Adjournment Matters

Hospital Services

I welcome the Minister for Health to the House.

I welcome the Minister, Deputy Reilly, to the House. The last time he was in the House when we had a discussion about a Bill to reform the HSE, I mentioned a working group that was established to look at hospital networks. The Minister will also be aware of a south-east hospital working group, which also sent a submission to him and which is headed up by Professor Fred Jackson. The submission was about a regional structure for the south east, that works and that is based on maintaining services in the south-east region, and obviously wanting to protect the status of Waterford Regional Hospital.

Professor Fred Jackson, a spokesperson for the south east hospitals working group, has said that a key reform being proposed by the Department of Health involves the establishment of hospital groups in Ireland. His group believes that this proposal is consistent with the programme for Government and that it recognises the clinical networks which have already been established within the region. He went on to say that if implemented, the proposal would ensure that patients of the south-east region can access high-quality care on a timely, local and cost-effective basis and that is what the people of Waterford want.

There is certainly a need to realign some services, cardiac services being one example, across the south east. We do not have 24-7 cardiac care in Waterford Regional Hospital, for example. Some of the services are fragmented. There is an appetite within the region to build up capacity in the regional hospital but to do so in the best interests of all patients across the region. Obviously the hospital, like all others in the State, has suffered from cutbacks in recent years but I must put on record my appreciation of the staff and management of the hospital, who are doing their very best in difficult circumstances and are providing very good services to the people of the south east.

There is a genuine fear that there might be a proposal to create a new network which would link Waterford to Cork, with the possibility of services in Waterford Regional Hospital drifting away to Cork, which would not be in the best interests of the people of Waterford or the south east generally. It would also fly in the face of the logic of the Minister's attempts to ensure that people have access to world-class health services as close as possible to their communities, but also on a regional basis, where practical and appropriate. That is what we are seeking here.

The Minister is already aware of this issue and he received a copy of the submission. I appreciate that a review is being carried out across the country regarding hospital networks but I just wanted to put on the record the fear that many consultants, not just in Waterford, but across the south east have, of not maintaining a regional entity within the south east and of a drift of services towards Cork, under a new hospital network set-up. I look forward to the Minister's response and hope he will outline what he feels is the most appropriate way forward for the region.

I thank the Senator for raising this matter and for the opportunity to clarify the position. Senator Maurice Cummins has also made several representations to me on this issue.

Under the programme for Government 2011-2016, the Government committed to developing a universal, single-tier health service which guarantees access to medical care based on need, not income. On foot of this commitment, the Government will introduce a system of universal health insurance. A key stepping stone to the new system will be to develop independent, not-for-profit hospital trusts, in which all hospitals will function as part of integrated groups. As a first step on that journey, these groups will be formed on an administrative basis. It is envisaged that this will take place from early 2013 onwards, with groups being constituted and becoming operational as soon as is feasible, depending on their readiness and capacity to do so. Groups will be established on the clear understanding that the groupings and their governance arrangements will be reviewed prior to 2015, to ensure an appropriate environment for the introduction of universal health insurance.

The rationale behind the establishment of hospital groups and trusts is to support increased operational autonomy and accountability for hospital services in a way that will drive service reforms and provide the maximum possible benefit to patients. Each group will have a single consolidated management team with responsibility for performance and outcomes. It is intended that non-executive boards, consisting of representative experts, will oversee each hospital group management team and will have responsibility for decisions in relation to services in all hospitals in the group.

In June this year I appointed Professor John Higgins to chair a strategic board on the establishment of hospital groups. Professor Higgins is head of the college of medicine and health at University College Cork. He has a deep interest in organisational reform and change management. He was the director of the reconfiguration of the health system in Cork and Kerry from 2009 to 2011 and he remains chair of the reconfiguration forum there. The strategic board has representatives with both national and international expertise in health service delivery, governance and linkages with academic institutions. On the advice of Professor Higgins, a project team was established to support the strategic board, consisting of Professor Higgins and the team who were previously engaged in the reconfiguration process in the south, as well as members of the special delivery unit and acute hospitals section of my own Department.

The project team is tasked with making recommendations to the strategic board on the composition of hospital groups, governance arrangements, current management frameworks and linkages to academic institutions. In order to be in a position to do this they carried out a comprehensive consultation process with all acute hospitals and other health service agencies. In carrying out this work, use has been made of video conferencing and meetings have been scheduled to coincide with the presence of international representatives in Ireland, in order to minimise costs.

The consultation process included two days of meetings with the hospitals in the south east, on 9 July and again in October. A significant number of submissions, including one from representatives of the south east, have also been received by the team. Work is ongoing on finalising a draft report on the recommendations for submission to the strategic board for consideration when it meets at the end of this month. When the board has signed off on this report it will be submitted to me and I will then bring it to Cabinet.

I assure Senators that in many areas the hospital groups can be described as marriages made in heaven, but in other areas, they are more difficult. I am aware that the issue of a hospital group in the south east is causing great concern to people in Waterford, Wexford, south Tipperary and Kilkenny. The rationale behind these groups is that we do not have the management expertise to cover the 49 hospitals individually but by having hospital groups, we will be able to get the expertise necessary to turn our hospitals around, as has been done in Galway and is being done in Limerick. We can certainly do it with between eight and ten managers and we can grow new management beneath them. The group system will also give local autonomy.

Recommendations will be made and a discussion will be had at Cabinet but the hospital groups will not necessarily be permanent. If it transpires that a group which looked like it would work at the outset does not work, there will be another opportunity to realign hospitals before the actual hospital trusts are formed. I hope that gives reassurance to people who might be concerned about this. We are still listening to and consulting with people and the draft report has not been presented to me yet.

I have no difficulty whatsoever with hospital networks and agree they are necessary, based on the rationale outlined by the Minister, in terms of getting managerial expertise across a network of hospitals. The point is that in the south east, we already have a highly-effective regional network of hospitals, which provides a whole range of services, from cancer care, cardiology, acute trauma and orthopaedics and in many of those areas it is working well. In that context, if it is not broken, why fix it? What we need to do is develop capacity in the region and not see a situation where there is a realignment, even if it is on a temporary basis, of Waterford with Cork rather than the more natural regional alignment which prevails at present, with the existing clinical network teams. That is the argument of the consultants from Waterford and across the south east. I ask the Minister to be conscious of that when recommendations are made. Ultimately the Minister will have to make the decisions, based obviously on the information he receives but also on his own view of what is in the best interests of patients in the south east region.

I am afraid I must say to the Senator that it is broken and that is why it must be fixed. The Senator's party might say that the budget is broken, but it is not, but I am not trying to score points here. The bottom line is that the health service is not delivering the level of care it should and could do with the resources at its disposal. It has always been a mystery to me that this is the case, given that we have some of the best doctors, nurses and managers in the world in our health service. Clearly, what is needed is a reorganisation of the system to make it a service for patients, which is the core of this. That is the outcome we seek. We want to see better outcomes for patients. As I have said on the record a number of times, we must look at outcomes, not inputs. If we do not improve the journey or the outcome for the patient then we are not doing anything that is worthwhile. The setting up of hospital groups will seriously improve things and I accept and acknowledge the Senator's support for the concept. It will address a whole raft of issues concerning recruitment, retention of expertise, sharing of expertise and particularly, having patients at the lowest levels of complexity treated as close to home as possible.

I hope I have clarified the position. I will continue to listen to what those who work in hospitals and, most importantly, use hospitals have to say.

Before I was elected to the Seanad, apart from being a county councillor, I was a community welfare officer for 28 years, during which time I dealt with medical card assessments. I predicted that problems would arise with the centralisation of the medical card system to the primary care reimbursement service, PCRS, in Finglas. I cannot blame the Government for the centralisation decision because it was made by its predecessor.

The medical card guidelines are often interpreted differently by the PCRS than under the old, locally based system. For example, car loans were allowed to be considered under the previous medical card guidelines where a certificate could be produced to show a medical need to have a car. The guidelines state the HSE must have regard to a person's overall financial position. They do not refer to car loans, but the practice was to take them into account in cases of medical hardship. They permit home improvement loans to be considered, but there could be a situation where a woman decides to upgrade to a modern kitchen that she may not need because it looks nicer. Such a loan would be allowed to be considered, but people need their cars to get to work. A car is not a luxury in such circumstances. Many double income families own two cars and most of them have car loans. Furthermore, where a family relies on two cars to travel to work in different directions, an allowance of €50 per car should be taken into account. In most cases, however, the PCRS is only allowing for one car.

The PCRS is also interpreting child care costs differently. The guidelines state outgoings on child care are allowable, provided they are necessarily incurred in taking up or continuing in employment or education and training, or in providing family supports. Appropriate documentary evidence is required to ensure the costs claimed are reasonable and being incurred. The medical card application form asks for the name and address of the child's creche or childminder. Previously, if a neighbour or friend looked after the children, it was acceptable for him or her to state in a letter how much he or she was being paid. However, the PCRS will only accept such letters from registered childminders, even though the guidelines are silent on this issue.

As a Senator, I am doing as much work on medical cards as I did during my 28 years as a community welfare officer because of all the problems that have arisen. An individual who was refused a medical card was recently referred to me for advice. He brought his income calculation sheet to our meeting, but he had only studied the first page, which stated he was not entitled to a medical card because he was over the limit. I asked him to show me his P60 which indicated that he had earned €19,500. His wife was in receipt of maternity benefit and they had a mortgage, which meant they were under the limit for the receipt of a medical card. He was told that he was over the limit. Understandably, the PCRS has since reversed its decision.

I ask the Minister to address the issues of child care costs and car loans, which are necessary and were allowed to be considered in the past. Somebody needs to tell the PCRS that while it may want to do business its own way, it is dealing with people for whom these costs were previously allowed to be considered when deciding on medical card applications.

More than 1.8 million medical cards have been issued to individuals, the highest number in the history of the State. It represents an increase of approximately 500,000 since the end of 2008. It is expected that the provision of GP services and prescription drugs under the general medical services scheme will cost almost €2 billion in 2012. We have already issued a further 35,000 medical cards this year than we had budgeted for.

Under the provisions of the Health Act 1970, medical cards are provided for persons who, in the opinion of the Health Service Executive, are unable without undue hardship to arrange GP services for themselves and their dependants. Under the legislation, determination of eligibility for a medical card is the responsibility of the HSE. The assessment for a medical card is determined primarily by reference to the means, including income and reasonable expenditure, of the applicant and his or her partner and dependants. The HSE has produced national assessment guidelines to provide a clear framework to assist in the making of reasonable, consistent and equitable decisions when assessing an applicant under the general medical services scheme. The guidelines are publicly available and can be downloaded from the HSE's medical card website.

There is no automatic entitlement under the 1970 Act to a medical card on the basis of a specific illness. However, there is provision for discretion for the HSE to grant a medical card in cases of undue hardship where the income guidelines are exceeded. The HSE has set up a clinical panel to assist in the processing of applications for discretionary medical cards where there are difficult personal circumstances. It has also established a specific system for the provision of emergency medical cards for patients who are terminally or seriously ill and in urgent need of medical care which they cannot afford. These emergency medical cards are issued within 24 hours of receipt of the required patient details and a letter of confirmation of the condition from a doctor or medical consultant. This system is initiated through the local health office by the office manager.

Every year the HSE processes in excess of 500,000 applications for medical cards and GP visit cards. It centralised the processing of all medical card applications and renewals at the its primary care reimbursement service with effect from 1 July 2011. This established a single uniform system of assessment for all applicants to replace the various systems which previously operated through more than 100 local offices across the country. I am aware that difficulties with the centralisation project gave rise to a large backlog and long delays for both new applicants and those seeking medical card renewals earlier this year. However, the HSE has taken a range of actions which completely eliminated the backlog of almost 58,000 applications from earlier this year and confirmed that over 95% of complete medical card applications and renewal forms are now being processed within 15 working days. It has also implemented a range of changes to the application procedures which have improved the process for applicants.

I do not doubt that the person who wrote the Minister's response has five years of experience in dealing with health related matters, but I have 28. I take the Minister's point that 1.8 million people have medical cards, but that does not mean someone should be refused a medical card if he or she is entitled to receive it. I do not want to see a repeat of the response often given to those who apply for carer's and invalidity benefit in kicking the can down the road for one year or more before the applicant eventually receives his or her entitlements.

The Minister failed to mention child care costs or car loans. The guidelines are as clear as crystal. Child care costs and car loans are specifically mentioned as allowable, but the PCRS is refusing to take them into account. I ask the Minister to follow up with the PCRS to ensure clarity on how it is reading the guidelines.

I acknowledge that the Senator has raised issues in this regard.

Significant latitude was shown over the years, in the case of car loans and other loans, when the country was awash with money. We do not have the money now. We have 1.8 million people on medical cards and another 120,000 or more on GP cards. We want everybody in this country to have free GP care and we are moving towards that. However, there was no consistency across the country with regard to all the allowances allowed in the past. I will revisit the issue with the Senator, but as things stand the GMS is a demand-led scheme and the latitude shown in previous years is no longer open to us because we do not have the money.

Student Grant Scheme Eligibility

My query relates to third level grants. I understand this is not the Minister's area, but I presume he has been provided with a response on it. In the past three weeks I have been in contact with two people who have dropped out of college. In one case the person came to Ireland with parents who had been recruited by the health service to work in an Irish hospital. The mother, a maternity nurse, was recruited from the Philippines when there was a shortage of maternity nurses and her entire family came here with her. Her daughter spent a full five or six years in secondary school here and also spent some time in primary school here and got her leaving certificate. The mother got citizenship, but the daughter could not apply for citizenship until her mother had got hers. She got her leaving certificate and a place in university, but then found out that she does not qualify for a grant for attending university. Her mother has been paying income tax in this country for the past eight or nine years.

The second case is similar. The person in this case has been paying income tax since 2001. This student has done two years in university and has had to pay full fees. The student does not have citizenship, but she is not receiving the student grant for attending university, although both parents have been paying income tax for eight or nine years.

I seek clarification with regard to how these cases are dealt with. It appears to me that these students are being penalised even though their parents have been paying tax in this country and have contributed to the country. In the first case, the parent has made a huge contribution in the health care sector during a time when there was a shortage, but now despite the work she has done and the taxes she has paid, her family is being penalised. Can I have clarification on this matter?

I thank Senator Burke for raising this important matter which I am taking on behalf of the Minister for Education and Skills.

Under the terms of the student grant scheme, grant assistance is awarded to students who meet the prescribed conditions of funding, including those which relate to nationality, residency, previous academic attainment and means. The nationality requirements for the student grant scheme are set out in section 14 of the Student Support Act 2011 and regulation 5 of the Student Support Regulations 2012.

The nationality rules require that the student be an Irish, EU, EEA or Swiss national. There are a number of exceptions to this requirement. A person who holds refugee status or the rights and privileges as specified in section 3 of the Refugee Act 1996, or holds subsidiary protection pursuant to the European Communities (Eligibility for Protection) Regulations 2006, meets the nationality requirement. In addition, a person who holds one of the prescribed immigration status as provided for in the Student Support Regulations 2012 may also meet the nationality requirement. These include permission to remain as the family member of a European Union, EEA or Swiss citizen under the European Communities (Free Movement of Persons) Regulations 2006 and 2008 and EU directive and also permission to remain on the basis of marriage or civil partnership with an Irish national resident in the State or as the dependent child of such person. A person who has humanitarian leave to remain granted before the Immigration Act 1999 came into effect or permission to remain in Ireland following a decision not to deport a person under section 3 of the Immigration Act 1999, also meets the nationality requirements.

In all cases, to qualify for a student grant, it is the grant applicant and not his or her parents who must meet the nationality or prescribed immigration status requirements in his or her own right. The onus is on the grant applicant to provide the necessary documentary evidence as proof of his or her nationality or immigration status to the relevant grant awarding authority.

Article 32 of the student grant scheme 2012 provides for the review of eligibility for the award of a grant in the event of changes of circumstances in the academic year, including a change in relation to a student's nationality or immigration status. This means that where a student acquires Irish citizenship by naturalisation or acquires a prescribed immigration status during the course of his or her studies, he or she may make an application in the academic year for a student grant. This is done under the change in circumstances provision. He or she may also under this provision re-apply for a student grant if he or she has previously been refused a grant on nationality grounds. In both cases students may qualify for a student grant from that point, subject to meeting all other terms and conditions of the student grant scheme.

The Minister for Education and Skills has asked his Department to examine the overall issue of the entitlement of non-EU families to third level fees and grants generally and he is currently considering the matter to ensure that there is clarity as to precise entitlements in this complex area. Any decision on changes to the student grant scheme, including changes to eligibility criteria, will need to be considered in the context of availability of resources.

Other supports available to students include the student assistance fund, which will continue to be made available through the access offices of third-level institutions to assist students in exceptional financial need. In addition, tax relief at the standard rate of tax may be claimed in respect of tuition fees paid for approved courses at approved colleges of higher education, including approved undergraduate and postgraduate courses in EU member states and in non-EU countries. Further information on this tax relief is available from the Revenue Commissioners.

I notice the last paragraph on the first page of the Minister's response does not correspond with the decision by the University of Limerick with regard to the grant applicant. In that case, the mother was an Irish citizen and the daughter was living and had studied in Ireland. However, the University of Limerick advised them that they did not and would not qualify for the grant. As a result, the student opted out of college and is no longer attending college. The interpretation in the Minister's reply seems to be different to the interpretation given by the University of Limerick and that is the reason I sought clarification. This is obviously a matter I will have to follow up on further with the Department, but I appreciate the comprehensive response given.

My pages do not correspond exactly with those of the Senator, so I am not quite sure to which paragraph he is alluding. However, I will alert the Minister, Deputy Quinn, to the issue and will facilitate a resolution of this in whatever way I can.

I appreciate that.

Local Authority Offices

I thank the Cathaoirleach for allowing me raise this motion, thank his staff for processing it and the Department for preparing a response. I thank the Minister for Health, Deputy Reilly, for coming to the House to respond on behalf of the Minister for the Environment, Community and Local Government on the need for that Minister to confirm the approval of a loan to Roscommon County Council for the development of new civic offices in Roscommon town and to verify the date the original application was made for this loan, the amount sought and when the application was previously approved. Furthermore, I seek confirmation of when the approval of the loan was made by him as Minister, the amount sought, the terms and conditions and date sanctioned.

For some years, Roscommon County Council has been planning the redevelopment of its offices in Roscommon town, where it needs new centralised civic offices. The preparatory work has been going on some time.

As a former member of Roscommon County Council, I supported the processing of the loan by the previous Government. My colleague, Michael Finneran, who was a Minister of State at the Department of the Environment, Heritage and Local Government at the time was extremely helpful in ensuring approval of Roscommon County Council's application for the loan in order that the work could be carried out. We relocated the fire service to Circular Road in Roscommon town after a site there was made available. We removed temporary prefabricated buildings which had been used by the former Western Health Board. As a result, the site is very compact.

The development of these offices to accommodate approximately 250 staff would result in the centralisation of the services of Roscommon County Council in Roscommon town. In the light of new developments in local government, it is important that we retain that type of facility in Roscommon town to service the county. Roscommon town has had council offices since the 1800s. Roscommon courthouse was the centre for the services and senior staff now have offices there. However, the courthouse needs to be refurbished to facilitate sittings of the District Court, the Circuit Court and the High Court in circuit. The children and family courts are also very important. All of these consultations are taking place in the foyer of the building, which is totally unsatisfactory. The Courts Service will have further additional responsibilities relating to the care of children if the children's rights referendum is passed on 10 November. It is important for proper facilities to be provided, as the existing services are not suitable. The provision of new offices for Roscommon County Council would allow the courthouse to be used exclusively for court services, as originally intended.

We are fortunate to have the headquarters of the Roscommon-Longford division of the Garda Síochána in Roscommon town. We are also extremely fortunate that the General Register Office and the Property Registration Authority have been decentralised to the county town. It has been said there is spare capacity in these buildings. The Garda Síochána is moving some of its facilities to the General Register Office, while the Department of Agriculture, Food and the Marine is moving some of its services to the Property Registration Authority. The Government is ensuring all State services will be combined in suitable buildings. If those buildings are environmentally designed with proper heating and lighting facilities, there will be a reduction in costs in the long term. The council is paying an enormous amount in rent. It would be far more desirable to have these rents put towards a loan. I hope the Minister will be the bearer of good news on this occasion.

This issue has created controversy in Roscommon. Very few country towns would decline a loan to build new civic offices. It is unique. As the Minister knows, we have been campaigning for services at Roscommon County Hospital. In this case, some people are campaigning for a decision to be made to refuse permission for this building to proceed. It is ironic that the Minister is here to deliver good news for the people of Roscommon on this occasion. I am sure they will be waiting with bated breath to hear his response.

I am responding to this Adjournment matter on behalf of my colleague, the Minister for the Environment, Community and Local Government, Deputy Phil Hogan, who is not available. I thank the Senator for raising it.

Local authority office accommodation is a matter, in the first instance, for local authorities. However, they are expected to provide such accommodation in the most cost-effective manner possible, having regard to their needs and resources, a point the Senator has made clearly. In that context, future plans for the council office in Roscommon are a matter for Roscommon County Council, essentially, based on its assessment of the position.

A formal application to borrow €26 million was submitted to the then Department of the Environment, Heritage and Local Government in October 2007. As the Senator pointed out, approval for the loan was granted in April 2008. A revised application to borrow €22 million for the project was submitted in January 2010 and approved on 19 March that year, in accordance with section 106 of the Local Government Act 2001. Sanction was provided subject to the council being satisfied that it was receiving the best possible terms available, making sufficient provision in its annual budgets for the repayment of the loan charges over the repayment period and being satisfied that the financing of the project would not adversely affect the provision of council services during the repayment period. I am sure we would all be very strong on that point.

I am advised that the fragmentation of local authority offices in Roscommon at eight locations, just two of which are fully owned by the county council, causes operational inefficiencies, including the need for staff to spend time delivering files and post and attending meetings at various locations in the town. There are additional indirect hidden costs to the council as a result. I understand issues regarding health and safety, staff welfare, fire safety, disabled access and facilities for the public and elected members have necessitated the extension and refurbishment of the existing headquarters. I understand Roscommon County Council has negotiated a loan of up to €22 million from the Housing Finance Agency over 40 years at a variable interest rate. The Minister for the Environment, Community and Local Government has completed the necessary steps at his end to allow the council to proceed with the work, in accordance with the conditions I have outlined. It is a matter for the council to do so in accordance with the sanction provided.

I thank the Minister for his comprehensive response. When I was chairman of the former Western Health Board, I promoted the development of new offices for the health board in Roscommon at a cost of approximately €5 million. We have since spent €3 million on the rental of inadequate facilities in Roscommon. That this was allowed to happen is an indication of the manner in which the health service was managed at the time. The Minister can consider it in the context of the future development of services and buildings, etc. However, I do not want something similar to happen in the case of Roscommon County Council. I welcome the Government's clear decision to support the project which I hope will proceed.

I concur with the Senator that it does not make sense to rent premises for a prolonged period of time rather than building a new premises. Of course, one has to factor in maintenance costs. Obviously, a new building will require less maintenance than an older one. There will never be a better time to buy because property will never again be as cheap. We have a real opportunity to develop modern, well insulated and low-maintenance buildings heated using renewable energy resources. The Government is glad to support this initiative.

The Seanad adjourned at 7 p.m. until 10.30 a.m. on Thursday, 18 October 2012.