Leaders' Questions

Last year, the Taoiseach made an apology regarding discretionary medical cards. He apologised to the people and stated that the Government had to take remedial action to make up for the unintended consequences of the savage review that was in train at the time. He stated that the Government had announced a new plan that would bring flexibilities, local input and discretion. Certainly, there were improvements and many people had their discretionary medical cards restored. Nevertheless, I put it to the Taoiseach that there are still very serious issues with quite a number of children who have very serious conditions and illnesses.

I know of a case involving a nine year old girl with B-cell lymphoma, which is a very rare cancer. The story is in the public domain. She has had surgery and intensive chemotherapy but despite considerable submissions to the HSE, she has been denied a discretionary medical card. We pursued the issue when we heard about it. She is under the care of a medical team in Crumlin which has also made submissions to the HSE. The mother has had to give up work and the issue has caused immense strain and anxiety. I put it to the Taoiseach that parents should never be put in this position, particularly when children have such serious conditions. Last week, a family travelled from Mayo with their 18 month old son, Ryan, who has Down's syndrome and also has a significant cardiac condition, apnea, and so forth. They were accompanied by the Our Children's Health campaign. The Taoiseach wrote to Ryan's mother, Nichola, indicating that he trusted the issue would be resolved to her satisfaction as soon as possible.

This year, it is intended to roll out free GP care for children aged under six. That is fine. Many people cannot comprehend how two young people in this position, in one case the child is over six but in the other the child is 18 months old, can still be denied full medical cards despite all the talk of flexibility and applicability of local inputs. This is happening while perfectly healthy children aged under six are to receive free GP care towards the end of the year.

Will the Taoiseach ensure that what he stated last year will apply and there will be common sense and flexibility applied to very serious cases? I should not have to raise such cases on Leaders' Questions and I am only doing so because it is the last opportunity I have to achieve some realism and common sense in the two cases I mentioned. I have been working on the case of the nine year old child for some time now. Yesterday, officials indicated it would be another year before the discretionary card system would be in place. I do not think that is correct. Perhaps it was a reference to the new flexibility or the new medical panel. Children in these cases cannot wait. I ask the Taoiseach to intervene. How can he justify rolling out the programme for children aged under six while at the same time denying a medical card to children who are over six years?

Where is the Minister hiding?

I do not want to comment on the details of a particular case. In some cases, a card was refused on the basis of income. The Keane report commissioned by the Minister considered whether cards could be granted on the basis of an illness and it indicated that this was not morally, ethically or in any case justified. The application process goes back to the element of discretion. An application would be made and the case of a child or children would be considered by discretion. That process is much more flexible than it used to be. There has been an increase from approximately 52,000 discretionary cards issued in the middle of last year to over 77,000 at the end of December 2014. There is a far greater degree of common sense and sensitivity applied here. There is also the question of checks with local medical and health officials to see if there are local issues or changes in circumstances that apply.

I note the Deputy's comment in respect of the first case he mentioned, where one of the parents has given up work. That would lead to a change in income circumstances for the family. Access to facilities and treatment is important in these cases, including issues that might arise for the children involved. My understanding of the second case is that the child has access to the long-term illness and GP card, as well as the facilities that the child needs. I understand that whatever is the medical requirement of the child has been approved. If the child needs orthopaedic shoes, they will also be made available, depending on when the child would be fitted.

I do not have the details of individual cases around the country. The Minister has made it very clear that we need a degree of common sense and, where discretion has to be considered, it should apply. If the Deputy has different information, I will certainly make it available to the Minister for Health, who is very anxious about these issues. Nobody wants a case of a sick child not having access to medical facilities and treatment. As has been indicated, until one gets to a universal health scheme, there will always be people over the limit for a medical card application. This leads to the question of discretion for circumstances that arise.

Without detailing the individual circumstances of children or any individual here, I hope the point mentioned by the Deputy about a change of circumstances in the case is checked. I do not accept that there should be a wait of 12 months before a decision can be made about a discretionary card, as that is clearly not true if we have gone from 52,000 to 77,000 discretionary cards issued in the past six months.

With young Ryan's case, 50 pages of information has been sent to the HSE and the long-term illness card does not cover all the aids and facilities required by the child. The Taoiseach is claiming that by the end of the year, free GP care for children aged under six will be rolled out, so there is no justification for this kind of behaviour. In October, the Taoiseach indicated his hope that the case would be resolved to the satisfaction of Ryan's mother; it has not and 65,000 people have signed a petition in that regard.

I do not wish to mention the name of the little girl, although it is in the public domain. There was a submission from Dr. Aengus Ó Marcaigh, consultant haematologist, which outlined very clearly that the diagnosis and treatment has required the parents of the child to provide a level of care which is greatly in excess of that normally required by a child of her age. The mother wrote that her daughter has been diagnosed with B-cell lymphoma, a very rare cancer, which is being managed by a medical team consisting of a number of consultants. The medical condition is constantly evolving.

In such cases, parents want security and they do not need the stress and anxiety that the endless toing and froing with officialdom brings while they are dealing with a very sick child in hospital. It seems there is no acknowledgement or recognition of that when parents are in such very difficult circumstances.

What about the GP card?

There is a juxtaposition of very healthy children getting free access to GP care but very sick children aged over six still being denied the medical card, which could provide a significant degree of security and reduce worry and stress levels. It would also be of practical help because of the frequent visits to GPs and the need for medication arising from this condition.

The Taoiseach did not answer the core question of how we can justify this as a society and children like this can be left in such a position. The Taoiseach apologised and promised flexibility with respect to medical cards.

These cases do not illustrate any such flexibility or common sense being applied to genuine situations.

Nobody believes that parents should be stressed or put under pressure in respect of their children. That is one of the reasons the Government has the objective of introducing universal health insurance in the long term. In the short term, nobody wishes to see parents stressed by difficulties with their children. Clearly, a far greater degree of discretion has been applied because 22,000 extra discretionary cards were granted from mid-2014 to the end of 2014.

They were the cards that were taken in the first place. They are not new ones.

The important issue is whether there is an outstanding treatment, facility or product that either of the two children needs, because parents need to know that they are not blocked from access to the treatment and facilities. In the second case, my understanding is that everything the child requires is being made available. If Deputy Calleary has different information on outstanding facilities or products that are required by these children, he should make it available to the Minister for Health.

With regard to the analysis of the discretion, the Our Children's Health group was outside Government Buildings for a number of months and I met its members on many occasions. They are very reasonable people and they are now working with the clinical team in assessing discretion for treatment and facilities for children. There is local check-back every week. If 22,000 extra cards have been issued on a discretionary basis, I would hope that the HSE could see that common sense is applied to these cases. I do not have all the details of the individual cases because I do not work in the HSE, but is there a product, facility or access to a treatment that either of the two children is not receiving?

Just give the card.

We cannot have a situation where people are put under that pressure. The Keane report was commissioned to report on whether to give medical cards on the basis of an illness and it said that cannot be.

I have issues with that as well.

Therefore, one goes back to the income threshold and discretion after that. It is in the application of the discretion that the Deputy's question, which is a valid one, must be dealt with. As the Deputy has raised the matter, I hope the people dealing with this can tell us what is outstanding for either of the children in terms of treatment, facility or product.

The Taoiseach knows what a medical card provides. It gives one access to a GP and to a range of things which this young girl does not have.

The Deputy has put his question. He has had a good run and received five minutes more than his allocated time. I call Deputy Adams.

Clearly, what is outstanding is the Taoiseach's commitments that he made four years ago.

There is growing frustration and anger at the continuing overcrowding crisis in our hospitals. This morning the number of patients awaiting admission is again at near record levels. Some 472 patients were on trolleys in emergency departments or wards this morning, and for the third day in a row Our Lady of Lourdes Hospital in Drogheda has the highest number of citizens on trolleys. It is clear the Government is not providing adequate resources.

Consider the scenario. A patient who is ill presents at a hospital and a clinical decision is taken to admit the patient, but Government policy prevents them from receiving proper medical attention and denies them admission. Instead, they are left for several hours or days on a chair or trolley. I invite the Taoiseach to make an unannounced visit to Our Lady of Lourdes Hospital in Drogheda, or indeed to any other hospital, to see the challenges being faced by committed health workers and the indignities that are being inflicted upon patients and their families. Perhaps he will take the time to visit a ward from which patients have been clinically discharged but who cannot be sent home. It is not safe to send them home because they are denied the services they require as a result of Government policy.

The Government has decided that this is the price our people must pay for its austerity policies. Meanwhile, last year the Government paid €7.5 billion in debt interest, including private banking debt. Will the Taoiseach accept that he cannot and will not tackle the overcrowding crisis in our hospitals while he pursues these brutal austerity policies?

No, I do not accept the Deputy's assertion. The Government is acutely aware of the challenges and difficulties in the health service. That is why an extra €650 million was put into the system for 2015. It is also the reason the Minister established a specific unit to deal with the emergency department trolley numbers. There were 400 at 8 o'clock this morning, and obviously that will decline during the course of the day. That unit met on 2 February to consider a strategy to deal with this. In Drogheda, for example, there is an acute shortage of beds in the locality to deal with delayed discharges from the hospitals.

The Government closed them.

This is one factor that feeds into the problem. I listened to an eminent medic say this morning that the attitude of the Government is that it will be all right on the day as we have had this problem for years. The fact is, however, that the Government takes this very seriously.

It is not in anybody's best interests to have people on trolleys, particularly elderly people. I have had first-hand experience of going to wards and emergency departments, although I thank the Deputy for the invitation. In the case of Our Lady of Lourdes Hospital, funding was approved for construction of a 12-bed surgical assessment unit and a clinical decision unit which will open next April. The acute medical assessment unit is open 24 hours a day, seven days a week for direct access for GP referrals. The hospital is increasingly making use of relationships with other hospitals in the Louth and Meath group to distribute work more appropriately. A total of 15 transitional care beds were identified this week and five patients have been discharged to date. Our Lady of Lourdes Hospital will be the next hospital to benefit from the Irish hospital redesign programme, and advertisements have been placed to recruit a new hospital manager.

Our Lady of Lourdes Hospital joined the Royal College of Surgeons in Ireland hospital group and will benefit from that networking and reconfiguration in the nearby hospitals, which include Connolly Hospital, Beaumont Hospital, Cavan-Monaghan hospital group and Louth County Hospital, Dundalk. The hospital has been collaborating recently with the private sector to accelerate the exit of long-term care patients, with 24 beds expected to come on stream by the end of this month. The hospital has also implemented fully the improvement plan agreed with the Health Information and Quality Authority as part of the special measures since 2012.

The Minister for Health asked for co-operation from front-line staff and medical personnel, and I thank them for that co-operation. This is an issue that must be managed in a way that will bring about a reduction in the use of trolleys in emergency departments and in the corridors of hospitals, but it is not something that can be fixed overnight. I am anxious that the Deputy understands that the Government does not have endless resources. If it was a question of money, the problem would have been fixed years ago. It is a matter that arises regularly and the issue is to be able to manage it effectively in the interests of the patients. That will be the priority for the Government. The special unit dealing with trolleys in emergency departments will continue to meet and access whatever beds are available, so delayed discharges can be discharged and pressure can be relieved on the hospitals. Again, I thank the medical personnel for their co-operation.

The Taoiseach should listen to what he says sometimes. He said it is not in anybody's best interests to have patients on trolleys. There is no need to tell me or anybody else that, particularly the families of these patients. The Taoiseach said there were 400 patients on trolleys this morning, but there were 472. He said a new module unit is being opened at Our Lady of Lourdes Hospital, which is the case, but last week there was no commitment of staff, especially nursing staff, for that unit. He said the hospital is trying to find beds for patients who have been clinically discharged, but at the same time the Government closed Drogheda Cottage Hospital and has yet to honour the commitment regarding St. Joseph's in Ardee.

Last month, I crossed the floor of this House and gave the Taoiseach a letter I had received from HIQA in which it pointed out that the recommendations of the 2012 report on Tallaght hospital had not been implemented. It said that if these recommendations had been implemented, the current risks would be significantly reduced for patients. It also said that it told the Department of Health and the HSE this. It said all of this in very clear language, publicly and in correspondence.

It is the explicit responsibility of the Department of Health and the Minister for Health to take prompt action to implement HIQA recommendations. When I asked the Taoiseach why the Minister for Health had failed to implement these recommendations, he failed to answer me. When I gave the Taoiseach the letter, he promised to write to me. He never did. I am still awaiting a letter from the Taoiseach dealing with this core issue, which is that HIQA states that if its recommendations had been honoured, this risk would have been significantly reduced. Will the Taoiseach explain to the House why the HSE, the Department of Health and the Minister for Health, in the face of this ongoing crisis, have failed to implement HIQA's recommendations on patient safety in our hospitals?

What about the Royal Victoria Hospital in Belfast?

In Deputy Adams's back garden.

I have made the point that the Government put more than €600 million extra into the health budget this year. It takes time for that spend to filter out in terms of treatment for patients and facilities.

The Taoiseach has been Taoiseach for four years.

I am surprised that Deputy Adams did not get a letter back from me. I will see that he gets it today.

An sin é? Will the Taoiseach not answer the question now? He must know the content of the letter.

I will answer the Deputy's question in the letter.

What is in the letter? The Taoiseach should tell the House what is in the letter.

It will be a one-pager.

The Taoiseach is getting more like Bertie Ahern every day.

I do not mind sharing the correspondence.

A Deputy

The Taoiseach should acknowledge receipt.

I, along with other public representatives in Kerry, attended a monster meeting in Caherciveen on Monday night regarding the future of our rural schools. Strong opinions were expressed regarding the frustration and concerns of parents, teachers and boards of management. A very dismal picture was painted of boarded-up schools and of many other schools which are in danger of a similar fate in the very near future. Every one of us from rural Ireland, particularly the Taoiseach, is well aware that these schools are at the heart of communities. They have been the main focal point of rural Ireland since the instigation of the education boards in 1931. The situation has been exacerbated, particularly by Government policies, over the past number of years. There has been a phased increase in the pupil-teacher ratio in two-, three- and four-teacher schools since September 2012. This has affected schools with fewer than 86 pupils and approximately half of the 3,200 primary schools.

In 2011, a two-teacher school needed 12 pupils to retain its teachers, a three-teacher school needed 49 pupils and a four-teacher school needed 81 pupils. From this September, a school will need a minimum of 20 pupils to retain two teachers, 56 pupils to employ three teachers and 86 pupils for four teachers. This is replicated across the country, particularly on the western seaboard and across rural Ireland.

Rural depopulation, migration, emigration and the economic decline in our rural areas are significant factors. It was suggested at the meeting that the introduction of emergency measures be examined. The figures quoted are impossible for these schools to reach. It was suggested that, as a gesture, a minimum retention figure be allowed. Otherwise, we will be faced with a serious dilemma and another hit on our quality education and, as already pointed out, on these communities in general. I ask the Taoiseach to seriously reconsider what is happening and to intervene.

Deputy Fleming stole a march on Deputy Healy-Rae.

Deputy Griffin brought this to my attention yesterday.

(Interruptions).

He was in a coma for four years and he voted to close them.

A Deputy

Deputy Healy-Rae should look to his right.

The local election woke him up.

Deputy Healy-Rae is advised to watch his blood pressure.

The Taoiseach should get his teacher's cap now.

I thank Deputy Fleming for raising this matter, which is very sensitive and important in many locations in rural Ireland.

The Government has done this for three years.

Monster meetings began with a Kerryman many years ago.

It was as big as the one in Roscommon.

A Deputy

I hope they are not arrested.

(Interruptions).

I am not sure whether that one is considered to be a monster meeting or not.

Daniel O'Connell had more success, though.

This is an issue that needs to be considered very carefully.

What does the Taoiseach mean when he says he is considering it very carefully? This has been going on for three years.

Deputy Fleming mentioned four, three and two-teacher schools, and some that have become one-teacher schools. The Government has no intention of closing any schools. The problem is that in many areas, the demographics over the next period are going to mean a continued drop in the number of children who are born-----

No. The Government changed the ratio.

Change the ratio.

It is not Deputy Martin's question. Deputy Fleming is entitled to a reply. I ask the Deputies to stay quiet.

The pupil-teacher ratio is one issue. The number of children born and living and eligible to go to school in any locality is another. Where I come from, there has been a huge drop in numbers in many rural areas. There are 14 one-teacher schools in the county at the moment.

The former Minister, Deputy Quinn, reduced the pupil-teacher ratio.

I do not support the concept of one-teacher schools. They are not in the best interests of children. The numbers can be very small and the schools do not have all of the facilities or the competitive peer activity that children would expect in school.

So the Taoiseach wants to close them.

(Interruptions).

Will the Deputies please allow a reply to the question?

This is an issue that needs to be looked at very carefully and in the longer term. I did not hear any proposition coming from the monster meeting in Kerry except "Do something about it."

(Interruptions).

What needs to be done is-----

Reverse the ratio.

-----to look at the projections for the number of years ahead for every school-----

They have been looked at long enough.

-----and say to people, if the trend continues, that the population of school-going children is dropping in many localities in rural Ireland.

The Labour Party did this.

This has got to be examined in the context of what we must do for the future. Do we provide incentives for communities in order that they will want to continue with the school if it becomes a one-teacher school-----

The Government will have made it a one-teacher school.

-----or should the school consider amalgamating with another school? These are issues that need to be addressed.

The Taoiseach has addressed them, but disastrously.

There are many parishes in my own county where the number of eligible children of school-going age has dropped away completely.

The Taoiseach is waffling.

It is not like it used to be a hundred years ago, when schools were built within walking distance. It is all very different now. Population numbers are way down in many areas.

It is different because of the Taoiseach's policy.

I accept that this issue is of great importance to people all over the country.

So why did the Government make those cuts?

An enrolment Bill is coming before the Dáil in the not too distant future. We need to look to the longer term and to the future of the numbers in these schools. I thank the Deputy for raising the question.

(Interruptions).

The Government targeted rural schools in the cuts.

Fianna Fáil broke the country. Wake up to that.

(Interruptions).

I find it very disturbing that people who did not ask a question are interrupting, which means the Deputy who asked the question cannot hear the reply. Will Members please show some respect to the Deputy who asked? All of the Deputies had their turn. Please accept that Deputy Fleming is entitled to ask a supplementary question without interruption and to hear the reply.

The Taoiseach has a better grasp of this than probably any other public representative or any Deputy in this House today, as teaching was his profession. He is well aware of the situation facing rural schools. The Government has not been looking at many options to address the matter. It is not too late at this stage. It may be the 12th hour before the September term starts.

The Government is giving a fiscal reason, but we have to get away from the policies of austerity and recession at this stage.

The choice is to go back to the people.

We have to give a bit of hope back to the people.

We need to return to the policies of positivity and progression. People in areas that are dying on their feet are acting up and will do so to an increasing extent in the near future. I foresee that many of these meetings will be held throughout the country because of the huge impact of the decline of rural society and the rural fabric of this country. It has been pointed out that amalgamation is not an option. Schools in many of these remote areas have already been amalgamated. This solution means there are more school buses on the road. Some people have to travel back and forth seven or eight miles. It was pointed out at the meeting that the return trips made by the parents of some pupils, when added up over the duration of those pupils' school careers, are more than the extent of the circumference of the globe. It is interesting to look at it in those terms. We have huge class sizes. Between 30 and 35 pupils are being taught in some rooms due to teacher losses. It is not acceptable that some schools are down to one teacher.

I ask the Deputy to put his question.

Special needs pupils and the vulnerable are falling behind in all of this. Rural Ireland is falling behind as well. The loss of resource teachers for special needs pupils was also pointed out. I ask the Taoiseach, who has a real grasp of this issue, to discuss with the Minister for Education and Skills the implications of where we are going. We are sliding down in Europe, so to speak. We have the second largest class sizes in the EU. We are going down on a slippery slope. I ask the Taoiseach to halt it immediately.

The Government needs to do something for rural schools.

I thank Deputy Fleming for that. Clearly, school-going populations have dropped in quite a number of areas, particularly on the west coast. I know of one location where nine schools have closed over the past 30 years because of depopulation. I have spoken to the Minister for Education and Skills about this important issue. Clearly, there is an issue here in respect of teachers themselves and the peer support they have. In addition, communities need to look at the future of the educational facilities in their areas. I think people are beginning to focus more than they did in the past on the futures of their local schools. How can the local school be maintained if the population is dropping and there are just seven, ten or 15 pupils in the school?

The ratio is going up.

Is that in the best interests of the children from an educational point of view? Obviously, there is a very strong feeling for the school situation in any locality.

What is the Taoiseach on about?

I attended a two-teacher school many years ago.

I would say it was a good few years ago.

There is a great strength in having the local entity. The Minister is acutely aware of this.

Why does she not do something about it?

Why is she not doing something acutely?

She is very conscious of the impact of the situation for rural Ireland. Obviously, she is considering the position. I thank the Deputy for the points he has raised. As I said, they were raised with me by Deputy Griffin the other day. It is an issue that we will address.