On behalf of the Irish Medical Organisation, I thank the Chairman for the opportunity to address this committee. The Irish Medical Organisation and general practitioners have experienced difficulties with the medical card scheme for as long as it has been in existence. Some difficulties are inevitable. Particular difficulties arose since approximately January 2009 when the processing of all over-70s medical cards was centralised. Mr. Timmins has already outlined the situation in some detail and the types of scenario he has outlined have been replicated in doctors' surgeries throughout the country. I am a general practitioner in Cork, Dr. Walley is a general practitioner in inner city Dublin and Dr. Daly is a general practitioner in rural Galway. Irrespective of the part of the country we work in, we have experienced difficulties. The difficulties are not confined to citizens over 70 years of age, although we have had particular difficulties with senior citizens since the centralisation of their medical cards. More recently, however, since approximately June or July of 2009, all medical card renewals in two local health office regions, Ballymun in Dublin and the Rathdown Road region, have been centralised. The problem is most acute in those regions, but in general throughout the country there are difficulties with regard to other particular groups. These include newborn infants of eligible parents, who should automatically be entitled to a medical card. However, due to bureaucratic delays, it often takes many months before those children are deemed eligible by the PCRS, which oversees the medical card system.
With regard to 16 year old dependents in full-time education, they are obliged to apply for a medical card in their own name as their previous cards are automatically deleted on their 16th birthday. This is the case also for citizens over 70. Medical cards have an expiry date and the card is, as far as I am aware, automatically removed from the system. The removal of the card from the system is an automated procedure and does not involve a member of staff of the HSE cancelling the card. Once the card's expiry date is reached, the card is deemed ineligible for service on the PCRS system. The PCRS has outlined that there is only one national list and, therefore, I understand that once the expiry date has passed, the card is no longer valid. We have a situation where 14 and 15 year olds are given laminated plastic medical cards with expiry dates into their 17th or 18th year. They possess a piece of plastic that states they have a valid medical card, but yet on their 16th birthday the card is automatically removed from the PCRS register. They have a valid card, but they are not on the one national list to which the HSE refers to repeatedly in correspondence.
There seem to be particular difficulties in the two local health office regions mentioned with regard to new medical card applications, including for people over 70 and those whose cards have lapsed. The difficulties apply to all regions with regard to dealing with the necessary paperwork for those over 70 and it is difficult to make direct contact with a HSE individual where difficulties arise. Some of the issues are as simple as a change of address and review forms being sent to the wrong address. For example, if someone's card lapses, I get a notification on the fifth or sixth of the month that the person's card is no longer valid. I may be aware that the person moved house six months or a year previously and can see that on my computer system. I know the person's circumstances have not changed and he or she is not working and is dependent on social welfare. However, the person must go through the process of applying again for a medical card. This is often difficult and paperwork is often returned because of missing information.
Every general practitioner in the country has difficulty in this regard and the issue has become even more significant over the past year as the centralisation process advanced. In principle, there is nothing wrong with centralisation provided the end users of the service — the HSE's clients and our patients — get a timely service and can validate their entitlements quickly. Due to the level of frustration doctors were experiencing when making phone calls on behalf of patients who should have been eligible for services, but were not, we contacted doctor members and asked them to give us some data in this regard. Members can see evidence of some of the problems from the submission we made. I will not go through the data in detail, but it is available in the submission.
Some examples of the practical difficulties we have experienced since the centralisation of the offices include problems where elderly patients or families whose medical cards have lapsed erroneously are no longer on the single list referred to by the HSE as the only list determining entitlement. Such patients are, in effect, passed from pillar to post. They cannot get satisfaction at local office level and are given the phone number for Finglas. Some patients have spent €25 or €30 — money they cannot afford to pay — on mobile phone credit to try and get through to an individual. Staff in my practice practically refuse to ring the Finglas office when I ask them, because it is such a waste of time. My staff, like others, are very busy and work on the phone constantly, but they cannot get through to a human person at the Finglas office to try and address the difficulty of a needy patient or family. I am not just talking about access to doctors, but about people's entitlement to medicines and access to the other services that are available by way of a medical card through primary care teams, such as physiotherapy, occupational therapy, etc. We need a valid medical card number to make an application for these services on behalf of the patient.
These issues present significant difficulties, particularly for vulnerable medical card holders, the elderly, people with poor literacy skills, people of poor means, people with limited telephone access, people who do not have access to the Internet, people with intellectual difficulties and people with psycho-social or family problems. The situation for these families is often chaotic. We all deal with them in our various occupational roles. They are people for whom the filling in of forms in a timely manner presents a challenge. The current system is not sufficiently flexible to give us confidence that if we move from a situation where two local health office regions out of 32 are centralised to a situation where, over the next few months, all medical cards for the country will be centralised, the new system will work. Our concern is that the difficulties we currently experience will be compounded. This will create real difficulties for needy and vulnerable patients in accessing services.
In our submission we put forward 17 practical suggestions. Some of these relate to simple administrative practices such as guaranteeing that a minimum of three months notice would be given to medical card holders. This suggestion was also made by Mr. Timmins. We suggest practical measures such as allowing a change of address to be made on-line and putting in place a fast-track mechanism to restore cards cancelled in error. I do not mean a person should be given a piece of paper by someone in an office to say the medical card has been extended. We should decide whether we have a single national medical card list or not. Therefore, somebody must have the authority to grant people a medical card and put them on the single national list. Every doctor has seen pieces of paper given to patients which state their card is valid until further notice. I had 30 of these in my practice last Friday, relating to cards deemed invalid and expired but declared eligible pending the issue of a card. How can a card be expired and issued at the same time? Perhaps somebody can explain this to me.
We would welcome a centralised single national list. The HSE has indicated it is confident it will be in a position to have a 15-day turnaround of all medical cards and that all patients will be able to establish their entitlement to service in a short space of time. If that happens, we will be delighted. However, we have concerns that the kinds of difficulties we have experienced will be compounded if the centralisation goes ahead post haste without the flexibility we feel is required. This would include provisions such as having a lo-call number with facilities for people who may have a hearing difficulty and with some form of accountability in the system. If, for example, I on behalf of my patient feel my patient is entitled to a service, but the patient did not get the forms or failed to return them in time, the flexibility will be there to allow me, or somebody on my behalf, to pick up a phone or communicate by e-mail with a HSE official. The least we can expect is a timely response from the HSE to such queries and to the kind of difficulties outlined by Age Action Ireland and by every practice and doctor in the country. Currently, we cannot get through to a human being to have these difficulties addressed.
We are here for these reasons. There is more detail in our submission in terms of other practical steps we feel could be taken. Ultimately, we all want to get to the same place. That is a position where patients who are entitled to all the services a medical card brings can get those services in a timely manner and through an accountable system. We are happy to meet with the HSE at any time. It made contact with us in writing shortly before this meeting and indicated it would follow up with a phone call with a view to arranging a meeting. We did not receive that telephone call but we would be happy to meet with the HSE on this issue and all related issues.