Operation of the Medical Card Scheme: Discussion

I welcome the witnesses from the Department of Health and the HSE who will be presenting virtually to our meeting this morning. They will provide us with a briefing on the operation of the medical card scheme. From the Department of Health we have Ms Celeste O'Callaghan, director of model of care policy, primary care policy and eligibility policy, Ms Emma-Jane Morgan, principal officer, eligibility policy unit, Mr. David Noonan, principal officer, GP services and General Medical Services, GMS, contract unit, Mr. Finian Judge, principal officer, community pharmacy, dental, optical and aural policy unit, and Dr. Dympna Kavanagh, chief dental officer; and from the HSE, Mr. Joe Ryan, national director of national services, Mr. Shaun Flanagan, assistant national director, primary care reimbursement service, Dr. Joe Green, national oral health lead in the operations unit, and Ms Kate Halliwell, head of eligibility, national medical card unit.

Before we hear the opening statements, I point out to the witnesses there is uncertainty as to whether parliamentary privilege applies to evidence given from a location outside the parliamentary precincts of Leinster House. If, therefore, witnesses are directed by me to cease giving evidence in respect of a particular matter, they must respect that direction.

I invite Ms O'Callaghan to make her opening remarks.

Ms Celeste O'Callaghan

I am pleased to have the opportunity to update the committee on the medical card scheme. I am joined by my colleagues, Ms Emma-Jane Morgan, principal officer, eligibility policy unit, Mr. David Noonan, principal officer, GP services, Mr. Finian Judge, principal officer, community pharmacy, dental, optical and aural policy unit, and Dr. Dympna Kavanagh, chief dental officer.

Eligibility for health services is determined in accordance with the 1970 Health Act. The Act provides that if an individual who is ordinarily resident in Ireland is deemed unable, without undue hardship, to arrange GP medical and surgical services for him or herself and his or her dependants, that individual is considered to have full eligibility and receives a medical card as evidence of that. Guidelines are in place relating to the income level at which undue hardship would be expected to arise. People whose income is assessed by the HSE as being at or below the thresholds receive a medical card. This system of financial means assessment is considered to offer an objective and equitable approach to determining eligibility, ensuring those with the lowest level of means in society can access healthcare when needed. More than 1.5 million people currently hold medical cards and the vast majority of these are awarded on the basis of a financial means assessment. However, it is recognised that only looking at a person's income level might not provide a full picture of hardship, so where a person's income might be above the thresholds, if there is a significant cost or burden associated with his or her illness, that person may be awarded a discretionary medical card on the basis of undue hardship.

The provision of medical cards for those who are at the end of life is a particular situation where cards are provided on a discretionary basis. Until recently, these cards were provided for individuals who were considered to have a prognosis of up to a year. A clinical advisory group was established by the HSE in 2019 at the request of the Minister to consider the issues arising in extending medical cards for those with a terminal illness. The report was published in November last year. The group included both clinicians and patient representatives, and its report made a number of findings and recommendations. In particular it affirmed that patients in the last 12 months of life are likely to have significant medical needs and to face undue hardship if they do not have a medical card. It also found that patients with a longer prognosis may have medical needs, but those needs might not be at a level that would satisfy the legal test of undue hardship. It identified that estimating a prognosis is challenging and becomes more accurate when an individual's expected timeframe is, sadly, shorter. The report also recommended that if the current prognosis timeframe were to be extended, it should be undertaken on the basis of legislative change rather than via the current discretionary process, but it also found, however, that developing a definition for that purpose would be challenging. Following on from the report and related Government decisions, the Department is working on the development of legislation to underpin that extension but in the interim an administrative extension to award medical cards to people with a prognosis of 24 months or less has been implemented this month.

Legislation was enacted in 2020 to extend free GP care to children up to the age of 12. In terms of considering a date for commencement of the measure, it is important as always to ensure that an expansion of free GP care does not limit the capacity of general practice to meet the needs of all patients in the community. That is particularly important at this time given the impact of the pandemic in terms of increased demand on GPs. For that reason, a suitable commencement date remains under consideration.

The Health Act 1970 requires the HSE to make dental treatment and dental appliances available for medical cardholders. These services are provided under the dental treatment services scheme, DTSS, by independent private dentists contracted by the HSE. The Minister has acknowledged that the DTSS has not kept pace with today's preventative approach to dental intervention and he is committed to a root-and-branch review of the scheme. A new national oral health policy was launched in 2019 and provides the policy context within which a review of the DTSS would be undertaken. However, the pandemic and the immense disruption it caused to the work of the health services and of the Department of Health has caused the roll-out of that policy to be delayed and the proposed contract review to be deferred. The Minister has acknowledged the challenges that contracted dentists have faced during the pandemic and the efforts of the dental community in continuing to provide services in a challenging environment.

He accepts that the profession has concerns about the current contract and is keen to ensure the sustainability and viability of contractual arrangements in order that all eligible persons can continue to receive the services to which they are entitled from their local dentists.

In conclusion, overall, the range of measures in place, including those that have been introduced in recent years to expand access to medical cards and GP care, means that today, 2.1 million people, or just over 42% of the population, have access to free GP care. While every effort is made to ensure the medical card system is responsive to those who need it most, as challenges arise, and they do, the Department will continue to work in collaboration with the HSE to address these.

I thank the committee. I am happy to address any questions members may have.

I thank Ms O' Callaghan. I call Mr. Ryan.

Mr. Joe Ryan

I thank the Chairman and members for the invitation to discuss the operation of the medical card scheme. I am joined by my colleagues, Mr. Shaun Flanagan, assistant national director of the primary care reimbursement service, PCRS, Dr. Joseph Green, assistant national director and national oral health lead in HSE operations, and Ms Kate Halliwell, head of our national medical card unit in PCRS.

The PCRS is responsible for ensuring that eligibility is in place for qualifying persons for primary care schemes such as the general medical services scheme, the drugs payment scheme, the long-term illness scheme, the dental treatment services scheme, DTSS, and other schemes and arrangements. These schemes and reimbursement arrangements are essential to the operation of the health service.

PCRS is also responsible for making payments to primary care contractors, suppliers of essential high-tech medicines and acute hospitals and others across a range of schemes and arrangements. The proportion of the HSE’s budget for 2021 that PCRS is responsible for amounts to €3.269 billion. We constantly focus on patient and service user experience in using the services of PCRS. It works hard to make the best use of its resources, and as a result, its administration costs represent less than 1.5% of all costs over the past decade.

The past 12 months have been unprecedented and Covid-19 has had major impacts across all sectors of society. It is important to reference the challenges that Covid-19 has presented to the primary care reimbursement service and the efforts made to address those challenges.

Throughout the pandemic, PCRS has ensured that all necessary eligibility and reimbursement systems to underpin the arrangements for existing health services are in place and has sustained its performance in meeting key performance indicators. Important new Covid-19 services, negotiated with and provided by our primary care contractors, have been put in place in a timely manner to enable key elements of the overall HSE Covid-19 response.

The staff of HSE PCRS have responded admirably throughout the pandemic to new needs and new work streams. PCRS staff were called upon and responded to multiple other Covid-19 initiatives in support of colleagues. This included the national ambulance service testing of patients and staff in nursing homes, co-ordinating the booking of Covid-19 vaccinations for GPs and their staff and providing pharmacy support to mass vaccination clinics.

Over the past 12 months, applications for new medical cards or new GP visit cards have remained reasonably consistent with historical patterns, with on average between 3,000 and 4,000 new applications being handled weekly. In the early phases of the pandemic, while new applications continued to be processed, the HSE suspended reviews of existing cards. This was because, first, PCRS staff were required to support multiple Covid-19 responses; second, PCRS wanted to reduce requests for GPs to complete the relevant sections of application forms; third, PCRS needed to be in a position to process the then expected large numbers of applications, which did not develop due to the significant economic supports put in place by Government, for new medical cards; and, fourth, PCRS staff needed to support new reimbursement systems such as the GP Covid-19 supports.

Reviews of medical and GP visit cards recommenced for cards that were due to expire from 31 August 2020 onwards. Of those cards, up to 80% of expiring cards have been automatically extended without requiring individuals to engage with the application process. Cards which are reviewed are those which are risk-assessed as more likely to not meet eligibility criteria.

As at 28 February 2021, 1,579,589 individuals held medical cards. This has increased from 1,544,374 medical cards on 1 January 2020. Some 531,121 individuals hold GP visit cards now compared to 524,494 individuals on 1 January 2020.

The PCRS is responsible for making payments to healthcare professionals such as general practitioners, dentists and pharmacists, for free or reduced cost services provided to the public. In 2020, PCRS received in excess of 80 million reimbursement claims from more than 7,000 contractors.

With regard to terminal illness cards, on 9 February, the Government decided to extend provision of medical cards to individuals with a terminal illness who have a prognosis of 24 months or less and have been certified by their treating consultant. It asked that the HSE put this in place as soon as possible. The card will be awarded to the individual for his or her lifetime and will not require a means assessment, nor will the card be reviewed.

Adult medical card holders have access to dental services under the DTSS through care provided by private dentists that hold DTSS contracts with the HSE. Medical card holders can choose which dentist they wish to attend. In a typical year, just over 30% of the eligible population receive treatment through the DTSS. In 2020, this level dropped to 22.4%, mostly due to the impact of the Covid-19 pandemic. Some 1,084,321 claims were received under the scheme in 2019, resulting in expenditure of more than €56 million. In 2020, 789,940 claims were received at a cost of €40.57 million.

An electronic claims system was introduced in late 2017. Currently, 67% of contractors claim online, with 74% of treatment items under the DTSS now claimed electronically. The HSE is aware that some medical card holders have experienced difficulties in accessing treatment under the DTSS. Wherever this is made known to the HSE, each inquiry and representation is followed up by local community services which seek to assist medical card holders. As well as assisting medical card holders, the executive is working closely with the Department of Health on the operation of the scheme and difficulty faced by some patients. The executive liaises with the Department on a regular basis. This concludes my opening statement.

I thank Mr. Ryan. As witnesses will be aware, Deputies and Senators are asking questions virtually from their rooms within the Leinster House precinct. There may, therefore, be difficulties with the system this morning but please bear with us. The first questioner is Senator Conway.

I thank the Chairman very much. I welcome all our witnesses this morning. In the first instance, I thank them for the work they have done during Covid-19, but also the work they do in general and for their response to our representations, which I find to be very efficient. My team also finds that the staff on the Oireachtas hotline are very helpful. I want to put that on the record.

As a starting point, do the witnesses have information on the 1.5 million plus medical cards? How many of those medical cards are active and how many are inactive? They might only be used perhaps once or twice a year compared to others that are used on a regular basis. Do the witnesses have any percentage breakdown on the activity within that cohort of medical card holders?

Who wants to take that question?

Mr. Joe Ryan

I will pass that question to Mr. Flanagan.

Mr. Shaun Flanagan

I am sorry; I do not have that information with me today but we can definitely get those details for the Senator.

That is fine; I would appreciate if Mr. Flanagan could make it available. I have had a concern for a long time that a percentage of people have medical cards in their possession simply because they are used as a criterion for accessing other services such as school bus transport.

I have been concerned that the number of medical cards is inflated to some degree because of that requirement. I think that a medical card should specifically be for medical purposes. I will move on because I have made that point. Will the witnesses make those figures available, because we would be interested in developing that body of work?

I have spoken to John Wall about end-of-life care, as I am sure have many of my colleagues, on many occasions. I welcome that the process in that area has begun. We are talking about 24 months. How many of those end-of-life medical cards have been issued to date?

Mr. Shaun Flanagan

It is a relatively small number at the moment. We have received less than ten applications at this point but the system has only been in place since 12 March. We would all have to be aware that hospitals have been especially busy over the last quarter with Covid activity. As the hospital system is trying to catch up with that, I expect that number will grow significantly over the next while.

How many end-of-life-care one-year medical cards have been issued to people in the last 12 months?

Mr. Shaun Flanagan

There were 1,801 in existence at the end of February 2021. We had previously done an exercise in 2020 about the number of cards that had been issued. At the end of 2020, 1,883 cards were in existence. There were an additional 1,683 individuals who had unfortunately died with an end-of-life card. Our estimate is that approximately 3,500 cards were issued during 2020. The average time for which a person holds one of those cards is 7.7 months.

I ask Mr. Ryan from the Department if he could give us an indication about where we are with the legislation that will underpin the two-year end of life medical card. What stage of preparation is that at?

Ms Celeste O'Callaghan

I am Celeste O'Callaghan from the Department of Health.

Sorry, Ms O'Callaghan.

Ms Celeste O'Callaghan

That is okay. We have commenced work on the legislation. That followed on from the publication of the report in November and the decision by the Government to proceed with this approach. We are currently in the preliminary analysis phase. We are doing a couple of strands of analysis to underpin the development of options relating to the legislation. The clinical advisory group report set out some of the challenges that are likely to arise when we are trying to legislate for something like this. In particular, there are challenges around defining what a terminal illness is. That is one area that we are examining in order to do the preliminary analysis. We are at that stage with the legislation.

When does Ms O'Callaghan expect to be in a position to publish heads of Bill?

Ms Celeste O'Callaghan

It is hard to be precise about timing. The Senator might allow us to be imprecise about that, given there will be other challenges across other Departments and with the Office of the Attorney General with regard to developing legislation, a schedule into which we will have to fit somewhere. If we had to estimate, however, we would say it will happen in the autumn legislative session. We do not anticipate that we will have heads before the summer recess.

My concern is that with the best will in the world, given the present system of administration, will people be denied a medical card because we do not have this legislation?

Ms Celeste O'Callaghan

If an individual case arose where somebody was having difficulty getting a medical card and felt that he or she was entitled to it, I am sure that could be followed up by colleagues in the HSE. I do not think that we have had a situation like that yet. One aspect of this of which we are conscious is that it is a new scheme and works on an administrative basis. There are challenges around areas such as making a prognosis. It was flagged clearly in the report of the clinical advisory group that it is not a precise science and it is a clinical judgment at a point in time. What we would expect is that over the coming months, while the new administrative scheme is in place, there will be lessons about some of those issues and these can be examined and incorporated into the work we are doing to develop the legislation.

Is the Department engaging and consulting with any advocacy groups while in the process of preparing that legislation? Is it consulting with them?

Ms Celeste O'Callaghan

At this stage, we have not done consultation of that kind because we are still doing the preliminary analysis. Once we have a baseline of options and the preliminary analysis is done, we anticipate that there would be a consultation exercise. We would certainly want to take on board the views of patient representatives and various advocacy groups, bearing in mind that this legislation is not disease-specific and will involve people with various kinds of conditions. We intend to engage with different advocacy groups as part of that consultation.

Moving away from end of life care and addressing advocacy in general, do we have structures to engage with advocates on a constant basis?

Ms Celeste O'Callaghan

There is engagement with patient advocacy groups and representatives in a number of different fora by the Department. While I do not have the full list of those to hand, there are patient representatives on various key groups. Bringing patient advocacy groups and representatives into the policy-making process is always an important feature.

Mr. Shaun Flanagan

Ms O'Callaghan probably forgot to say that the Department has instructed us, in the primary care reimbursement service, to make sure that after six months, we review the operation of the new scheme so that we can provide it with information on the system in the legislative process. The Department has instructed us to put in place a communication working group. We are in the process of getting that group in place and there will be stakeholders there. The HSE has a special division that runs a stakeholder engagement process. I am not involved myself. I can information in this regard, if the Senator wishes.

Mr. Flanagan might send a note to that effect. On discretionary medical cards in general, outside end-of-life care, what percentage of the 1.5 million cards that are issued are issued on a discretionary basis?

Mr. Shaun Flanagan

At the end of February, there were 170,617 discretionary medical cards in place, about 10.8% of the entire medical card cohort. There were just over 39,000 discretionary GP visit cards in place, which is about 7% of GP visit cards. Much of the GP visit card cohort is age-dependent.

What is the level of rejections of people who apply for a card on a discretionary basis? Does the Department have figures of the numbers that it has rejected?

Mr. Shaun Flanagan

I do not have those to hand but I can get a follow-up note on that.

I will put my questions to Mr. Ryan first. I will give him a heads-up about the type of questions that I am asking. We have limited time so I am not looking for three people to answer the same question. If it is possible, just Mr. Ryan or one other member of his staff might answer the questions. They are about data regarding expanding the terminal illness card, the changes to income thresholds for the over-70s, and issues about expanding medical card eligibility to under-eights. What Mr. Ryan be best placed to answer those questions?

Mr. Joe Ryan

The experts are Mr. Flanagan and Ms O'Callaghan.

I will address them to Mr. Flanagan. I am only looking for data and do not want three or four people to answer the same question. The expansion of eligibility for a terminal illness card to where there is a prognosis of 24 months or less has commenced on an administrative basis. We will have to wait for the legislation in the autumn. If it is in place, what is the anticipated number of additional cards expected on a full-year basis as a consequence of the change?

Mr. Shaun Flanagan

There is not a robust estimate of that. It was work that the clinical advisory group tried to do but it was not able to provide a robust estimate. This comes down to the challenge of prognostication: the longer the period of life that one is trying to estimate, the wider the confidence intervals. For the 12 months we award some 3,500 cards in respect of that cohort, so one must assume it would be 3,500 when it gets up to full speed. This is a plus, and it would probably be a bit more than that due to the wider confidence intervals.

Is there even any estimate as to how many additional cards would be issued?

Mr. Shaun Flanagan

None whatsoever.

On the changes that were made for the over-70s such as the income thresholds, how many additional cards have been-----

Mr. Shaun Flanagan

Since November 2020, we estimate there were just over 2,000 extra over-70s cards that would not have been awarded until the thresholds were increased. Prior to the change, 15% of applications were over the threshold. That has now reduced to about 7% of applications over the threshold.

What was that figure again?

Mr. Shaun Flanagan

Just over 2,000 extra people have got the card.

Based on that change alone, what would the HSE expect the additional number of cards to be in the course of a full year?

Mr. Shaun Flanagan

The 2,000 figure is for approximately three months, which is less than the original projection.

I am asking for that projection. What is the projected yearly number of additional cards?

Mr. Shaun Flanagan

I am stuck on that number in terms of what was in the national service plan. On the basis of the experience in the first three months, however, we would expect in the order of 10,000 cards or maybe a little more, particularly if the pattern continues as it has over the past three months. This is lower than in the budget projection.

Where are we with the negotiations with the IMO to extend the medical cards for those aged eight to 12? Where does that stand? Legislation was passed by the Houses of the Oireachtas and I assume it is now part of the negotiations with the IMO. Can we get a sense of where that stands?

Mr. Shaun Flanagan

I will give that to Ms O'Callaghan from the Department. It is more appropriate for the Department to answer that.

Ms Celeste O'Callaghan

On the numbers who might qualify for the terminal illness medical card, providing an assessment of the likely expansion is part of the analysis we are doing to underpin the legislation. There is other work ongoing to try to get a better handle on those numbers.

On the GP negotiations, I will hand over to my colleague, Mr. Noonan, who is the principal officer with responsibility for GP services.

Mr. David Noonan

The negotiations with the IMO have not yet begun on this specifically. We have raised it in a general sense but we have not yet entered into specific negotiations with the IMO on the costings. We have been busy with engagement with the IMO for the past year on Covid-related matters and, as we know-----

I am going to stop Mr. Noonan there. I asked if the negotiation has commenced. It has not. I put it to the Chairman that this is unacceptable. Obviously, there are many other issues on which the Department would engage with the IMO. Legislation was passed in this area. Government representatives were out saying that this was great news, as it was, and claiming credit for the fact that the legislation had passed. We all passed it in the Oireachtas and we want to see it progressed. The negotiations should have commenced. Simple as. Through the Chair, I ask that the committee will write to the Minister to push the case. We need to make sure that when the Oireachtas passes legislation, it is acted upon. This is an important matter.

In the time remaining, I will ask about the dental treatment services team. Is Mr. Ryan best placed to answer my questions in that regard?

Mr. Joe Ryan

Dr. Green is the head of that.

I will put my questions to Dr. Green. Earlier, Mr. Ryan stated, "The HSE is aware that some medical card holders have experienced difficulties in accessing treatment under the DTSS." Is this Dr. Green's view also?

Dr. Joe Green

Yes, that would be my view.

Is that an understatement?

Dr. Joe Green

We are aware that some medical card holders are experiencing difficulties in accessing services. There appears to be greater difficulty in some parts of the country than in others. Where we are made aware of a difficulty, we follow up with the medical card holder and try to assist him or her in any way we can, including by providing-----

I put it to Dr. Green that the problem is systemic. The problem I have with Mr. Ryan's opening statement and the response I have received so far is that it puts it back onto the individual medical card holder. What the Irish Dental Association has said is a world apart from what Mr. Ryan stated earlier. The association has said the treatment scheme for medical card holders is in an unprecedented crisis and a full-blown resourcing crisis. It used the words "complete chaos" and described it as a service on "the brink of collapse". This is what the Irish Dental Association has stated. Record numbers of dentists are dropping out of the scheme. Is this Dr. Green's experience with regard to what the Irish Dental Association is saying? Is this his experience of how serious the situation is with the scheme?

Dr. Joe Green

We have had a number of resignations, particularly in the past eight to 12 months. The majority of contractors have retained their contracts and continue to provide medical services to medical card holders. I acknowledge them and thank them for doing that. We are aware of problems with the scheme, as I have said, and we are working closely with the Department of Health. We have made the Department aware-----

The figures I have been given show that from 2015 to 2020 there was a 31% drop-off of dentists from dental treatment service scheme contracts, going from 1,847 to 1,279. That reduction was significant. The Irish Dental Association also said that some of the contracts are what it would call "inactive". I have received many representations from patients who are medical card holders and who have had difficulties in this area. It was characterised in the opening statement as some patients experiencing difficulties, and then put it back on the patients themselves to contact the HSE. That is not the problem. The problem is systemic and it goes back to the resourcing of the contract. That is the problem. It needs to be dealt with. The Irish Dental Association is saying that we are facing an unprecedented crisis - a full-blown resourcing crisis - and that there is a real difficulty with this scheme.

Dr. Joe Green

I accept that there is a real difficulty with the scheme. We have been working with the Department to try to address the difficulties patients are experiencing. I refer the Deputy to the Department's opening statement which indicates that the Minister acknowledges those challenges and that there needs to be a review of the scheme. With regard to resources, we would have to work with the Department to improve the level of resources available for the scheme.

I am going to say to the Cathaoirleach, as I finish because I assume my time is up, that again we are hearing about a promise of a review and a promise of changes. The issues with this scheme are long-standing. The crises that I have been hearing about in respect of public dentistry, orthodontic waiting lists, medical card holders' access to the scheme and the resourcing of the scheme are long-standing. A recognition by the Minister in the Department's opening statement does not cut it. We need a resolution in the same way that we need a resolution on the engagement with the IMO on expanding medical card eligibility, for which we democratically voted in the Oireachtas. There does not seem to be an urgency around reviewing this scheme. I ask again, through the Chair, that we write to the Minister for Health and state that we need urgent negotiation with the Irish Dental Association in order to resolve this issue. It is unacceptable that public patients are not getting treatment they need or access to a service because the scheme is not fit for purpose. I do not hear an urgency coming from the HSE or the Department. I ask again that the members present at this meeting agree - we can discuss the matter later in private session - to write to the Minister to express concern for the operation of this scheme.

The Deputy has made the point. We will discuss the matter in the private session later.

I welcome everyone. I am very pleased we are discussing this type of medical card, in no small part due to the efforts of activists in the area. Deputy Cullinane asked my first question which was on the Irish Dental Association. I echo some of his concerns and the need to address them. We can deal with that in private session.

It is the early stages of this medical card and I acknowledge we are early in the process of formulating the legislation but cards have been given on that basis. I wish to run through some of the parameters of what it looks like for people who are trying to access that card. Where there is a dispute about prognosis, how is it envisaged that will be addressed?

Mr. Shaun Flanagan

The system is a certification system by a treating consultant. The HSE does not see itself as getting into dispute with treating consultants around prognosis. We accept it is a fairly challenging issue to try to estimate a prognosis of two years or less, particularly for different diseases and so on. If a treating consultant certifies that it is 24 months, we will accept that is his or her expert opinion.

Where a consultant in the Irish system decides that is the prognosis, is there a possibility for a second opinion from an outside source? Is that built into the system?

Mr. Shaun Flanagan

The Government decided that where a treating consultant decided that his or her patient had a prognosis of 24 months or less, that we were to provide a medical card and that is what we are doing. Individuals can receive second opinions but it is not a part of the system as it has been built. Against that, in terms of a treating consultant, whether it is a first or second opinion, the HSE will not get into a dispute with consultants on that basis.

Where does the information on the files reside when that decision is made? Does it stay with the consultant?

Mr. Shaun Flanagan

The consultant certifies on a form. There is a five-page form, and there is one section where he or she certifies that the person has a prognosis of 24 months or less. The consultant provides very brief information to the HSE on the diagnosis and the disease. That is more so that we can understand the groups who are accessing, and are able to access, the terminal card, in case we are missing a group. We do not take detailed clinical information from the consultant.

This might be more around the primary care reimbursement service, PCRS. Since 2019 have there been any interactions with the Data Protection Commissioner?

Mr. Shaun Flanagan

Yes, we have interactions with the Data Protection Commissioner on an ongoing basis. We are the biggest processing organisation in the HSE. We have 80 million reimbursement transactions and we have millions of eligibility records of individuals. The nature of an organisation like that will be that the Data Protection Commissioner will be involved. HIQA also did a review on our data protection and data management in 2019.

What was the outcome of that review?

Mr. Shaun Flanagan

There was a series of suggestions on how we could improve things but there was no substantive issue which would raise concerns about the management of data. There were strategic recommendations around how we might have slightly better governance processes on how our management teams interact across the reimbursement and the medical card section but there were no alerts or concerns, it was generally a fairly positive review.

Did the review include the new system of electronic claims from contractors?

Mr. Shaun Flanagan

The system we referenced in our opening statement related to the dental treatment services scheme, DTSS. We have had electronic claiming from contractors back to the 1990s. I am a pharmacist by training, when I worked in a community pharmacy in the 1990s the PCRS had electronic claiming systems then.

Have there been any data breaches there or issues around cybersecurity?

Mr. Shaun Flanagan

No. There will always be input errors and things like that that need to be fixed and around which there have to be rectification processes but on cybersecurity breaches or someone coming in and taking data from us, that has never happened. At the moment, the HSE has an internal audit ongoing as part of our normal governance, an ICT internal audit, just to make sure all the required controls are in place. I am not an ICT expert, I should say.

I take that point, none of us are. None of us are experts in GDPR either, even those who claim to be. Does the HSE operate a system of open disclosure? Can those applying for a medical card access the files related to their medical card application? Can Mr. Flanagan outline how someone might do that?

Mr. Shaun Flanagan

Under data protection, people can request all their records. On our standard process, as part of our decision-making process, when we make a decision around a medical card, an individual receives a full record of how we financially assessed him or her, how we managed his or her income, and how we have taken his or her expenses into account. If we have made an error in that, individuals will get a full financial report as to why they did not receive their medical card.

What is the timeline in the process of appealing that?

Mr. Shaun Flanagan

I will ask my colleague, Ms Halliwell, in the national medical card unit if she has that information to hand, in case I give the wrong information.

Ms Kate Halliwell

An individual has up to three months to appeal that decision. Written confirmation is provided with a full breakdown of what we have assessed based on incomes, outgoings and any discretionary elements to the application, after which the individual can appeal. We also have a change of circumstance process where a person's circumstances have changed in that period. The person can write back in to us and we can reassess his or her application.

Sorry, I did not mean the amount of time that a person has to complain or appeal but how long it takes the HSE to process the appeal.

Ms Kate Halliwell

It is an independent appeals office which deals with appeals. We receive the request and we try to overturn the information back to the appeals office in a seven-day period.

I thank everyone for their opening statements. I refer to medical cards for life-limiting conditions. It is very welcome that the clinical advisory group recommended that those with 24 months or less would have access to medical cards. I also commend John Wall who has campaigned on this tirelessly for years. He has done amazing work for those who find themselves in this situation. I spoke to John yesterday about any questions I should ask today. He said that when anyone gets a prognosis, it is very traumatic. He said the process is very good to get access to the card. He said it usually takes less than 36 hours, so that is good. The last two programmes for Government stipulated that those who have a terminal illness should have access to a medical card, without a time limit on their prognosis, without a means test as it is a very arduous process. Is there any scope to expand it without a time limit in future?

Ms Celeste O'Callaghan

The decision made by the Government was in relation to people who have a prognosis of up to 24 months. At the moment, that is the basis on which we are working to develop the legislation. On the difficulties of making a prognosis, the clinical advisory group was clear that as one moves further out and as a person is likely to live longer, making a prognosis becomes more challenging. I am not a clinician but we are mindful that there is a crossover space between terminal illness and chronic disease which needs to be thought about. As we are developing the legislation, we will look at all those issues to try to come up with a definition and an implementable model. Within that context, we will inevitably acquire more information about what issues or challenges might arise if a decision was made by government in the future to go beyond the 24 months.

Mr. Ryan could probably answer my second question, which is on the primary care reimbursement service. I am not sure if anybody can answer it, but hopefully somebody can. It relates to those who have been granted a ministerial licence for medical cannabis products. My experience from working with families trying to reimburse under ministerial licences has been extremely arbitrary and bureaucratic. This has put families in a very difficult position in which some of them could not access reimbursements and, in one case, the family had to look at selling their home. The situation is far from ideal. The news that the medical cannabis programme will be up and running in the summer is welcome. My experience and that of other families of getting reimbursement under the primary care reimbursement service has been haphazard. Will the witnesses clarify why, in some cases, it takes up to nine months to get reimbursement for a medicine that works for children and why it is so difficult? Meeting the criteria places a financial burden on families.

Mr. Joe Ryan

I will defer to my colleague but, in advance of that, the programme will be up by the end of quarter 2. We will look to have that finalised and in place. Regarding products sourced under licence, it is a slightly more complex arrangement and I ask Mr. Flanagan to describe that.

Mr. Shaun Flanagan

The products provided under licence are not paid for by the primary care reimbursement service but under the treatment abroad scheme because the medicine, as I understand it, is procured through pharmacies in the Netherlands. On that basis, the system fits in with the treatment abroad scheme. As I understand it, applications have to be made by the clinician responsible for the care and, once received, the HSE tries to process them in as timely a fashion as possible. There may be occasions where individual pieces of information are missing, which delays a decision. There have been parliamentary queries on this which have been responded to in the last week or two. As it is in the treatment abroad scheme, I am not 100% up to date on the licensing part of it. The medical cannabis access programme will be run by the primary care reimbursement service. That is what we are busy planning at the moment.

Mr. Joe Ryan

Given that we do not have any colleagues here from the treatment abroad scheme, I will convey that question to my colleagues and revert to the Deputy with a written response.

I welcome the witnesses and thank them for the information provided. A couple of issues come to mind which I have had to deal with recently. The first relates to discretionary medical cards and the medical cards issued on the basis of life-threatening illness. I would have thought that, during the course of Covid, those who were about to lose their medical card or have it reviewed and who had obtained the card based on a diagnosis would have had a medical card reissued to them almost automatically because of the danger of causing stress and anxiety to them and their families at a critical time. I have had some difficulty in that area. We managed to resolve it but it took some time. Is it possible, at this stage, to devise a system that is more conscious of the needs of the families affected by such a serious illness, including spouses and siblings, and to ask those who have the means of doing so if they can in some way alleviate the impact on those people at a vulnerable time?

Mr. Joe Ryan

End-of-life medical cards are not reviewed for the lifetime of the patient once they are issued. Under the existing 12-month arrangement for emergency cards, where those are issued to people with terminal conditions, they are not reviewed either. We suspended reviews of medical card at the start of the pandemic, which was around this time last year. They were resumed at the end of August but in any month between 65% and 80% of cards would not require any further application process and would be automatically extended. We risk-assess cards where they are unlikely to meet that threshold and we have to go through an application process with people in that regard. To be clear, end-of-life cards are provided on the basis of end of life. In relation to medical cards, they are provided on the basis of the person's means and residential status.

Mr. Shaun Flanagan

Medical cards awarded in the past on the basis of discretion have not been reviewed during the pandemic. Where we are aware that a medical diagnosis has driven the award of a medical card, we have not reviewed those cards. On occasion, people can have a diagnosis but may have secured a medical card on the basis of means and maybe it is in such scenarios that this issue has emerged. We only know when a person has a particular diagnosis if that formed part of a previous application. There may be scenarios where someone got the card on the basis of means but then-----

The problem I am concerned with is the emphasis on a number of occasions on the reference to end of life. My response to that is that people who have a life-threatening diagnosis have enough to be worried about without trying to determine whether they can get a letter from somebody to say they have two or three months to live, or whatever the case may be. They are suffering enough already. I presume the services would be sufficiently sympathetic to their position to take on board what has been said to them in good faith, knowing there will be some other time for review in any event. I would like much more emphasis placed on that part, in other words, on sympathy with the patient who has a serious problem on his or her hands.

Another issue that has come up on a few occasions recently concerns an application for a medical card from a person whose income is over the limit but who has a serious diagnosis. A letter from the GP is not sufficient. It has to be a letter from the consultant. Due to the general data protection regulation, GDPR, the consultant will not send the letter to the advocate. Incidentally, all public representatives are advocates and we should not forget that. Our job is advocating on behalf of our communities, and we are not always wrong. The point at issue is that after much toing and froing, with a lot of stress on the patient, the spouse had to go to the consultant to get the letter. Otherwise, it was going to go into the mix and might not come out of the system for five or six weeks. Five or six weeks is a long time to somebody who is in pain and concerned about their health and their financial position. I would like to see more sympathetic processing of medical cards in those particular instances.

Regarding the points raised by a number of speakers, generally speaking, the health services are supposed to respond to the needs of the people as and when the needs arise. Ninety per cent of the time members of the public do not have to rely on the health services but when they do, they anticipate a sympathetic response. I repeat the words "sympathetic response" again and again. If they do not get that they feel ignored. To be ignored at any time is a serious issue. To be ignored at a time of health-related stress and pain is a very serious issue.

Deputy Cullinane raised a question about orthodontic treatment. The position has not changed one bit in the past 20 years. The system has avoided the issue when it should have been simple to refer children for treatment at an early age. Instead of creating two or three categories, in one of which they will never receive treatment, and pushing as many people as possible into that particular category, we should be doing it in a different way. We should deal with the cases on the basis of their necessity and severity and not presume that they will be all right in any event.

The new reimbursement system and the authorisation of new and orphan drugs has been an issue for a long time, continues to be an issue and will remain an issue. I appreciate the fact that drug companies should not be allowed to charge what they wish. That has to be dealt with at a different level but we need to be mindful of the need to respond to the particular drugs that are required by the patients and prescribed by a medical doctor.

Mr. Joe Ryan

I might respond to a couple of those points. With regard to the diagnosis and the consultant not sharing the data with an advocate, the Deputy referred to public representatives. As Deputies and Senators are covered under the GDPR and the Data Protection Act, a consultant should be in a position to seek those data once the permission of the patient has been given to that particular person. We would be more than happy to deal with any specific incidents on a case-by-case basis as they arise.

In terms of responding sympathetically, we try to be sympathetic with everybody. That is part of the way in which we are trying to drive the culture of the HSE. Part of the transformation of the health services is about ensuring that we have a caring and considerate approach to everybody. When we fail in that, we are particularly keen to know about that and to try to address it. Everybody in the HSE goes to work every day with the best of intentions to give the best service they possibly can to the patients and citizens of the country.

In terms of new and orphan drugs, in the letter of determination in the service plan this year we have €50 million allocated for new drugs. So far this year, in the order of 25 to 28 new drugs have been approved and there are more to be considered. There is a long list of new drugs that are always coming up and we have to assess them rigorously for all the elements of value in terms of their efficacy and the cost. We have to strike that balance. We have processes in place and we have our drugs group, as well as Dr. Barry and his team, who assist us in assessing all new drugs.

With regard to the orthodontic treatment, I ask Dr. Green to give a short response on that.

Dr. Joe Green

I thank Mr. Ryan. With regard to the orthodontic question, I think the Deputy referred to the assessment system indirectly. The type of cases that are up for treatment by the HSE are very complex cases. The system we use, which is known as the modified index of treatment need, is an international grading system. The two categories within that system that are offered treatment in the HSE are grade 4 and grade 5. Typically, those cases would take at least two to three years to treat. Orthodontic treatment is not a single episode of care. As well as the active treatment, which as I said could take approximately two years, there would be at least another year in retention where the patient will be wearing retainers. The patient is within the system for a lengthy period, usually during the teens. There is huge demand on our services and the need that is being expressed has exceeded the capacity that has been available.

Over the past four years we have had a procurement arrangement in place where we have managed to place just under 2,000 patients with private service providers. That recently expired and currently there is an invitation to tender in place through eTenders. That will close in the next couple of weeks and we hope that the successful arrangement will start to allocate patients who are the longest waiting from the end of the second quarter or early in the third quarter. Currently, the capacity of that system is uncertain because it will have to await the outcome of the tender response process.

What is the waiting time?

I thank the Deputy. We need to move on.

I thank the Chairman.

Our next contributor is Deputy Shortall.

Can you hear me, Chairman?

Yes. Unfortunately, we cannot see you. The system seems to be breaking down again.

I want to thank all our witnesses today. Many of the questions being asked by members are questions that require political answers and it is unfair to take it out on some of the people today who are administering the schemes. The decisions with regard to who gets a medical card or a GP visit card are essentially political ones and it is important to bear that in mind. We are told that 42% of people have free GP care. That leaves a very large number of people who do not have access to subsidised or free GP care. It is important to bear in mind that we are very much an outlier in European terms in that the majority of people in the country have to pay to see a GP. That does not make any sense from a health perspective, an equality perspective or anything like that.

We have a very long way to go in providing access to primary care. It is also worth pointing out that if Sláintecare had been implemented in the timescale it was supposed to be, there would now be access for the population to free or subsidised GP care. We have a very long way to go and we must always keep that in mind.

What is the position with the increase in medical cards for people who are unemployed, given the huge increase in the unemployment rate over the past 15 months or so? What number of people have come into the scheme? There was a proposal where if people were unemployed for six months or more, they would retain their medical card when going back to employment. Not many people have gone back to employment but is that still operating? When is the review of the dental treatment services scheme, DTSS, likely to take place?

I note what Ms O'Callaghan has said about the legislation with respect to the extension of medical cards to more children but my understanding is agreement had been reached with GPs in the context of an overall agreement with them last year taking in the reinstatement of pay by unwinding financial emergency measures in the public interest legislation and so on, as well as various practice supports. Part of that agreement was that GP visit cards would be extended to children. What is the exact problem with doing that and why have we not seen it happen? What is the timeline for the permanent scheme to provide medical cards to people with terminal illnesses? Has there been movement on the question of people who are over 70 having means assessed on the basis of gross income rather than net income, as it applies to people under 70?

Ms Celeste O'Callaghan

A few different matters were raised by the Deputy so I will call on Mr. Noonan to speak about GP services and Mr. Judge and Dr. Kavanagh will speak to the DTSS review. The Deputy asked about the timing of legislation for providing medical cards to people with a terminal illness. The administrative scheme has been put in place for an initial 12 months to allow time for the legislation to be developed. We want to do a fairly robust analysis at the policy end as we develop the heads because it is a tricky area. We do not anticipate producing the heads before the summer but we anticipate having them for the autumn session. I suppose the period to allow this to pass through the Oireachtas depends on other factors, including the overall legislative schedule.

Are we talking about the middle of next year at the earliest?

Ms Celeste O'Callaghan

I would not anticipate that, necessarily. The administrative scheme has been put in place for 12 months to allow us to produce the legislation. We would not see the process extending that far.

It would be into next year, obviously.

Ms Celeste O'Callaghan

It is impossible to say at this stage but I am not necessarily anticipating that timeline. It is hard to be definitive at this stage.

Ms Celeste O'Callaghan

I will ask my colleagues to address the other two matters.

Mr. Finian Judge

I thank the Deputy for her questions on the DTSS. As she might recall, we launched a new Government-approved national oral health policy, Smile agus Sláinte in 2019. That policy was meant to provide the context for the review of the dental treatment services scheme. It was always the intention that the scheme would be aligned with the policies, principles and goals outlined in that new policy approved by the Government. As members know, the roll-out of that policy has, unfortunately, been delayed because of Covid-19. The review of the scheme has also been postponed because particular personnel resources have been assigned elsewhere.

The Deputy would know from responses given to the House by the Minister that he is fully committed to the review and our intention is to commence it as soon as resources can be freed from Covid-19 work to allow us do significant preparatory work before we even sit down with the representative organisation about the review. It is a scheme that goes back to the 1990s and we all accept it is very much out of date with the principles contained in the new policy. There is much work to be done there and our intention is that as soon as resources are freed, we can begin that work.

To where have those resources been deployed? What are the people who might be expected to do that review doing now?

Mr. Finian Judge

I can only speak in the context of the Department. I am employed in the public health arena led by an assistant secretary, Mr. Fergal Goodman. All his staff are currently involved with Covid-19 work. Some of them are working seven days per week and very long hours.

I thank Mr. Judge.

Dr. Dympna Kavanagh

To add to Mr. Judge's comments on the national oral health policy, I can reassure the committee that work has been going on in the background, particularly with respect to services. A national clinical guideline group has been established and a chairperson has been appointed to look in particular at background to ensure when we are ready to do the review, we know what the packages will contain. We will look at all the infrastructure and the appropriate management and guidelines for clinicians. That time will not be wasted in future. There are other aspects relating to the Dental Act etc. and they are ongoing in the background.

Could I get a reply on the medical cards for unemployed people and children?

Mr. Shaun Flanagan

I can take the question on medical cards for unemployed people. The back-to-work scheme is still in place. The Deputy referenced the numbers and we expected when the Covid-19 pandemic started that there would be a massive increase in new applications for medical cards but that did not emerge. One of the reasons we suspended reviews in the first few months of the pandemic was that we thought we would get a major influx of new applications for medical cards. That has not emerged and I presume that must be down to the pandemic unemployment payments and maybe the age of the cohorts that are unemployed. Perhaps they are not pulling on the health service. The Deputy asked about assessment of means for those over 70. There is a gross system for those over 70 but if an individual makes a net application, we will also look at that.

Okay. That has not changed. Is there a number for new applications on the basis of unemployment over the past year?

Mr. Shaun Flanagan

I do not have a number but had a number in the opening statement for the increase in medical cards.

Okay. There are different reasons. What is the difficulty in adhering to the agreement relating to children's medical cards?

Mr. David Noonan

The 2019 agreement included a general commitment to moving towards providing care to children under 13 and, on the part of the Irish Medical Organisation, a commitment to negotiate. It did not have any detailed proposals or there certainly was not a specific agreement on how anything would be rolled out. It was always the intention that whereas the 2019 agreement included a general commitment to move in that direction, implementing such a provision would require much detailed negotiation on how the service would be structured, the costings and so on. What is in the agreement, as such, is not sufficient to deliver a service.

That is not the way it was portrayed. Is there any timeline for commencing those negotiations?

The Deputy has gone over her time and Senator Kyne needs to come in.

I welcome the witnesses.

I have a number of questions and perhaps the person best placed to answer them will jump in at the end. Regarding the review of medical cards, a letter is sent and in certain cases I have come across the individual does not respond. The people involved might be elderly and if they do not have family or a carer keeping an eye out for post sometimes these letters go unanswered. They are quite simple, asking whether the person's circumstances have changed and if the details correct. Are these followed up with phone calls? Very often in the cases I have dealt with, these people do not know they have lost their medical cards until they go to the pharmacist to get a prescription.

Why do those aged over 70 who want to be considered for a full medical card based on a medical, and who have already been granted a GP card, have to submit their financial details again even though they have already been submitted? It is very stressful.

When we know someone is going to fail the financial test and is looking to get a discretionary card based on a medical is there a way to bypass the financial test when going through the process?

With regard to dental services, I am led to believe there has been a reduction of assessments in school settings over the past decade. I am dealing with the case of an individual who has a rather severe underbite that was not picked up in primary school. The person is now over 16 and does not qualify for care. This means the parents will have to go private, which will place a huge strain on them. Is there any way these cases can be looked at where issues were not picked up in earlier assessments?

Mr. Joe Ryan

With regard to the medical card question and the follow-up where people have been written to but have not responded, the volume can be quite significant and I will refer the question to Ms Halliwell to provide the detail on this.

Ms Kate Halliwell

Generally speaking, what usually happens is we correspond with the individual during the review period. We allow for a three month period prior to the card expiring. At the end of the second month, the individuals receive a second piece of correspondence advising them the cards are due to expire and asking them to engage with us. At present, we do not correspond over the phone with these individuals due to volume, as Mr. Ryan has said. Generally, we review up to 15,000 cards a month so the capacity to undertake that role would be huge. We could pull the figures on non-response rates for the committee because it seems quite low at present. People are engaging with us. We can provide a written submission if that would help.

Yes. Ms Halliwell said that non-response rate is quite low. Could these individuals be followed up before the card is finally pulled to ask them whether they received the correspondence and if they need help in answering the questions? Very often it is quite simple because circumstances have not changed and neither have the details, and it is just a case of signing the form and returning it.

Ms Kate Halliwell

I must refer the Senator back to the risk assessment ratio built into our system with regard to why we select people for review. We previously discussed this. Mr. Flanagan wants to comment on this.

Mr. Shaun Flanagan

I was planning to come in on the next question but I can come in here.

Ms Kate Halliwell

I apologise.

Mr. Shaun Flanagan

We try to risk assess people and where we can we pull out cases where it is obvious that people will retain their cards. We review a minority of the people whose cards expire and we are progressively trying to make it more and more sensitive. We have tried to put in place a team that reaches out in difficult cases where people are not engaging or where there a lot of calls to our contact centre. We have tried to put in place a team that reaches out to people, almost like a case manager if we want to put it like that. We are always open to seeing whether we can improve. We can look again at the phone calls to see whether there is a possibility of doing something if we are down to a very small number of non-responders.

I may not have fully understood the question with regard to those aged over 70 who apply for a full medical card when they already have a GP visit card. If somebody gets a GP visit card because they are aged over 70 it is without a means test. It is automatic eligibility. We would probably not have a means test in this circumstance. If somebody has been through a means test in the past it may be out of date if it had taken place a good number of months previously. I may have misunderstood the question.

I was asking about people who applied for a full medical card and received a GP visit card.

Mr. Shaun Flanagan

Are these cases where people applied for a full medical card and we gave them a GP visit card and they come back with an appeal?

Mr. Shaun Flanagan

My understanding is that what we would do is assess on the previous means test unless was a change in circumstance. If there was a change in circumstance obviously the means test would recommence. If there is a specific case where the Senator feels we have been awkward or inappropriate we would be quite happy to look at it to try to learn from any mistake we might make. Generally we do not try to put people through multiple means tests if we can avoid it. We try to be as efficient as we can.

The Senator also asked about discretionary medical cards. We must remember that the discretion relates to how we apply the means and financial thresholds. It is not that we decide that individuals get a medical card purely on the basis of a disease. The system is based on means. We manage the means and look at people's expenses. Then we look at their medical expenses. As part of this process we use a burden of illness questionnaire to try to maximise or capture medical costs. This is what the discretion relates to. It relates to how we apply the financial thresholds, taking into account the costs of the disease and the challenges for the individual of paying for the treatment that arises out of it. I hope this answers the question.

Mr. Shaun Flanagan

One of my dental colleagues will have to answer the next question.

Dr. Joe Green

We will follow up and get in touch with the Senator on the question on dental services. I am not quite clear as to what stage the patient is at. We will follow up once we get the details.

I thank Dr. Green.

I thank the witnesses for their presentations and for dealing with the questions raised. I want to deal with an aspect I am concerned about, which is orthodontic treatment for people aged under 18 in Cork. We have a four to five year waiting list. In fact, the most recent letter I received from the HSE was to the effect that the people being treated at present have been on the list since 2016. Can someone give me an explanation as to why people who require orthodontic treatment in Kerry are referred to private practitioners under a scheme, and I am not sure which one, but in Cork we just leave people on a list? Can people apply under the National Treatment Purchase Fund for orthodontic treatment? If not, why not, particularly with this waiting time period? Perhaps someone might clarify this issue for me please.

Dr. Joe Green

I thank the Deputy. With regard to Cork and Kerry, I will do some work on it and come back to the Deputy with a more detailed answer. The procurement arrangement he mentioned involved seven of the CHO areas in the country. We hope the revised arrangements will include the entire country. I will follow up and come back to the Deputy with a more detailed answer on Cork and Kerry.

In regard to the National Treatment Purchase Fund-----

I do not understand why there is a different set of rules in one county compared with another county. Will Dr. Green provide a written response in this regard? I have put down questions to the Minister on the matter and am awaiting a reply. I would like a detailed response, with particular reference to why somebody in Cork who is on the list since 2016 is only now getting treated.

Dr. Joe Green

I will come back to the Deputy with a detailed answer on the situation in Cork and Kerry. I will have to go back and check on the arrangements that were in place when the procurement procedures were established.

The Deputy's second question was on the NTPF and why orthodontic services are not accessed via that fund. The legislation governing the NTPF does not allow for an orthodontic waiting list to be considered.

How it is proposed to deal with the waiting list of five years in Cork? We do not have enough orthodontists employed in the public service to deal with it but there are people working in the private sector who could provide the service. What do the Department and the HSE propose to do with this list? Is it a case of waiting until it gets to six, seven or eight years? When will action be taken on it?

Dr. Joe Green

As I said in an earlier answer, there is an invitation to tender to provide treatment for HSE patients. It is active at the moment and the responses to the tender are due in the next couple of weeks. We expect to allocate patients who have been longest on our waiting lists at the end of the first quarter or early in the second quarter of this year.

Can Dr. Green give a timescale for getting the waiting list down? If people do not take up the offer of the HSE work, how do the Department and the HSE propose then to deal with it?

Dr. Joe Green

I have quite a reasonable level of confidence that we will get responses but I cannot pre-empt the outcome of the invitation to tender. As I said, the plan is to start to allocate patients within three months. It is the end of March now and we expect to begin allocating soon. It will involve the longest-waiting patients, including those the Deputy mentioned who are waiting up to five years. They will be the first to be allocated to service providers. We need the tender response to go to plan and to have sufficient capacity available to allocate the patients to a service provider in their own locality, if possible.

Mr. Ryan referred in his presentation to an allocation of €3.269 billion in budget 2021 for the PCRS. What is the breakdown of that sum in terms of the amount going to pharmaceuticals and hospitals?

Mr. Joe Ryan

I have that information to hand but, given the limited time available, I undertake to provide the Deputy promptly with a written response.

I understand that a large quantity of orphan drugs are being brought in and there is a special fund for that purpose. Overall, however, the cost being incurred by hospitals for medication is significant. What kind of progress is being made in achieving cost efficiency in that area?

Mr. Joe Ryan

There are two primary initiatives in play at the moment. One is that we have pulled all the hospitals together under a common procurement framework that allows them to work together to put the best possible arrangement in place nationally. They still have the capacity to do things locally where they have their own local requirements. Second, there has been excellent work delivered, even throughout the pandemic, by consultants in a number of hospitals in replacing some of the originator high-tech drugs with biosimilar drugs. They are slightly different from generic drugs but the same principle applies that they tend to be less expensive. That has driven much more competition in the market for those very complex drugs and significant savings have been made in this regard. That is helping us to contribute to the cost of new drugs.

Can we have a breakdown of those savings figures?

Mr. Joe Ryan

I can get that information for the Deputy.

Will Mr. Ryan also provide a breakdown of the allocation of €3.269 billion to which he referred?

Mr. Joe Ryan

I have that information in front of me but it would eat up all the committee's time to go through it today.

Mr. Shaun Flanagan

I can give a summary of the funding at gross level, which might be helpful to the Deputy. In 2020, we spent approximately €800 million on GP services, some €1.2 billion on pharmacy services, including medicine costs and fees, approximately €825 million on high-tech medicines, €41 million on the dental treatment services scheme, DTSS, and €23 million on the ophthalmic scheme.

Will the witnesses from the HSE send on the full details of that breakdown?

Mr. Joe Ryan

I will do so.

I thank Mr. Ryan.

Does Ms Morgan wish to comment?

Ms Emma-Jane Morgan

On Deputy Burke's question about orthodontic services, he may be familiar with the recent Northern Ireland planned healthcare scheme that we established to replace the provisions of the cross-border directive. A large number of people travel to the North to access orthodontic treatment through that scheme. It requires payment upfront before being reimbursed by the HSE. Information on the scheme is available from the HSE's treatment abroad scheme, TAS, office. I hope that is of use to the Deputy.

I have no difficulty with people going to Northern Ireland but I object strongly to the Department passing the buck in this way. It is directing people to the treatment abroad scheme when this service could easily be provided under the NTPF. I do not accept that we should be requiring people to travel long distances to access treatment. This is especially the case with orthodontics, which usually does not involve once-off treatment but, rather, a series of treatments over a period of time. I am absolutely appalled by the suggestion that people from Cork should travel to Northern Ireland for treatment.

Ms Emma-Jane Morgan

I wanted to inform the Deputy about the scheme in case he was not aware of it. It was not to suggest anything. I ask my colleague, Dr. Kavanagh, who deals with the dental side, to comment further.

Dr. Dympna Kavanagh

I would like to update the Deputy on a Sláintecare initiative in this area, which has just begun, that involves working with our colleagues in the HSE and the NTPF. A total of €110 million has been released to the HSE for waiting list initiatives. Our HSE colleagues can bid into that funding for such initiatives. Separately, Sláintecare, working with our colleagues, is looking at a considered approach with the NTPF, not just for acute services but also for community services, which would include the 17,000 people on the orthodontic waiting list.

A number of key points have emerged from the initiative so far. Fifteen acute specialties have been looked at to date and the evidence that has emerged shows the numbers on the waiting list can be reduced by as much as 20%. It is proposed that a very specific clinical assessment should be taken of cases to see what would give the most value. That effort has just commenced and it involves a three-week, intensive approach. A plan has to be produced at the end of it to provide clear guidelines for both acute and community services, including dental services, to bid in for that waiting list initiative.

The Department is liaising with the NTPF specifically around dental provision because there is concern that some of those services are not being considered by the NTPF, notwithstanding the services, such as dental extractions, that are taking place in public hospitals. Thus far, the information the NTPF holds on dental services is that there are 3,363 surgery cases being dealt with under the fund.

There are 352 that have not been clarified vis-à-vis their condition but the Department is liaising with the NTPF to look at those figures and to expand on what is being recorded in the future. As I said, that waiting list initiative is intended to extend to community services and €110 million has been released for waiting list initiatives.

Dr. Kavanagh will have to accept that is very hard for me to go back to a parent to say that I am waiting for another report. What we are looking for in Cork is action. We do not have orthodontists employed by the HSE so the HSE must consider alternatives but the response is not fast enough. It is not good enough that I would have to go back to a parent today and say that I do not have any further information and there is a chance his or her child will still be on the waiting list in four years time. That seems to be the answer I am getting today.

Dr. Dympna Kavanagh

With respect, money has been released this year for waiting list initiatives and our colleagues can bid for some of that €110 million within the HSE. If they wish to bid in for orthodontics, they can do so.

To clarify, is Dr. Kavanagh saying that under the NTPF, someone who is waiting for more than two years for orthodontic treatment, for example, can apply to be treated privately?

Dr. Dympna Kavanagh

No. The NTPF is currently limited, under legislation, to acute services and public hospitals.

What am I going to say to the parent who has been waiting for four years for orthodontic treatment for a child who is now 17? Am I supposed to tell that parent to find an orthodontist and run a go-fund-me campaign?

Dr. Dympna Kavanagh

With respect, the money that has been released separately for the waiting list initiative is not confined to the NTPF. It is for waiting list initiatives for the HSE, so people would bid for that funding within the HSE. That would be a matter for my colleagues in the HSE.

I am still looking for the answer as to what I am to say to the parent. What is that parent to do this morning? Am I to go back to the parent and say that I do not have an answer on treatment for a child who has been waiting for four years?

Dr. Dympna Kavanagh

I will have to refer the Deputy to my colleagues in the HSE in that regard because that is an operational issue. I was just outlining the policy issues relating to the release of money for waiting list initiatives this year.

Dr. Green wishes to respond.

Dr. Joe Green

I can confirm, in the context of Dr. Kavanagh's remarks on the waiting list initiatives, that the HSE will be applying for funding for both dental and orthodontic services. We are aware of the timeframe involved and will meet the deadline with our application.

When am I going to be able to give an answer to the parent with a child who has been waiting for four years?

Dr. Joe Green

The initiative I spoke about earlier is intended to treat all children waiting in excess of four years.

When am I going to have an answer?

I do not think Deputy Burke is going to get an answer this morning so I suggest that he takes the matter up with the Minister. I need to move on now. Senator Clifford-Lee is next.

I have a quick question on application processing capacity in the Irish language. Are there many people who can process applications and any follow-ups in Irish for Irish speakers?

Mr. Joe Ryan

I do not know the answer to that question but my colleagues in the PCRS may be able to respond.

Mr. Shaun Flanagan

In terms of capacity, we have managed any applications we have received in the Irish language. As with any public service, if a large proportion of people submitted applications as Gaeilge, we would probably be somewhat challenged but would do our best to respond. Currently, the vast majority of people make their applications in English and on the basis of current patterns, we can manage and have sufficient capacity. I do not have the exact number of Irish-language applications that we would have received in the last year.

That is the issue. A lot of Irish speakers who have the right to deal with the State in the Irish language are opting to fill out applications and have them processed in English because they fear that the capacity does not exist to process them quickly in Irish and that they will be held up. I ask the witnesses to provide data on the numbers employed currently who would be able to process applications in Irish if so demanded. If everybody who requested an application form in Irish went ahead and submitted their application in Irish, what kind of delays would we see?

Mr. Shaun Flanagan

We can come back to the Senator on that but obviously we would put whatever resources were needed in place if that scenario unfolded to ensure the equal treatment of applications, whether in Irish or English. Our intention would be that our key performance indicators would not change or would not be different for one scenario versus the other. I absolutely accept that we should respond to that 100%.

Ms Halliwell wishes to respond.

Ms Kate Halliwell

Working within the processes in the unit at the moment, the number of individual applications in the Irish language remains very low. We have three full-time equivalents who are fluent in Irish and can respond. However, as Mr. Flanagan has said, if there was an increase in Irish-language applications, there would be no problem increasing our capacity to suit.

Thanks. That is what I was looking for - the number of people employed who have a high standard of Irish. Is Ms Halliwell saying that the service would be able to recruit extra people or train existing staff?

Ms Kate Halliwell

We could recruit or train up. We also have Irish-language specialists within the HSE with whom we can link up if we have any questions or queries. We are working on an application form in the Irish language at the moment and hope to be in a better position in that regard in the coming months.

Would Ms Halliwell be able to give an exact timeframe for when that form will be available? Are we talking about two months-----

Ms Kate Halliwell

We have just signed off on the new MC1 application form for applicants in the 0 to 69 category. That was signed off two weeks ago and we hope to commence the Irish language section of that form now.

I have a couple of questions. Several members have expressed frustration this morning regarding access to services for medical card holders. Earlier we heard about a crisis with regard to the number of dentists in the GMS. Do we know exactly how many dentists have left the scheme? What do patients of dentists who have left the scheme do? Do they move to another dentist or do they contact the Department to alert them to the fact that their dentist is not operating under the scheme? Do the witnesses have any advice for people who are in that situation who may be listening this morning? A similar situation pertains with chiropodists, apparently. We have been told that a lot of chiropodists are leaving the scheme. Do we have exact numbers in that regard?

A number of years ago ease of access to medical cards depended on geographical location, for historic reasons. Has that changed? In 2014 an expert panel conducted a review of medical card eligibility under the GMS and made several recommendations. Were those recommendations fully implemented?

Another area of concern relates to medical cards for those who are terminally ill. Thankfully, the number of such people making applications is low but is there a red-flag process or any way within the system of fast-tracking those applications?

Mr. Joe Ryan

I will answer the questions I am best placed to address. On access to medical cards based on where one is in the country, we have put significant work into centralising the medical card process. Equity is crucial and we do not want postcode lotteries to apply to access to healthcare. All the applications are now handled centrally and supported by a proper appeals process. We have taken away the notion, which was a reality some years ago, that where one was in the country determined how difficult it was to get a medical card. When someone is entitled and eligible for a card, we make sure he or she gets it as quickly as possible.

A specific team is in place to handle applications for end of life and terminal illness cards in order that they do not get caught up. We realise how important it is for somebody in that position not to be put through any unnecessary or undue stress.

I am not sure about the 2014 report. I will refer to Mr. Flanagan on the implementation and recommendations of the report, as the PCRS predates me.

The report referred to eligibility and some of the areas which were not covered and remain uncovered. Crohn's disease, coeliac disease and asthma were referred to, as were older people and persons with mental health issues such as schizophrenia, and it was stated that medical card eligibility should be based on medical need rather than specific medical conditions.

Mr. Shaun Flanagan

The HSE put in place a clinical advisory group based on the Keane report. The group came up with three reports on identifying and being more responsive to need. One report assisted the primary care reimbursement service, PCRS, in designing a burden of illness questionnaire to maximise the capture of cost and challenges in relation to medicines. The findings were addressed.

The Keane report also flagged that the means assessment worked grossly for many people but the need base had to be better managed. The burden of illness questionnaire was a key change suggested but the clinical advisory group reported other changes to the HSE and the PCRS implemented most of the recommendations. Some of the report was made up of commentary rather than recommendations.

I flag the emergency application system which the Chair is probably aware of. It has a separate application form and is designed to fast-track individuals who urgently need a medical card and may not be in a position to submit a means test application. In the scenario in which there is a clear, medically defined requirement for an urgent medical card, a healthcare professional makes the application on his or her behalf which sets out the need and provides a medical report. We suspend the means test for six months. The system is for documented issues in which there is a medical need for a card but the person cannot engage with the process.

Are figures available on the numbers of dentists and chiropodists who have left? What do people do in those circumstances?

Mr. Joe Ryan

Since January 2020, 199 dentists have left, including 19 dentists since January 2021. One of the members quoted some figures on the number of active contracts. In late 2017, there was an exercise to deal with inactive contracts and we are going through a similar exercise, with three CEOs yet to complete it. There are approximately 100 additional inactive contracts which happens when a dentist moves on from a practice without letting the HSE know. We are therefore not in a position to put an exit date against the contract.

We share the Chair's concern about frustration experienced by patients. We do not want anyone to be left without an essential service and dental treatment is one such service. We follow through on each concern made or representation raised with us. If a patient makes a complaint about not being able to access a dentist, we follow through on that as well. We assist medical card holders, when we can, with lists of available contractors. Sometimes we must go beyond that and assist a vulnerable person with making contact with the dentist.

We operate the scheme within the parameters set out in the legislation and regulation that governs the scheme. As I said, we work closely with our colleagues in the Department of Health on the operation of the scheme. We are bringing the difficulties some medical card holders experience to their attention.

As our Department colleagues said, we expect to see a shift from a diagnosis and treatment approach to a preventative approach in a revised scheme. We look forward to that.

Does Mr. Ryan have any data on where the 199 dentists who have left the scheme were working?

Mr. Joe Ryan

Each county has seen resignations but I can provide the Chair with a full breakdown of the figures.

I thank the witnesses for their participation. On the GMS scheme and the contracts in place with GPs, as I am sure the HSE staff here are aware, due to the huge demands on GPs in rolling out Covid-19 vaccinations, many levels of healthcare cannot be provided for. Most people understand and accept that. That is a reality as mass vaccination is rolled out but I am concerned by a few scenarios I would consider essential. Recently, the GP of a young man who had been accepted, in principle, to the Air Corps could not do the required final assessments as he or she was too busy. Are the witnesses aware, as the administrative body for the GMS, of shortcomings during Covid-19 vaccination roll-out in terms of the level provided by GPs?

Mr. Joe Ryan

We are not aware of that case but we are aware that we have been challenged across our system, not least our GPs, in terms of our ability to deliver care. The way GPs operate has had to change for reasons such as the need to use PPE and separate patients to avoid them having to queue. This has affected their overall capacity.

There is a return to services plan. Obviously, it is completely contingent on what the virus does, which is contingent to some degree on how we quickly we can roll out vaccines. I do not know the specific case but we are aware that across our system, be it with regard to GPs, hospitals or our primary care or social care side, we are challenged in terms of being able to deliver all of the services we had been delivering. There is a plan to get us back to a level of service.

I get that and I know Mr. Ryan cannot have knowledge of all the cases that are being thrown his way today. As a Deputy, I am aware of a significant number of people behind the scenes who are crisscrossing by phoning GPs asking whether they can take them in because they cannot get to their local GP. We appreciate there is significant strain but as the administrative body for the GMS, I want the HSE to get that picture as well, namely, that it is not all just essential healthcare and that people are losing out on some employment opportunities because their local GP is unable to take them.

In general terms, I always was of the view that someone who had a medical card would, by and large, receive a free hospital stay or that it would be largely subvented. However, it has come to my attention that in St. Camillus's hospital, Limerick, to where many people from the southern part of my home county of Clare occasionally have to go as patients, medical cardholders are being charged a weekly stay rate of €179. That might not sound too high compared to other hospitals but it is rather high when one factors in other things. One constituent with whom I am dealing had to stay there for three or four months following a stroke. This person is on a low income and has a medical card but he left hospital facing a mammoth bill that he and his family do not know how to pay. Are there many cases like that where there is still a payment for hospital stays, regardless of whether or not the person has a medical card?

Mr. Joe Ryan

I need to come back to the Deputy on that case.

Mr. Shaun Flanagan

I am originally from Clare. I do not know St. Camillus's hospital. My first question is whether it is a public or private institution

It is a public hospital on Shelbourne Road. It is about half a mile from Thomond Park. It is the old county home in Limerick.

Mr. Shaun Flanagan

We will have to come back to the Deputy on that.

I submitted a parliamentary question. It is of key importance to people in the mid west that some clarity is brought to bear on this because it is quite a hefty fee to face after a hospital stay in St. Camillus's hospital, which has been there for over two centuries. It took a lot of us by surprise to hear that a charge has been set for people when they are discharged.

I know that earlier in the meeting, Mr. Ryan outlined the review of medical cards. Is there an algorithm for the sample of medical cards - the 20% or so that the HSE reviews each year? Some cases merit review because people's health situations or incomes may change but is there an algorithm or trigger that initiates a review? For many people, it is fine but for others, certainly people of a certain age category, it can be a huge stressor to find out that the medical card upon which they lean so heavily is under review and is under threat of being taken from them. What are the criteria or what is the algorithm used to select the 20% of cards that are reviewed each year?

Mr. Shaun Flanagan

In the first instance, it is important that we flag upfront to the committee that the vast majority of cards we review are cards that were due to expire. We do not review cards per se. It is a very small random sample of cards of the order of 100 per month. We review cases where there have been protected disclosures in the same way as would the Department of Social Protection when information is sent to us as a protected disclosure. Other than that, when cards are due to expire, we go through them. We have data sharing agreements and legislative underpinning for the sharing of information with the Department of Social Protection and Revenue and we try to identify from those systems people who will clearly hold their cards. We also try to identify all the individuals who got a discretionary card and we try to exclude them from reviews. I would say that we select out 80% of what we are left with, rather than selecting 20%. That will obviously vary month on month. Between 64% and 80% would be selected out depending on the month of the cards. We try to avoid reviewing people who are over 80 because we do not want to upset that cohort and most of those individuals will have had their medical cards for a long time so we age stream it as well.

I thank Mr. Flanagan for that. If there is a random selection element, which Mr. Flanagan more or less explained-----

Mr. Shaun Flanagan

It is a very small number.

That needs to be explained very clearly. It might be in the review correspondence people receive but it needs to be explained a bit better. In normal times when politicians are holding clinics, people appear saying that they have received a letter from the HSE telling them that their medical card is under review, telling us that their situation had not changed income or health-wise and asking how on earth it could be up for review. It needs to be a lot clearer.

Mr. Shaun Flanagan

That is a really good criticism. Ms Halliwell and I have a small team working on our communications. There was a time when the vast majority of reviews were actually reviews. As time has moved on, we only review a small proportion so we are planning to change the communications we send to take some of the threat component out of it. They should be more along the lines of telling people their medical card is due to expire and to prevent their medical card from expiring, they should please make sure they have submitted the following information.

I have to bring the meeting to a close. I thank the witnesses for all their contributions. They were really helpful. The witnesses heard many members express their concerns regarding backlogs, waiting lists and the frustration of many people with a medical card due to the difficulties they have in accessing services. The message from the committee would be that if at all possible, we should take steps to reduce waiting lists, address some of the concerns that medical card holders have and look at those who feel let down by the system and that they are outside or in the grey area where they are not eligible to apply. I thank the witnesses and all their staff for all the work they have done, particularly during this difficult time.

The joint committee adjourned at 11.37 a.m. sine die.