Is that agreed?
Health (Amendment) Bill, 1991: Committee Stage.
Question proposed: "That section 1 stand part of the Bill."
On section 1, Sir, as you will see from the list, I have tabled an amendment but your office has just communicated to me that it is deemed not relevant. In this respect I seek your advice. I would like to raise the substance of that amendment at this point.
The Deputy would be entitled to comment briefly on the relevance of my ruling in that regard but he may not move the amendment. It is out of order.
Can I discuss the reasoning for the amendment I tabled to section 1?
You may comment on it, Deputy, no more.
Not on your ruling. The purpose of my amendment which you feel is not within the remit of this Bill is to develop the idea of a patients' charter which was integral to the Programme for Economic and Social Progress, and the Government under this legislation are implementing the main eligibility changes. It is very important that such a charter would have a legal underpinning, and I think this is the opportunity, when the Health Act, 1970 is being amended, for the Minister to develop such a charter. It is important that a charter have legal underpinning because without such underpinning you cannot impose an obligation on the health boards and the different health agencies to make every reasonable effort to fulfil that charter. Equally it is important that a patients' charter have provision for review of the progress on the charter and statutory provision for action to be taken where shortcomings are found in the execution of that charter. In Ireland we have a system of health services which have no quality guarantees, and we need to enshrine such guarantees in law. This is an opportunity we will not get again, I fear, for several years to put in some clear, defined health targets and guarantees to patients. The present situation is that patients do not even have open access to their own medical records which I think is a fundamental right that should be on any patients' charter. My experience, and I am sure the Minister will confirm this, is that patients' complaints are typically being left unanswered by hospital authorities and even by his own Department. Recently I tabled questions to the Minister seeking to know the number of complaints and whether they had been dealt with. While the Minister furnished me figures on some odd thousands of complaints that had been furnished to his Department, he did not reply on the issue of how those complaints had been resolved or whether they have been resolved. I think that is a fundamental problem. There should be the right for patients, without having to go into the courts, that hospital authorities and the Minister account for all that has happened. That is why it is so important that we have a charter in respect of patients' rights.
I hesitate to interrupt the Deputy, but the amendment to which he refers and which has been deemed out of order by me is in connection with section 2 of the Bill.
No, it is before section 2.
Deputy Bruton's No. 1 amendment is before me on section 2. I have asked earlier if section 1 is agreed. The Deputy spoke on it. I thought his amendment was in relation to section 1 but it is not.
I wanted your guidance, Sir.
We must proceed properly.
I wanted your guidance——
Can we proceed properly? Is section 1 agreed to?
Question put and agreed to.
Amendment No. 1 not moved.
SECTION 2.
Question proposed: "That section 2 stand part of the Bill."
I indicated to Deputy Bruton that he could comment briefly as to why his amendment was ruled out of order. I am not obliged to give reasons but I will give a reason for this. It is clear to me that amendments Nos. 1, 8 and 9 must be adjudged out of order as they are not relevant to the provisions of the Bill as read a Second Time. Deputy Richard Bruton's amendment seeks to provide for a charter of patients' rights. That is outside the scope of the Bill. Amendment No. 8 seeks to make health contributions tax deductible, and amendment No. 9 deals with the issue of reception of patients into psychiatric centres. The Bill deals only with two issues, eligibility for hospital services and the abolition of the income limit for health contributions. Therefore, all three amendments are not relevant to the provisions of the Bill and are more appropriate to other legislation. That is the position. The Deputy may comment on my ruling but let us not waste unnecessary time on these matters.
The Title of the Bill reads that this is "An Act to amend and extend the Health Act, 1970, and the Health Contributions Act, 1979, and to provide for related matters." I would have thought that if the Health Bill is being discussed in the House we would be given the opportunity to discuss the proposal in my amendment in relation to a patients' charter, an integral part of the package announced by the Minister to which the Bill will give legislative force.
Having read the amendments, I totally accept your ruling, a Cheann Comhairle. The reason we put down these amendments is that we referred to these matters on Second Stage and hoped that the Minister would have agreed with the arguments for a patients charter which was recommended by one of the expert committees set up by the Minister. The point has been well made by Deputy Bruton and I repeat that the Minister has lost the opportunity to include such a provision in this legislation. Admittedly, there is no reference to a charter of patients' rights in the Bill as passed on Second Stage, which has led to the Ceann Comhairle's ruling, which is correct, but the Minister has the opportunity to put down an amendment on Report Stage to include such a provision in the legislation. I ask the Minister between now and Report Stage — which may be difficult because of the guillotine motion — to avail of the facilities at his disposal to introduce an amendment along these lines which would take into account the concerns expressed by us on Committee Stage and by those people who have made various recommendations to him, some of which he has included in the Bill.
I too regret very much that this amendment has been ruled out of order. I am not questioning your ruling, a Cheann Comhairle, but I had hoped that at some stage the Minister would have considered the rights of patients. At times the Minister can sound like Ben Dunne with his value for money principle. However, it is more important to ensure that patients are getting the service they deserve. Many patients who are paying their health contributions and those who have medical cards are being refused the health services to which they are legally entitled. Surely any good Minister would introduce a provision which would ensure that patients, the most important element of our health services, are protected.
At present patients who need surgery are being told — I am not going to labour this point — they may have to wait for up to three years for surgery but that if they have the money they can get the surgery done privately. The Minister, if he has any sense of responsibility, should protect the public from that type of touting for business which is going on at present in our health services. It is in the interests of some consultants to ensure that the long waiting lists are maintained because they gain from them. Surely the first priority of any good Minister would be to protect the rights of patients. People who need urgent surgery are being told in a subtle and polished way that if they can pay the money they will get the surgery. I have raised this issue in the House before but the Minister has taken no action on it——
I have to dissuade the Deputy from proceeding along lines which I believe are more appropriate to a Second Reading of the Bill. We are now on Committee Stage of the Bill and the question has been proposed in respect of section 2.
I regret very much that there is no reference to the rights of patients in this legislation. I want to give another example, and I will finish on this point. People in the social welfare area who require medical certification of their condition are being refused certification by some consultants who think it is above them to write such letters for their patients. Surely a patient has rights when he is dealing with a Government agency who can affect his income and his family life. As I have said, I regret that there is no reference to patients' rights in this legislation. The Bill is merely a value for money exercise.
Section 2 proposes to amend section 45 (1) of the 1970 Act which provides that:
A person in either of the following categories shall have full eligibility for the services under this Part——
(a) adult persons unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their dependants, ....
Section 2 of the Bill proposes to amend section 45 (1) of the 1970 Act by the inclusion of the words "who is ordinarily resident in the State" and section 45 (7) by the inclusion of the words "or who is not ordinarily resident in the State". I should like the Minister to spell out for me what this means. Does it mean that a person who emigrated for a number of years and who returns home will not qualify for services?
Like Deputies Bruton and Allen, I regret that amendment No. 1 has been ruled out of order. I think it reflects a certain frustration at the way Second Stage was dealt with in the House. Only two and a half hours was allocated for the Second Stage debate and I and many other Deputies who would have liked to broaden the debate did not get the opportunity to do so. I merely want to put that point on the record.
I want to refer to the table in section 2 which provides that adult persons unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their dependants shall have full eligibility for the services under Part IV of the 1970 Act. On Second Stage the Minister introduced the concept of equalising the determining factor for eligibility for medical cards. The frontline of our medical services should be the ability of someone to be able to contact their GP without undue financial hardship. If this service was liberalised — I am not sure whether the Minister's equalisation is liberalisation — the cost on the health services would be much less because people would be in a position to go to their doctor without undue financial hardship and be treated rather than waiting until they need hospitalisation. I am concerned that there are cases of real hardship because of the manner this clause operates. If it is appropriate I will give one or two examples.
One of my constituents who lives in the Eastern Health Board area is deaf and dumb. He works in sheltered employment and his income is slightly in excess of the limits as laid down by the Eastern Health Board for a medical card. Had the health board taken into account the cost of his board and lodgings he would be in receipt of less than half the eligibility limit. That person has been refused a medical card. I appealed that decision and produced medical evidence. Yesterday morning the health board communicated that they considered him excluded under the Act. I am hoping the provisions of this Bill will take into account hardship cases. This man is unable to explain his position to an investigating officer because he is deaf and dumb. He is able to work and cook but is unable to write out his problem. The person in question is under medication. I will give the Minister the letter from the health board and the name of the applicant whom I consider to be a genuine case. His case was brought to the attention of other Ministers also as the person in question is involved nationally with organisations for the deaf and dumb.
I put down a question to the Minister on the subject of medical cards some time ago and it transpires that the number of medical cards is falling because of the Minister's new arrangements with the GPs which is referred to in the table. There is now a different system of payment of GPs. In borderline cases health boards consider they should withdraw medical cards even though people are £1 or £2 over the limit. This has led to a fall in the number of qualified people under the provisions of the section.
In the Eastern Health Board region the number of medical card holders has fallen from 364,900 to 351,000; in the Midland Health Board region the number has fallen from 81,000; in the Mid-Western Health Board region it has fallen from 102,000 to 101,000; in the North Western Health Board area it has fallen from 99,000 to 98,000; in the South Eastern Health Board region it has fallen from 142,000 to 140,000; in the Southern Health Board region it has fallen from 180,000 to 173,000 and in the Western Health Board it has fallen from 163,000 to 160,000. The Minister's explanation was that people had died and that, when the procedures were tightened up he took out the cards for persons who had died. I am talking about legitimate applications for people who need medical cards. The number of medical cards has fallen dramatically since 1988. The figures I quoted were given to me in reply to a parliamentary question and I will give a copy of it to the Minister.
This problem should be addressed nationwide because there appears to be different interpretations — not in the guidelines— by health board officials or chief executives who have the final say in regard to cases of hardship, medical and otherwise. I would like the guidelines included in a regulation so that we could all interpret them before making representations on behalf of these people. The bureaucracy involved in means testing for medical cards is a tremendous waste of public money and leads to friction between patients, investigating officers and public representatives who try to reflect the views of their constituents. We have to bare the souls of our constituents before we can convince health boards they are genuine cases of hardship.
I am aware that health boards have been liberal in the case of terminal illnesses and that is appropriate. However, they are very difficult when interpreting transfer orders of property and otherwise for people who qualify for non-contributory pensions. If there is a clause in such orders to the effect that the applicant will look after a father or mother because they have managed to maintain him and his family, it is interpreted by the health boards as being responsible for their medical condition now and in the future. If the Minister's regulations were on the table we would see whether he intends to address this major problem. If we could get as many people as possible to see their GP that would be the cheapest possible form of medical care. It would cut down the cost of hospitalisation and would be a service to the community to which the Minister said he is committed.
First, I accept the Chair's ruling on the patients' charter. It is not appropriate to this Bill. Deputies are aware that in the Programme for Economic and Social Progress my commitment and that of the Government and the social partners to a patients' charter is set out very clearly.
Will it have legal force?
In reply to Deputy Bruton I will quote from paragraph 55 of section IV of the Programme for Economic and Social Progress which states:
The Government recognise the central position of the patient in all aspects of the organisation and delivery of health care. To this end, a "Patients' Charter" is being developed which will be based upon the following principles:
—the right of access to services in accordance with need;
—the right to considerate and respectful care;
—the right to privacy;
—the right to information;
—the right to confidentiality of all medical records;
—the right to refuse to participate in research projects;
—the right to respect for religious and philosophical beliefs; and
—the right to make a complaint.
That is a very comprehensive charter. I should like to say to Deputy Allen that it recognises the central position of the patient in all aspects of the organisation and delivery of health care.
That has no status outside this House.
I am answering the points made by Deputy Allen.
The Minister should bring it into the House; it has no status.
Let us have an orderly debate. This is a Committee Stage debate. The Deputy may rise as often as he wishes but in the meantime he will listen with respect and courtesy to the other Members' point of view.
I am sorry.
I would also like to inform the House that we are developing that charter and, indeed, some of the points have been put in place in a number of hospitals. In two weeks' time I will be launching the Kennedy report which includes some of the recommendations for a patients' charter. We will ensure that they are implemented after that. In relation to the point raised by Deputy Allen about what patients are being told subtly when they go along to a consultant, to have private care, I would be glad to have the information on any of those cases from the Deputy.
The Minister received it before.
I take a serious view if, as Deputy Allen suggests, patients are being manipulated to accept private care when public care is available to them, depending on their particular need. It is only right to respond to the point Deputy Allen made about value for money. In the patients' charter the prime position in the health services is for the patient. I do not think it is wrong that there should be value for money.
It appears that a fundamental difference is developing between the Government and Fine Gael in relation to the health services and the public services generally. Yesterday I referred to the fact that the Fine Gael spokesperson in the Seanad had stated that so far as he was concerned he wanted a comprehensive education service and a comprehensive health service and did not want the books balanced at the end of the year if that impinged on an open cheque for either the health services or education. We have to be prudent in management. Indeed, many of our problems in the public service generally are as a result of that sort of open cheque approach which, apparently, Deputy Allen recommended here during the years 1980 to 1986.
It is important that we look at opportunities to get value for money. If we save on energy on the health service it does not inconvenience patients and the money saved can be spent in areas of greater priority.
I would be pleased to raise with the health board the case mentioned by Deputy Ferris and I will contact the Deputy in relation to the matter.
It is the responsibility of the chief executive officers of health boards to draw up guidelines for medical cards. We are putting in place a medical cards appeal system and are in the process of appointing appeals officers to each of the health boards. There is nothing to preclude them from looking at appeals on eligibility. It might have been implied in what Deputy Ferris said that there should be a more strict legal definition of who is entitled to a medical card. There was a proposal that there should be statutory guidelines but I am not in favour of that because there should be flexibility in the system to cater for people who may suffer hardship while being above the guidelines. Such people must be entitled to service on the basis of hardship. Health boards have accepted that they will not take into account the family income supplement or income under the social employment scheme when assessing eligibility for medical cards.
Section 2 provides for the amendment of section 45 of the 1970 Health Act to specify that a person be ordinarily resident within the State to have full eligibility. Section 2 (b) amends section 45 (7) of the Act to provide that where a person is ineligible on the grounds of not being ordinarily resident in the State, the chief executive of the relevant health board may still give the person eligibility for necessary services on hardship grounds. It is standard practice in other countries to use residency as the primary criterion in determining eligibility for health services. In Ireland the chief executive officers of health boards have the authority under the 1970 Health Act to determine a person's eligibility for health services and they have evolved a similar policy. Those deemed to be normally resident here are entitled either to full eligibility or to limited eligibility, depending on their income. Those deemed not to be normally resident here would not, of course, be denied necessary care but they would be liable for the cost of providing it.
The fact that there is no statutory basis for the operation of the residency qualification has given rise to the difficulty that there are varying interpretations between one health board and another or even from case to case as to when somebody should be regarded as resident here. This difficulty was highlighted by the Commission on Health Funding. It can be resolved by having uniform criteria and this is best achieved by having a statutory basis for the residency qualification. I can then issue guidelines to ensure that uniform criteria are applied. Deputy Sherlock sought further clarification on this matter this morning and yesterday on Second Stage.
The guidelines I intend to issue will incorporate the current practice to ensure that where there is evidence that a person intends to establish a permanent residence here that person will be regarded as eligible for health services immediately. Discussions will take place between my Department and the health boards on the problem of the interpretation of residency. It is my intention that anybody with a reasonable case will be regarded as eligible for health services here. The guidelines, which I will issue following discussions with the health boards, will be available to an appeals officer appointed by me to hear, appeals in relation to decisions on eligibility taken by a chief executive officer. These guidelines will assist in determining whether a person is normally resident in the State for the purposes of eligibility for health services.
I am happy that the Minister has made a commitment to a patients charter but we want that commitment underpinned by legislation. The experience in any country which has charters for the disabled for some other category is that agencies will not act unless there is a legal obligation on them to make every reasonable effort to honour the terms of the charter. The Minister talking about the charter and what he would like it to contain will not bring about major change in practice. We need to see a dramatic change in the way people address their problems. There are major gaps in what the Minister is advocating by way of a charter. He does not include the notion that there should be a maximum waiting time and that there is a point beyond which nobody should be asked to wait for treatment, either in hospital or in the community care area. The Minister is aware that many people who are handicapped are waiting for residential care and that people are waiting for unacceptably long periods for surgery. We want a charter which will set targets that the agencies will be expected to make reasonable efforts to achieve. It must be legally underpinned.
I now refer to the accident and emergency departments in hospitals. A short spell of cold weather can succeed in sending these departments into a tailspin. Patients are not being treated with the care which would be expected under any charter. This problem must be addressed and the Minister cannot deal with it by pretending it does not exist. Consultants must give this problem the importance it deserves. In some cases hospitals have not geared themselves to give accident and emergency departments the attention they deserve. The only way to tackle the problem is by underpinning the position in a legal way by means of a charter. If any hospital or health board is found wanting, we must have a legal charter to which we can refer and to the terms of which they can be held accountable.
It is frustrating that there are no quality guarantees and in many cases there are no targets for health agencies. Voluntary groups to which I have spoken feel they are not acting to a plan and that there are not targets by which different health agencies will be judged. This is an opportunity to set about bringing in these targets, particularly in the area of community care. People should know they have a right to expect a certain level of care and that the health agencies are expected to provide it. We know the resources will not be there for everything, but any such charter must provide that reasonable efforts be made to achieve targets. This is the yardstick against which agencies must be judged.
It is rather late for the Minister to frame an amendment to bring in regulations by way of a patients' charter but a simple enabling section would be an improvement to the Bill. If the Minister objects to specific elements of what I have proposed, we can talk about that. The principle must be accepted that patients are legally in the driving seat. They are the people towards whom all our efforts are directed.
The last point I want briefly to refer to is the provision relating to people who are not ordinarily resident in this country and are deemed ineligible for this service. I presume the Minister is trying to protect us against the position where people would come here solely for the purpose of getting medical treatment. I take it that the provision in section 9 honours all our EC commitments to visitors and that we are not going to back out of any of those commitments. I presume the regulations will provide that if a tourist from a non-EC country has an accident in Ireland he will not find himself in the position that prevails in other countries whereby he would have a struggle on to a plane to get back to his own country so that he would not be exposed to very high health costs. As a country that welcomes tourists we should not enshrine in our legislation anything as draconian as that. We need an assurance from the Minister that bona fide tourists who have an accident on the roads here are not denied health care. It is reasonable that we should afford care to these people when we make such efforts to invite them here to enjoy the benefits of our country.
I welcome the Minister's announcement today in the House that he intends to initiate a patients' charter. Although it had been mentioned in the programme, the fact that it has been mentioned in the House will allow us to occasionally ask on the Order of Business when the Minister intends to implement it. I would like to know — this matter has been referred to by Deputy Bruton — if this charter will have any legal basis. Will it be launched outside the House, and, if so, does the Minister think that is the correct way to approach something that is fundamental to all of us? We should be given an opportunity to debate the contents of the charter. By the voting strength of the Government, the Minister would be able to put through whatever charter he feels is appropriate. A discussion would enable us to raise some of the other matters that have already been mentioned. This Bill amends the 1970 Act. I would like to know if a further Bill will be introduced to implement the charter or if it will be announced by way of regulation under the 1970 Act. Are there provisions in that Act which would allow for the setting up of a charter of patients' rights?
As regards tourists and others coming here from outside the State, I am concerned that some of them, particularly from Britain, where most people are entitled to free health services, will not enjoy the same privilege when they come to Ireland. When people move to this country on retirement, they lose their right to a medical card. I am concerned that we are setting up a regime that will not comply with EC regulations and that will not provide the facilities that people enjoy elsewhere. I hope that is not the case. We, as part of the European Community, should provide health care facilities similar to those provided in other EC countries.
If a tourist is considered to be not normally resident in this State, as defined in this section, and is liable for their own hospital care following an accident, by the time the matter is decided the person may have left the State and the money cannot be recouped. If on appeal it is decided that an account is legitimately due and the person owing the money is by then outside the jurisdication, particularly the European jurisdiction, there is no way of getting that money. This matter should be teased out. We support the Minister in what he is doing, but we would like the matter explained further so that if and when we are queried about it we will be able to give a valid answer.
I welcome the Minister's announcement that he intends to introduce a patients' charter. It is something that is long overdue. I am glad the points raised by people on all sides about patients' rights have been accepted by the Minister. The aspirations in the programme as agreed by the social partners are as worthless as a Fianna Fáil manifesto unless they are underpinned by decisions of this House.
I would ask the Minister to clarify the position as regards the rights of medical card holders. What are their liabilities on a stay in hospital of over 30 days? Health boards have different interpretations of that rule. I read very clearly the statement by the Minister, Deputy Flood, in the House in February and again last week. What he has said is at variance with what has been said on other occasions. Some medical card holders in receipt of a State pension who have to stay in hospital for more than 30 days are obliged to pay the major part of their pension to the health board. That discriminates against medical card holders. If a person is a category 2 patient he pays a maximum of £125 but a medical card holder who is treated in an acute hospital for more than 30 days is forced to pay indefinitely. The vast majority of their pension, be it old age, disability or invalidity pension, has to go towards their care.
The person to whom I referred in this House in February was a psychiatric patient in receipt of an old age pension and was in and out of hospital on different occasions, the overall stay being more than 30 days. The interpretation of the rule by the Southern Health Board was that the patient had to pay for her care, which could amount to several hundreds of pounds over a number of months, out of her pension or that of her husband. That is a serious discrimination against the medical card holder vis-à-vis other categories. This matter is relevant to section 2 and is related to patients' rights. Deputy Flood was reasonable in his approach but this is a matter of interpretation and should be clarified. A directive should be sent to the health boards in this regard. Health boards are going as far as sending debt collecting agencies to these people who are puzzled and frightened. This is happening at a time of their lives when they are very vulnerable — as I said, one patient was a psychiatric patient. The Minister should clarify the matter once and for all so that we can advise the people accordingly.
I wish to speak about two issues. In regard to the issue of full eligibility I note that there is evidence in each health board area, and particularly in my own health board area, of a decrease in the number of people who have full eligibility. It is very hard to understand how that comes about when the numbers of unemployed and long term unemployed have increased. The Commission on Health Funding showed that about 37 per cent of the population had full eligibility in 1988-89 — it is now down to about 32 or 33 per cent of the population — but in my own health board area there is a very substantial reduction which demonstrates a very strict interpretation of the guidelines.
It is accepted that some flexibility is shown in the application of the guidelines. Appeal is made to the Director of Community Care when there is medical evidence to support a case, and that system works fairly well. The most appalling problem arises when a family may not be eligible for a medical card because tax and social welfare payments are not deductible in the assessment of eligibility for those cards. Until the mid-1980s tax was deductible and the assessment was consequently made on take-home pay but that is not so at the moment. I ask the Minister to consider that issue. If people on low incomes are denied full eligibility the likelihood is that they will finish up in hospital. When people go to the doctor they have to find £12 or £15 to meet the hospital charge and sometimes they cannot afford to purchase the drugs prescribed for them. It is not right when that happens, especially when small children are involved. Very often it happens that at a particular time of the week people just cannot afford to go to the doctor.
I am not satisfied with the Minister's reply to my question. I asked how long a person would have to be resident in this State to be considered an ordinary resident and to qualify for services. I wish to pursue that matter because no such qualification is contained in the 1970 legislation. Provision is made for an executive officer to make recommendations on a case, but the position is certainly not specified in the Bill. Section 2 (1) of the Bill states that a person in any of the categories listed who is an ordinary resident of this State shall be included in the provision. I should like the Minister to be more specific about his thinking on that subject because the measure changes present legislation.
Every contributor to the debate welcomed the bringing forward of a patients' charter. That measure will have a major impact in making clear to patients what their rights and entitlements are. Such a charter has already been introduced in relation to the Revenue Commissioners. Those of us who serve on the Committee of Public Accounts recognise that that charter has made a considerable difference to people who have occasion to do business with the Revenue Commissioners.
The aims and ideals of the patients' charter are very laudable. The Minister will be introducing the charter, which is a fundamental part of the Programme for Economic and Social Progress. The charter will have a major bearing on informing patients of the kind of services and the level of services to which they are entitled. All Members of the House would accept that it has long been the tradition of Irish hospitals to provide patients with a very high quality of service, care and attention. The charter will simply spell that out more clearly, particularly from the patients' point of view. The introduction of the charter is obviously the right direction to follow in the provision of health care.
The Government have gone into the medical card case referred to by Deputy Allen, which he brought to my attention. About two or three weeks ago I issued the Deputy a detailed letter that referred to the various legislation under which the charges were made and I invited the Deputy to come back to me personally if he felt unhappy with the content of the letter. I issue that invitation again today. I should be more than happy to sit down with officials and go through the contents of the letter in relation to that specific case in order to clarify that they are acting——
I am not talking about a particular case now, I am talking about the rights of medical card holders in general. Let us broaden the issue now because a fundamental principle is involved. I am sorry; I shall let the Minister of State finish. The letter referred to one particular case, but there is a conflict.
I just make the point because the Deputy raised the matter of an individual case. I should not want the impression to be given in the House that the Government ignored the Deputy's intentions, which were legitimately brought forward on behalf of a particular constituent. I should be more than happy to go through that case with the Deputy.
Deputy Ferris and Deputy Sherlock raised the matter of eligibility. Eligibility for medical cards has been the subject of some concern to the Minister and myself, there is no question about that. There is a degree of concern about the lack of uniformity in the allocation of medical cards, and that concern goes back over a long period of time. Many of us in the House are unhappy that during our work as public representatives we increasingly come across variations on the question of eligibility. It is precisely for that reason that the Minister has decided to appoint an appeals officer to each health board area. The appeals officer will have the responsibility of determining criteria for eligibility and will be available to individual members of the public or to public representatives should the need arise in order to clarify variations in eligibility. That system should work, and it will certainly help to take away the confusion and the hardship that can exist for individual medical card applicants who feel that their case has not been treated properly or fairly.
The appointment of appeals officers will make a considerable difference and is a move that is certain to be welcomed. I should like to hear directly from the health boards their views on the question of a decrease in the number of people holding medical cards. There could be a range of reasons for such an apparent reduction.
Could I give the Minister one important reason?
No, I think the figures of variation are not very great in terms of the total number holding medical cards. Part of the reason could be the lack of uniformity in approach to the allocation of medical cards and the wording of medical cards, but the appeals officers appointed by the Minister will certainly deal with the issue in a full and fair manner. That provision may help overcome some of the difficulties that have arisen in the allocation of medical cards.
I am very happy to hear that the Minister is bringing forward a charter on patients' rights. Will that charter include a provision for patients in mental hospitals? As the Minister is responsible for all health institutions, I presume that people in mental hospitals will be included. I am particularly interested in the aspirations set out in the Programme for Economic and Social Progress: the right of access to services in accordance with need; the right to privacy, the right to information, the right to respect for religious and philosophical beliefs and the right to make a complaint.
When this charter is brought forward will it deal with all the circumstances raised in this House last week, the kind of circumstance now governed by the 1945 Mental Health Act, which would have been dealt with to some extent by the legislation enacted in this House in 1981, which so far as I am aware never came into force? Grave concern and distress are being caused with regard to patients' rights in this area. Will a charter of rights be extended to these people, particularly those who are involuntarily committed to mental hospitals? The Minister in his response last week said that there was adequate protection under legislation. Professor Anthony Clare also said that he was happy that there was adequate protection. There is not adequate protection. Under existing legislation there are abuses and there is grave injustice. I will catalogue 15 real cases with which I have been presented. This is a problem which must be dealt with. I regret that my amendment was ruled out of order because its objective was to try to ensure that abuses will not occur. I would much prefer to see that people were not committed to mental hospitals illegally or lawfully, than to have to deal with these circumstances.
I have been advised that what the Deputy is speaking about now is not relevant under this section.
I respect what the Chair says but under the section the Minister has given a commitment to have a charter of rights for consumers and is this not what we are discussing?
Acting Chairman
No.
The Minister raised it.
If the Minister is talking about the principle of giving rights to patients I would like him to understand that I and many other people would expect that this charter would be extended to people in psychiatric hospitals. I will reserve my comments in this regard.
In all the instances of which I have been made aware where people were confronted by doctors with detention orders, action was instigated by husbands in marriages where there was great disharmony, and the doctors signed the committal orders without examining the patients. The Garda and the ambulance were brought in and the person was taken away. These people who were not patients at that time should have some rights. I know there is an inquiry in progress and I welcome it. I hope the Minister will be able to produce the results of that inquiry soon and let us know what happened in that case and in certain other cases which I am referring to the inspector. I hope people who have suffered so gravely will be compensated in advance of needed legislation.
The Minister of State, Deputy Flood, brought my query down to an individual case. An individual case is just an example. I was referring to the broad principle of medical card holders being discriminated against in that they are being charged for a hospital stay when they stay in hospital for more than 30 days. I am not talking about institutional care but care in an acute hospital. Category 2 patients have to pay £12.50 per day to a maximum of £125. After 30 days medical card holders must surrender from 90 per cent to 100 per cent of their pensions. I do not want the Minister to say that he will look into an individual case. I want to know if medical card holders are entitled to free hospital care when they stay more than 30 days in an acute hospital, because at the moment health boards are interpreting this in another way and are stopping pensions. I want the matter regularised.
That point should be clarified. The most disappointing thing about what has happened in the health services is that, the capitation system of payment to doctors and pharmacists having been introduced, the cost of the GMS has increased. Will the Minister give a reason for that? Did somebody get the figures wrong or say that when we had a capitation system of payment to doctors and pharmacists we would be able to judge the outlay on the GMS scheme and consequently we would be able to contain the cost? That apparently has not been the case and the cost has increased under the capitation system, over the fee per item system which obtained up to a couple of years ago.
Indications are that the GMS is seriously over-running the budget. Will the Minister now have to introduce a supplementary estimate to deal with the over-run on the GMS?
Deputy Bruton referred to what I would like to see in a charter and perhaps that is why he believes it cannot be implemented without legislation. I referred to what we intend to implement under the charter. There is a very high standard of patient care and patient service in Ireland. The Irish people have a caring philosophy and nowhere is that better demonstrated than by the people working in our health services. We will ensure that what is in the charter will be implemented. Everybody would agree, for instance, that it is not appropriate in this day and age that 40 patients should be brought to an outpatients department at 9 a.m., when it is known that at least half of them will not be seen before 11 or 12 o'clock. That is the sort of consumer service that is very important.
Will it be addressed by legal regulations?
We are implementing it. Many of the recommendations were made in the Kennedy report.
It will not be legally underpinned?
It will not be legally underpinned.
That is a disappointment.
I can understand Deputy Bruton, as he thinks that these are only some aspirations that we have.
No, that is not what I said.
I am telling the House that we intend to implement it.
On a point of order——
Deputy Bruton also referred——
On a point of order——
The Minister is misrepresenting the Deputy.
Acting Chairman
Please let the Minister conclude and you can speak afterwards.
No, I want to make a point of order.
Acting Chairman
I insist.
I am entitled to make a point of order.
Acting Chairman
The Deputy should have allowed the Minister to conclude.
I am raising a point of order.
Acting Chairman
What is the point of order?
The Minister should not attribute words to me which I did not use in the House. I have a right to expect the Minister to honour the record of the House and not to distort it.
Acting Chairman
The Minister will respond later.
That is no good.
Acting Chairman
The Deputy will get an opportunity later but at this time the Minister is dealing with another issue altogether.
To clarify the issue, what Deputy Bruton kept referring to was what the Minister would like to see as a patients' charter. I stated here before he spoke that we intended to implement it. Deputy Bruton referred to "what the Minister would like to see." I said that we would implement the charter and that legislation is not necessary.
I did not say that legislation is necessary, that is a false reason.
Deputy Bruton also asked what effect this section would have on our commitments under European Community regulations. I assure the Deputy that it will not have any effect and we will be dealing with that in section 9 of the Bill which provides that there will be no prejudice to EC regulations to which we are a party.
It is fair to take the points raised by Deputy Sherlock now. It is a question of balance; in theory, at present there is nothing to stop anybody coming into this country and claiming service, irrespective of where they come from. We want to ensure that that does not happen. However, at the same time — this is the reason for the guidelines — we want to ensure that people who are legitimately in the country, or indeed our own citizens who may be abroad on a short-time basis or young Irish emigrants who might go to a non-European country, become ill and come home, will get treatment. In spite of all that, the chief executive officer will still have discretion and I assure the House that nobody will be denied treatment in this country because of inability to pay. That is our basic philosophy and position in this country.
Deputy Allen raised the question of long stay charges for patients. Those charges have been in place since 1976 and the Deputy's Government were in office at the time. They introduced the 1976 in-patient services regulations which were amended in 1987. The position is that anybody in a long stay hospital——
Long stay?
Yes.
I referred to acute hospitals.
A patient in a long stay hospital is liable for charges and health boards are entitled to regard a person as not being a medical card holder in the circumstances.
I said "acute", not "long stay".
If the Deputy knows of a case in an acute hospital we will be glad to pursue it.
The Minister has been given evidence in this regard and the Southern Health Board are acting illegally as they are sending debt collectors to collect money and the Minister is standing over it.
Is the Deputy suggesting that every patient in the Cork Regional Hospital for more than 30 days is charged? If the Deputy has evidence I want to see it.
I will answer that question, I have given him evidence.
It is Committee Stage of the Bill——
Acting Chairman
The Minister should be allowed to continue without interruption.
The Minister asked me a question.
Acting Chairman
You will get an opportunity to answer it.
I will investigate the individual case for the Deputy.
I am not talking about individual cases, I am talking about a general rule.
Acting Chairman
Please, Deputy Allen, allow the Minister to continue.
My understanding is that the regulations apply to any hospital when you have been a patient there for more than 30 days.
Even an acute hospital?
That is my understanding.
There is discrimination in relation to medical card holders——
I have not finished.
The Minister has made a very important statement that medical card holders who are receiving a service in an acute hospital are liable to charges in excess of the £12.50 per day. Their pensons will be confiscated by the Department and they will be charged more than category 2 patients who are charged a maximum of £125 per year — £12.50 per day for ten days and a maximum of £125. The Minister has admitted in the House that medical card holders receiving a service in an acute hospital can have their pension books confiscated by his Department, in other words they can be subject to a charge of over £2,000 per year. Is that what the Minister is saying? It is blatant discrimination against the least well off in our community and the Minister should be ashamed to admit it. I am glad it took this long to get it out of him because they have skirted the problem and allowed health boards to get away with it for a long time, although it had been brought to the Minister's attention. The Minister should now make an order retracting that.
We should sort out this problem now before there is an unnecessary row. As I understand it, up to recently all health boards understood that the 1970 Act conferred rights on people who are medical card holders for acute hospital treatment, irrespective of the length of time they required the service. Under the 1970 Act there is no power to permit any health board to charge a medical card holder for acute hospital treatment as defined in the 1970 Act. There are regulations which permit health boards to charge anybody a percentage of their income if they are in long stay geriatric or psychiatric hospitals. That is understood because the 1970 Act was amended to define that as not being hospital service.
However, an acute hospital, I emphasise the word "acute" because the other interpretation was also used in sub-acute or district hospitals, means that after 30 days people could be considered as long stay patients and not in hospital care. We should clarify this matter once and for all because the public want to hear that medical card holders are entitled to free hospital treatment which is defined in the Act and redefined in the table. If the Minister interprets it differently I should like to hear it.
The House should adjourn if there is a question of the Act being suddenly taken out of context. For a short time I did not believe that what Deputy Allen said could possibly happen in any health board area but I am glad he raised it, even though it is a contentious issue. I read previous debates in relation to debt collectors and I understood it applied to long stay care only. However, if it applies to medical card holders in acute hospital care we are deceiving everybody whom we represent.
We are dealing with a case which was brought to the attention of the Minister of State, Deputy Flood, which referred to a patient in a psychiatric hospital. I referred to the 1976 regulations and I suggested that we should leave this issue until we come to the section dealing with charges in hospitals because this section deals with those ordinarily resident in the State. It is not an appropriate section to debate eligibility beyond the range of the question which Deputy Allen asked the Minister of State some weeks ago.
We are dealing with a table which spells out the situation in relation to a person who is unable, without undue hardship, to arrange general practitioner and surgical services.
We are dealing with those ordinarily resident in the State.
The Minister made a clearcut statement that medical card holders are liable to charges in acute hospitals.
Acting Chairman
The Minister indicated that it would be better to discuss it on the section dealing with charges.
We have played with the problem far too long now and we have, on numerous occasions, tried to get to the bottom of it. A few moments ago the Minister said that medical card holders are liable for charges when they are in excess of 30 days in acute hospitals. The Minister should clarify the position once and for all. We are not imagining this. This is happening in my health board. It has gone so far that debt collectors are sending threatening letters to psychiatric patients in acute care.
That matter does not arise under this section. I think Deputies opposite are being most unreasonable to come in on a section which amends the 1970 Act by inserting "ordinarily resident in the State"——
Am I in order?
——and raise points of order, asking questions on every aspect of the health service and expect comprehensive replies. This is not possible. If we take the Bill section by section we may come to the issue raised by Deputy Allen and I will then have a comprehensive reply for him. However, Deputies are being most unreasonable to expect me to answer every single question about the health service on a section the terms of which are very narrow and specific.
Acting Chairman
The Minister has indicated that he will answer questions relating to the charges when we come to the appropriate section. This section does not deal with charges.
We are talking about entitlements set out in the table.
The Deputy is out of order.
We are also talking about the entitlement a full eligibility——
Acting Chairman
The table has been included for the purposes of clarity. I would be obliged if the Deputy would wait until we reach the relevant section to deal with charges.
The table forms part of the Bill.
Acting Chairman
It has been included for the purposes of clarity.
It forms part of the Bill.
Is the Minister not in a position to answer the accusations made?
Acting Chairman
The Minister has indicated that he will deal with charges when we come to the relevant section.
I am not referring here to a particular case; the Minister keeps saying he will deal with a particular case. I am talking about the general principle of medical——
The Deputy referred one particular case to the Minister of State——
I gave the example of a medical card holder who was cared for in an acute psychiatric hospital over a period exceeding 30 days. Surely, as Minister for Health, he is in a position to inform the House whether medical card holders are entitled acute hospital care without having their pension books confiscated.
Acting Chairman
The Minister has indicated that he will answer that question when we come to the relevant section.
Because he cannot answer it now?
On a point of order, we accept that it is the practice to impose a charge in respect of a stay in excess of 30 days in a long stay institution, but would the Minister clarify whether we are talking here about long stay care or acute general hospitals?
We are talking about people ordinarily resident in the State as defined in the section.
I will deal with that point when we come to the section dealing with charges. It is my understanding that the regulations cover a person who has been more than 30 days in hospital. I will clarify whether this includes acute hospitals when we come to the section.
Can the Minister not clarify it for us now?
Deputy Fennell referred to the patients' charter and asked if this will apply to patients in psychiatric hospitals. The answer is that it will. She then made very serious allegations with regard to admissions to psychiatric hospitals. There is a careful legal procedure laid down. Under the 1945 Act, before a person can be admitted to a psychiatric hospital a close relative of the person concerned, a community welfare officer or, in a specific emergency, other persons, can submit an application for recommendation for reception. A recommendation order must then be signed. In the case of admission to a private psychiatric hospital two doctors must sign the recommendation order and they must have seen the person concerned within specified times. Finally, a reception order must be signed by a doctor in a psychiatric hospital. They are fairly substantial safeguards. I do not think Deputy Fennell is complaining about the safeguards that are there but rather that they were not adhered to. That is a different issue and a change in the law would not necessarily correct it. Procedures have been laid down to deal with cases where the procedures have not been adhered to. Under the 1945 Act, a recommendation order must be signed by two doctors who must have seen the patient and a reception order by a doctor in the hospital who takes responsibility for the patient. One is breaching the law in not adhering to the procedures but this does not mean that the law itself is defective.
Provision is made under the law for an inspector of mental hospitals to examine any complaint made. As Deputy Fennell is aware, under that section an inquiry is being made into the specific case mentioned by her last week. A charter of rights will apply but, as I have outlined, there are safeguards there at present.
The Minister smugly attempted to suggest that I hold some particular views but the reality is that he is trying to conceal his unwillingness to give a patients' charter statutory force so that people could say that it was unacceptable that they have to wait for two years for a vital operation and the Government have guaranteed that they will not have to wait for that long, and they have redress. That is what we are talking about— a patients' charter with legal force. The Minister said he is implementing a charter. If he is, and it is not aspirational at this stage, he should tell this to parents who have been trying for years to have a mentally handicapped child admitted to a residential home or to those who have been waiting for years for elective surgery. The Minister does not have a patients' charter and he should face that fact.
It is good that the Minister is willing to introduce a charter but we want it put on a statutory footing so that the people would be aware that health institutions would be obliged to make a reasonable effort to achieve its objectives. The Minister is fooling no one in trying to suggest that he has a charter and that everything in the garden is rosy; that is not the reality. If this charter is not legally underpinned, it will be nothing more than a pipe dream. As the Minister knows, he does not have the right to tell the health agencies what they should do. That is the reason the charter should be put on a statutory footing.
I thought when the Minister announced this morning that he was going to introduce a patients' charter that it would be a real charter but he subsequently said it would be announced outside the House. As I said, the aspiration in the programme agreed with the social partners are as good as his party's manifesto if the charter is not given the force of law by way of legislation or regulations.
The only thing the patient is interested in is gaining access to services and any charter which does not give him that right legally enshrined will be worthless. I am sick and tired of hearing the Minister say Pontius Pilate like that he is not aware of certain things.
The Minister should be aware by now that the most important issue is that people cannot get public services when they want them but if they have the money they will get service overnight. To talk about the terms of reference of a patients' charter is meaningless and will fool nobody, because the public, and especially patients, are interested only in access to in-patient, out-patient or community services, which they are not getting at present.
It is not right to say that patients are interested only in service. Certainly one of the issues that a patient is interested in is access to service in accordance with need, but clearly Deputy Allen is ignoring the other major items contained in the patients' charter. The Minister has said that the patients' charter will be implemented and guarantees rights, for example, the right to privacy which is a basic and fundamental right.
That presumes that the person gets into hospital in the first place.
The person has a right to information, which is another important aspect of patient care.
The fundamental right is to have access.
Frequently we get complaints, and certainly I do when people are unhappy with the information——
I thought this was well under way.
That is why this issue is incorporated in the patients' charter. There are several issues covered by the patients' charter which I think are important, and to which patients have a right. That is the purpose of the charter. For example, patients have the right to refuse to participate in research projects. We want that provision included in the patients' charter, and the Minister has said it will be implemented.
These are fringe issues. The basic issue is access to service.
They are not fringe issues. They are issues which are important to patients.
They do not cost you any money.
It does not matter that they do not cost money, the patient is still entitled to them.
How will a person get his or her rights under this charter if the provisions of the charter are not subject to regulation under the 1970 Health Act, or other legislation? Will breaches of the provisions of the patients' charter be a matter for the Ombudsman, so that we could report the matter to him if the person does not get his or her rights? The Minister of State, Deputy Flood, has said that a person is entitled to privacy. That is a basic human right but at present, with ward closures, men and women may now be in the same hospital ward and this could not be in accordance with their right to privacy. I am not talking about patients in intensive care units, but men and women in hospitals for acute care who have no privacy at present. I welcome the fact that the Minister for State has made this announcement in this House but will this be a matter which can be raised with the Ombudsman when a person is aggrieved?
I have had to raise breaches of people's existing legal rights with the Ombudsman, a simple matter such as a person having dental care under the Health Act at the local clinic. They had been told before all their teeth were extracted that they would be entitled to be supplied with dentures but the day the last tooth was extracted the health board pleaded inability to provide dentures. I reported this case to the Ombudsman, and he considered the case so serious as to document in the 1990 report a case brought to his attention. It was I who brought this case to his attention. The health board pleaded their inability to pay for the dentures although under the 1970 Health Act the person is legally entitled to them. Whether a person is legally entitled or not, if the Minister does not provide the funding they cannot get the service. The law is brought into disrepute because of that. I want to check that the rights which the Minister has told us about, but which have no legal underpinning, can be raised with the Ombudsman so that he at least could pressurise the health board and Government Departments, by force of public opinion, to do something about patients' rights.
The Minister can give us a grandiose list of patients' rights but I can give instances where existing rights under the law are not being respected. I am not looking for spending ad infinitum, which the Minister seems to be accusing me of, but for priorities. If the Department do not have priorities for the people entitled to a health care service at whatever level and if we are not honest with them, we are doing a disservice to those we represent. The Minister almost did not believe us when we told him that people were waiting for long times for this or that. The Minister even asked Deputy Allen to give him details of a case when we told him that the service was available for people willing to pay for it. This in fact is happening every day in the area of orthodontic treatment and other treatment areas.
If the Minister does not think that he is for the birds.
I can give the Minister a list of people in the South Eastern Health Board area who are on the waiting list for hip replacement operations. In this health board area alone there are 2,500 people on the waiting list for in-patient service, and 5,000 patients on the out-patient list who are waiting to get on the inpatient list, making a total of over 7,000 people who have been referred by their GPs for treatment and are entitled by law to this service but cannot get it. I can give the Minister details of the hospitals, the operations they are seeking and comparative dates of waiting lists for the previous year. Yesterday I said that while there is increasing activity there are still waiting lists for the service. The Minister said there will always be a waiting list; of course there will, but some people will have to wait up to eight years, as somebody was told yesterday, for an operation on varicose veins. They will be in a wheelchair before they get the operation.
Patients have rights, charter or otherwise, health estimates or otherwise. They are entitled to the service but we cannot deliver it. This is a great pity. We say that the health services in Ireland are among the best in the world. The Minister says that our health services are very good, are better than anywhere else, and that nobody will be without treatment, but still thousands upon thousands of people are waiting for treatment. Obviously we are not able to meet the demands and therefore we are shirking our responsibility. That puts the patients' charter in context. Although the charter has been approved in the Programme for Economic and Social Progress and has the approval of the Minister, we still have to meet the people on the ground who cannot get a service.
I will deal with the points raised by Deputy Ferris and the other Deputies who raised similar points. We all recognise there are waiting lists. I challenge any Deputy to come into this House and tell me the last time there was not a waiting list. There were always waiting lists and unfortunately because of the nature of the health services there will continue to be waiting lists. In Northern Ireland there were 800 people at one point waiting for hip replacement operations, it was decided to provide the money to eliminate the waiting list altogether and that was done, but in three months there were 800 more people on the waiting list for hip replacement operations. No country in the world has discovered a means of eliminating waiting lists even when they put the money into the service. I accept also that the length of time that some patients are on certain waiting lists is not acceptable but that is not a new feature of our health services either. However, in the areas where we have identified that problem we have taken the appropriate action to deal with it. I have referred to the hip replacement operations, and last year, for example, we increased the number of hip replacements by 14 per cent and in Cappagh Hospital, in particular, which is the largest provider of hip replacements, we increased the throughout of patients for hip replacement operations by 40 per cent.
Could the Minister give me the figures please?
The number of operations went from approximately 530 up to 730. That is what is happening and we are taking the appropriate action. We reduced the waiting list for tonsils and adenoid operations in Temple Street Hospital by 55 per cent and the waiting list for tonsils and adenoid operations in the South Infirmary in Cork was reduced by 45 per cent.
However one still has to wait two years for the operation.
We are putting the resources into the service as more resources become available. Again I will refer to the very substantial increase in funding over the past three years. There was a 24 per cent increase in the funding to health boards over the past three years——
What was the increase in real terms?
——which is very substantial funding. There is no point in Deputies thinking they can eliminate waiting lists. Unfortunately, waiting lists are a feature of every health service thoughout the world. Every developed country has to deal with the problem of trying to meet increasing demands with limited resources.
Deputy Ferris referred to the dental service. I have recognised for years that the dental service was the cinderella service here, that it was under-funded. However, in 1979 an effort was made by the present Taoiseach, who was then Minister for Health, to come to grips with that and he established the ad hoc service whereby patients could go to a private dentist. Who dismantled it?
Children got free toothbrushes. That is as far as it went.
What have we done about it? In 1989 we put £300,000 extra into the dental service.
It made no difference to my constituents.
We put £3 million in in 1990 and £3 million in 1991. I do not accept what Deputy Ferris is saying, that it made no difference in his constituency. It had to make a difference in his constituency because they got their share of the £3 million last year and they are getting their share of the £3 million this year.
I had to go to the Ombudsman.
Again, it is an indication of the improvement of the services within the resources available.
The next point raised was the question of medical cards. It is true, as Deputy Allen said, that the cost of the general medical service is continuing to increase as has been the pattern for many years, but, on the question of the number of people covered by medical cards, the House appreciates that there was a change in the method of payment to doctors. Formerly doctors were paid on the basis of a fee for each item of service delivered. Two years ago there was a change and doctors were paid on capitation. As the House will appreciate, from an administration point of view it did not very much matter if there were people on the register of medical card holders when the doctor was only paid when they turned up for a visit. However, when the arrangement was made for doctors to be paid a capitation fee the doctor was paid for each person on his list of medical card holders irrespective of whether they visited him or not. It became incumbent then on the health boards to address the issue of having the lists brought up to date. Following that a number of patients' names were removed from the list because they had passed away, had left the area or for some other reason. That is the reason there was a sudden drop in the number of medical cards. The point Deputy Allen made about the increasing cost of the medical card service certainly indicates that there are still people, and more people in my view, benefiting from the medical card scheme.
There is, of course, the problem of the escalating cost of drugs. Deputy Allen referred to the cost of the service this year. It is too early to say what the outrun will be on the general medical service. It is an open-ended scheme. Patients turn up and medicines are prescribed for them, so it is not possible to say at this point what the outrun will be at the end of the year. That has been the position every year since the scheme's inception in 1972. We have adopted certain measures on the drugs side to try to contain the cost of medicines. For example, we had an agreement with FICI last year that would reduce the bill to the State in the current year. We also introduced a national formulary and as a result of the recent negotiations with the doctor in the GMS I am hopeful that we will be able to contain the cost of medicines. Again, I have to tell the House that there are new medicines coming on stream every day, very expensive medicines, and the health services here provide the medicines that are appropriate to each patient who needs them. That feature of the health services will be continued, but there is a cost involved, and I am sure the House appreciates that.
I would like to thank the Minister first for dealing with my remarks because this is the first time I have spoken in the House about it. I will not labour the point and I would prefer to speak to the Minister about it. However, I would like to stress that if there was a charter that would give statutory rights to patients, the case I raised in the House last week, and those I have come across since, would not have happened. If they did happen there would be redress for the person. That is not the case. There is no definition of what is an examination for those involuntary commitals under the 1945 Act and section 260 of it prevents persons bringing cases to the High Court. I was anxious to put that on the record because I intend to talk to the Minister about the case. A charter for patients under which they would have redress would certainly help prevent this happening.
I was amazed to hear the Minister say there are new drugs coming on stream. We are always being told that there is no control over the drug companies and that appears to be the problem. I was told that at the health board meeting when I raised this question of new drugs. Who is monitoring them? Are they necessary? Are they keeping people out of hospital? There is no evidence of that.
As the debate on a charter of patients' rights went on I did some thinking about it. Much sorting out needs to be done about such a charter because I have now figured out that free access may not mean equal access. In the fist instance the Government followed the recommendations of the Commission on Health Funding by abolishing the income limit. I support that wholeheartedly and it is about time it happened. However, the Government did not adopt the recommendation that there should be a common waiting list or the recommendation on the abolition of the tax allowance on VHI contributions. We could still have public and private in the hospital system and, without a common waiting list, free access may not mean equal access. There should be the right to equal treatment on the basis of need contained in a patients' charter, the right to equality of access and care when in hospital, and the right to information and access to one's medical records.
The overall effect of the reform of the hospital services while maintaining a public and private mix in the public and general hospital service would ensure a quality of access and care for all and for additional private funds into the public system because there is an amount of public finance being spent on patient care in the private system. Up to now consultants were paid their salaries by the health board while at the same time they were treating private patients in beds in the public hospitals and being paid by the VHI. This is what we want to eliminate.
Acting Chairman
I have given a lot of latitude to Deputies in this debate. Deputies have strayed far away from the section. We cannot go on indefinitely discussing matters which are not relevant to this section. I would remind Deputies to discuss matters of relevance from now on and I say that in the best interests of everybody.
The debate has really been about the charter. On Deputy Sherlock's point, it is our intention to implement the charter. Under section 72 of the Health Act, 1970 the Minister has authority to see that the charter is implemented. We intend to do that. There will be equal access for people and a right of access. The whole purpose of this Bill is to ensure that we will have a public health service and that there will be no queue jumping for the beds in the public health service. The public beds will be available for public patients and they cannot be taken up by private patients. Deputy Allen said yesterday that 40 per cent of patients in public beds are private patients. It is unreasonable of him to say I was unaware of that. I am unaware of it because I have no evidence of it and I ask him to produce the evidence.
It is in a health board report, an official report. Let the Minister keep an eye on his health boards.
It will be irrelevant after 1 June because the beds will be designated.
Let the Minister get in touch with Mr. Dudley. He will give him the evidence.
The Minister has now replied to the question I asked him almost an hour ago, that the charter he has talked about can be provided by regulations under the 1970 Act and it will have some status. He has just now confirmed that section 72 of the 1970 Act allows him to make regulations and to provide charters and ensure they are operational. I am satisfied with that. Had we that information an hour ago we would have been perfectly happy.
I wanted to clarify the issue for Deputy Ferris. It is not my intention at this time to introduce a legal instrument, either an Act of the Houses of the Oireachtas or new regulations. Section 72 of the Health Act, 1970, provides that:
`(1) The Minister may make regulations applicable to all health boards or to one or more than one health board regarding the manner in which and the extent to which the board or boards shall make available services under this Act and generally in relation to the administration of those services.'
I believe the legal instrument is there.
All the Minister's aspirations are worthless now when he admits to the House that he has no intention of introducing a patients' charter that will be based on regulations or legislation. It will be another Pádraig Flynn-type Gary Glitter show presented for the media with no real effect on the ground. It will be worthless.
That is Deputy Allen's opinion. I intend to implement it.
What we want are rights for the patients to be enshrined in regulations or legislation. Aspirations are no good.
Question put and agreed to.
SECTION 3.
Question proposed: "That section 3 stand part of the Bill."
Section 3 provides for the amendment of section 46 of the 1970 Health Act to provide that a person who does not have full eligibility but satisfies the residency requirement shall have limited eligibility.
Eligibility for health services in Ireland is based on income. There are at present three categories of eligibility. Category 1, or medical card holders, are entitled to the full range of public hospital services free of charge. The 1976 In-Patient Regulations which have been referred to already apply to category 1 in respect of hospitalisation after 30 days.
Category 2, or hospital services card holders, are entitled to a public bed free of charge, except for the payment of modest statutory charges, the £10 out-patient charge and the £12.50 in-patient charge which is subject to a maximum of £125.00 in any period of 12 consecutive months. Persons in Category 2 are also entitled to public consultant care in public hospitals free of charge, and expectant mothers in category 2 are entitled to free general practitioner services under the mother and infant care scheme. Persons and their dependants are deemed to be eligible for category 2 services if their previous year's income is below a specified income limit. The income limit for eligibility for category 2 services in the year ending 31 May 1991 is £16,700.
The final category, category 3, is composed of persons and their dependants whose income is in excess of the income limit, that is £16,700. Persons in this category are entitled to a public bed free of charge — except for the statutory charges I referred to in the context of category 2 — but are liable for public hospital consultant fees. In addition expectant mothers in category 3 are not entitled to free general practitioner services under the mother and infant care scheme.
The purpose of section 3 is that in future there will be just two categories of eligibility. Persons with full eligibility, that is, medical card holders, will continue to be entitled to all necessary medical care free of charge. The remainder of the population will have limited eligibility and will therefore be entitled to the services currently available to those in category 2. The practical effect of this change is that persons in category 3 will now be entitled to public consultant services free of charge and expectant mothers in category 3 will now be eligible for free general practitioner services under the mother and infant care scheme.
Under the new arrangements the hospital services card will no longer be issued. Provided a person is a resident of Ireland he or she will not require any evidence of eligibility in order to avail of public hospital services.
The arguments for the extension of eligibility, that is, the abolition of the income limit for category 2 services, were discussed in detail in my speech on Second Stage. In brief, the present system is no longer equitable as it is impossible to operate the income limit fairly, and because the existence of category 3 can in practice work against equitable access to public beds.
Yesterday on Second Stage we made it clear that Fine Gael did not feel this was a priority in our health services at the moment. I am not convinced that the Minister has removed an administrative problem with the income limit. We have had income limits for all sorts of services and it does not seem a fundamental issue just because there is a change in self-assessment or in the provisions of the income tax code.
The other point the Minister makes is not a fundamental reason for queue jumping. It is not that private patients are being put into public beds.
That is what Deputy Allen said.
The fundamental reason for queue jumping is people having money in their pockets. What is very disturbing about the new provision is that the Minister is deciding there are to be two separate streams, a public waiting list and a private waiting list. I will have to go back to the Health Commission whom the Minister is always quoting in support of his case. Yes, the commission favoured the eligibility limit and providing care to all, but it was on one fundamental condition which they spelled out, that there be a common waiting list.
What the commission say is worth reading into the record because it is fundamental to the way we think of it. They say that there is a major problem regarding access to public hospitals. The common perception is that those opting for private care are able to obtain admission more quickly than those using the public system. They say an objective system of assessment for access to public hospitals should be introduced for all planned admissions involving a common waiting list for both public and private patients from which cases would be taken in order of medically established priority. The new approach would require the regular publication of criteria for hospital admission and of maximum waiting periods for access to specific non-emergency procedures. The operation of the common admissions policy would have to be monitored closely.
That is the Health Commission's fundamental proposal which this Bill is ignoring. They saw as fundamental extending cover to everyone but on condition that there was a common waiting list being operated. There would be clear specified maximum waiting periods and people would not have to wait beyond a certain acceptable level to gain admission to hospital. By adopting one half of the commission's recommendation and not the other, the Minister is neutering what they were trying to do. By saying that everyone will be eligible but that there will not be a common waiting list the Minister will reinforce the problem all of us believe exists in the health services. I want to give the reason this problem will be with us in the years to come. The Minister wants people to stay in the VHI because, obviously, he does not want those 30 per cent becoming a drain on his Department's budget. The only way people will stay in the VHI is if the public service, to which the Minister says they will now be fully entitled, is sufficiently inferior that they cannot get the care they want. These people will have to continue scrimping and saving to come up with the £500, or whatever amount is necessary, to get VHI cover for their family.
The Minister is ignoring this point. He has not at any stage in the debate addressed the issue of the common waiting list. Neither has he said why he believes the people to whom he is now giving cover should not take it up. The reason people will not take up the costless consultant care the Minister is giving them is that they believe, on the basis of the evidence before them, that they will not get the care when they need it and that they will be placed on long waiting lists.
If free health care at an acceptable level were available to all Irish people we would not be in the VHI, we would all avail of the public system. This is why the jettisoning of the common waiting list proposed by the Health Commission is so serious. The Minister must explain to the House why he believes this extension of care will be costless. He keeps insisting that there will not be an extra burden, he will not put any more money into the system and he will not make any more public beds available. The fundamental underpinning his ability to say this is that he knows in his heart of hearts that the public health service will be sufficiently inferior to the private health service that people will not exercise their rights. The commission tried to address that equity question. That is the principle Gleeson tried to address in working out a system of payment to the consultants which would give them the incentive to operate the system fairly and not give them incentives to favour and promote their private patients in order to secure financial return. Gleeson did not want to just give them money; he wanted to set up a system whereby the Department would have an agreement with the consultants that they would police the common waiting list deal. As I understand it, that was the fundamental principle in those two documents. Much of what was in those documents has been turned on its head by the Minister.
The separation of public and private patients and the earmarking of beds is a rather crude way of policing the system when Gleeson was offering a system of monitoring through actual admissions of patients. That is what we are talking about. We do not want beds people can hang hats on; we want to see public and private patients getting a fair share out. I understood this was what the Gleeson commission were all about. I am genuinely afraid that with the £35 million payment to the consultants we will be dropping the pass in respect of what the Health Commission proposed as the ideal way for us to proceed.
Section 3 proposes to extend eligibility. If the Government are to extend eligibility, no politician would deny more people access to care. However, I question the thinking underpinning this proposal and whether we can put our hands on our hearts and say that this is in some way an answer to the Health Commission's report which was all about equity, common waiting lists and giving patients, whether public or private——
Acting Chairman
The Deputy is making a Second Stage speech.
It is relevant.
Acting Chairman
The Deputy has strayed away from the section.
He has not. What he is saying is relevant.
I do not think the Chair is being fair. The section is linked with the Minister's proposals. It is supposed to be based on the commission's report and the Minister cited the evidence of the commission. It is here that we get a chance to tease out the Minister's thinking. I do not think the Minister's Second Stage speech addressed all the issues.
Acting Chairman
The advice I have received is that the Deputy is making a Second Stage speech.
The advice from whom?
Acting Chairman
The officials.
The Chair has to use his own judgment. I will not labour this point any further. I should like the Minister to outline in more detail how this procedure will work and why he believes people will not take up the rights he is giving them. He keeps saying that they will not take up these rights. However, he will not make money available so that they can take up these rights. This is fundamental to the section.
The Labour Party welcome the extension of eligibility to this service to everybody. Even the previous speaker welcomed this proposal. However, the only way the Minister can achieve this is by providing a service for everyone. At present those who are entitled to the service — those who have full eligibility, those paying PRSI contributions and those paying the £12.50 a day charge — cannot get it. People in the VHI who could be accommodated under this section will remain in the VHI because they know that if they do not remain in the VHI there is no guarantee that the queue they will join will be shorter, particularly if the number of beds stays the same, which I suspect it will. This is why I put down an amendment to a later section.
I want to refer to some of the comments made by the Minister on this section. He referred to the section of the Health Act, 1970 covering the three existing eligible categories, one of which will be abolished. The Minister said the first category included people with medical cards who are entitled to full and free services in a public hospital. Is it not time the Minister addressed the problem we raised previously with him, the eligibility of medical card holders who are in acute hospitals for over 30 days? The Minister has just confirmed that these people are entitled to beds in public hospitals but can he now confirm that everybody with a medical card will be entitled to a free bed in public and acute hospitals after 30 days? Although sub-acute hospitals are public hospitals, they can be redefined under the amended regulations which have been brought in. Will the Minister answer that question? It is a good time for him to answer it as he proposes to introduce a new category of people who will be eligible.
This is a simple section which proposes to amend the 1970 Act by substituting a new section for section 46. This section will make it very easy to determine eligibility as there will be only two categories. I do not have any objection to this section but I should like to ask the Minister if it covers everything. There are eight subsections in section 46. Will that section be deleted entirely and substituted by a new section which will provide that, "Any person ordinarily resident in the State who is without full eligibility shall, subject to section 52 (3), have eligibility for the services under this Part". Will the Minister in his reply explain the provisions of section 52 (3) of the 1970 Act? Does it mean that that section of the 1970 Health Act will be deleted and substituted by:
Any person ordinarily resident in the State who is without full eligibility shall, subject to section 52 (3), ...
I do not see any subsection (3) in section 52 of the Act. Section 52 has two subsections and I would like clarification on that matter.
If the people of Ireland get an improved hospital service, especially those who did not have access to services up to now, they will pay dearly for it. I outlined the cost to the person who is dependent on VHI at present and who is outside the range of the service. They pay up to £300 or £400 a year extra and are getting what I would term a ramshackle service. They are just being added to the waiting lists. They are now entitled to a service that is full of waiting lists and inequalities. That is what they will get for their extra contribution. Those with medical cards and hospital service cards will find it more difficult to avail themselves of the service because of the influx of new people.
In his Second Stage contribution yesterday, the Minister said category 1 persons would be entitled to the medical card and would receive all the services free of charge. It is now time for the Minister to come clean on what the medical card holder is entitled to. Is the medical card holder entitled to acute hospital care over 30 days, be it at a general hospital or a psychiatric hospital? I have in mind the person who is in and out of hospital for five or six days, home for two months, in for another eight or nine days, home again and is not fully recovered and has to return for further treatment and exceeds the 30 days. Is such a medical card holder entitled to free hospital services or is he discriminated against vis-à-vis category?
I would like to refer first to the question of medical cards and second to some of the other points that have been raised. This is very important, especially in the light of Deputy Allen's last statement in which he alarmed the people of Ireland about waiting lists getting longer.
They are alarmed already.
That is not so. That has prompted me to come to my feet. In my own constituency, as the Opposition spokesperson on Health is fully aware, his party and Deputy Ferris's party kept a general hospital closed after it was built and the medical card holders were not able to avail of the services of Beaumont hospital.
On a point of order, is this relevant to the section we are debating?
I am referring to the medical card holders——
Acting Chairman
You are making only a passing reference, you cannot discuss Beaumont Hospital.
We have a guillotine motion on this debate.
I take one simple, basic fact and I seem to upset some of the Deputies in this House.
Tallaght Hospital.
May I also say that there are other changes in relation to medical card holders and their entitlements, particularly in the Dublin area, with the opening of Beaumont Hospital on 365 days a year, 24 hours a day. That is a service we never had before.
Acting Chairman
The Deputy cannot make a Second Stage speech.
On a guillotine motion this is a disgrace.
I am referring to entitlements of medical card holders. Is it correct to do that at this stage?
Not on section 3. On a point of order——
I am simply pointing out that in my own constituency and in the greater Dublin area, the Eastern Health Board area, there have been great developments and major strides in health services, and that should go on the record of the House. Nobody should be allowed to stand up and mislead people in relation to services.
On a point of order, that is a serious allegation. I can stand over what I said and I have documented it.
Acting Chairman
That is not a point of order.
The Minister failed on numerous occasions today to answer questions. He begged for time to get a response from his officials. The Deputy came in out of the blue, not having been here all the morning, and accused me of misleading the House.
I was here earlier.
The Minister asked for time so that his officials could leave the House and go and get an answer for him because he could not answer.
Acting Chairman
Please allow Deputy Callely to continue.
On a point of order, is it not in breach of House rules to accuse a Deputy of misleading the House? I understood that Deputies were put out for doing that.
They have been put out for doing that.
Acting Chairman
I do not recall him say the Deputy was misleading the House.
The record will show that he accused the Deputy of misleading the House.
I am sure that you, a Leas-Chathaoirligh, and the Members in the House present will fully appreciate the point I am trying to make, which seems to be upsetting so many Deputies——
Is it not the order of the House that a Deputy should not accuse another Deputy of misleading the House and is under obligation to withdraw that remark?
It was done this morning on the Order of Business.
Acting Chairman
As I have stated, I did not hear him make that statement. If Deputy Callely made that statement he should withdraw it.
I hope he is honourable enough to do so.
Is the Deputy going to withdraw it?
Yes. I am giving clarification on it. I was prompted to respond to Deputy Allen's statement in relation to the people of Ireland and the waiting lists getting longer, particularly for those with medical cards. I am suggesting that that is not so. If I said that Deputy Allen misled the House——
That is not what I said.
On a point of order, the subject matter we were discussing on eligibility was whether in fact people with medical cards were obliged by health boards to pay for services in acute hospitals over 30 days. What the Deputy is now referring to is totally irrelevant because we were not discussing it.
Acting Chairman
I would like to clarify that section 3 provides for the amendment of section 46 of the Act of 1970 as follows:
Any person ordinarily resident in the State who is without full eligibility shall, subject to section 52 (3), have limited eligibility...
That is what section 3 is about.
In the Minister's introduction to the section he talked about medical card holders' entitlements to public hospital services free of charge. We have now asked him to clarify a point we had raised two hours ago when the Deputy in possession was not here.
Acting Chairman
Can we allow the Deputy to conclude and then we can have that matter clarified.
I wish to press my point of order. The Chair may not have heard the reference by the Deputy that Deputy Allen was misleading the House. I certainly heard it and I think the bulk of the other Deputies heard it.
I heard it.
The Deputy should have the good grace to withdraw that accusation and he can develop whatever points he wishes——
Acting Chairman
I am sorry I did not hear the Deputy make that remark but if he did he should withdraw it.
If I made any remark that is out of order I will withdraw it and I will be guided by your good self, chairman.
Acting Chairman
Does that satisfy? Agreed. Deputy Callely to continue without interruption.
It is my understanding, and this is what I wanted to make clear following the statement by Deputy Allen, especially in relation to the people in my own constituency and that of the greater Dublin area in the Eastern Health Board, about waiting lists and eligibility for medical cards. In the Dublin area, in my own constituency, we now have a general hospital operating 24 hours a day, seven days a week, 365 days a year. That type of service was not in operation previously. Indeed the hospital was built but closed——
Who built it?
——built but closed by both of the people I seem to be——
I deem it necessary to rise on a point of order. There are just nine sections in this Bill. Because there is a guillotine on the debate, it is not easy to accept the kind of discussion that has nothing to do with the section before us. I say this with due respect to the Chair.
Acting Chairman
On a number of occasions I have reminded Deputies about that. We have been dealing with one section since I came into the Chair at 11.30 a.m.
I respectfully suggest that the section has nothing to do with Beaumont Hospital.
Acting Chairman
I accept that, but we are talking about eligibility for medical cards.
If I had been allowed to make my point without interruption I would have been finished by now.
The Deputy made serious allegations.
A further interruption. There is an expansion of the services to which medical card holders are entitled, including the opening of a general hospital and the development of a mobile day hospital for elderly patients. In excess of nine consultant posts have been created, from which medical card holders will benefit. A 24-hour accident and emergency service has been developed in the Dublin area. Specialist units have been opened for AIDS patients. General practitioners have become involved in various district hospitals. There is a great development in the services for medical card holders.
Will the Minister answer the questions?
I was one of the Deputies who waited patiently to make a speech on Second Stage but unfortunately I was not called. The ethos of this Bill reflects the ethos of the Government.
Could we have the ethos of section 3?
The Bill reflects the wider ethos of the Government.
We must confine ourselves for discussion purposes to the section before us.
The other Deputy was allowed to waffle for ten minutes. Let us have consistency.
Deputy Creed on section 3, please.
The Bill reflects the ethos of the Government in that it extends eligibility to a section who have not sought this benefit at the expense of those who currently cannot gain access to an adequate level of medical care. This is most regrettable. The inbuilt departmental and ministerial policy is the perpetuation of a two-tier medical system. This section budgets unequivocally for the fact that the public patient service will remain significantly less attractive to ensure that those to whom eligibility is being extended will not avail of it and will maintain their membership of the VHI. It will maintain the gap between the level of service available to public patients and that available to those to whom eligibility is being extended. This is regrettable coming from a Minister who insists that access to treatment on the grounds of medical need is the guiding principle. This section explodes that myth. It will be obligatory on the Minister to ensure that there is a gap in the standard of health service available to medical card holders and that available to others, yet the Minister claims that the two tier system does not exist. It is unfortunate that the Minister does not take into account the global recommendations of the commission on health funding. That commission recommended a single waiting list for public and private patients. The divisive nature of the health service is being perpetuated.
I reject everything Deputy Creed has said. There is no question of trying to create or perpetuate a system where people in the private sector would be better off. I recently had a letter from a consultant enclosing a copy of a letter to him from a general practitioner who had been unable to get a private appointment for about four months but got a public appointment within three weeks.
That is a selective quotation.
That letter was sent to me last week for my information. The consultant was fed up listening to the kind of stuff we hear from the Opposition.
Rubbish. A Pontius Pilate attitude again.
(Interruptions.)
Deputy Ahern should be concerned about the Mercy Hospital in Cork.
The Minister should circulate the letter.
Could we all purge ourselves of the emotions which are making little of the debate and making little of this House?
(Interruptions.)
If Deputy Browne does not want to listen to the Chair, he has his option. This is a Committee Stage debate on what has been described as very sensitive legislation. You could have fooled the Chair. Is it sensitive or is it not? I do not propose to delay the proceedings but I will be intolerant of any interruption when any Member is making his contribution. Committee Stage allows Deputies to take issue in the normal way but let us not give the appearance of a football match or something in the national boxing stadium to something which is a sensitive matter.
I agree with the Chair. Deputy Creed stated that I had said there was no two-tier health system. I have said no such thing. I have defended, both in Opposition and in Government, the integrated private-public mix which has served the people well and ensured that the very best consultants are available to public patients. Private practice in public hospitals ensures that consultants are available to public patients for most of the day, particularly when consultants do not work outside a particular hospital.
Regarding the common waiting list, the recommendation from the Commission on Health Funding relied on the monitoring of admissions to ensure that private patients were not admitted to available beds ahead of public patients with greater medical need. There would be tremendous difficulty with this recommendation in practice. The decision to admit a specific patient is a clinical decision and must always remain a clinical decision and the responsibility of the consultant. Effectively there would be a common waiting list with private and public patients, but the consultant would decide which patient was due to come in next. For this reason the Government and the social partners believe that public patients would be best protected by ensuring that for non-emergency treatment public beds are available exclusively to public patients.
Secondly, it is very much in the interest of the public hospital system and the public patient to maintain the balanced mix of public and private care in public hospitals. The public patients benefit from the availability of the best and most skilled consultants who can be retained in the public hospital system because of the opportunities for private practice there. Under the new arrangements any increased demand for private care can be met by expanding the number of private and semi-private beds in public hospitals without any disadvantage to the public patient. This expansion will be possible because it will be self-funding. If, however, a common waiting list applied to those beds such an expansion would not be possible and the likelihood is that the focus of private practice would begin to move away from the public hospital. I do not support that and neither did Deputy Ferris support it last night on Second Stage. In the long term this would not be in the best interests of public patients.
Another issue raised earlier which I said I would come back to is the question of in-patient services regulations and who they apply to. These regulations were first introduced in 1976 by Brendan Corish who was then Minister for Health and signed by Richie Ryan, then Minister for Finance. They allowed for charges for in-patient services to all patients entitled to section 52 services. In other words they applied to everybody. The regulations now refer to patients in hospital for over 30 days. It is a matter for the chief executive officer of the health boards to make a decision regarding these patients. This is not a new measure. The practice in most health board areas has been that when a patient was in hospital for 30 days the chief executive officer decided they were no longer entitled to a medical card because they were being maintained in the hospital. That has been the practice right back to 1976. Not very many patients are hospitalised in acute hospitals for longer than 30 days. There is a variation from one health board to another. We are in the process of reviewing the legislation introduced by the Fine Gael Government when they were in power as it affects patients in acute hospitals. As of now it is a matter for the chief executive officer at the end of 30 days to decide whether a patient is still entitled to a medical card. As the Deputy knows from replies he has received to parliamentary questions, this measure has applied in a uniform way to patients in long stay hospitals throughout the country. However there is a variation in regard to acute hospitals.
This is a major announcement by the Minister today. Irrespective of what Government brought in the measure, and I am not interested what Government brought it in——
Why would the Deputy be interested?
I am interested in the medical card holder who as the Minister has stated, is liable to hospital charges. This measure is much more pernicious than the measure relating to the category 2 patient, in other words the man with the hospital services card. That person is liable for a maximum of £125 per year whereas, as a result of this measure, the medical card holder could be liable for up to £1,500 or £2,000 per year if he is in hospital for over 30 days. This is the way the health boards are interpreting the regulation. A medical card holder with a State pension must surrender his pension after 30 days in hospital and that pension could be £40 to £60 per week. That is a blatant discrimination against the medical card holder. Irrespective of who brought in the measure the Minister should move immediately to eliminate this most unfair practice.
Again Deputy Allen is extending the debate. What we are dealing with here in section 3 is whether those who hitherto did not have full eligibility but who now satisfy the requirement are now eligible. Matters extraneous to that are not proper on section 3. The Deputy said the Minister referred to this point but I presume he was courteously replying to a question that was out of order. We must confine ourselves to what is in the section.
With due respect, a Leas-Cheann Comhairle, you were not here when this issue was raised earlier.
Regardless of whether I was here, I know what is in the rules. One does not have to be present to know what is required on Committee Stage. Committee Stage requires of us to consider line by line what is in the section.
The Minister responded and you allowed it. He gave a detailed reply, which was a major departure from the section.
I assume he was responding to a question that was put earlier.
I will conclude by asking the Minister to immediately remove this major discrimination against the medical card holder who is a social welfare recipient. It is most unjust and I appeal to him to move on it immediately. At present some health boards are acting conscientiously and fairly but others, including the Southern Health Board, are hard-pressed for finance and will go on to any lengths to get it.
We are not concerned about any board who are hard-pressed.
For your information, a Leas-Cheann Comhairle, the Minister introduced this subject matter in this section before anyone else said anything about it.
On a point of order, it is only fair that I should explain that this issue was raised on a section dealing with ordinary residents in the State. I said that if it was left until such time as we were dealing with charges — we are still not dealing with charges — I would respond to the Deputies. In order to finalise the matter, there is no mystery here today. The same information was given to Deputy Allen in a letter in April 1991——
That is not true.
——regarding the specific regulations and charges. What I am clarifying for Deputy Allen is that the regulations introduced in 1976 apply to acute hospitals in the same way as to long stay hospitals. I informed Deputy Allen that because there is a variation in different health board areas in regard to acute hospitals I would examine the matter, and we are in the process of doing that. That should conclude the issue and I will not be coming back to it.
I do not want to come back to this matter either. What the Minister said is correct in that we should wait for another section to raise this subject. In introducing the section the Minister referred to eligibility of medical card holders in public hospitals, and that raised the previous problem. I asked if it was appropriate, since he had raised it, to address this problem, and he has addressed it in a mysterious way. He said this is normal practice. It has not been normal practice for medical card holders to be charged by health boards for medical services in an acute hospital. Regulations were introduced in 1976 and amended by the Minister in 1987, allowing him to impose charges on people in another category. However, that never interfered with the rights of medical card holders, which is the only subject we are talking about. Accusations can be made of any Minister, dead or alive, for regulations they brought in, but the basic question is whether the provisions became operational.
That is not related to the health boards.
Deputy O'Kennedy, please do not interrupt.
The Deputy is the chairman of a health board, so I suppose he knows everything.
Deputy Ferris, please do not acknowledge interruptions.
I apologise, a Leas-Cheann Comhairle. My colleague, Deputy Howlin, who was previously our spokesman on health, brought to the attention of the present Minister for Health the matter of a specific hospital that had implemented these charges. The Minister said that the charges were incorrect, he notified the health board of that, and the health board withdrew the charges and refunded the money. It was always intended that people with a medical card with full eligibility in an acute hospital were entitled to services. No chief executive officer, irrespective of the powers held — and chief executive officers do have powers under this legislation and under the 1970 legislation —should be empowered to withdraw a medical card from someone whose income has not changed but who has been in hospital for more than a prescribed number of days. That has nothing to do with eligibility. The legal position is that medical cards are given on the basis of eligibility, and that is provided in the 1970 legislation. It comes within the remit of the Ombudsman and is provided for in other legislation.
The House is not having a full discussion on medical cards. The House should confine itself to the proposal that those who did not have full eligibility hitherto but who may now satisfy residence criteria will qualify for limited eligibility. That is what the section tries to achieve.
I was prepared to wait for the other section that is appropriate to the question we are discussing, but the Minister introduced the subject matter in his grandiose introduction to this section when he talked about medical card holders and their eligibility for services in a public hospital. However, to be orderly, I am prepared to wait for debate on the next section and discuss the matter again. The public of Ireland, whether they live in Deputy Callely's constituency or in another constituency, are entitled to know whether they are eligible for services in an acute hospital if they have a medical card. I shall wait all day, for that information.
The Deputy should wait until the proposal is put that the Bill do now pass, when he can discuss anything.
No, I shall discuss the matter in debate on the section on which the Minister has promised it is appropriate to discuss it on.
The Chair will decide what is appropriate to be discussed in debate on any section — not the Minister nor anybody else. The Chair will decide what is appropriate.
The Minister said that it was not possible to monitor the common waiting list. I draw it to the Minister's attention that the Gleeson Commission examined that issue and provided for full disclosure of information by consultants and for a review of the actual mix of public and private patients being treated on the principle that medical need should be the overall criterion for the provision of hospital services. The issue was addressed by Mr. Gleeson——
What issue was that?
The issue the Minister was talking about.
The Chair will now insist that the debate is confined to section 3. Any Member who does not want to speak to section 3 has that option. Section 3 refers to the inclusion of people who hitherto were excluded from full eligibility but who now, because of residence qualification, may qualify for limited eligibility. That is what is dealt with under this section.
This has nothing to do with residence, this is removing the income level.
It concerns the residence requirements. The Deputy should read the explanatory note to the section.
The House is speaking to section 3, the amendment to section 46 of the original Act, which states that any person of ordinary residence in the State who is without full eligibility shall have limited eligibility for services.
That is what is proposed.
The Minister's explanation for the measure has to do with the inoperability of the common waiting list concept. He said that himself.
The Minister does not decide what is appropriate.
You are totally at sea.
I should not like to be as much at sea as some Deputies are.
The Minister made a worthwhile contribution on the section, and, in fairness, I should have the opportunity to respond to the points he made.
The point I make is that although the Minister said the common waiting list concept was not operable because consultants make clinical decisions, and they are the ones who make those decisions in the final analysis, I feel that clinical decisions by their very nature are decisions made on the grounds of greatest medical need. The essence of a clinical decision is to discern who is in greatest medical need. It is not acceptable for the Minister to suggest that because consultants take clinical decisions, decisions cannot be made on the basis of medical need. Clinical decisions are ipso facto ones that should be made on the basis of medical need.
I recognise that there is a problem in relation to monitoring of the common waiting list. Gleeson examined that problem and provided both for full disclosure of information and a system of annual review of the actual mix. That was the tool offered by the Gleeson Commission and the other commission to make possible the operation of the common waiting list. That was what all of us wanted. I have no objection to a requirement that public beds be used exclusively by the public, but under the Gleeson recommendations the Minister could have had the common waiting list under a common contract without losing the consultants to private hospitals. I do not believe that consultants would decamp in vast numbers. That is my attitude to the Minister's defence of the problem.
The Minister referred to the regulations under section 53 that enable charges to be made, and I should like him to come back to that matter. It is clearly stated that the imposition of charges for inpatient services is to persons who do not have full eligibility — the section provides only for persons who do not have full eligibility, and they are the people who are being charged in the cases made by Deputy Allen and Deputy Ferris.
I wish to deal with the last point first. In a very detailed letter from my colleague, Deputy Chris Flood, to Deputy Allen it was pointed out how those institutional charges work. These are charges which have been in place for 17 years so they are not news.
What about the position in acute hospitals?
All I am saying is that the 1976 regulations apply equally to acute hospitals and long-stay hospitals. There has been a variation and they are not used in several acute hospitals. The fact that they are causing a problem in acute hospitals is being addressed by the Government in order to find out whether something needs to be done. The regulations are the same and the way in which they apply to medical card holders has been pointed out in detail.
On a point of order, I draw attention to the fact that a letter is being quoted selectively. I raised the issue of a 60-year-old person, a pensioner, who was a medical card holder and who was in an acute hospital for more than 30 days within one year at different periods. In that case it was not institutional care or long-stay care that was involved, it was short term care at different times during one year in an acute psychiatric hospital. The Minister should not try to mislead anyone.
I should like to clarify something with the Minister. The 1976 regulations, brought in by the late Brendan Corish, empowered Ministers — and that was amended in subsequent Acts — to make charges on people who were not eligible for full entitlement, people who were not eligible for medical cards. I am sure the Minister did not want to mislead the House, but he said that a chief executive officer had the power to withdraw a person's medical card while that person was in hospital for an extended period. Chief executive officers would not have that power.
They have.
How can a medical card be withdrawn from someone who is entitled by law to it? The goalposts cannot be changed in the middle of the game. How could any Minister or any executive of a health board decide that a person who had a medical card was no longer eligible just because they were unfortunate enough to be in hospital for an extended period? The 1970 legislation does not allow for charges to be made to people who are eligible for free service in an acute hospital. The Minister has been in his Ministry for long enough now — he has been there for four years with the present Government in coalition with the Progressive Democrats and previously in a minority Government — and it is time for him to tidy up that regulation so that there are no anomalies. I shall say no more about the subject.
Whatever the Deputy's view, I am now required to ask that we agree to report progress.
Progress reported. Committee to sit again.
Sitting suspended at 1.30 p.m. and resumed at 2.30 p.m.