards have been withdrawn. Previously they had the comfort of being able to visit their doctor without incurring cost while trying to recover from a life threatening illness. Discretionary medical cards are being targeted and withdrawn. It is an appalling situation which this Government should not stand over. It should instead ensure that people who have discretionary medical cards retain them.

Debate adjourned.
The Dáil adjourned at 9 p.m. until 10.30 a.m. on Wednesday, 9 October 2013.