Health (General Practitioner Service) Bill 2014: Fifth Stage

Question proposed: "That the Bill do now pass."

I support the Bill's passage. However, we are against a very unhappy backdrop in dealing with this matter and it would be wrong of us to let this occasion go by without reflecting on some of the widely shared concerns in regard to medical cards. We are providing for GP-only cards for all children up to the age of six years. Also, we are advised that some 15,300 people who lost their medical cards since 2011 will receive notices by letter that these cards are being reinstated in the next two or three weeks. This, because of the criteria set down, is confined to former holders of medical cards on a discretionary basis, related to hardship caused by particular illnesses, conditions or disabilities. Those concerned must, as criteria No. 2 states, have submitted documentation to the HSE when they were notified that their cards were being reviewed.

There is a significant discrepancy. The Minister of State has cited the figures, as have other Government voices in recent weeks. There is a huge discrepancy between the number of people in the category I have just described - some 15,300 - and the number of medical cards that have been removed under this heading.

Somewhere in the order of 30,000 has been suggested by the director of primary care, Mr. Hennessy. I have no doubt that many people who had their discretionary medical cards taken from them looked at the situation, at what was happening and being reported and decided there was no point in proceeding with the review process. Others among them might not have been able to do so for a variety of reasons including issues of personal competency or ill health. I have already posed the question as to whether people who validly held medical cards under the discretionary heading but did not proceed with the review process will now be excluded from the restoration process just announced. If so, that will compound a very serious situation.

Will there be a process of appeal or review for those who have had their medical cards cut over the relevant period but who do not receive a letter in the coming weeks? What can they do? There are thousands of them - according to the numbers the Minister of State has reported to us, some seven odd thousand of the 15,000 referred to previously. What about those who applied for cards on discretionary grounds over the relevant period, 2011 to 2014, whose applications were refused? This is important, given that the same criteria of assessment were applied to such people over those years as to those who had their medical cards taken from them. Surely they are equally entitled to have their situation taken into account now. These are matters that will not go away. All of the wishful thinking in the world will not set those particular discrepancies aside.

There is also an issue with regard to recompense. The Minister of State has very strongly rejected appeal after appeal from Opposition Deputies. I have no doubt that such appeals are also coming from Government Deputies, albeit in a more hushed tone. It is absolutely essential that for whatever period of time we have to wait for the introduction of universal entitlement that-----

I am afraid the Deputy is straying a little.

We cannot have a body of people, hurt and excluded, who have been doubly hurt by being further excluded, as in the cases to which I referred.

I indicated to the Minister of State before any and all of that presented that I would support the introduction of free GP cards for children up to the age of six years as an integral part of a programmed, timeframed introduction of universal entitlement to free GP care, itself a pillar of what I believed we all wanted to see, namely universal entitlement to health care across the board on the basis of need alone. I am still anxious to get to that point. I still need assurances from the Minister of State that such a timeframe is in his mind and those of his colleagues at the Cabinet table. It is very important that we do not park what this Bill now provides for and allow an inordinate period of time to pass during which we are looking after one body of children up to a particular age, with a very different picture presenting for everyone else. That simply would not be acceptable and I want to make that absolutely clear to the Minister of State. My support throughout has been based on the understanding that this was to be a first step; a replacement first step for earlier first steps which were set aside. I trust that we will hear from the Minister of State very soon how he intends to proceed to continue to roll out access to free GP care for others in the population, culminating ultimately in such access for everyone. That is where I want to arrive at.

In the context of the backdrop of the discretionary medical cards and all that we have had to contest across the floor of this House in recent months, I ask the Minister of State to take on board those particular sores that continue to fester. The fact that there are people who are to be excluded again is wrong. Recompense must be provided. I appeal to the Minister of State-----

I am sorry, Deputy, but contributions must be confined to what is in contained the Bill, not what he would like to be in it.

In confirming my support for-----

The Deputy is not listening to me.

I hear the Ceann Comhairle very clearly.

I have been very liberal. Please do not spoil the party.

In confirming my support for the passage of the Bill I am asking the Minister of State to take on board the appeals I have just made.

I call Deputy Denis Naughten and ask him to confine his comments to what is in contained the Bill, not what he would like to be in it.

I am sure the Ceann Comhairle will be as liberal in his interpretation of that as he was with Deputy Caoimhghín Ó Caoláin, but I will be brief.

All of us in this House, whether in opposition or government, are concerned that we are now going to create a huge discrepancy between the entitlements of children under the age of six years and those over that age, particularly with regard to children with chronic or ongoing conditions. That is the fear that we have vis-à-vis this legislation. The Minister of State has made it quite clear that this is only the first step on the road to universal entitlement and that it is his intention to progress this further. We are all taking him at his word. However, with the announcement that he made during the Second Stage debate on this Bill regarding discretionary medical cards, the Minister of State has created an anomaly which I have described as institutionalising discrimination. I will give one brief example of what I mean and will then sit down.

Take two teenagers attending school, for argument's sake, in Athlone. I use Athlone in my example because it crosses the old Midlands-Western Health Board boundary. These two kids are sitting side by side in school and their parents have the exact same income. One of them resides in County Roscommon and the other in County Westmeath. They are both diagnosed with cancer in June of 2011. The child in County Westmeath got a medical card automatically because of the cancer diagnosis. The child in County Roscommon applied for a medical card, was refused, appealed the decision on the basis of medical hardship but the appeal was not upheld. When the discretionary medical card of the child in County Westmeath came up for renewal under the PCRS, the card was withdrawn because the child did not meet the standardised criteria. With the Minister of State's recent announcement regarding the return of discretionary medical cards to those who had them withdrawn, the child in County Westmeath will get the medical card back. However, the child in County Roscommon who applies again for a medical card will still be judged on the current rather than the historical criteria and will be refused again. That discrimination is continuing and what the Minister of State has now done has institutionalised that. The Minister of State has made a fundamental error in the context of his recent announcement and he needs to look again at the criteria for assessing entitlement to discretionary medical cards to ensure equality of treatment.

I thank Deputies for their contributions to the debates on the various Stages of this critically important legislation which incorporates a public health initiative, of which we can be proud. Despite the great financial constraints and retrenchment that have marked recent years, most notably in the health service, the legislation highlights the fact that we are taking a first step together to reform the health system and put in place, beginning with those under six years of age, universal access to GP services. I thank Deputies for taking in good faith my assertion that the legislation is, in accordance with commitments in the programme for Government, only the first step in the introduction of this necessary service.

Deputy Caoimhghín Ó Caoláin has stated what we are doing is taking place against an unhappy backdrop and I am inclined to agree with him in that regard. We have, to some extent, been struggling to address the issue of medical cards awarded on a discretionary basis and decisions made in that regard. I agree with the Deputy that this is not the context in which we would want to be discussing and deliberating on a universal system of health care. The first priority of the health service must be to deal with those who are ill and need immediate access to care and services. It must be stated that in trying to deal with the various anomalies, contradictions and injustices that arise and the real need among families with sick children and adults with particular medical conditions, we must also begin to consider how best we might introduce a universal system of health care. For many people, including me, the introduction of such a system is ultimately the only way to address the issues to which I refer. We are trying to operate on two fronts and I accept the Deputy's assertion to the effect that this is not the ideal backdrop to what we are seeking to do. However, that fact is not a basis for stating we will delay the introduction of a universal system of health care. Notwithstanding the contradictions, anomalies and injustices that have been thrown up in the context of the existing medical card system, I remain convinced that we are right to proceed with introducing the universal system.

In the context of appeals, those who have not heard from the PCRS by mid-July should contact the HSE about the return of their discretionary medical cards. The PCRS is working through the cases it has in hand in respect of individuals and families and I am advised that it is making good progress. It is anxious to expedite matters, but if people have not heard from it by the middle of July, they should seek to make contact.

What Deputy Denis Naughten said is true in many ways. He referred to institutionalising discrimination, but, as he acknowledged, there was already that discrimination. In that context and if I recall the figures correctly, the rate for the awarding of discretionary medical cards in Cork was 71% above the national average, while in County Meath it was in the order of 68% below the average. The position differed in all other counties in between. That simply cannot be right, fair or just. Some people have stated the rates differed so significantly as a result of, for example, the strength of the advocacy in various areas. I do not know whether that is the reason. No one is ever going to criticise a local health officer for helping a family. Why, in all humanity, would anyone do so? At the same time, however, we, as legislators, and the Government must ensure fairness and see to it that resources are allocated properly. I hope I am not interpreting her words incorrectly, but Deputy Róisin Shortall stated resources should be allocated in a fair and just way, not to the person who shouts loudest. I agree with her in that regard and, ultimately, that is what we are seeking to do.

Deputy Denis Naughten was right when he referred to the problem vis-à-vis people whose medical cards had been withdrawn and then returned and those who never had them in the first instance. That problem has been ongoing for some time, but it will ultimately be solved.

It is being copperfastened.

It is not because we have signalled our intention to develop a policy which will ensure we can actually supply necessary services to people on the basis of their medical need. That policy will be standard throughout the country and it will mean that children in Roscommon and their counterparts in County Westmeath will be dealt with on the basis of their needs rather than, as was historically the case, on the basis of where they live, who is their local health officer, the strength of advocacy or anything of that nature.

I again thank Deputies for their extremely valuable contributions and input. I am delighted to see this landmark legislation being passed by the House.

A Cheann Comhairle-----

I am sorry, but the debate has concluded because the Minister of State has replied.

I just wanted to ask him if he would consider correcting the record.

We cannot enter into a debate on that matter. Unfortunately, the Deputy was not present before I called the Minister of State to reply and it is not possible for her to make a contribution now.

Question put and agreed to.