Dáil Éireann díospóireacht -
Tuesday, 31 Jan 1984

Vol. 347 No. 6

Private Members' Business. - General Medical Services: Motion.

Dr. O'Hanlon

I move:

That Dáil Éireann calls on the Government to provide General Medical Services to those between the ages of 16 and 25 years who are dependants of persons who do not have full eligibility for these services.

I am calling on the Government to restore medical services to those between the ages of 16 and 25 years from whom they have removed eligibility for such services. I see the Minister for Health has tabled the following amendment:

To delete all words after "Dáil Éireann" and insert:

"endorses the Government decision to withdraw certain health services from persons aged between 16 and 25 years who are dependants of persons who do not have full eligibility for the services under Part IV of the Health Act, 1970."

Members should be clear when they come to vote that by voting for the Government's amendment they will be voting in favour of withdrawing health services from persons between the ages of 16 and 25.

On 16 December the Minister published the Health Services Regulation No. 3, 1983. Section 2 states:

The services provides under Sections 58 (1), 59 (1), and 67 (1) of the Health Act, 1970, shall not extend to persons between the ages of 16 and 25 who are dependants of persons who do not have full eligibility for the services under part IV of the Health Act, 1970,. . .

The Minister also stated:

These Regulations shall not apply to persons in receipt of an allowance under section 69 (1) of the Health Act, 1970.

This means persons who are in receipt of a disabled person's maintenance allowance. The regulations published by the Minister also stated:

These regulations shall come into operation on the first day of January, 1984.

Even when the regulations were published it should have been obvious they could not come into operation on 1 January 1984 because between 16 December and 1 January there were 15 days including the Christmas period and it would have been impossible for the health boards to notify the persons concerned and the family doctors that they were no longer eligible for services. While students are receiving these notices at the moment, a number of them have not yet had the services removed from them.

In reply to a question in the Dáil on 18 January the Minister stated:

With effect from 1 January 1984 this situation was changed by Regulations to provide that students and other persons between the ages of 16 and 25 who are dependants of their parents and whose parents are not eligible for medical cards will not retain automatic entitlement to medical cards. These persons will retain their eligibility for free hospital services. . .

The Minister went on to say that the regulations do not apply to persons who are in receipt of a disabled person's maintenance allowance or to persons who are entitled to services under EEC regulations.

On this side of the House we are concerned because we believe this decision will cause undue hardship for a large section of the population whose disposable income is already reduced, and much of it reduced as a result of the policies pursued by this Government in the past 14 months. It is the duty of any Minister of Health and any Government to prevent stress in the community. On this occasion the action of the Minister will create stress not alone for the students who find themselves without the right to free medical services but also for their parents, many of whom are struggling to maintain their children in second and third level education.

We are very concerned because of the serious problems it will create for people between the ages of 16 and 25 years, particularly for students living away from home in flats in Dublin, Cork, Galway, Coleraine, Belfast and in other towns where regional colleges are situated. Thirdly, we are concerned because we believe this will put an extra charge on the health services to look after the needs of these people in hospital. Many of them will end up in hospital when they become ill, whereas when they had the right to general medical services they would have been treated by their family doctor, thus avoiding very expensive treatment in hospital.

In my constituency and elsewhere I see families who are maintaining children in third level education but none of them is in a position to pay out money at random. The vast majority are struggling to keep their children in second and third level education. There may be a few millionaires who have no difficulty in paying but they are not the people to whom I am referring. In respect of children in receipt of local authority grants, their parents have to subsidise the grants to maintain their children in "digs" or flats. They will find it very difficult to meet the cost of health care.

The Minister said that those students whose parents have medical cards will retain their right to general medical services but account must be taken of the guidelines with regard to the issue of medical cards. I will give the House a few examples. A man, with a wife and with two children under 16 years with a third child aged 21 years who is at university or a technical college, having a gross income of £126 per week will not get a medical card; but if the guidelines allowed the net income to be considered that man would have a medical card. In the above case, a son or daughter who is a student will not have the benefit of a medical card.

The most serious aspect is the effect it will have on students, particularly those living in flats away from home and this was recognised by Dr. O'Grady, the students' doctor at UCD. He is quoted in the Irish Times of 3 December 1983. Dr. Alan O'Grady, a student doctor in UCD, said he felt a dangerous situation could arise. A youthful student up from the country living on his own in a flat gets ill and has little money. He may not call a doctor and very serious problems could arise. He also said that casualty departments in hospitals could be inundated by students with health problems if the free medical service was withdrawn. He said: “I don't personally think the Minister will be saving much money in any case. It is our experience that only about 10 per cent of students use the service, but it is a crucial 10 per cent.” Those are not the words of a politician on this side of the House trying to score political points. Those are the words of the doctor with a great deal of experience looking after students in the largest centre of third level education. He says very serious problems could arise. We recognise those problems could arise. For example, a student living in a flat who gets pneumonia and has not the money readily available for a doctor will suffer hardship. A student who complains of headaches but has not got the money available to go to a doctor may develop meningitis and find himself with a very serious health problem. This could be the direct result of a decision by this Government to withdraw a basic service from those between the ages of 16 and 25.

The Minister for Health lives in Dún Laoghaire, and the vast majority of students in that area probably live in family homes and so the Minister may not be aware of the problem of the very serious situation facing students from the country who are living in flats in this city or in any other large centre of third level education. There will be problems for those who may find themselves acutely ill. There are 120,000 students from whom the right to general medical services will be withdrawn. It is estimated that in the case of one-third of these the parents are entitled to full eligibility, and that means that approximately 80,000 students will have that right, a right they enjoyed for over 10 years, but a right which will now be withdrawn from them. We are very concerned about the serious consequences that will have not alone on the parents but also on those people of 16 to 25 years of age, and particularly those living in flats.

The Minister talked about saving money. He believes he will save £2.5 million. Basically those in that age group, 16 to 25 years, are the healthiest section of the community. While the national average of visits to the doctor in the health service generally is six per annum the student rate is only two and, as Dr. O'Grady pointed out, only 10 per cent of students avail of the service. It is important to recognise that not alone are these students losing their entitlement to the general medical services and the facility in regard to their family doctor but they are losing their entitlement to the medicines and drugs they may need. They are also losing their entitlement to dental and ophthalmic services. This could have very important consequences for students and for the parents who find themselves confronted with the cost of dental and ophthalmic services as well as of general medical services.

The Minister stated on a number of occasions — indeed he stated it here again last week when speaking on the budget on 26 January — that, and I quote, "The special position of students was an anomaly." Perhaps that is his view. One would not deny that there are anomalies in most of the services administered by the State. What did he do? He removed what he saw as one anomaly and put numerous anomalies back in its place. The first one one would question is, at what age are you no longer a dependant of your parents? Would it be realistic for the Minister to say that if someone of 50 years of age was at home on a farm with his parents he would be a dependant? That would be realistic if he had no income of his own. I believe the constitutionality of declaring someone over 21 years of age a dependant on his parents is something that might be worth looking at.

Another anomaly would be a man with a wife and two children, one 16 years of age and one a student, a student who is married with a wife and a child. He is soley dependent on his father and mother who have no medical card. Is he entitled to a medical card? Will he get a card if he applies for one? Are his parents, who may be on a very low income — perhaps the man we referred to earlier with £126 — obliged to look after the medical needs of not alone their son but his wife and child as well, because he is a dependant of theirs and the regulation refers to a dependent? Also in the regulation, persons on disabled maintenance allowance are excluded but other categories are not excluded, such as the person I mentioned who may be married but is still a dependant on his parents.

Another anomaly, two children of 18 and 19 years of age, one at home in receipt of unemployment assistance and the other a student. One will be eligible even though she will have a small income and she will have a right to the general medical services, but the student away from home will have no such rights even though she has no income whatsoever. Yet another anomaly created by the Government in removing this one anomaly, as they saw it.

Take persons living in a flat. Students from other EEC countries are automatically entitled to general medical services but the students from our own State have no such right. What is the position of students in receipt of unemployment assistance in the summer or at Christmas, when they are not at university? Will these be entitled to medical cards or not? Again, another anomaly created by the Minister because of this decision.

Last week I asked the Minister if a person in receipt of a part-time income while being a student would be entitled to a medical card. The answer I got was:

Students who are dependants of persons who do not have full eligibility for health services no longer have automatic entitlement to medical cards. This obtains whether the students are in part-time employment or not. In any individual case on eligibility for a medical card, due regard will be taken of all the relevant circumstances of that case.

The regulations refer only to dependants. If people are in part-time employment and financing their own way through third level education, I cannot see how they can be considered dependants. When the regulation dealt with one specific exclusion, why did it not deal with that?

In his statement of 16 December and in this House on 26 January when speaking on the budget, the Minister said:

It has also been provided that students will retain their eligibility for free hospital services, both in-patient and out-patient, including the services of hospital consultants.

In other words, all students, irrespective of their parents' incomes' will have limited eligibility entitling them to free hospitalisation, free maintenance, free medical care, both as in-patients and as out-patients in hospital. This creates a further anomaly. A student whose parent might be a millionaire will have full comprehensive medical care in hospital or as an out-patient, while a student of a family with, say, two other children, even though that family's income might be only £125 per week, will have to pay the family doctor and also for the medicines.

To provide full comprehensive hospital services while removing the right to general medical services is contrary to the present day philosophy on health care throughout the world and to the Minister's own commitment to strengthening community care services and transferring resources from hospital to community care. I quote the Minister talking about an examination of the services in this House on last Wednesday.

We will, in the current year, clearly have to give a great deal more thought to the appropriate mix of services between community and the hospital services. Of their nature, the hospital services tend to be very expensive, and while it would be a mistake to consider that in all cases, an appropriate level of community care will necessarily be cheaper to provide. It is obviously desirable that we try to ensure that only those who require the high level of expertise and the technological facilities available in our general hospitals are admitted to them for care. This imposes on us the need critically to examine all the services we are providing within the community, in order to establish how effective these are, how they might be improved and how they can be altered to provide a more effective and efficient health service in general.

He spoke about limiting admissions to hospital, operating day hospitals and providing five-day-week hospital care, all because he recognises the expense of keeping persons in hospital and having persons attend hospitals at present. What does he then do? He withdraws the medical card from students, people living alone in flats in Dublin who if they get ill, as everybody in this House knows, will not have money readily available to attend the family doctor and pay for medicines in the chemist shop.

Mr. Gene Fitzgerald

A neat turn, a U-turn.

Dr. O'Hanlon

Everybody knows that the student will not have the money readily available in his pocket at the present time. The Minister is encouraging those students who need medical care and attention to get up from their sick beds and go to the casualty department of a hospital — as he says himself, the most expensive location for the delivery of health care. The Minister is encouraging those 80,000 students to do this, and a number of them will be admitted, possibly for social reasons because of living alone in a flat with nobody to look after them whereas, if their family doctor was calling to them in their flat on a daily basis they would be able to be maintained outside hospital. The Minister, recognising that problem and the need to transfer resources from hospital care to community care, makes a decision which is the exact reverse of what one would expect any Government to make at the present time.

Mr. Gene Fitzgerald

Any sensible Government, Deputy.

Dr. O'Hanlon

Any sensible Government, but any Government.

An Ceann Comhairle

Deputy Fitzgerald should not interrupt.

Mr. Gene Fitzgerald

I am just helping my colleague.

An Ceann Comhairle

I should not imagine that Deputy O'Hanlon thinks that.

Dr. O'Hanlon

I do not object to Deputy Fitzgerald's interruption, but I would say that any Government, sensible or not, would know the basic fact that it is much more expensive to have people treated in hospital than to have them treated outside. I am surprised that the Minister made that decision and that the Government were a party to that decision. If they felt it necessary to make any change, it should have been in hospital care and certainly not in the general medical services care.

The Minister said that in the event of hardship arising the chief executive officer of the appropriate health board will be empowered to make available the required services without charge. In theory that sounds well, and I have no doubt that there will be cases of students whose parents do not have medical cards and who are suffering from some chronic illness which would create hardship who will be able to apply to the chief executive officer who will allocate a medical card. However, what about the students who become suddenly ill in their flats in the city of Dublin, or Galway, or Cork, or Athlone? How long will it take them to get the chief executive officer of the health board to provide a medical card? It is unreasonable to fool ourselves into thinking that somebody who has become acutely ill and is without the money will merely have to lift the telephone and call the chief executive officer and will have eligibility of services right away. It does not happen like that. We are all aware, from our own experience, that it takes a minimum of three weeks to get a general medical services card and in many cases a lot longer. To suggest that there will be no hardship is absolute nonsense.

In the joint Fine Gael/Labour Programme for Government under the section of health it is stated:

Looking ahead beyond the immediate situation a comprehensive review of all aspects of Health Services will be carried out as a matter of urgency with the objective of ensuring that everyone within the community has adequate medical protection and access to services. A guiding principle of this review will be the extension and development, on a phased basis, of Community Based services to encourage a real switch from institutional to Community Care.

That is exactly the reverse of what the Government have done in this case, because certainly they are not ensuring that everyone in the community will have adequate medical protection and access to service. In fact it is directly the opposite to their commitment. Listen to it again:

. . . community-based services to encourage a real switch from institutional to Community Care.

Here they are encouraging people to institutional care away from community services.

I have received a number of letters on this subject, including one from somebody in University College Cork in which it is stated:

This further cheeseparing exercise of the Coalition has already cost one of our members over £300. It is causing particular hardship for those students living away from home.

I have another letter which questions the administration of assessing students during the Christmas and summer recesses, students who will be applying for medical cards, who will then have them withdrawn, and all of the administration involved. I might quote the last paragraph, which reads as follows:

Everyone is entitled to free hospital care. With the eradication of the student health card scheme, it is obvious that more and more hospital beds will be taken up by students with ailments which could otherwise have been forestalled by early medical treatment. In the long run this could cost the Government far more than £2 million a year.

That is a letter from a students' body in this country. They recognise what the Government fail to recognise but what Dr. O'Grady — and he could be considered to be very independent in all of this — recognises; indeed what we on this side of the House recognise. I do not accept the statement of the Minister that he will save £2.5 million. I say that because students and those in the age group 16 to 25 are very low users of a health service, they are the healthiest section of the population and it is only when they are forced to do so that they will use the service. It is inevitable that parents and students will suffer. Even if there is hardship it is just not possible to provide an immediate medical service under the existing health boards arrangement. It is not possible to provide that sort of service sufficiently rapidly for those students who find themselves acutely ill when they are away from home attending third level establishments.

I would ask the Minister to reverse his decision. Indeed I am glad to say that as recently as 29 November 1983, when I asked a supplementary question of the Minister as follows, at column 407 of the Official Report of that date:

Would the Minister accept that those over 75 years of age are high risk patients, irrespective of income, and should be subject to the same guidelines as apply for those in the younger age groups? Would he not consider that a case could be made at least for raising those guidelines to include the over 75s?

The Minister replied as follows:

I would not accept that on the grounds of utilisation of scarce health resources ...

I am glad to report that some time between then and Wednesday last wisdom descended on the Minister and the Government, because it was announced in the budget that they were changing those guidelines. The Minister himself said in the House that he had arranged accordingly with the health boards that a special age allowance be built into the medical card guidelines. I compliment the Minister, when he saw that he was not right — and it is important to remember that he did withdraw medical cards from the aged this time last year when he first came into office — on having the courage to reverse a decision he recognised as being wrong. I would ask him now to do the same on the question of medical cards for those between the ages of 16 and 25.

In this evening's Evening Herald I see that the Taoiseach was in Trinity College today to address a breakfast meeting of final year business students on the Irish economy. The Students' Union vice-president, Karen O'Connor and Entertainments Officer, Paddy Goodwin — from our constituency, a Ceann Comhairle — met the Taoiseach. It is reported in that paper and I am quoting:

The Taoiseach today promised student representatives at Trinity College that he would consider their reservations about the plan to withdraw medical cards.

It is said, later on in the same article:

Dr. FitzGerald had promised he would pursue their claims and invited them to make a written submission to the Cabinet. . . .

I welcome that decision of the Taoiseach. I believe the Government will recognise that they made a mistake on this occasion and that they will reverse that decision.

I am not going to talk about the Government's social policy and the serious problems it is creating for the whole of our community, not alone with regard to health but with regard to social welfare. For instance, there is the 7 per cent increase in social welfare benefits for six months of the year which represents 3½ per cent for a whole year. That is an indication of their social policy. Then there is the cutback of 4 per cent to the health boards, which will probably cost up to 1,500 jobs. Those are just examples of the Government's commitment to the poorer sections of our community. Then there was the family income supplement, promised in the budget this time last year, repromised at the famous Barretstown Castle meeting of July, that it would be here in December of last year, while we were told on Wednesday last, that it will not now be here in February, March or April but rather we were promised it for November next. They are indications of the social policy of this Government. Therefore it is not surprising they made the decision they did. I would ask them to do what they did when they recognised that they were wrong on the question of the aged in our community, and reverse this decision.

I want to read out again the Government's amendment:

That Dáil Éireann endorses the Government decision to withdraw certain health services from persons aged between 16 and 25 years who are dependants of persons who do not have full eligibility for the services under Part IV of the Health Act, 1970.

That calls on every Member of Dáil Éireann, Fine Gael and Labour, and on us — but we will not accept it — to proceed into the lobbies tomorrow evening to vote to withdraw these medical cards from students. That is what that amendment is seeking. We on this side of the House will be voting against that amendment. Rather we will be voting for our own motion to restore medical cards to those between the ages of 16 and 25 years. We would ask the people on the Government side of the House — those in the Fine Gael and Labour Party who believe this was a wrong decision — on this occasion to come into the lobby along with us. It will not pull down the Government, if they are defeated on it, but it will bring home to the Government that this was a wrong decision and that the majority of Members of Dáil Éireann expect and want the Government to reverse that decision in the interests of those between the ages of 16 and 25 and of their parents who are hard pressed throughout the country.

Minister of State at the Departments of Health and Social Welfare (Mr. Donnellan)

I move amendment No. 1:

To delete all words after "Dáil Éireann" and insert:

"endorses the Government decision to withdraw certain health services from persons aged between 16 and 25 years who are dependants of persons who do not have full eligibility for the services under Part IV of the Health Act, 1970."

Mr. Gene Fitzgerald

The Minister is not serious.

Mr. Donnellan

The Deputy will have an opportunity of speaking himself.

Mr. Gene Fitzgerald

I am listening with great interest to ascertain how he will push this one through.

Mr. Donnellan

It might assist the House in considering the motion before it if I begin by outlining the general principles governing entitlement to general medical services in this country and put them into their historical context. Very broadly, a person who is eligible for these services without charge is required to show that his financial circumstances are such that if he were to provide these services from his own resources, this could cause hardship.

Since about 1850 the State has accepted a responsibility for ensuring that no one is denied access to medical care because of inability to pay for it. The establishment of the dispensary service, which was an enlightened move in its time, ensured that the poor would receive the medical care they needed without payment. On the other hand, it was designed in such a way that persons who could afford to pay the doctor were excluded from its scope.

Just how suited this approach to medical relief was to Irish circumstances is confirmed by the tenacity with which it survived to modern times. When the legal code of the poor law and the medical relief system was replaced by the Public Assistance Act of 1939, the criteria for deciding eligibility for medical services remained unchanged.

During the forties there were demands for a health service free of direct charge to the whole population, including a general practitioner service. In the 1947 and 1953 Health Acts, the Governments of the day responded by providing free hospital care for persons suffering from infectious diseases and by extending general hospital services to the middle income group.

But the 1953 Act made no change in eligibility for dispensary medical services, because the Government accepted that paying for general practitioner care would cause no hardship for the middle and upper income groups. The Act provided a safety net for persons whose doctor or drugs bill was beyond their capacity to pay by permitting health authorities to assist them with the costs.

In 1972 the dispensary system was replaced by the present choice-of-doctor scheme. The new scheme differs from the dispensary system in that it provides a general practitioner service without charge for the poorer sections of the population on the same basis as persons who can afford to engage their doctor privately and pay their private fees. This was a radical change from the system which it replaced. Nevertheless, it retained the two principles which had been part of the system since its beginning:

—that nobody should be denied the general practitioner service because of financial problems, and

—that public funds should not be spent in providing the service without charge for persons who could afford to pay for it from their own resources.

The second of these two principles has attracted considerable attention and comment in recent years. People are beginning to realise that, in some circumstances, money which is spent on the provision of a State service, even though that service is good and useful in itself, may result in resources, to which the poorer sections of society contribute their due share, being used largely for the benefit of their better off countrymen.

In the last few years it became evident that access to the free general practitioner service was being given to persons for whom there would be no hardship in meeting the cost of the service from the resources which were available to them. Many students, particularly those attending third level colleges, belong to families to whom the cost of paying the family doctor is of little consequence. Yet, these students were being given automatic entitlement to medical cards and to a free family doctor service. The criteria of hardship and need were not being applied to this group in the way that they were applied to the rest of the population.

Mr. Hilliard

They are not living with their families.

Mr. Donnellan

Scarce State resources, on which there were increasing demands, were being used to satisfy needs which applicants were quite capable of meeting themselves.

It became clear to many that the automatic granting of medical cards to students was unfair because students were not being judged by the same standards as other persons applying for medical cards and because many students came from privileged homes where meeting the cost of general practitioner charges imposed no strain on family finances. In addition many third level colleges provide medical advice for students without charge, largely at the taxpayer's expense.

On assuming office at the end of 1982, the Minister inherited a position in which the anomalous treatment of the student population in regard to their entitlement to medical cards was already being questioned. A considerable volume of representations were being made pointing to the inequity involved in providing free services for persons, some of whom could not, by any stretch of the imagination, be regarded as being at risk of hardship if the service were not available without charge. Some of these representations came from persons whose own children held medical cards and who could not understand why public money should be spent on doing this.

For a number of reasons, including the limited resources available for health services and the consequent need for a more critical approach to all items of expenditure, the Minister felt that this anomaly justified further investigation. However, in order to allow time to have the implications of any policy change to be fully considered, it was decided to defer action, pending a thorough analysis of all the factors involved. This analysis was undertaken, and it was only when its results became known that the Government decided on their present policy in the matter. Some of the facts which came to light in the course of this analysis, and which influenced the decision taken by the Government, are of interest. The first point is that of the 120,000 students holding medical cards in 1983, it is estimated that less than 30 per cent belonged to families in the lower income group. The majority of students who held medical cards belonged to families in the middle and upper income groups. With public policy coming under increasing criticism for failing to take sufficient account of the distributional effects of social services, it was clear that some action had to be taken to remedy this situation. As a society, it must be one of our primary concerns to distribute resources in favour of the less well off sections of the community. Any movement in the opposite direction must be carefully examined to see whether it is justified on humanitarian grounds. Having identified the anomalous position of students, the Government would have been guilty of seriously neglecting their responsibilities had they not acted to remedy this situation.

The second fact which emerged from the analysis is that the student population, as a group, represents a young and predominantly healthy section of the population. This assertion is borne out by the patterns of usage of the general medical services by different age groups in the population. It has been established that the average usage by young persons over 16 years of age of these services is significantly lower than that of the medical card population as a whole. As an illustration, the number of visits per person to a doctor by persons in the age group to which most of these students belong is less than 2.5 per year. On the other hand the average number of visits per person for the entire medical card population is more than six per year. This demonstrates the relatively low demand from the student population for general medical services and must lead to the conclusion that opposition to the changes introduced is based on an exaggeration of any possible hardship involved.

If we were in a situation in which money was freely available to meet the many stated needs of our people, there would be no problem. Even in the relatively more affluent times which we passed through during the seventies the students' automatic access to the general medical service might have been accepted.

I do not need to remind the House, however, of the tight budgetary situation within which the Government must currently frame their policies. The resources available for public spending are strictly limited. We must face up to this and realise that all demands for public services cannot possibly be met. We must therefore establish priorities and resign ourselves to meeting those needs which are regarded as most urgent, leaving lower priority needs to be fulfilled at some later stage. In this context it is essential that we are clear about the objectives of public spending on social services. We must, at all costs, try to protect the level of services afforded to those sections of the community which are materially least advantaged and we must realise that, in so doing, it will not always be possible to preserve the status quo in relation to the more advantaged sections of the community.

In drawing up the budget for 1984 the Government had considerably less money available to them than was required to meet the legitimate demands on their resources from all areas. When in addition, account was taken of the likely impact of inflation during 1984, it became obvious that, in order to keep expenditure within the general Estimate provision, some economies would have to be made. The health services, as well as other areas of public expenditure, would have to make their contribution to these economies. The Minister was therefore faced with the difficult problem of identifying the potential for savings throughout the health services and deciding on the areas in which cutbacks could be made without imposing undue hardship on any section of the community or without damaging any of the essential services.

I should mention that the imposition of cutbacks on health spending did not begin in 1984. Of necessity, the search for economies in this sector has been an on-going process over recent years, and a number of initiatives aimed at cost containment have been, or are being, implemented. Naturally, the initial thrust of these efforts has concentrated on the elimination of any inefficiencies in the system, and worthwhile savings can be achieved in this manner, up to a point. However, it is also necessary to examine the effectiveness of public spending on health services, and this implies a review of the quantity and quality of services provided, as well as the extent to which services are provided free of charge.

It is anticipated that the withdrawal of these services from some 85,000 students will save in the region of £2½ million in a full year at 1984 costs. While this sum might appear small in contrast to the overall health budget, nevertheless this and other savings are necessary to ensure that other and more essential health services are not reduced or withdrawn.

Other options to achieve savings were, of course, open to the Government. For example, the adjustments to the medical card guidelines might have been less generous. This would, however, have involved a risk of depriving some people of their free access to the general medical service, people who could ill afford to lose their entitlement.

There were other possibilities for savings, but the implications of these were much more serious. Charges might have been introduced for visits to general practitioners in the general medical service, or charges could have been placed on prescribed drugs. A move in this direction would have both produced income and made savings by discouraging the use of the service. Consideration might have been given to the possibility of making cuts in payments to doctors and chemists taking part in the general medical service. The list of items which are excluded from reimbursement under the scheme might have been extended. Moves such as these would have had a major impact on the nature and quality of the service. They would have posed major administrative problems and would have seriously affected the services available to persons least able to afford them.

The implication of the motion now before the House is that the savings which will be yielded by the Government's decision to withdraw eligibility for certain services from students could be compensated for by cut-backs in some other areas. Having examined the options, the Government are satisfied that their decision is the right one, on the grounds of equity and commonsense. The policy for the future will be that, in assessing the eligibility for a medical card of any student who is a dependant of his parents, account will be taken of the financial circumstances of the family. Eligibility will no longer be regarded as automatic. Students will get medical cards if financial circumstances and inability to pay for general practitioner services justify this. This does not single out students for harsh or unfair treatment. Rather it puts them on the same footing as all other members of our society for whom financial circumstances and inability to pay for the service without hardship are the criteria which determine eligibility.

The Government's decision to remove the anomaly of a group of persons having automatic entitlement to free general practitioner services without reference to financial circumstances was implemented by regulations made by the Minister for Health. The general effect of these regulations was that students and other persons aged between 16 and 25 years who are dependent on their parents will retain their medical cards only if their parents have medical card eligibility.

Many of the students in this age group are dependent on parents who are covered by medical cards. There may be 30,000 to 35,000 such students. These students are not affected by the regulations. They do not lose any of their entitlement to health services. They remain eligible for medical cards while their present circumstances continue.

I should stress that, as well as applying to only some of the students in this age group, the regulations apply to only some of the health services for which these students have been eligible. The services which have been withdrawn are the free general practitioner service and free drugs, together with the ophthalmic and aural services. No other services are affected by the provisions of the regulations. This is an aspect of the matter which may be lost to sight, and I would like it to be borne in mind in any objective assessment of what is now being done.

One major service which is not involved in the new arrangements is the hospital service. Students will retain their entitlement to free hospital services. This includes hospital in-patient services and hospital out-patient services without charge. It also includes entitlement to free hospital consultant services. This is a special concession for students. They are entitled to free hospital consultant services without reference to their parents' income. Persons with incomes in excess of £11,000 a year, together with their dependants, are normally not eligible for free hospital consultant services. However, students from these upper income group families, whose medical cards are cancelled under the new arrangements, will retain their entitlement to free hospital consultant services. In terms of expenditure on health services, the hospital service is the area where most of the large bills for health care can arise. Students are fully protected against the risk of such bills.

It has been suggested that some students, in order to avoid paying a fee to their family doctor, would choose instead to go to hospital, thereby placing an extra burden on the hospital service. I doubt if this will happen, because there would be no great advantage in it for the students and this will be apparent to them.

Some concern has been expressed that the withdrawal of students' medical cards might give rise to hardship. This concern was appreciated and the matter was very carefully considered before any action was taken. In framing the regulations, the Minister set out to ensure, beyond all doubt, that no hardship could arise in any case. In order to achieve this, the regulations contain special provision to guard against the danger of hardship. If in the case of any student whose medical card is withdrawn it is clear that the provision of a required service would cause hardship, the chief executive officer of the appropriate health board is empowered to make that service available without charge. Persons who are in receipt of disabled persons' maintenance allowance are also specifically excluded from the terms of the regulations.

These provisions are supported by a number of other factors which I have already mentioned and which also have a bearing on the issue of hardship. The first of these is that students who are at the greatest risk of having financial problems in meeting the cost of general practitioner services are not affected by the arrangements now being made. These are students from the lower income group whose parents are eligible for medical cards. Their medical cards are not being withdrawn and they retain full eligibility for all health services. They form a sizeable part of the total population of these students. Their number is probably in the region of 30,000 to 35,000.

A second factor is that students whose medical cards are being withdrawn lose only some of the services to which they have been entitled. In particular, they do not lose any part of their eligibility for hospital services. This is potentially the most costly part of health care and the one in which serious financial problems can arise. By comparison, general practitioner fees are not of major consequence and students, as well as the rest of the population, are protected against excessive drug cost by the long-term illness scheme and the refund of drugs scheme.

These various safeguards provide a comprehensive insurance that no serious hardship will arise as a result of the adjustment to eligibility which is now being made. If any individual case of hardship does arise the chief executive officer of the relevant health board will deal with the matter as soon as it is brought to his notice. If, despite the safeguards which have been built into the system, the problem of hardship presents itself in a more general way, the Minister will be prepared to take whatever action is necessary to resolve this problem.

There is one other category of persons to whom I would like to refer, that is, students from other countries who are pursuing courses in Irish colleges. Some doubt has been expressed as to whether these students get, or are entitled to get, services on more favourable terms than their Irish colleagues. The position is that students from non-EEC countries do not have automatic entitlement to medical cards and would not normally be eligible for them. However, the hardship provisions would apply and any such student who was unable to provide a service which he required without genuine hardship could have that service made available to him without charge.

Students from other EEC countries, including the United Kingdom, on the other hand, receive their entitlement to health services from EEC legislation. The provision of health services for these students remains the responsibility of their home country. The Irish health authorities act as agents for these countries in providing health services for the students while they are resident in Ireland. They receive the full range of Irish health services but at the expense of their home country. There are no Irish public funds involved. Costs are reimbursed by way of special reciprocal agreements between the countries of the Community.

Arrangements are now being made to put the new provisions into effect in a uniform way throughout the country. Accordingly, meetings have been held between officials of the Department of Health and representatives of the health boards in order to draw up standard procedures to implement the new arrangements. Steps are now being taken by the health boards to write to all students informing them of these arrangements. There will be a form enclosed with every letter that is issued. This is a standard form of application to retain the medical card. The purpose of the form is to enable students to whom the regulations do not apply to retain their medical cards. If any student wishes to retain a medical card on valid grounds, then that student should complete the application form and sent it back to the health board.

Of necessity, these arrangements will take some time to complete. Students will be given time in which to re-apply for medical cards. Decisions will have to be made on these applications. Doctors will have to be informed of any changes being made. As of now, no student has yet had his medical card withdrawn because of these new arrangements.

If I may summarise, the most important point is that the principle on which the general medical services is based, that nobody should be denied access to the general practitioner service because of inability to pay for that service, is being preserved. Every person in the State has access to the family doctor service when it is needed. Any person who is unable to pay for this service for himself and his dependants, without incurring hardship, is entitled to avail of the service as made available by the State. There can be no argument about upholding this principle. It is not in question now and any changes which are now being made have built-in safeguards to ensure that it is preserved.

Mr. Gene Fitzgerald

How do we know that? What criteria will be laid down for the students?

Mr. Donnellan

I have quoted many of them to the House already.

Mr. Gene Fitzgerald

There is nothing in this.

Mr. Donnellan

The Deputy did not listen to what I said.

An Leas-Cheann Comhairle

There must be no interruptions.

Mr. Donnellan

Where disagreement can arise, and has arisen, is on the question of equity in the State's financing of public services. The principle involved here is that expenditure on the provision of public services should not work in a way which results in money, to which the poorer sections of society contribute their due share, being used to pay for services which could be well afforded by the more well-to-do sections of the community. If we accept this principle, then we could not argue against the changes now being made under which the financial circumstances of their parents will be taken into account in assessing the eligibility of students for medical cards.

Mr. Gene Fitzgerald

Do the parents have to pay for the medical card? Let us be straightforward. We have had enough bluff.

An Leas-Cheann Comhairle

Please Deputy Fitzgerald.

Mr. Donnellan

When, in addition, account is taken of the present financial climate and the non-availability of sufficient money to enable all the undertakings which are considered desirable to be tackled, the case for adjusting the eligibility of students for medical cards is compelling.

Mr. Gene Fitzgerald

Do the parents have to pay for the medical card?

An Leas-Cheann Comhairle

The Minister has one minute left.

Mr. Donnellan

I hope to finish in one minute.

Mr. Gene Fitzgerald

What does the Minister mean by a strict limit?

Mr. P. Gallagher

What about the middle income group?

Mr. Donnellan

If we accept, as we must, that there is a strict limit to the amount of money that can be made available for public services, then it follows that priorities must be established between programmes and services and choices made which favour those with relatively higher priorities.

Of course, it is easier to designate, and act on, priorities when a choice has to be made between proposed new services. It is much more difficult to curtail or discontinue an existing service, one to which the recipients have become accustomed and have accepted as their right. This has happened in the case of the students. If we were now starting from the position that students did not have automatic entitlement to medical cards, and if we were dealing with a proposal that this should be given to them, the arguments against doing this would be more acceptable. Such a proposal would attract very little support and the chances of its being successful would be very slim. We are, however, starting from the position that students have enjoyed this concession for some time and its automatic nature is now being discontinued. It is natural that there should be some sympathy for the students who are losing something which they had come to accept without question.

This, however is an emotional response and does not have any regard to the merits and demerits of the position as it obtains and of the reasons why changes are now considered necessary.

Mr. Gene Fitzgerald

It is a very understandable response.

An Leas-Cheann Comhairle

The Minister must conclude.

Mrs. O'Rourke

I notice that the Minister of State did not protest too much at being told to sit down. His heart was not in what he was reading.

Mr. Donnellan

I would like to have finished if I had been allowed to.

Mr. Gene Fitzgerald

The Minister is more vociferous now than he was when he was standing up.

Mrs. O'Rourke

Let me say——

Mr. Donnellan

If I had contained——

Mrs. O'Rourke

——that the Minister was surprisingly inarticulate and unemotional and, with respect to whomsoever writes those long dull speeches that are delivered here——

Mr. Donnellan

I was referring to the facts of the situation.

Mrs. O'Rourke

Will you please shut up?

Mr. Donnellan

I will not.

Mrs. O'Rourke

At the beginning of his speech the Minister said:

Many students, particularly those attending third level colleges, belong to families to whom the cost of paying the family doctor is of little consequence.

Later in his speech he stated:

Many of the students in this age group are dependent on parents who are covered by medical cards.

This is from the same script writer. From time to time Homer nods and somebody certainly nodded here.

I second this motion which states as follows:

"That Dáil Éireann calls on the Government to provide General Medical Services to those between the ages of 16 and 25 years who are dependents of persons who do not have full eligibility for these services."

This is the motion of which the House and the country are asked to take notice, yet the amendment calls on us to follow the Government line in withdrawing medical cards from young people.

I wish to deal with this in the context of the various cut-backs which have been imposed on young people since this Government came into power. I do not think this is all the idea of one party, since the Coalition parties set out with a joint programme for Government which did not say anything about taking away medical cards from young people or the cut-backs which have been imposed on those attending third level colleges.

(Interruptions)

Mrs. O'Rourke

The Minister could not raise his eyes from his very lengthy script but now he has suddenly found his voice. In the past 12 months we have seen the imposition of school transport charges, cut-backs in relation to guidance and remedical teachers, savage increases in third level fees, increases in examination fees, the two-honour requirement imposed without consultation on students wishing to avail of VEC scholarship grants and now the latest, the student loan scheme. This country is anti-youth and anti-anything which will help the progress of young people. There is a very subtle attempt to imbue young people and their parents with a sense of guilt because they are costing the State so much. In one breath we say that our young people are our greatest resource, yet we are told throughout this sanctimonious, smug, stupid speech that the cost of a doctor is nothing to parents nowadays. It is degrading to us and to young people to have to listen to this sort of thing.

A scant 14 months ago in November 1982 the Labour Party manifesto stated that Labour rejects utterly any policy that makes the poor, the unemployed, the sick, the homeless and the young bear the brunt of corrective measures. The manifesto further stated that Labour government would oppose any cuts in health, education or security.

Dr. Ormonde

That from the conscience of the Coalition, the Labour Party.

Mrs. O'Rourke

The Tánaiste visited the students in Trinity College on 24 November to woo the young people and stated:

We will not tolerate cuts in essential public services but above all we will not tolerate cuts in health, in education and in welfare.

Mr. Gene Fitzgerald

Where is the credibility now? Where is the long lost soul of the Labour Party?

An Leas-Cheann Comhairle

Deputy O'Rourke to continue.

Mr. Donnellan

Deputies opposite should read The Boss.

(Interruptions.)

Mrs. O'Rourke

When I hear various spokesmen on radio talking about what they observe of the morality of Ireland today and the actions of people in public life, I wonder how they can stand over what they are doing to the young people.

Dr. Ormonde

All this from a Labour Minister for Health.

Mr. Gene Fitzgerald

Where is he?

Mrs. O'Rourke

The Minister of State told us how infrequently young people use the medical card and that argument proves our case. The precise statistic is 1.1 for the number of times a student would visit a doctor in a year, while 6.4 visits is the average for an adult holder of a medical card. The very argument which the Minister used is the one we would use in support of our case for the retention of medical cards for young people. If they will not be used very often, why take them away? The doctor in charge of medical services at UCD has said that the 10 per cent of students who use medical cards are those who will experience hardship. In Dublin the only student who will be refused a medical card is the Irish student from the 26 Counties. Is there not something ridiculous about a situation wherein a boy or girl from Germany, Northern Ireland or any EEC country can come here and avail of full medical facilities while the Irish girl or boy is not allowed the use of a medical card?

Mr. Donnellan

The Deputy has got it wrong.

Mrs. O'Rourke

I will now deal with some of the social repercussions. We all know that there has been a massive assault on the problem of drug taking and I applaud the Government on their initiative on setting up a sub-committee of Ministers and experts to consider this problem. I read recently of the importance of young people developing a rapport with a medical practitioner in whom they can confide any worries or leanings towards a dependency on drugs or alcohol. That facility whereby young persons can visit a doctor of their choice will now be taken from them. I do not know the ages of the Minister's children. For a parent living down the country whose son or daughter is a student in Dublin, Galway, Athlone, or wherever, there is a feeling of security when they know their child can visit a doctor if he or she feels ill. Very often these young people are living in digs or flats without any parental guidance. When the Minister spoke about parents to whom the calling of a doctor was of no consequence he showed he had no conception of what it means to send a boy or girl to third level education. I cannot understand how the Minister could accept the pap he was fed in his speech or that he could deliver it without it sticking in his gullet. Any parent who has children going to third level education knows that it is a struggle all the way. It is a struggle to get points, to gain entry and pay fees which are rising dramatically every month. They must be kept and must have pocket money.

(Interruptions.)

Mrs. O'Rourke

I never heckled the Minister while I listened to his boring speech and the least he might do is give me an opportunity to have my speech heard. The Minister showed that he was out of touch with young people when he said that to send young people to college was a matter of no consequence. There are commitments all the way. Whether a student has a county council scholarship, which has not been increased for some years, or a VEC scholarship at a maximum of £1,000 plus fees, it goes nowhere near their upkeep in a third level institution. Add to that the other charges which parents have to bear and we see that their disposable income is really reduced. We have increased ESB charges, local authority charges and higher rents.

This is an attempt by the Government to put something over on what they think will be a docile audience because many of them do not have votes or are registered in a constituency outside of the one in which their college is located. Leaving aside the question of votes how can the Minister say this will not impose any hardship?

Mr. Gene Fitzgerald

He was told to say that.

Mrs. O'Rourke

The Minister will come in here tomorrow.

Mr. Donnellan

Repeat that please.

Mr. Gene Fitzgerald

His Minister told him to say that. Is the Minister not listening?

Mrs. O'Rourke

It is a fairy tale. They did not get their facts right.

Mr. Donnellan

I thought I heard the Deputy make some remark of relevance.

Mrs. O'Rourke

The Minister will come in tomorrow and be very smug and suave. There is a saying "poacher turned gamekeeper". The Minister is the greatest gamekeeper of them all. It was a Labour Party motion which brought down the Government in November 1982. It was a motion condemning the health cuts imposed by the Fianna Fáil Government. I went to the Library today and took out the Dáil reports for those two days. They make such interesting reading. The serried ranks of Fine Gael and Labour amid several interruptions — far more than the gentle little nice help-ons I got here — screamed and roared at the Government that they could not allow the country to be dragged down the path of these dreadful health cuts imposed by the dreadful Minister, Deputy Woods.

Mr. Gene Fitzgerald

A great U-turn.

Mrs. O'Rourke

Here we have the same smug people and the media machine they organised among their own party — I am not talking about the newspapers but——

Mr. Gene Fitzgerald

The propaganda machine.

Mrs. O'Rourke

This machine will portray them as a caring, concerned Government. They have come together with the national youth council and various other bodies representing young people. This was to bring them the voice of young people because the Taoiseach said he wanted to hear their views on all matters of priority. The Taoiseach heard it this morning at Trinity College where he went for breakfast.

Mr. Gene Fitzgerald

More egg.

Mrs. O'Rourke

While he was there he met the students' group. In a very correct fashion they told him that the withdrawal of the medical card would affect them as young people. The Taoiseach promised them that he would go back to the Government and ask them to look again at the issue. If the students would deliver a written brief to him he would bring it to the Cabinet table. I hope the student representative group will do so immediately.

This Government, who desperately wish to have the ear of the young people, have certainly got their ear right now. The voice of the young people is saying: leave the medical card with young people. They do not use them unnecessarily. No young person runs to a doctor at the drop of a hat. They are more interested in going to their lectures, attending games and so on. When they need to use it they need it badly and it should be left to them. The Minister said that many third level colleges had resident doctors or medical aid which students could have recourse to and that this was supplied at the taxpayers' expense. I come from a town where there is a regional technical college catering for 1,000 students. They have no medical aid of any kind. I have been assured by the student bodies in various schools of technology in Dublin that they do not have a medical representative in their colleges. What they depend on is the help and goodwill of some member of a faculty and a good first aid box.

I am glad that the Minister with responsibility for Women's Affairs has come into the House because the worry of this is borne by the mothers of rural students. Every possible support should be given to students but the Government, who in recent days have shown their strong anti-youth bias, will withdraw medical cards from young people aged between 16 and 24 years.

Debate adjourned.