JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Tuesday, 23 Mar 2010

Age Action Ireland and Irish Medical Organisation.

Chairman

I apologise to the witnesses because we did not believe when we scheduled this meeting there would be such momentous events taking place in the Dáil Chamber. Some of the members of the committee are still in the Dáil and will be coming in and out during the course of this meeting. I welcome Mr. Eamon Timmins and Mr. Gerard Scully of Age Action Ireland, and Dr. Ronan Boland, Dr. Martin Daly, Dr. Ray Walley and Ms Vanessa Hetherington of the Irish Medical Organisation.

Before we begin, I draw delegates' attention to the fact that while members of the committee have absolute privilege, the same privilege does not extend to witnesses appearing before it. I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House, or an official by name or in such a way as to make him or her identifiable.

Members will have studied the written submissions of both groups of witnesses. We are grateful the witnesses are present to assist us in our deliberations on the proposed centralisation of medical card services. It is a very important issue for people nationally and of considerable concern to members. We will hear the executive summary of each group and then take questions from the members. I invite Mr. Eamon Timmins to begin.

Mr. Eamon Timmins

I thank the Chairman and members of the committee. As a charity that works to improve services and policies for older people, Age Action Ireland appreciates the opportunity to address the committee on this important issue.

The details and case studies we will allude to today come from our information service, which is one of the services we run. We took over 3,000 calls last year. We use the service as a barometer to determine the issues that arise. Older people ring us with all sorts of issues and medical cards have certainly featured among them. The case studies I am using today are anonymous to protect the confidentiality of the people who ring us.

Mr. Gerard Scully

We are concerned that centralisation is over-dependent on technology. It results in the loss of the human interface we believe is essential to ensuring the service is responsive to the needs of older people. Where problems arise, there needs to be a much more responsive human interface that would help to expedite the resolution of problems. We are not opposed to centralisation but are worried about how the system is being designed.

Mr. Eamon Timmins

Media reports suggest there are waiting periods of up to six months. We have certainly dealt with people who have been waiting for three months to have their cards renewed. Some of our information officers have tried for up to three weeks to make contact with officials in the office in Finglas to query these cases.

If it is not regarded as overkill, I will refer to one of the case studies we picked out. It is fairly typical and highlights many of the problems that might be raised today. It concerns a gentleman who is applying for a new card and who previously had an over-70s card without being means tested. He filled in his application form and sent it to the relevant address. Two months later, not having heard anything, he contacted us to see whether we could do anything. He gave us the details and permission to take on his case on his behalf. Our staff tried on numerous occasions to contact officials in the office in Finglas but they were left on hold listening to music. We rang the HSE's general helpline and were told there was nothing the HSE could do to get through to Finglas. It stated all it could do was divert our call to Finglas, only for the same circumstances to repeat themselves. Our information officer rang the helpline and insisted on getting a number for the manager in the Finglas office. When the officer rang this number, the call was diverted to the queuing system.

Eventually, after three weeks of regular attempts to get through, we managed to make contact with an official in the office to discuss Peter's case. We were told there was a shortage of staff dealing with cases and a delay in getting to Peter's case which, we gathered from the conversation, the office had not considered by that stage. Some of the factors contributing to delays were invalid applications and having to chase people for proper paperwork. Age Action Ireland was assured Peter's card would be available within a fortnight. In a couple of days, it arrived, but three months had elapsed from start to finish and from taking on extra help.

At a HSE briefing earlier this year, we were assured that with a new computer system, which was being piloted at the time, and a small increase in staff at the Finglas office, the HSE would be able to deal with the processing of all medical cards from one centralised location. Up to last Friday, we were told by somebody who answered the phone in Finglas that there was a six-week delay in processing applications for medical cards. A message we want to send out today is that people should apply in good time for a new card. The flip side of this argument is that a computerised system should be able to identify expiry dates well in advance and have cases processed on time rather than relying on individuals to apply early for their cards.

Part of the problem is that there has been a breakdown in communication. We can only put it down to this. The stress caused by the delays in processing medical card renewals has been added to by misunderstandings that have occurred over people's entitlement to a general practitioner and pharmacist service between the expiry of a card and the making of a decision on whether they are entitled to a new card.

We received a number of calls from older people who believed that once the expiry date on their cards had passed, they were not covered. In these cases, they paid their general practitioners and pharmacists for services covered by their cards in the intervening period. We have been stressing to people on the information lines that people remain covered by their cards until the HSE deems they are not. Their cards should still be shown to be valid on the centralised computer system used by general practitioners and pharmacists. These health professionals should continue to honour the cards until they are removed from the computer system. No general practitioner or pharmacist should have accepted or expect payment from medical card holders who are waiting for their cards to be renewed. We urge the HSE to communicate to everybody involved in the scheme that if one's card has expired and one is waiting three months to have it renewed, one is covered by the card in that period and until one is removed from the computer system. That is the gist of our presentation; there is a lot more detail in the written submission.

Chairman

I thank Mr. Timmins. I invite Dr. Ronan Boland of the Irish Medical Organisation to make his presentation.

Dr. Ronan Boland

On behalf of the Irish Medical Organisation, I thank the Chairman for the opportunity to address this committee. The Irish Medical Organisation and general practitioners have experienced difficulties with the medical card scheme for as long as it has been in existence. Some difficulties are inevitable. Particular difficulties arose since approximately January 2009 when the processing of all over-70s medical cards was centralised. Mr. Timmins has already outlined the situation in some detail and the types of scenario he has outlined have been replicated in doctors' surgeries throughout the country. I am a general practitioner in Cork, Dr. Walley is a general practitioner in inner city Dublin and Dr. Daly is a general practitioner in rural Galway. Irrespective of the part of the country we work in, we have experienced difficulties. The difficulties are not confined to citizens over 70 years of age, although we have had particular difficulties with senior citizens since the centralisation of their medical cards. More recently, however, since approximately June or July of 2009, all medical card renewals in two local health office regions, Ballymun in Dublin and the Rathdown Road region, have been centralised. The problem is most acute in those regions, but in general throughout the country there are difficulties with regard to other particular groups. These include newborn infants of eligible parents, who should automatically be entitled to a medical card. However, due to bureaucratic delays, it often takes many months before those children are deemed eligible by the PCRS, which oversees the medical card system.

With regard to 16 year old dependents in full-time education, they are obliged to apply for a medical card in their own name as their previous cards are automatically deleted on their 16th birthday. This is the case also for citizens over 70. Medical cards have an expiry date and the card is, as far as I am aware, automatically removed from the system. The removal of the card from the system is an automated procedure and does not involve a member of staff of the HSE cancelling the card. Once the card's expiry date is reached, the card is deemed ineligible for service on the PCRS system. The PCRS has outlined that there is only one national list and, therefore, I understand that once the expiry date has passed, the card is no longer valid. We have a situation where 14 and 15 year olds are given laminated plastic medical cards with expiry dates into their 17th or 18th year. They possess a piece of plastic that states they have a valid medical card, but yet on their 16th birthday the card is automatically removed from the PCRS register. They have a valid card, but they are not on the one national list to which the HSE refers to repeatedly in correspondence.

There seem to be particular difficulties in the two local health office regions mentioned with regard to new medical card applications, including for people over 70 and those whose cards have lapsed. The difficulties apply to all regions with regard to dealing with the necessary paperwork for those over 70 and it is difficult to make direct contact with a HSE individual where difficulties arise. Some of the issues are as simple as a change of address and review forms being sent to the wrong address. For example, if someone's card lapses, I get a notification on the fifth or sixth of the month that the person's card is no longer valid. I may be aware that the person moved house six months or a year previously and can see that on my computer system. I know the person's circumstances have not changed and he or she is not working and is dependent on social welfare. However, the person must go through the process of applying again for a medical card. This is often difficult and paperwork is often returned because of missing information.

Every general practitioner in the country has difficulty in this regard and the issue has become even more significant over the past year as the centralisation process advanced. In principle, there is nothing wrong with centralisation provided the end users of the service — the HSE's clients and our patients — get a timely service and can validate their entitlements quickly. Due to the level of frustration doctors were experiencing when making phone calls on behalf of patients who should have been eligible for services, but were not, we contacted doctor members and asked them to give us some data in this regard. Members can see evidence of some of the problems from the submission we made. I will not go through the data in detail, but it is available in the submission.

Some examples of the practical difficulties we have experienced since the centralisation of the offices include problems where elderly patients or families whose medical cards have lapsed erroneously are no longer on the single list referred to by the HSE as the only list determining entitlement. Such patients are, in effect, passed from pillar to post. They cannot get satisfaction at local office level and are given the phone number for Finglas. Some patients have spent €25 or €30 — money they cannot afford to pay — on mobile phone credit to try and get through to an individual. Staff in my practice practically refuse to ring the Finglas office when I ask them, because it is such a waste of time. My staff, like others, are very busy and work on the phone constantly, but they cannot get through to a human person at the Finglas office to try and address the difficulty of a needy patient or family. I am not just talking about access to doctors, but about people's entitlement to medicines and access to the other services that are available by way of a medical card through primary care teams, such as physiotherapy, occupational therapy, etc. We need a valid medical card number to make an application for these services on behalf of the patient.

These issues present significant difficulties, particularly for vulnerable medical card holders, the elderly, people with poor literacy skills, people of poor means, people with limited telephone access, people who do not have access to the Internet, people with intellectual difficulties and people with psycho-social or family problems. The situation for these families is often chaotic. We all deal with them in our various occupational roles. They are people for whom the filling in of forms in a timely manner presents a challenge. The current system is not sufficiently flexible to give us confidence that if we move from a situation where two local health office regions out of 32 are centralised to a situation where, over the next few months, all medical cards for the country will be centralised, the new system will work. Our concern is that the difficulties we currently experience will be compounded. This will create real difficulties for needy and vulnerable patients in accessing services.

In our submission we put forward 17 practical suggestions. Some of these relate to simple administrative practices such as guaranteeing that a minimum of three months notice would be given to medical card holders. This suggestion was also made by Mr. Timmins. We suggest practical measures such as allowing a change of address to be made on-line and putting in place a fast-track mechanism to restore cards cancelled in error. I do not mean a person should be given a piece of paper by someone in an office to say the medical card has been extended. We should decide whether we have a single national medical card list or not. Therefore, somebody must have the authority to grant people a medical card and put them on the single national list. Every doctor has seen pieces of paper given to patients which state their card is valid until further notice. I had 30 of these in my practice last Friday, relating to cards deemed invalid and expired but declared eligible pending the issue of a card. How can a card be expired and issued at the same time? Perhaps somebody can explain this to me.

We would welcome a centralised single national list. The HSE has indicated it is confident it will be in a position to have a 15-day turnaround of all medical cards and that all patients will be able to establish their entitlement to service in a short space of time. If that happens, we will be delighted. However, we have concerns that the kinds of difficulties we have experienced will be compounded if the centralisation goes ahead post haste without the flexibility we feel is required. This would include provisions such as having a lo-call number with facilities for people who may have a hearing difficulty and with some form of accountability in the system. If, for example, I on behalf of my patient feel my patient is entitled to a service, but the patient did not get the forms or failed to return them in time, the flexibility will be there to allow me, or somebody on my behalf, to pick up a phone or communicate by e-mail with a HSE official. The least we can expect is a timely response from the HSE to such queries and to the kind of difficulties outlined by Age Action Ireland and by every practice and doctor in the country. Currently, we cannot get through to a human being to have these difficulties addressed.

We are here for these reasons. There is more detail in our submission in terms of other practical steps we feel could be taken. Ultimately, we all want to get to the same place. That is a position where patients who are entitled to all the services a medical card brings can get those services in a timely manner and through an accountable system. We are happy to meet with the HSE at any time. It made contact with us in writing shortly before this meeting and indicated it would follow up with a phone call with a view to arranging a meeting. We did not receive that telephone call but we would be happy to meet with the HSE on this issue and all related issues.

Deputy James Reilly

I welcome Mr. Timmins and Mr. Scully from Age Action Ireland and apologise for the fact that I was not present for the presentation, though I have read it. I also welcome Dr. Boland, Dr. Walley, Dr. Daly and Ms Hetherington from the Irish Medical Organisation.

The purpose of this meeting is to establish how much difficulty the centralisation process is causing. It is clear from the documents provided by Age Action Ireland and the IMO, and from my own immediate experiences in Dublin North where I have discussed the matter with GPs, that it is creating very significant difficulties. As I have said in private sessions of this committee, and in public in the Dáil, local GPs had the option of sending a patient up to Finglas to get the matter sorted but the response of the HSE was to put a security man on the door to stop little old ladies and others from entering. This is a very serious problem which is causing tremendous anxiety to people who already have enough stress in their lives. Many of them are already ill and cannot understand why they need to keep filling out forms. They do not see how the circumstances of people with terminal cancer or with a lifelong disability, such as motor neurone disease, can change.

I recently had a very interesting meeting with SIPTU representatives of community welfare officers. We do things differently in the greater Dublin area and the involvement of community welfare officers is not as big as it is in rural areas, where they provide a face-to-face service and help patients to fill out their forms. Many patients have difficulty with dyslexia or illiteracy, they may be visually impaired or have arthritis, dementia or depression and cannot otherwise fill the forms out. Do people realise the form runs to eight pages of questions? One wonders if one needs a third level degree to fill it out. It is extremely frustrating. In addition, the more pages there are and the more information that is required the more there is a chance of a mistake.

We will have the pleasure of meeting the HSE soon and I have no doubt Mr. Burke will have a lot to say to us but I intend to ask him how he can guarantee a 15-day turnaround even if the form is properly filled out. Given that so much is to be filled out, the odds are that something will be wrong and will be marked with a red biro.

Chairman

Does Deputy Reilly have any questions for the witnesses?

Deputy James Reilly

The IMO has offered a clear outline of the situation but how does Age Action Ireland see the matter being resolved? Would its representatives agree that the brakes should be put on the process until all the problems have been ironed out? I will ask the other witnesses whether a proper analysis was carried out before this scheme was undertaken.

Deputy Jan O’Sullivan

I thank the representatives from Age Action Ireland and the IMO for coming before the committee. I asked for this to be put on the agenda because of the great difficulties that have come to our attention. The Labour Party had prepared a motion on the matter but we decided to defer it until we held these hearings and read the written submissions. The motion still exists and proposes deferring the centralisation programme until such time as the problems are ironed out. If we are not satisfied with the response of the HSE we will move the motion.

The people who have come to us are very affected by the issue. Many people are more affected by the issues we discuss in this committee than by the moving of deckchairs on the Titanic which is taking place in the House next door. In the latter case, Ministers are being moved from one position to another but this is a real human issue that affects the most vulnerable people in the country. The story of Peter, as told by Age Action Ireland, is replicated in stories told to me by various people who cannot get the information they require and cannot get any human being to answer the telephone. My colleague, Deputy Shortall, came to a previous meeting of this committee to explain her experiences as a representative of one of the areas of Dublin which has been centralised for all medical card applications. She told me that the situation has not got any better and that she still cannot get replies on behalf of her constituents. As a committee, we need to sort out these problems before there is any further centralisation.

The submissions, in particular that of the IMO, make it clear that there is still a great deal of confusion about what is happening. Dr. Boland said that people were being told they had a valid card but then found they were not on the list that mattered. I will ask questions of the HSE on that matter later but do Age Action Ireland and the IMO feel that getting information and gaining access to a human being in Finglas has improved in the past couple of weeks?

In its submission the IMO makes a proposal that all medical card holders, including dependants approaching their 16th birthday, should be notified in writing a minimum of three months in advance of the precise date of expiry of their card and sent the necessary forms. I have been trying to get clarification on this and received a response to a parliamentary question on the subject on 3 March, which stated that medical card reviews or renewal forms were issued to medical card clients three months in advance of their eligibility review date in order to give clients sufficient time. The reply from the HSE goes on to state:

Clients are requested to return completed review forms at least one month in advance....The HSE will issue a reminder letter to the client if the review form is not received by the Executive within one month of the review date.

There seems to be wishful thinking on the part of the HSE that all this is happening. Can Age Action Ireland and the IMO clarify whether, in their experience, reminder letters are being sent out three months in advance? Is it their experience that, if a person has not filled in the form within the month, another letter goes out? We are presented with a lovely picture by the HSE of a 15-day turnaround but I do not trust the HSE to make it happen. In my experience, what we are being told is happening is not actually happening.

I may need to ask the HSE my next question but the witnesses before us may have experience of the issue from talking to patients and older people. The HSE states that there is still a frontline service in the local area but when people go to their local office they are told it does not have the information and has no input into the decision-making process. Is that the experience of Age Action Ireland and the IMO?

Deputy Rory O’Hanlon

I apologise for the fact that I was not present for the whole presentation but I am a member of a committee which is sitting next door and I had to get that meeting started.

The new system is not in operation in our area yet, except for the over-70s. I have not had any complaints from the over-70s, which I suspect is because most of those who had medical cards are entitled to hold on to them as their income will be somewhat lower than the national average.

The IMO raised issues concerning access to information and a relatively small survey found 645 people who went onto the national list. That is a matter of concern but was there any variation between the city and the country? It appears that for people on PAYE the centralised process would probably work quite well because they will qualify for a medical card on the basis of their income. However, in a rural community, particularly dealing with small farmers, it may not be that easy for them to complete the form that accurately describes their income, which in itself may cause a problem. In its surveys has the IMO found any variation between the city and country?

The witnesses made a number of good recommendations. Have they met representatives of the HSE to go through the recommendations and, if so, what response did they get?

Deputy Paul Connaughton

I welcome the witnesses as professionals, who are at the coalface in the same way that we are. In case anyone might think we were doing a political solo run on it or that we did not have the overall picture, before I finish today I intend to prove to the HSE that it is an overall picture that we have.

In County Galway, about which I know most, there are 91,000 medical card holders. I do not have the statistic as to how many of them are over 70, but that does not make any difference. I am concerned about the full force of the country — the deluge as I call it — flowing through Finglas. I have no problem with the centralisation. I notice that was a trend that came from the witnesses also. That is not the issue. I can see the reason for that policy as an overarching system to ensure it is the same for every county and every person, regardless of where he or she lives. I have no problem with that. However, I am told that when this is fully operational next month or the month after and when every medical card application will go through it, there will be 1.6 million transactions going through Finglas. I have nothing against the staff in Finglas although it took 11 days to make contact at one stage. When one gets through they are most professional, but that is not the issue. Is it feasible or sensible to put that number of transactions through given what the HSE was able to do with the limited number of over 70s in a year and a half? This situation is likely to get much worse. I would like to get the professional views of the two organisations.

Deputy Margaret Conlon

I welcome the representatives of the IMO and Age Action Ireland. I agree that centralisation is a good approach because there were anomalies and people in some counties might have found it easier to get a medical than those located somewhere else. That needs to be stopped. I have always believed that income should not be the overriding principle as to who gets a medical card. It should be based on medical needs. In some ways the medical card has become like the gold Visa card in that it entitles people to free travel on school buses and other things that are not necessarily related to medical needs. That is for another day's discussion.

In looking at the centralisation, of course we need to get greater value for taxpayers' money, on which we are all agreed. At the same time there is a need for some level of personal contact, particularly for people who find it difficult to fill in forms. We are told that the HSE's local office will provide this and yet the experience would suggest otherwise. In recent times we have had industrial relations difficulties with public sector unions, which I am sure has compounded the difficulties with people getting their phone calls answered. We have seen it through the public sector offices where it is very difficult to get through to a human being. However, I do not believe that anybody should need to wait at the end of a telephone line for 25 minutes or more to have a particular query addressed.

I have read both submissions and the IMO one in particular has some sensible recommendations, including the automatic registration of newborn babies, which makes perfect sense. There needs to be a meeting between representatives of the IMO, the HSE, Age Action Ireland and any other stakeholders to get this situation sorted so that the system works properly.

I do not have a major difficulty with people's medical cards expiring. One's passport expires. When a child reaches a certain age the parent receives a letter advising that they are no longer entitled to child benefit unless the child is in full-time education and forms need to be completed. I do not have a great difficulty with that.

As with Deputy Jan O'Sullivan, I had the impression that people were getting reminder letters and forms to complete. That is a question we will need to ask the HSE. Are the problems being exacerbated by the recent industrial action? It is very important that the meeting takes place as soon as possible.

Deputy Beverley Flynn

I welcome the representatives of Age Action Ireland and the IMO. The story Mr. Timmins told about Peter is something we have all experienced in our constituencies in recent months. The presentations indicate that the organisations are somewhat supportive of the centralised system. Based on the experience in my constituency, I do not like the idea of a centralised system. It worked quite effectively through our local health office. Our community welfare officers were very much involved in the assessment of cards, which was a very important aspect of the decision, particularly regarding discretionary cards. The IMO presentation indicated that 80,000 medical cards were discretionary, which is a major factor for somebody like myself in a rural constituency. How are we to address that issue? As I said at a committee meeting in the presence of Professor Drumm and the Minister for Health and Children, if it was just down to meeting the requirements for a medical card, a robot could issue a medical card. One would not need anyone to assess it; it would be a straightforward following of the formula. However, it is a real issue when dealing with a discretionary card.

The representative of Age Action Ireland made a very good point about explaining the system. The HSE should issue a statement clarifying that the medical card is still valid on the system pending the renewal procedure. I assume that only applies provided the person has sent in the renewal forms. What happens to those aged over 70 who have not sent in the renewal forms? Is there a period of grace in which the card remains active on the system? I know of a number of people aged over 70 whose applications have been in the system for at least three months. I would be very anxious to issue that reassurance after this meeting if it is the case that their cards are still valid.

The IMO presentation indicated that it had been in contact with the primary care reimbursement service going back to 2005. From that do I understand that it is generally supportive of a centralised system? The same question regarding the discretionary card would apply in that particular case. Obviously we will be hearing from representatives of the HSE later. Its presentation made the point that centralisation has resulted in considerable savings of €5 million since the introduction of this service. It describes these savings as being payments made to GPs that should not have been made on the basis of cards that should not have been used in the first place — perhaps belonging to people who were deceased or whatever. Does the system work both ways? Do GPs notify the HSE when a card should no longer be valid?

Some of the recommendations in the IMO's 16-point plan are excellent and I sincerely hope the HSE will take them on board, particularly regarding being able to send documents via registered post. This is a major factor for people with vital information being mislaid delaying the entire process resulting in people being without a medical card for perhaps three months. That is an excellent point. I agree with most of the points in the 16-point plan.

My colleague, Deputy Conlon, referred to the importance of the HSE meeting the IMO. "Independent third party" is underlined. Is it possible for the HSE to meet the IMO to thrash out issues or does everything have to be done through an independent third party? Why is there seen to be a need for that?

Mr. Eamon Timmins

The one thing that has become clear from today's meeting is that we need to nail the communication issue. We have been told consistently by the HSE that so long as one's medical card application is being processed the card remains valid and one is covered. However, it is clear from what Dr. Boland said that the card is falling out of the system and as far as the GP or the pharmacist is concerned, one is not covered. We need to at least clarify that matter today. It is important to get the message out.

As an organisation representing older people we are in favour of any system that is streamlined, more efficient and provides better value for money for the taxpayer. The system as currently devised does not tick all those boxes. It is clearly not working given that we have three month waiting lists and that it takes three weeks to get through to a human being at the other end of a telephone line. What the old system had in its favour was that when there was need for documentation whether a birth certificate, bank statement, or when a person changed doctor or moved into a nursing home it was easy to get the documentation from the local health office, LHO. We heard of a case where a man's documentation was lost. It was put in the post but was never received and he was struck off. His card ceased to be effective when he did not respond to the request for documentation within the period.

There was value in the local system when problems occurred. The new system must have a public face. There must be enough staff to answer the telephones and there must be public access to it. However, I accept that if one is from Castlebar public access in Finglas is not much help. Those are the central points we make. We are not aware of any period of grace. The problem existed long before the latest phase of industrial action commenced.

We do not know whether people were writing in advance. People only come to us when they have sent in the form but have not had any satisfaction. Overall we would welcome the centralised system if we could improve it, give it a public face and provide some way of dealing with documentation at a local level where extra documentation is required.

Dr. Ronan Boland

Several questions have been directed at us. I will direct some of them to my colleagues. Please remind us if we fail to address any question. Deputy O'Sullivan inquired about our experience of whether forms were issued on time. I invite Dr. Walley to address that issue.

Dr. Ray Walley

I practice in the north inner city which is one of the pilot areas. The pilot areas were the local health offices Nos. 10 and 11. The north inner city is an area of long-term unemployment. The Celtic tiger did not roar for many of those individuals. Their circumstances have not changed. Getting a medical card usually involves renewing a medical card. It should be a formality but it is not a formality. In my practice we write to patients four months in advance to notify them because it is our experience and that of other GPs in that LHO area that medical card holders are not contacted. Because many patients have literacy problems they bring forms to the practice to be filled out. The only letter they tell us they get is from our practice and other GP surgeries. That is what we hear from patients anecdotally.

Recently, we heard that 16-year-old patients were being contacted in writing two weeks in advance of the expiration of their cards. The cards are laminated and they have an expiry date that is similar to that of their parents yet the card becomes invalid on their 16th birthday. It is difficult to explain that to patients who have a piece of plastic in their hand which has an expiry date two and three years hence. Because we are Internet-linked to the PCRS we print out the sheet that says "card expired" and give it to patients. There is no fast-track system for those individuals to get a card. I had a case today of a 16-year-old to whom we wrote three or four months ago who had not dealt with the matter. We saw her for free but she has to pay for a private prescription. Money is short in many of those households.

My experience with the elderly is that they are not written out to in advance. In general they note if the form comes in and they tell us when that happens. An 84-year-old gentleman to whom I wrote in January came to see me recently. He was not contacted. He is on medication and we have no quick way to get him a card. If the system works for him, it works. The gentleman in question does not have a telephone or access to the Internet. He does not have any family. We ended up directing him to his local Deputy. It is generally the experience of the north Dublin GPs in looking at the review of the IMO information that the system is worst in new LHO areas. They were piloted in June and July. Elderly notification is patchy. It occurs in some circumstances but in general it is our experience that it does not happen.

Before Christmas a number of patients who are in nursing homes were seen by the out-of-hours agency and we noted that their cards were due to expire so we were able to give notice to the PCRS. They were without a medical card for several weeks. One individual was in the Mater Hospital for a year prior to that. If he did not have access to medication he was going back to the Mater Hospital because he did not have the wherewithal to buy the tablets. He is a man on a full subvention bed paid for by the HSE. There is a disconnect between one part of the HSE which is paying for a full subvention bed and the part that provides medical cards. The man was without cover for several weeks.

A number of individuals in the same nursing home have dementia. They have no families to chase up matters for them. Some of them had PPS numbers belonging to their spouses who have now passed away. It was not noted in the original application taken in by HSE staff that the PPS number related to one individual and was then used for two individuals, one of whom had passed away. The card was stopped without any notice to the GP or the patient that the card had been stopped. The only way to pick up on it was by my staff going through the computer system to see when cards were due to expire. In many cases the expiry date of cards is not notified.

Dr. Ronan Boland

The question of whether local offices are able to deal with the issue ties in with Deputy Conlon's inquiry about industrial action in local offices. I am aware of a case concerning a lady in her mid-20s. I have a letter on headed notepaper from the HSE confirming the granting of a medical card to her on 16 December last. She is the subject of a court order and she has to attend me on a weekly basis. She is on four different expensive medications. She is not on the HSE single list although it is three and a half months since I was notified that she was put on my panel. My staff have repeatedly telephoned the local office in Cork — Abbeycourt House, where I work, to be told that they cannot do anything to assist and that we have to contact the Finglas office because the data has already been transmitted there. We cannot get through to speak to anyone in Finglas. I see the patient on a weekly basis. I do not charge her. I am writing a medical card prescription for her which I am not even sure I should do because as far as the HSE is concerned there is a single client eligibility list and she is not on it, which ties in with another question Deputy Flynn asked about an independent third party.

We had a mechanism as part of an agreement in 2005 that the HSE and the PCRS would meet us on a regular basis to consider housekeeping issues around medical cards. That group met under the auspices of a third party. It has been our experience that we have had great difficulty getting anyone in the PCRS and the HSE to talk to us on those issues. The reason we suggested a third party forum was to ensure that all parties were accountable to the process. Time and again the biggest complaint of individual doctors is that they write, e-mail and telephone but they do not get a response, or if they get a response to the query raised it is not substantive.

We have responsibility in regard to notifying the HSE about people who may no longer be entitled to a service. In reality, it is the one area in which the HSE has become extremely efficient. I recently received a phone call at 9.15 a.m. on a Monday morning asking me to confirm whether a patient of mine, a man in his 50s suffering from cancer, had died. I was not even aware he had died. He had been granted a discretionary medical card the week before and the officer of the HSE was ringing me to confirm it was one and the same person so the HSE could cancel his eligibility within a fortnight. Needless to say, I was not particularly happy to be notified of my young patient's demise in that manner. There appears to be great efficiency in this area. The HSE has improved greatly in terms of addressing the problems that arose in the past with regard to removing deceased patients from the register of eligible clients.

There is a practical difficulty in that we, no more than the HSE, are not necessarily aware of people leaving the jurisdiction or changing address. We do not check on a weekly basis to determine whether Mrs. Murphy may have returned for her medication. It is more often a case of visitors from other countries staying in Ireland for a short period. I acknowledge we have responsibility in this area.

The issue associated with the need for a third party is more about ensuring everybody takes the engagement seriously. It is not because we cannot address the matter. We talk to the HSE about a range of issues regularly, notwithstanding difficulties over impending legislative changes or other such matters. We are more than ready, willing and able to address these issues and have made some practical suggestions in that regard.

Deputy Connaughton asked about the feasibility of extending the service to the entire country and Deputy O'Hanlon asked about the urban-rural divide. I will ask Dr. Martin Daly to address those issues.

Dr. Martin Daly

Deputy O'Hanlon suggested there is a difficulty in rural areas. Our experience is that the issue does not just arise in rural areas but in urban areas also. From my experience as a rural general practitioner, I understand the community welfare officer acted as the interface and facilitator for people wishing to obtain their entitlements. The system, which had a human face, has been replaced by a cold and callous one in which people's entitlements are being decided at the end of a phone without any indication of their medical needs or particular circumstances. This is also the case with regard to nursing homes. Community welfare officers used to be contacted by nursing homes and they helped to facilitate people in obtaining their entitlements. I refer especially to patients who suffer from dementia and those who are very ill, disabled or debilitated.

We are being told that when people are not on the central register, we should treat them like a credit card customer and that they are simply not entitled to a service. Many general practitioners are not charging their patients in this category but when we become aware that somebody no longer has a medical card, we are obliged, according to indirect HSE channels, not to write a GMS prescription. We are told we must write a private prescription. This is when the issue comes to a head. People can keep coming to us and it does not matter to the HSE, which is getting a free service. Provided we write a GMS prescription, the patient is happy because he or she has seen a doctor and the HSE is not paying for the service. It has been inferred that if we write the GMS prescription on a nod-and-wink basis, the pharmacist will be paid because that is how the system works. There is a fund to reimburse the pharmacist. However, the minute we write a private prescription, all hell breaks loose and that is what has brought the matter to a head.

I take issue to some extent when medical cards are referred to as some form or gold card or passport. Medical card holders are the sickest, poorest and least well off in the country. Any social research will show they have considerably higher medical needs than the rest of the community. They are entitled to a service from the State and should be facilitated in obtaining that entitlement. Any suggestion that they should not be entitled to the card and that their entitlement should be based only on medical need is questionable. If one wants to change the system from one based on income to one based on medical need, one will require someone to design a new contract for general practice. Unfortunately, we have not had much engagement with the HSE in that regard for a number of years.

Dr. Ronan Boland

I will summarise briefly because I am aware the members have yet to be addressed by the HSE and engage in their deliberations. Our experience is that the system lacks sufficient human interaction and, in particular, accountability. It requires human input at CWO or medical officer level. Some officer is required to allow for sufficient discretion.

I accept Deputy Conlon's point that there must be accountability in the system. We completely understand and take it as a given that the HSE is answerable to the Comptroller and Auditor General and others in regard to how public moneys are spent and that there must be checks and balances, but there should be sufficient flexibility in the system such that where there is a blank expiry date and it is clear that the medical card holder's circumstances have not changed, his or her eligibility can be extended until the paperwork pertaining to the application for another card is adequately completed. This also applies to discretionary cards in that the system should have human input to allow a certain degree of discretion in issuing them.

I agree absolutely with Age Action Ireland. In 2005, the HSE told me and others with me that, within a matter of weeks, there would be a single client eligibility index for every medical card holder in the country. There was a third party appointed by the State to oversee the process. We were told the index would be updated in real time and that the person giving the medical card to the citizen would automatically include that citizen on a national list. As far as I can see, five years have elapsed and, on the basis of the examples we have given the committee, it is still not happening.

There have been certain improvements and credit must be given where it is due. At least we can now check on-line whether somebody is deemed eligible. There have been more recent improvements in terms of documenting whether letters have been sent to clients. The analogy I have given to some journalists who have contacted the Irish Medical Organisation is that if I register a letter and put it in the post, I can go on-line and check its exact status using the registration number. Considering this is 2010, the Internet age, it should be clearly visible to everybody involved in the process, be they an elected politician, general practitioner providing services, pharmacist or, most important, a citizen, exactly where an application is in the system. One must have sufficient information to allow one to see the exact status of an application.

Deputy James Reilly

Given the problems Age Action Ireland, the IMO and patients are experiencing, do the witnesses believe the centralisation process should be put on hold until they are resolved? I do not need a long answer.

Mr. Eamon Timmins

The system, as it stands, is not working. People cannot have their cards processed in a reasonable time, nor can they communicate with an officer. We made a number of suggestions, namely, to have a human face, more staff and a way of dealing with documentation when there are problems with applications and backlogs. Until the problem is solved, putting hundreds of thousands more cards through the system will not improve circumstances. The problem should really be resolved.

Dr. Ronan Boland

Some 2,050 general practitioners do not have confidence in the ability of the system, as it is currently functioning, to process medical cards within the timeframe outlined by the HSE. We do not have any objection in principle to centralisation. It is the HSE's decision, in conjunction with that of the Government and legislators, to decide whether medical cards are processed and by whom, but we are not confident, considering how the system is currently structured, that there will be an improvement. Unless the majority of the 17 suggestions in our document are addressed, problems will get worse for individual patients.

Chairman

Could Dr. Boland clarify that? What he is saying is vital. Based on his experience of the pilot areas and of over-70s medical cards, what is his reaction to centralisation thus far?

Dr. Ronan Boland

We have been receiving complaints. In my practice and at every meeting we have gone to in the past year, we have experienced problems with regard to the over-70s, specifically because of the position at local level. For whatever reason, local officers are saying they cannot bring this matter to completion and that they have done as much of the paperwork as they can or will do. They state it is up to Finglas to have the matter dealt with. We simply cannot get through to Finglas. The difficulties in respect of over-70s have been felt most acutely in the past year. The difficulties in the two regions in Dublin, as members have found, have now extended to the entire population who are entitled to medical cards. Our concern is that two will become 32 in three months' time unless housekeeping issues are dealt with. Until we have a way of dealing with the issues with the HSE, the problems will get worse for all of us.

Deputy Jan O’Sullivan

Does Dr. Boland believe people whose cards are being renewed but have not yet been processed should retain their cards until they are processed?

Dr. Ronan Boland

Absolutely. We would like clarity on the matter. Notwithstanding the fact that the HSE and the PCRS may state on their website that people's cards have expired, if people are entitled to an ongoing service they should receive it. They are either entitled to the services afforded by a medical card or they are not. I would like the HSE to confirm the current position to every doctor, pharmacist and elected officer in the country because there is a degree of cloudiness around the issue which serves nobody.

Dr. Martin Daly

There will be absolute chaos if this spreads nationally. Deputy Connaughton has been involved in the issue locally and I am sure he will agree with me. The system is already bursting at the seams and it is impossible for general practitioners to obtain entitlements for people.

The experience with the over-70s has been a disaster. An Independent councillor who lives beside an elderly woman in south Roscommon worked on renewing her card for four weeks but still could not get an answer. He processed her application and was eventually told that a post office stamp was missing to verify her pension. He suggested the officer look more closely and was told that the necessary stamp was in place, though it was faint. It had been sitting for two months in a drawer without being dealt with. Someone should have telephoned the woman to tell her something was missing from her application form and to ask her to resubmit it. That is a breakdown in communication and we will have real problems by July if this becomes a national issue.

Dr. Ray Walley

The original pilot was to include three LHO areas in north Dublin but the third area currently has a four-month backlog. It was meant to go onto the new system on 1 April.

Ms Vanessa Hetherington

Deputy Flynn asked if the HSE and the IMO could sit down together. The PCRS contacted us and we agreed to meet but we have not heard anything since.

Chairman

I thank the delegations for assisting us with our deliberations and taking our questions. They are more than welcome to take their places in the Gallery.

Sitting suspended at 4.43 p.m. and resumed at 4.44 p.m.