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Dáil Éireann debate -
Wednesday, 25 Jun 2014

Vol. 845 No. 2

Priority Questions

HSE Expenditure

Billy Kelleher


1. Deputy Billy Kelleher asked the Minister for Health if he will provide an update on the Health Service Executive's financial situation; if he expects the HSE to require a Supplementary Estimate this year; and if he will make a statement on the matter. [27413/14]

This will be the Minister's last health questions before the summer recess. It would be appropriate for him to outline in detail the precarious financial position in which the HSE finds itself again where we are talking about a potential budget deficit of over €500 million, the warnings by officials from the HSE, and the concerns and the impact of this on front-line delivery of services. The Minister might outline in detail the actions he intends to take to address this spiralling problem for the HSE and the provision of funding.

There has been significant focus recently on the challenging resource constraints within which the HSE is operating. While the budgetary targets this year are particularly constrained, it is important to recognise that similar financial and resource constraints have applied in each of the past number of years as a direct consequence of the emergency financial situation the State has had to address since 2008.

The cumulative impact of this unprecedented period of financial and resource restraint has resulted in reductions in the health service budget of the order of €3.3 billion, that is, over 20%, with the numbers employed reduced by over 14,000 in the same period. On a comparative basis the OECD report, Health at a Glance 2013, shows that recent reductions in public health expenditure per capita in Ireland are the highest experienced in any OECD country with the exception of Greece.

These challenges come at a time when the demand for health services is increasing each year which, in turn, is driving costs upwards. However, despite these resource reductions and increasing service demands, the HSE has managed to support growing demand for its services arising from such factors as population growth, increased levels of chronic disease, increased demand for prescription drugs, and new cost intensive medical technologies and treatments. The HSE is to be commended on meeting these increased demands on its services.

That said, 2014 is proving to be a particularly challenging year for the health services. Cumulative net expenditure to the end of March is €114 million lower than in the same period last year, but given the extent and the phasing of the targeted budget reductions, the cumulative deficit of €80 million is higher than last year's €27 million. The Vote for the HSE is reporting a net deficit of €158 million at the end of May.

As the Deputy will be aware, the expenditure ceiling for the HSE is decided by Government, among other things, against a backdrop of national budgetary objectives and the prevailing macroeconomic conditions.

Additional information not given on the floor of the House

Very difficult decisions were taken by Government in the context of the overall budgetary arithmetic. Certain savings targets required of the HSE at the time of the budget were considered so challenging that it was agreed that a separate validation exercise to assess their achievability would be undertaken by the Departments of Health, Public Expenditure and Reform, and the Taoiseach. While work continues on the maximisation of the savings achievable under the Haddington Road agreement, the initial savings targets under medical card probity were reduced by €110 million in the context of the Revised Estimates Volume, REV. Along with pay savings targets, and taking account of the reliance on agency workers which is further compounded by the European working time directive, it is clear that the challenges facing the HSE in 2014 were extraordinary from the outset.

There is ongoing and intensive engagement each month between officials of my Department, Department of Public Expenditure and Reform, DPER, and the HSE in the context of regular monitoring of expenditure. The HSE is proactively engaged in internal efforts to maximise savings and cost containment plans and to ensure that additional measures are identified and safely implemented to mitigate any projected deficits which are within HSE direct control, while engaging on an ongoing basis with my Department. I assure the Deputy that the national director for acute hospitals has written to all hospital groups-hospitals setting out clear key messages around the need to reduce costs safely and to submit additional cost containment plans. Additionally, a full round of high level performance assurance meetings has been completed and another round is starting. The director general has met the board chairs, CEOs and clinical directors of the ten hospital groups-hospitals with the greatest financial challenges to ensure the messaging is explicit right up to board level in terms of the hierarchy of performance management priorities, that is, service safety and quality first, financial management next and then all other priorities, including elective access for non-clinically urgent cases.

Work is ongoing between the HSE and my Department on finalising projections to year end based on data for the first four months of 2014, in tandem with assessment of performance in the same period and risk to year end within its cost containment plans. It would be premature for me to comment further at this stage, pending the outcome of this work, but as the HSE has indicated, the scale of the risk and challenge in achieving financial break-even by year end remains extremely significant as predicted in the national service plan 2014.

Year on year, our difficulty is that we highlight time and again the inadequacies in terms of the Estimate that is brought to this House. The Government will be well aware of it as well. Even the language the Minister uses in terms of the HSE service plan, for example, in the context of unspecified savings, is an indication that he is grasping for or pretending that he has the funding to run the health services for the year ahead. That is what is happening year in, year out.

The Minister states consistently that there has always been a Supplementary Estimate from the Department of Health to the HSE. That has been because of a change in policy, but everybody knows that one addresses the Estimate from a no-change policy perspective first and if there are changes in policy, one either adjusts the budget forward or up or down in that context.

What if the economy collapses?

A question, please. This is Question Time.

In 2008, even in that context, the HSE came in on budget and there was not a Supplementary Estimate. We must try deal with facts here.

We have to deal with time as well.

The difficulty is every year the Minister, Deputy Reilly, presents a fatally flawed budget.

Did Deputy Kelleher hear me? We are over time.

I remind Members there are two minutes for the Minister to answer and a minute for each supplementary.

I thought it was two minutes. My apologies.

It will not take me two minutes to respond to Deputy Kelleher.

As they say, one can avoid the facts but they will not avoid you. Deputy Kelleher alludes to 2008. Would he tell us what the Supplementary Estimate was in 2009? Would he like to tell us what it was in 2010? In his party's last year in government, it was nearly €600 million in health. Let us deal with the facts. In 14 of the past 17 years there have been Supplementary Estimates in health. For 12 of those 14 years, the budget was increasing, and was quadrupled, and still they failed to keep it within budget.

At a time when we have had to take €3.3 billion out because of the mess the Government of which his party was a member left this country in, we have had to take serious decisions about how the health service is run. The good men and women who work in the health service have managed to achieve a reduction in the number of patients who have to lie on trolleys for long periods of time and a reduction in the number of patients who have to wait long periods for inpatient treatment and, for the first time ever, and have quantified the number of outpatients and treated 95% of them within a year. The health service is improving, despite the serious challenges that it has to face.

We consistently get the history lesson but the Minister does not live in the real world when it comes to the budgetary estimate process. Year on year, as I stated, we face a situation where the Minister presents a flawed budget to the House. That has happened over the past three years. I see no reason this year's budget was presented in any different way because it includes unspecified savings of €108 million.

In October last, the Minister went to the Minister for Public Expenditure and Reform and the Minister for Finance to look for €1 billion extra and he walked out of the room with €666 million less.

That is what happened last year. It is not that I have a difficulty with credibility. The issue is the Minister's credibility with his Cabinet colleagues in the delivery of sufficient funding to provide a budget that will sustain health services. That is what we are talking about. In terms of a history lesson of what happened in the past ten or 12 years, people want to know what is happening this year in the health service.

We have made it very clear what is happening this year. We have a national service plan for the HSE, in regard to which patient safety is a clear priority. There are other things in it, including an expansion of the transplantation service. Last year was a very successful year one, with more transplants carried out than ever before. We have also put in place diabetic retinopathy screening and colon cancer screening services. Many good things have been done, as well as maintaining the services. If it had been all about money, as the Deputy seemed to think when his party was rolling in it, it would have been able to fix the health service. Instead of reforming it, it just continued to throw money at it. As we all know, the Deputy's party leader was the creator of the HSE, which has become an absolutely devalued brand and which the Government is committed to replacing.

Ministerial Appointments

Caoimhghín Ó Caoláin


2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will set out in full the circumstances in which he appointed a founder and 50% shareholder in a private health consultancy firm as chairperson of the West-North West Hospitals Group, which subsequently awarded a contract to said firm; if the potential conflict of interest was known to him when he appointed the person and, if not, when he became aware of same; the date on which he became aware of the breach of the financial procedures of his Department in the awarding of the contract; the further steps he has taken since the resignation of the person concerned; if he has considered his own position; and if he will make a statement on the matter. [27109/14]

I seek a detailed explanation from the Minister for Health on the matter of the appointment of Mr. Noel Daly to the position of chairperson of the West-North West Hospitals Group, despite the clear conflict of interest created by his role and interest in D & F Health Partnership, a private company in which he was then a 50% stakeholder.

In order to address concerns about persistent underperformance which had arisen in a number of hospitals in Galway-Roscommon, a CEO was appointed to the Galway-Roscommon Hospitals Group which was subsequently extended to become the West-North West Hospital Group in January 2012 and Mr. Daly was appointed chair of the non-executive board on 29 May 2012.

My Department and the HSE first became aware that an issue had arisen in the commissioning of the review of maternity services on behalf of the West-North West Hospitals Group from a media query on 19 May 2014. The director general of the HSE informed my Department on that day that he had requested a team from the HSE's internal audit unit to conduct a report on the matter. In the course of its investigations the HSE internal audit team was assured by the CEO that he had made the decision to source D & F Health Partnership based on its suitability for the project and that the chair had no role in this. The investigation found that while Mr. Daly had disclosed to the board that he was a former employee and former director of D & F Health Partnership, he had failed to disclose that he continued to hold a 50% shareholding in the company. The investigation also established that the procurement of services had not been in accordance with HSE national financial regulations.

On 22 May the findings of the audit were presented to the director general of the HSE who informed my Department and wrote to both Mr. Daly and the CEO to make it clear that further breaches of procurement rules would be unacceptable and that Mr. Daly should have made it clear to board members that he retained a 50% shareholding in the company concerned. The letter to the chair of the board also requested that the chair take immediate steps to ensure a register of members' interests was established and maintained at the hospital group in order that potential conflicts of interest would be avoided. It is important that anyone serving on the board of a public body make a full disclosure of his or her interests in order that potential conflicts of interest can be avoided. Mr. Daly did not want his reputation or that of the West-North West Hospitals Group to be compromised. I shared these concerns and accepted Mr. Daly's resignation.

I have a number of questions. Did the Minister know Mr. Daly personally and, if so, for how long? Did he know in June 2012 when he appointed Mr. Daly to the position of chairperson of the West-North West Hospitals Group that he had been the founder, director and joint owner of D & F Health Partnership, with a 50% stake in it? If he did know, why did he appoint him? If he did not know, does he agree that it begs the question of the basis on which he is appointing people to these positions if he does not know the very basic facts about them. He has indicated that Mr. Daly did not bring his position to the attention of the board. Did he not bring to the Minister's attention his other interests? Did Mr. Daly not see a conflict of interest? Does the Minister recall when appointing the new boards to the hospitals groups that he cited the need for an assessment of potential conflicts of interest of potential board members? Does he accept that there was a clear conflict of interest in this appointment?

The last question is astonishing in some respects. Is the Deputy suggesting anybody with business interests is not fit to be chair of a board? I do not accept this. It may be the Sinn Féin way and the Sinn Féin's Ireland of the future, but it certainly is not the Government's view that people involved in private enterprise, with a tremendous skills set in terms of organisational and leadership skills, should be excluded from membership or becoming chairs of boards. I reject this out of hand.

The Deputy asked me if I had known Mr. Daly before I appointed him. I did not know him and do not believe I had ever met him before then. Perhaps I had met him, but I certainly did not know him or of him. However, I was told about his curriculum vitae and the fact that he had been a great servant of County Roscommon, having been an excellent footballer who had represented his county, and had knowledge of the health service and that he would be an ideal candidate to be chair of a board. I was particularly taken by the idea that, being from County Roscommon, we would send a very clear message that the hospital groups would be representative of the hospitals in the entire group, not just the large university hospital at the centre of them.

I regret that Mr. Daly did not declare his shareholding in the company. I think he was concerned about his reputation being damaged and that of the group and that is why he stood down and I accepted his resignation.

Does the Minister accept that his reputation is somewhat in question as a result of this appointment? Make no mistake about it, his effort to digress in regard to Sinn Féin's position vis-à-vis appointments is the nonsense he usually employs. What is the status of the HSE's internal investigation? What was the nature of the breach of the HSE's national financial regulations in the award of the tender to D & F Health Partnership, as the Minister understands it? Will he confirm that Mr. Daly's D & F Health Partnership was paid €20,000, plus VAT, for its report? What is the status of the report prepared by D & F Health Partnership which recommended cuts to vital maternity services at Portiuncula Hospital in Ballinasloe and Letterkenny General Hospital? Does the Minister recognise, despite his blustering comments, that, in this instance, there most certainly was a breach, a conflict of interest and a failure on his part and that of Mr. Daly and the system, if the Minister is dependent on others to advise and inform him properly and adequately before approving said appointments?

Bluster and nonsense are more particular to the Deputy and his style, but I have made it very clear what happened, that Mr. Daly stood down and that I regret the fact that he did not disclose his shareholding to the board. The Deputy asked me a range of specific questions which I am not in a position to answer, but if he writes to me for further details, I will have no issue with giving him the full details of the procurement issue. Normally, in the procurement of smaller contracts of the nature we are talking about three tenders are required, but it is my understanding three tenders were not received, which is why the CEO of the hospital received the rebuke he did from the head of the HSE.

I would have thought within the time available-----

Question No. 3 is in the name of Deputy Thomas Pringle.

-----that the Minister would have the answers with him, rather than inviting me to write to him.

I have called Deputy Thomas Pringle.

More fiction from Sinn Féin.

Prescription Charges

Thomas Pringle


3. Deputy Thomas Pringle asked the Minister for Health the time period applicable for the reimbursement of the prescription charge to persons on the long-term illness scheme who are also medical card holders; the number of persons this affects, the number of persons who have been reimbursed to date; when he expects all those eligible for this refund to receive same; and if he will make a statement on the matter. [27107/14]

This question relates to the announcement by the HSE that it will reimburse patients on the long-term illness scheme who are also medical card holders the prescription charges they were wrongly charged as a result of having to use their medical cards to obtain prescription items, rather their long-term illness card.

Persons suffering from prescribed conditions can get free drugs, medicines and medical and surgical appliances for the treatment of the conditions under the long-term illness scheme. Medical card holders are required to pay prescription charges. Prescription charges are not payable in respect of items supplied under the long-term illness scheme.

In the case of persons who have both a medical card and an LTI book, it was HSE policy that they should use their medical card to access medicines. The main reason for this was that when a retail mark-up of 20% was payable to pharmacists for items supplied under the long-term illness scheme, it cost the HSE considerably more to supply medicines under that scheme than under the GMS scheme.

Following a review of the rates of fees payable to health professionals - under the Financial Emergency Measures in the Public Interest Act 2009 - my colleague, the Minister for Health, Deputy James Reilly, announced on 2 July 2013 the elimination of the retail mark-up. As a result, the HSE revised its policy on this matter and persons who have both a medical card and an LTI book can now access medication for their qualifying long-term illness condition or conditions under the long-term illness scheme.

The HSE is actively involved in the process of identifying any person who had eligibility under the long-term illness scheme and who, while having concurrent eligibility under the medical card scheme, paid prescription charges prior to 1 December 2013 for drugs, medicines, medical and surgical appliances related to their qualifying long-term illness or illnesses dispensed under the GMS scheme by a registered pharmacist. It is collating the details of the numbers affected and how much they will be refunded. It is anticipated that it will be in a position to make refunds to the relevant individuals in the coming weeks.

As this matter has been ongoing for a number of months, it seems strange that, even at this stage, we cannot obtain information from the HSE on how many people are affected. I have correspondence from the Minister going back to May in which he stated the process had started, yet we still do not have figures for how many are affected.

There is also confusion about the timeframe for reimbursement. The Minister of State has mentioned that it will cover the period July to December 2013 but earlier in his statement he said it was HSE policy that people should obtain items using their medical card all of the time. Since prescription charges were introduced for medical card patients, those on the long-term illness scheme who were entitled to free care have also had to pay prescription charges, according to the Minister of State's response. The reimbursement period should pre-date July 2013 because people on the long-term illness scheme have been paying charges for a long time. The HSE should tell us how many are affected. It should also ensure they are reimbursed straightaway.

The HSE has undertaken to expedite this matter as quickly as possible. As I indicated, it is hoped and anticipated that this will be done in the coming weeks. That is the position and, as the Deputy rightly said, it is related to the fact that people were paying GMS prescription charges they would not have had to pay if they had been able to use the LTI scheme book. The issue has been ironed out and, as I mentioned, the HSE is collating details of the numbers affected. I do not have to hand the exact number affected, but the Deputy and the House can be assured that anyone who is affected will be able to avail of refunds which will be made within the coming weeks.

Will the Minister of State clarify whether people affected before July 2013 will also receive reimbursements? Prescriptions charges were introduced in 2012. There is, therefore, a period up to July 2013 during which people with LTI books were wrongly charged for prescriptions because they obtained medicines while using their medical cards.

I will revert to the Deputy on that matter. The decision was made and announced by the Minister last July. I have indicated that this matter will be dealt with in respect of prescription charges charged prior to 1 December 2013. Prescription charges were introduced in 2010. I will revert to the Deputy with the further details he is seeking. The matter is being expedited by the HSE.

Mental Health Act Review

Colm Keaveney


4. Deputy Colm Keaveney asked the Minister for Health in regard to the ongoing delay in the publication of the expert group’s review of the Mental Health Act 2001, the impact of that delay in addressing the continuing human rights issues within the mental health system; and if he will make a statement on the matter. [27414/14]

The Mental Health Act 2001 was introduced by the former Minister for Health, Deputy Micheál Martin, and marked a significant improvement in mental health care. I have tabled this question to establish why we are experiencing a delay in publishing the expert group's report on the Act. I am concerned that this is impeding human rights as set out in the philosophy of that legislation. The Minister of State, Deputy Kathleen Lynch, has explained that the report was delayed for a range of reasons, including the fact that the Assisted Decison-Making (Capacity) Bill 2013 had not been published. In January she indicated that the review would be concluded in a number of months. When can we expect to have a realistic timeframe for the conclusion of the process and publication of the expert group's review?

The expert group set up to review the Mental Health Act 2001 first met in September 2012 and was originally due to report in 2013. When it began its work, I made it clear to its members that they should take an open and expansive approach and consider all issues which they might consider were relevant and necessary for a thorough review, having regard to the terms of reference for the review. The interim review of the Act, published in June 2012, was, therefore, a starting point for a much more detailed analysis of the issues involved. In line with this approach, the group requested additional time to consider the implications for mental health legislation of the Assisted Decision Making (Capacity) Bill which was published in July 2013. An extension of its timeframe was, accordingly, agreed to.

The Deputy will also be aware that the review takes account of the fact that the Mental Health Act 2001, despite what he has said, predated publication of the Convention on the Rights of Persons with Disabilities in 2007. The convention provides for a rights-based approach to disability and certain of its articles have implications for our mental health legislation. In this context, the need to achieve a balance between individual human rights and the requirements for public safety have given rise to detailed discussion and analysis by the expert group.

The Mental Health Act 2001 was introduced on a phased basis and fully enacted by 2006. It would not be usual to have a formal comprehensive review of legislation that has only been fully operational for less than a decade. The 2001 Act was fully consistent with prevailing approaches to rights at the time and continues to underpin a modern approach to regulation of mental health services in Ireland. I am satisfied that the extended timeframe which was necessary for the current review is not impacting on human rights issues within the mental health system. I expect to receive the expert group's final report by the third quarter of 2014.

Last week the Minister of State indicated that the review would be ready by the third quarter, yet we are experiencing delays in this process. I do not see urgency being demonstrated by the Minister of State in dealing what continue to be significant human rights issues within the mental health system. Last year 80 children were in adult wards in psychiatric units across the country. This is a significant human rights issue. One must look at what has happened in Carlow and Kilkenny concerning the loss of life and human rights. I am asking the Minister of State to pay special attention to this matter and accelerate publication of the expert group's review of the Mental Health Act 2001. In April the Minister for Finance, Deputy Michael Noonan, said it was only a matter of weeks before the review would be published. Why are we experiencing significant delays? I ask the Minister of State to provide absolute clarity in order to ensure we can protect those who are most vulnerable. I am appealing to her to put in place the best form of legislative base to enshrine a human rights philosophy to protect the most vulnerable.

That is the very reason for the delay, but the Deputy does not seem to understand this, nor does he understand we already have a Mental Health Act in place which, as he keeps telling us, his beloved leader published. It continues to provide the governance process by which mental health services are run. We have delayed publication of the review because we want to get it right. Unlike the 2001 Act, we want to ensure there will be comprehensive and rights-based legislation in place. That Act was appropriate for its time, but it is not appropriate anymore. I do not intend to rush this process because in dealing with very vulnerable people, and the people who care for them for whom we also have to care, we need to get this right rather than do it quickly.

I am delighted to hear that the Minister of State is concerned about the front-line staff who care for vulnerable people. She did not bother at all to respond to the front-line staff in Carlow for a significant reference period when they sent correspondence to her. She did not seem to take much action with respect to dealing or engaging with front-line staff. We have pointed out this issue consistently in this Chamber - the Minister of State fails to engage and fails to listen. She chooses whom she wants to listen to because they tell her what she wants to hear.

In particular administrative areas, including Galway, north County Dublin, and Carlow and Kilkenny, she is listening to the wrong people and it is having devastating consequences. Rather than bat them over the head with A Vision for Change policy when people speak out or demonstrate some dissent about her approach, she should sit down and engage with the front-line staff - she may learn something.

I met the same front-line staff on numerous occasions. When I met them first they told me they did not want the unit in Clonmel to close and they have not changed that position. Front-line staff in this instance, as the Deputy will know, are nine people out of 638. The rest of them are happily working and tell me that they are doing a very good job and that the new approach is the right one. Certain people are opposed and resistant to change, but I keep telling them that at the end of the day there is not an option. We are not stopping. A Vision for Change is the policy of this Government and was the policy of the Deputy's beloved leader and the previous Government. However, Deputy Keaveney may not know that; he is not in Fianna Fáil that long. This is where we are going. People have to get on board and be responsible, and they have to care for the people they are charged with caring for.

Long-Term Illness Scheme Eligibility

Thomas Pringle


5. Deputy Thomas Pringle asked the Minister for Health if he will reconsider extending the long-term illness, LTI, scheme list; if he will establish a review to ensure that all those who have an illness that is long term are eligible for the LTI scheme; and if he will make a statement on the matter. [27108/14]

This question relates to the necessity to review the long-term illness scheme and add to the list of conditions-----

I am sorry I did not hear that.

-----that are covered under the scheme. I think it came in in 1970 and needs to be reviewed. There are many lifelong conditions from which people are suffering and they need the assistance of the scheme.

The long-term illness, LTI, scheme was established under section 59(3) of the Health Act 1970. Regulations were made in 1971, 1973 and 1975 specifying the conditions covered by the LTI scheme. The conditions covered by the LTI scheme are as follows: acute leukaemia; mental handicap; cerebral palsy; mental illness in a person under 16; cystic fibrosis; multiple sclerosis; diabetes insipidus; muscular dystrophies; diabetes mellitus; Parkinsonism; epilepsy; phenylketonuria; haemophilia; spina bifida; hydrocephalus; and conditions arising from the use of Thalidomide. There are no plans to extend the list of conditions covered under the LTI scheme.

My Department is currently reviewing the operation of the LTI scheme. It is expected that this review will be completed later this year. However, there are no plans to review the scheme along the lines of the current work of the expert panel recently established by the HSE to review eligibility for medical cards.

Under the drug payment scheme, no individual or family pays more than €144 per calendar month towards the cost of approved prescribed medicines. The scheme significantly reduces the cost burden for families and individuals incurring ongoing expenditure on medicines. Of course, the introduction of that scheme post-dates the LTI scheme.

In addition, people who cannot, without undue hardship, arrange for the provision of medical services for themselves and their dependants may be entitled to a medical card. In the assessment process, the HSE may take into account medical costs incurred by an individual or a family. Those who are not eligible for a medical card may still be able to avail of a GP-visit card, which covers the cost of GP consultations.

I think there is a need to extend the scheme. There are a number of conditions, including Crohn's disease and colitis where people have lifelong conditions involving ongoing medical costs. It is strange to see the HSE recommending that people should apply for a discretionary medical card given the fiasco of the past couple of years with discretionary medical cards. The long-term illness scheme would provide relief for those many people. There are also people with dementia and Alzheimer's disease who have ongoing costs that could be covered by the scheme if the scheme was brought up to date and modernised. It would be of great benefit to those people. Rather than having to put them through the process of being means-tested through the medical card system, their conditions could be looked at and the benefit from the scheme could come from there. It should be reviewed and the list of conditions should be increased.

The very real situation faced by people, mentioned by the Deputy, who have a long-term illness or medical condition and are above the means-test limit for a medical card, will be addressed in the new policy shift signalled by the Minister, Deputy Reilly, and the Government last week, which is based on a review by an expert panel, and a paper and decisions in Government later this year. This will address the very real issue, on which I agree with the Deputy, faced by people who, although they are above means-test limit for a medical card, have a continuing medical condition requiring access to services. That is precisely what we are doing in respect of the decision the Government has made. The Government will certainly revert to the Oireachtas in due course as to how that will be addressed. I suggest to the Deputy that will cover in large measure the issue he is raising. Rather than adding new illnesses to the LTI scheme - nothing has been added to that since 1975 - let us now look to what the Government has determined which is to see how best to incorporate into the GMS persons who although they are above the income limits, perhaps in some cases substantially above the income limits and in many cases not so much above the income limits, but still have a medical condition or illness which is a problem for them. That is the real difficulty we have been struggling with in recent months and the Government made clear decisions last week on a policy shift there.

I ask the Minister of State to clarify if the expert review will consider a long list of illnesses or the medical need of a person when deciding. If it looks at a list of illnesses, it may result in illnesses being left out and people will be outside the system as happens with the long-term illness scheme. Will it look at the medical need of a person rather than having a prescribed list of conditions?

The expert panel has been formed under the chairmanship of Professor Frank Keane. The panel contains an extensive number of experienced health professionals. We will leave the work on determining whether it is lists or conditions to that expert panel in the first instance. As I understand it - I do not want to mislead the House - I believe the terms of reference are currently being determined for the expert panel. Perhaps we will be in a position to report back to the House in due course as to the precise terms of reference. I think I am right about that. It is an important piece of work for the expert panel to address and it will do that. There is an undertaking that work will be completed by September.