Health Service Executive.

I welcome Mr. Patrick Burke and Mr. Tadhg O'Brien from the Health Service Executive. Before we begin, I draw witnesses' attention to the fact that while members of the committee have absolute privilege, the same privilege does not extend to witnesses appearing before it. I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House, or an official by name or in such a way as to make him or her identifiable.

The witnesses will have heard the serious concerns expressed by the two previous delegations. The issue is important to the people of the country as a whole and is certainly of vital importance to the members of this committee. We want those who are entitled to a medical card to receive a card expeditiously, and to have a fair and just system throughout the country. The delegates will have to agree that, while the challenge of moving towards a centralised system is a major one, from what we have heard to date the task so far does not seem to have been undertaken effectively. I am sure Mr. Burke and Mr. O'Brien will address that matter.

Mr. Patrick Burke

A number of questions were sent to us in advance of the meeting and I understand they have been circulated and addressed. I have a statement but do not intend to read it out in full.

That will not be necessary.

Mr. Patrick Burke

One of the key things to come across from what other contributors said is that there is a communication issue. There is a view that the model we propose to put in place will centralise all medical card processing but that is not the case so I wish to debunk that from the beginning. The model the HSE will put in place will involve a front office in which staff will directly face the customer. Staff from across the HSE will continue to be available to provide services and give advice and that provision is written into the legislation as regards the over-70s, which states that the HSE will provide all and every support to any individual making an application. Our intention is to make a front office available in accordance with that provision.

Out of every 100 applications, 91 or 92 are in respect of individuals who are, as Dr. Daly said, among the poorest in society. They are eligible for a medical card on the basis of their income and they should immediately qualify. We have more than 500 people in 100 locations assessing those applications and doing the back office processing.

We must provide a better service. I have heard a lot said about the system but the previous system was not a good one.

Did Mr. Burke say it was not a good system?

Mr. Patrick Burke

Yes. The Comptroller and Auditor General looked into the system on a number of occasions and reported his findings to meetings of the Committee of Public Accounts. He always said that the old health boards and the GMS Payments Board systems needed to be reformed. The HSE intends to put the processing of all applications that lend themselves to immediate access to health services into a back office. We want to free up resources to make them available to people who need additional help and support, such as those who are over the income limits but have health or social circumstances that need to be taken into account. There will be challenges for us in delivering that model and we are not helped by the fact that IMPACT has set its face against centralisation in any form. It will not co-operate with a back office operation or with front office backlogs. It will not co-operate by dealing with telephone calls.

We have put a lot of time into putting in place a very good system that provides substantial information to local offices. I will issue an open invitation to committee members or Members of the Dáil to come and see the system in operation. There is a perception that the system will comprise a back office operation with a faceless machine processing applications but nothing could be further from the truth. We have individuals with the competence to deal with clients whose applications have to be assessed on a discretionary basis. We must also take cognisance of the fact that while we have 500 staff involved in managing a service across the country we have an urgent need for staff in other front line services such as primary care teams. We can deliver an amount of the repetitive work through a back office and we can free up staff and make savings.

The HSE has no difficulty meeting with any of the advocacy groups. We met them in the forum in January and we agreed we would meet Age Action Ireland and all the other advocacy groups. I am a little surprised that the IMO suggested I would not meet it. In March last year the IMO wrote to the CEO to talk about centralisation. On behalf of the CEO, I wrote back 11 times and telephoned twice but the IMO was not able to meet me. I have not seen the suggestions on how we might improve governance but I have no difficulty in sitting down with the IMO, working through the issues, whatever they are, and dealing with them. In 2005, as part of an agreement worked out with the Labour Relations Commission we put in place a system that allowed GPs to communicate with us. I checked that system during the week and there has been little communication in four years. Mechanisms and systems are in place to allow people to raise issues but I am not sure they are being fully utilised.

The Government took a decision on over-70s medical cards in November 2008. In a matter of weeks we went live in Finglas processing medical card applications for over-70s based on what was set out in the legislation. We moved to processing in two local areas in September 2009. When we went to those local areas we identified a difficulty in terms of a backlog of client applications that had not been processed. We were surprised that the problem had not been identified before then. We worked on the applications and we are on top of the problem. I set out in the statement the number of applications the central office has handled in the past year, the number of medical cards that have been issued and the number of questions we have dealt with.

We are changing the existing systems. Change is difficult. I accept some of the stakeholders are very concerned about the change. I accept all of the points from the IMO on individual cases it has identified. The IMO suggested that hundreds of clients are eligible for medical cards. I will take that list from the IMO and work on it meticulously. When we centralised applications for over-70s medical cards we also discovered that there were 22,000 clients on the central register in respect of which the HSE was reimbursing GPs but no one had communicated that to us. A balance is required. We can and will work with any stakeholder group to ensure that people who are eligible for the service get it, but we also have to take on board the concerns of the Comptroller and Auditor General to ensure that the system is not abused.

From 1 April we will launch a new on-line application form whereby clients can apply on-line. I mentioned that 92 out of every 100 applications fall under the income limits. The new system will allow a person to enter the data on-line and know within minutes whether he or she is eligible for a card. That pushes the boat out for anyone who wants to help a relative or other person to make an application. There has not been much change in that area in 30 years. There has been much argument and concern has been expressed by the Comptroller and Auditor General about the system and the architecture of the many databases that exist. In a short space of one year we have provided that on-line facility. Even if it is not fully used the on-line facility will take a number of the applications from clients who want to apply who will find out within minutes whether they have an entitlement. It also means that the HSE can take what resources it has and focus them on paying attention to clients who need a fuller assessment of their application.

I dealt briefly with our internal concerns. IMPACT does not agree with centralisation or the local offices supporting the back office. It does not agree with dealing with the backlog. We have to leap that particular hurdle in the current industrial relations climate. That has not helped. A tremendous amount of information is currently available to local offices to help clients and representatives deal with queries. A considerable amount of correspondence and the status of applications is available on-line for local offices to examine in order to help clients. I can demonstrate that to the committee or to a wider group. That has pushed a huge amount of telephone calls and communication on to the back office which was equipped to deal with processing of applications. It has not been resourced to deal with the 5,000 calls we receive per day. Over the course of weeks we contacted some of the local offices to find out whether they were dealing with client queries and we found they were referring them back to the central office.

Issues arise within the HSE. I accept the stakeholder groups have an interest in and concerns about how centralisation moves forward. Our bottom line is that we must provide a better service to customers. We must give consideration to the Comptroller and Auditor General's view on the system. We must provide a more standardised approach. Discretion is applied across 100 offices. We are not satisfied that the discretion is applied in a standardised fashion and we must rectify that. The model the HSE proposes for centralisation is for there to be a back office to handle the processing of all applications but that there would be a front office to deal with customers and spend more time with those who need help in working through their applications. I have covered most of the points. If anything else arises I will deal with it.

If I understood Mr. Burke correctly, he said the issues referred to earlier, in terms of the telephone not being answered and people waiting for weeks to get a response, relate not to the general operation of the facility but to industrial relations difficulties within the centre?

Mr. Patrick Burke

Absolutely. In November 2008 when the decision was made to cease automatic eligibility for persons aged 70 years and over there was a tight window in which to implement the new arrangement, which we did. IMPACT immediately voiced its disapproval with centralisation and instructed all of its members not to co-operate with it. In the course of 2009 we have had opposition to centralisation on the grounds of principle from IMPACT which has directed its members not to support it. That has meant that the model we have talked about where our local offices can help clients by answering queries has not been in operation in the past 15 months.

That is not true.

Before we start to make claims——

Mr. Tadhg O’Brien

On the IR issue——

The claims have already been made, we are just disputing them.

I welcome the delegates from the HSE. I do not agree with the main principle of their argument and I will tell them why. It is vital that this matter be addressed. It is bad enough to introduce a system for the over-70s that does not work as perfectly as we would have liked — we would not be here today were it not for that — but it is worse to introduce it for all 1.6 million medical card holders. One should regard this as an opportunity to be constructive collectively.

When I read Mr. Burke's statement, all I could say was that he was simply not listening. When he refers to a "front office", is he speaking about one in Finglas or in the counties where medical cards have been processed to date? This is a fundamental question. Mr. Burke seems to say that there is help available and that there will be help available locally. Will he explain to the committee who will be mandated to give that help locally? If I have a problem with a medical card and am unable to fill out my application, what will be the position? Many applicants will not be able to apply on-line, although their relatives may be able to do so. Who would be likely to help an applicant for a medical card in County Galway, be that applicant under or over 70? This is a fundamental question and must be answered.

I was at a briefing meeting for the HSE west division a month ago and the various managers of the HSE's divisions were in attendance. While we all accept fully that these are difficult economic times and that resources are very scarce, it arose at the meeting that one of the major savings that would accrue would involve the relocation of staff from the medical card office to somewhere else. On the basis of the funding we were talking about, this indicated there would be almost nobody left. If that is the case in every location, who will I be able to meet? Who will be my guardian angel? If that guardian angel is in Finglas, I am doomed. The HSE was not able to handle the system for the over-70s and it certainly will not be able to handle it for 1.6 million medical card holders. It is simply not on.

My final point was alluded to by Age Action Ireland and Dr. Daly. All of us who have spent a lifetime dealing with applicants for medical cards understand fully that they have certain medical needs. Dealing with them is part of our job and all my colleagues have spent as much time on this as I have over the years. I do not have to tell Mr. Burke or Mr. O'Brien that, at a particular stage in one's life and the lives of one's family, no document ever printed is as important as a medical card. I know people who would be prepared to have money deducted from their weekly wage to retain their medical cards. It is that important to them, so much so that we could not possibly allow the HSE to continue with a system that has not worked for a year and a half or two years even though it was dealing with very limited numbers. The HSE is now to implement that system country-wide. Will the local community welfare officers have any say under any circumstances in so far as discretionary cards or information, including medical certificates that the medical profession must look after, are concerned?

I have many questions but do not want to take up the time of the committee. Will application forms filled by applicants, either on-line or directly, be sent to an address in Finglas directly rather than to the local area offices as the first port of call? The delegates know where I am coming from in this regard. If the applications are sent directly to Finglas, the local offices will have nothing at all to do with them. Why would one seek help from somebody who has not seen one's application form and who knows nothing about it?

My secretary and I spent 11 days trying to contact an official in Finglas whose number I was given by the Minister for Health and Children. I was told to ring the person as a public representative but could not make contact for 11 days. I rang staff in the HSE at every single level and have a document detailing my calls for anybody who wants to see it. Two officials at a very elevated level told me they did not see the communication from the Minister and asked me to fax it to them. In other words, they did not know the Minister had sent out a list so public representatives could contact a person in Finglas. We could not have trust in such a system.

I do not mind saying the granting of a medical card does not concern me and the delegates because, for the time being, at least, we will be paid for the work we do, but we must consider the poor person at the end of the line who must present himself to a doctor when he knows his medical card is gone. If he tries to ring Finglas, as directed, he cannot get the ear of anyone. I assume that the two delegates, who have spent a good deal of time in the HSE, understand the psychology involved and the pressure on people. If they do not understand it, we are going nowhere.

There are two elements to this issue, one of which concerns communications, processing and efficiency. However, I want to focus first on the more crucial one, namely, eligibility. If we can get the processes right, cards will be issued to the nine out of ten applicants who qualify on income grounds but I am concerned about those who do not qualify on the basis of income. Dr. Daly referred to the system being based on medical need. It is not just an automatic system according to which one qualifies or does not on the basis of income. The people to whom I refer are the really vulnerable ones who will lose out under the centralised system. Let me focus on them first. Exactly who decides whether they are eligible for a medical card?

Until now, I and people I know were very satisfied with the system that obtained locally. In attendance at today's meeting there have been public representatives from all sides of the political spectrum, delegates from Age Action Ireland, which represents older people, and general practitioners, who deal with this issue daily. We cannot all be wrong and we are all experiencing problems with the system.

Where a general practitioner encounters an applicant whose income is above the threshold but who has a long-term, chronic illness that may not be on the list of long-term illnesses meriting automatic entitlement, will the application just be sent to somebody in an office in Finglas who will never be able to deal with the general practitioner and who may have to deal with a large pile of applications? I am worried that people in a back office who have no experience or knowledge of applicants' circumstances and who have not time to consider them will decide the applicants to whom I refer will not get a medical card. Deputy Connaughton is correct that they are the most vulnerable.

Before I will be satisfied with what the HSE proposes, I will need absolute assurance that there will a human being considering cases humanely with a view to making fair and compassionate decisions. This is the kind of system that is supposed to exist under legislation regarding medical cards.

Many issues arise over the application process and the difficulties people encounter in this regard. The delegates are saying the IMPACT directive not to answer the telephone was being applied all of last year. This is certainly not my experience. In recent weeks, a difficulty has arisen for public representatives in a variety of areas, including in respect of social welfare and local authorities. Up to that point, the issue was not about unions stonewalling the system and that is the experience of others.

I refer to issues raised in earlier submissions and to other information we have. Why does the centralised list differ from the information available both to front-line HSE staff and GPs regarding who is eligible? If applicants are not on the list, does that mean they are not entitled to a medical card and if doctors write a medical card prescription for them, they are doing something wrong? Where people's cards are being renewed and their circumstances have not changed, can they retain their entitlement to a card until the process has been completed? These practical issues affect people on a daily basis and we need clear answers.

There is a contradiction in the experience of GPs and the reply we received to a parliamentary question on 3 March which stated, "Medical card review and renewal forms are issued to medical card clients three months in advance of their eligibility review date...Clients are requested to return completed review forms" at least one month in advance of this date and if they have not done that, a reminder letter is sent out. Is that reply true, given it does not appear to be the experience of those dealing with medical card patients? What is on the computerised system? Why is it at variance with what appears to be the factual situation? Why did a GP in my constituency, who lives close to me, have a person standing in front of him or her having been told by the HSE the person was dead? Why did that happen to that doctor? Why are the systems not working?

I also welcome Mr. Burke and Mr. O'Brien. I reiterate the point made by Deputy Jan O'Sullivan. The Age Action Ireland presentation highlighted that clarification is needed about whether the over-70s medical card remains active during the processing of a renewal. Is it active even if the person fails to fill out a renewal form? Is a period of grace given?

I do not say the service provided by my local office was perfect. However, if I was contacted by a person awaiting a medical card, I could pick up the telephone and speak to the person dealing with the application and he or she could tell me, for example, that it would take three or four weeks. While that was not great, I could at least tell the person the application was in hand and it would take three or four weeks to deal with it. In addition, if there was a genuine emergency where someone was given a dreadful diagnosis and needed a medical card quickly, it could have been processed quickly. That was an important local service. I appreciate Mr. Burke's comment that backlogs in some areas were not acceptable and improvements could have been made.

However, the biggest issue I have relates to the discretionary card. There are 80,000 discretionary cards. I was alarmed by one comment made by Mr. Burke in his presentation. He said the HSE wanted to standardise discretionary cards. I cannot understand that. People's incomes are particular to themselves, their medical conditions are unique to them and their entire family circumstances are unique to them. The community welfare officer was important in assessing circumstances on the ground and that was another reason the local office worked well. How can the HSE bring about a situation where there would be standardisation of discretionary cards? They are mutually exclusive because if the cards are standardised, they will not be discretionary. I would like Mr. Burke to deal with this important issue.

I refer to the industrial relations issue that arose in late 2008 when the centralisation of applications for over-70s medical cards came into play. Mr. Burke outlined the functions of local health offices but I was contacted by staff from my local health office in late 2008-early 2009 because they did not know what was their role. There was a distinct lack of communication. Mr. Burke said this was sprung on him and he had to get people together quickly to get a system up and running. Given the speed at which the decision was arrived at and given perhaps officials were caught out, did this dreadful lack of communication mean staff in local health offices did not know what they would be doing and this led to the industrial relations problems? I acknowledge a new problem has arisen since. The initial problem emerged on the ground in my locality and I was approached by the staff who sought clarification about their role. Mr. Burke outlined their functions and they still have a significant role in advising people about eligibility requirements, tracking their applications and so on. Of the 500 employees in 100 local offices, how many will remain in place to do what they did previously? How many will be redeployed? What savings will be generated in regard to the employee count?

The IMO's 16-point plan contained many good suggestions, particularly regarding the registration of letters in order that documents are not lost. Mr. Burke stated he wrote 11 letters and made two telephone calls to the IMO in this regard, which is at odds with what the organisation's representatives said. They want to meet HSE officials under the auspices of an independent third party. Mr. Burke said he has written to IMO officials 11 times and telephoned them twice. Something is amiss and I would like him to clarify the position.

Did the Finglas office send the letters?

Members, officials and representatives of interest groups are here for one reason, namely, to ensure people who need a medical card are provided with an efficient service. That is what this process is about. I will not go into my experiences regarding the Finglas office with elderly people arriving at my door not having heard anything one month after their medical card was due for renewal and having to constantly engage in 25 to 40 minute telephone calls only to be told they left X out of the application form. No one ever contacted them and that is outrageous. I acknowledge Mr. Burke did not make the decision but throughout this submission he referred to a new business plan to centralise the medical card application process. What was the thinking behind it? I could not agree more with Deputy Flynn. How will the HSE "standardise flexibility"? The fact it is flexible means it is not standard. Is the intention to release staff or to save money or to ensure the discretion available to staff at local level is removed? What is the explanation for this? This service clearly worked well, yet the HSE has chosen to dismantle it.

Like Deputy Jan O'Sullivan, I did not have a problem getting through to my local office up until recently. What Mr. Burke said about the unions is not quite as he stated. We did not have a problem with local offices, which were extraordinarily efficient, and when the staff had the applications, they could tell people what was happening. However, in the main, applications are being forwarded to the Finglas office and the difficulty is getting through to staff there and dealing with them. Can all medical card applications be processed through this office? How long will the HSE need to provide an efficient service to cover the three areas that are supposed to transfer to Finglas? Does it have enough people? How will all the telephone calls be answered? We cannot get an answer.

I understand the point about on-line applications but this involves people who do not generally have computers. They did not grow up in the technology era and are not able to use them. They are often very reluctant to disclose their income to their families and this does not help the situation.

Why did the HSE dismantle a system that worked perfectly? When will the service operate in an effective manner? What is being put in place to overcome the hurdles? What do the delegates mean by "standard flexibility"?

I welcome Mr. Burke and Mr. O'Brien. There appears to have been a major breakdown in communication on all sides, including the HSE, the IMO, the general public and public representatives. We all seem to be on a different wavelength and it must be rectified as soon as possible. I do not have a problem with change if it is for a better service. I have not had problems with my local office but various people have said there were anomalies and different standards throughout the country.

The presentation states that applications for medical cards will be processed in 15 days. Does this refer to the new system being introduced in April or is it for the over-70s? What is the timeline for processing applications by the over-70s at Finglas? My experience is that it is certainly not 15 days.

Deputy Connaughton asked whether there would be a front office service in local offices. I do not see how somebody at the end of a telephone in Finglas can decide whether a person is eligible for a discretionary medical card without meeting that person face to face. I do not have a difficulty with those who fall within the income limit because that requires a standard procedure which can be performed by a robot. However, a person with a specific medical need must be able to sit down and explain his or her case — it cannot be done over the telephone.

I agree with Deputy Jan O'Sullivan about review letters. We need to ascertain if those letters are being sent out countrywide. Are different practices being followed in different parts of the country?

I welcome the on-line service because many services can be provided in this way and it results in a speedy response. However, I share the concern of Deputy Kathleen Lynch over the fact that many people do not have ICT skills and do not even possess a computer. Many people aged over 70 do not even have a mobile telephone so will not be able to give a number for the office to send them their reference numbers and so on.

I have spoken about IR issues before. We are told that the current IR difficulties relate to duties outside the original contract but if it is my job to answer a telephone and I do not answer it then I am clearly not doing my job. The people in the offices are supposed to process applications so if they are not doing that they are not doing their job. It is happening in passport offices around the country and something will have to happen very shortly to address it. This matter affects some of the sickest people in the country, who are waiting for a medical card to access treatment but are being held to ransom. It is very unfair and cannot be allowed to continue.

Can the delegates clarify a comment they made about industrial relations? They said the IR difficulties in 2009 only existed in Finglas and did not apply nationwide as they only related to applications by the over-70s. Is that correct?

The delegates said that the long-term illness scheme will continue for people who qualify. Do they have a figure for the numbers who avail of that scheme?

I welcome Mr. Burke and Mr. O'Brien, whom I know from a previous life. I apologise for not being here for the presentation but I have read as much of it as I could.

I said earlier that I met community welfare officers today. They are concerned about the lack of a face-to-face service. This is part of the service they offer to patients, especially those who have other issues in life. The community welfare officers need to understand clients' social situation and any changes in their social situation due to marital disharmony, separation and so on. We all know that people live apart for a long time before the law recognises the fact. The form to be filled out has many pretty colours and an awful lot of boxes. As we know, if one box is not completed correctly the form does not return. Nobody knows about it and people have to try to get through to the office to find out what the problem is. That has been a recurring difficulty.

At a meeting of the front bench this morning I heard about a person who spent €28 of mobile telephone credit listening to machines, without getting to talk to a human being. That is very upsetting for people. Community welfare officers provide help with the form and can tell people what they are entitled to. They can suggest giving additional information to help their case. However, none of that is available at the moment and I would like to know how the HSE intends to overcome the problem.

Community welfare officers want the brakes put on this programme and I agree with them, at least until the problems are sorted out. It involves a complex assessment and there are four or five different categories of medical cards, such as doctor-only cards, discretionary cards and the normal medical card. What analysis was carried out prior to the introduction of the new system? What analysis was carried out into the previous system and what problems were identified with it? I would like to know who carried out the analysis and where the relevant report is. One cannot hope to move a broken system into a centralised system without first fixing the broken system. What comparisons were made between the east coast and the rest of the country? Why is it that 49% of the population of Donegal have medical cards while the figure in Dublin is 22%? Is it because community welfare officers are not available to patients in Dublin?

Why can applicants not make contact with assessors to iron out queries and to find out whether their cards will be issued? Would a standardised means test improve the process? Is the system not working because of a lack of staff? Has there been a 200% increase in medical card applications in the past two years? That would not be surprising given the huge increase in unemployment in the changing economic environment. From a political perspective, it is disgraceful that if a person earns a little more than half the minimum wage he or she will not get the medical card on a means-tested basis.

Community welfare officers can take into account a person's health and social circumstances, as well as other factors such as dyslexia, illiteracy, visual impairment, arthritis, dementia or depression. Mr. Burke mentioned in my absence that he spoke twice on the telephone with the IMO and that 11 letters were issued. Could he specify the nature of those letters? Was it about medical card applications or other aspects of the medical card scheme? Does he have a problem with the suggestions made by the IMO, which others present have found to be reasonable? Which suggestions does he have a problem with and for what reason? It would be helpful for us to know that.

I will ask Mr. Burke a direct question and he can answer it in whatever way he feels appropriate. In the past the VHI controlled demand by limiting supply. To me this smacks of more of the same; putting as many barriers in place as possible to people getting medical cards who are vulnerable, sick and chronically ill. It is hoped that doctors will look after the patients, which they do, because they have a relationship with them, but pharmacists cannot dispense as they will not get paid for the drugs which sometimes are expensive. Now the doctors tell us they will not write a GMS prescription if a medical card is invalid. People will end up in hospital. We saw a case on television the other night where that happened. There will be many more such cases. That approach does not just raise questions about the ethics and morality of it but it is a case of being penny wise and pound foolish. I hope the delegates will be able to answer all my questions and that the Chairman will afford them the opportunity.

I certainly will afford them the opportunity.

We are talking about patient care. We are all on the same wavelength in that what the HSE, committee members and those at the front line want is that we have an efficient means of ensuring that everyone who is entitled to a GMS card receives it expeditiously.

Mr. Burke referred a great deal to freeing up resources. We could consider who carries out the assessments. Currently, we have social welfare officers, community welfare officers and local authorities investigating people for social welfare purposes, health service and education grants. Much duplication is involved and resources could be freed up if all of those assessments were amalgamated. It is proposed that we introduce a form of self-assessment, that people send in the information and a decision is made within 15 days. That would be good in the case of people who would be able to satisfy the HSE as to their means and ability to fill in forms using information technology. The classic example is a person who is an employee and has a P60 and can prove he or she is under the guideline income. My concern is with people who are self employed, especially those in the farming community, who could have difficulty putting together a satisfactory explanation of their real income. What facility will be in place for them to ensure they get assistance? It is not satisfactory for them to send a form to Finglas and for it to be returned to them on the basis that it contains insufficient information. From the figures supplied it seems that 13% of forms were returned due to insufficient information. That is a high percentage.

The question of hardship and the discretionary GMS card is one of some importance that needs to be addressed to ensure patients are properly looked after. Very often they are people who leave hospital and need a particular service or medicine that might be so expensive that they cannot afford it. They might have quite a good income but their circumstances might result in hardship and prevent them from meeting their needs. We must find some way to ensure that the application of such persons for a medical card is dealt with expeditiously.

While it might not be relevant to today's meeting, in the context of saving resources a great deal is spent on looking after people in hospital and elsewhere who had they been allocated a medical card on application it might have saved the Health Service Executive the hospital bill because they might have been maintained in their own community.

We were informed that the percentage of unsuccessful applicants is less than 3% which appears satisfactory. I am all in favour of pushing out the frontiers of information technology but only on the basis that we provide a service at least as good or better than the service we have in place. I would not consider the introduction of a new system to be justified purely on the basis of saving resources especially if it will create new hardships for people who did not experience difficulty in the past.

Mr. Burke indicated in his submission that GPs have access to weekly updates. He was present for the comments made by the IMO in its presentation. A divergence in view is evident. The IMO is not satisfied with the type of information it gets from the HSE. A valid question was raised by the IMO. I welcome the fact that the HSE saved €5 million by getting the names of people who were not entitled to a medical card off the list more expeditiously than was the case in the past due to computerisation. However, the point that was raised earlier about newborn children and people whose cards have been called in for review is also valid. It is important that patients are not deprived of a medical card while they are waiting for their applications to be processed. I favour the use of information technology. I have an open mind on the matter, but I would like to be assured that the interests of those who do not have easy access to information about their means and those who suffer hardship would be looked after and that they would not be any worse off than they are currently. Whatever system is introduced we must ensure that patients receive their medical cards expeditiously and that those suffering hardship are dealt with in a user-friendly way.

In his presentation Mr. Burke indicated clearly that the systems failures we have seen in recent months since the work began in Finglas relate to industrial relations difficulties, and that is the cause of the problems with the centralised system. Does he see any possibility of proceeding with the entire centralisation programme in advance of a resolution of those industrial relations issues?

Mr. Burke also outlined that the centralisation process would result in an annual saving of approximately €10 million. Where will the savings be achieved since the personnel dealing with the medical card applications are for the most part permanent staff? He referred to 140 whole-time equivalents being added to the team in Finglas to deliver phase three. It appears that 360 other people have been working in this area. How many of them will be retained in local offices to provide the type of advice and back-up service to which he referred in reply to Deputy Connaughton?

Mr. Burke pointed out that in the assessment of the over-70s, a total of 12,000 plus medical cards were returned on the basis of the applicants being over the income threshold. Did he refer to 32,000 cards? In response to a parliamentary question I asked some time ago the figure of 10,000 was mentioned. Will Mr. Burke explain where the 32,000 cards came from? I presume their cost was very substantial.

I agree with colleagues on all sides of the House who have been raising questions about discretionary medical cards. These comprise an area of particular concern. Very often discretion is required because, although applicants' incomes may be marginally over the limit, their circumstances may be very tragic, pressing and urgent. It is essential that their cases be dealt with expeditiously. In the system that the HSE wants to create and the model system towards which it is moving, at what grade would a decision be made about discretionary cards? How many staff in the operation in Finglas would be empowered to make a decision thereon?

Mr. Patrick Burke

I will pick up on the last point, which is probably one of the most serious. It concerns the question of who will be the guardian angel. The guardian angel will not be in Finglas but on the ground in local health offices, including in Galway, as part of a primary care team or as a member of our staff.

Can they make the decision?

Mr. Patrick Burke

We want to make the system more efficient. The one very positive point from today is that everyone agrees we want an efficient system in which every person eligible for a medical card can get one very quickly without question. We want to be able to focus on individuals whose applications require more attention.

Will the application be sent to the so-called guardian angel in that case? That is a key point.

We will be here all night if we interrupt the delegates.

That is the key point.

We will get clear answers.

Mr. Patrick Burke

The system will not work unless we have guardian angels on the ground making sure they assess applications properly. Since last January we sought to meet officials from SIPTU, whom I have met on occasion, and IMPACT with a view to talking to the people who currently have competence in respect of the guardian angel role. I cannot make that decision, in Finglas or anywhere else. In other words, for us to size and be clear about the responsibility and numbers involved in the guardian angel role on the ground, we must talk to the people who have a competence in that regard. I refer to the existing community welfare officers, the people on the ground who do the job at the present.

One must consider the position before the process even started last January. Deputy Reilly said he met SIPTU officials today and that they want to stop the process. I met SIPTU officials more than 15 months ago and they wanted to stop the process then.

The word was "defer" rather than "stop".

Mr. Patrick Burke

I do not want to get hung up on semantics. I just want to be clear about the fact that our data suggest 92 of every 100 applications are in respect of clients who are among the most vulnerable and who obtain a medical card immediately. Attention must be focused on those individuals whose needs require more attention, be those needs medical, financial or associated with the litany of circumstances presented to us today. There are people across the country competent at assessing those applications.

To be clear about the resources we need on the ground, we need to talk to those staff and size, agree upon and be explicit and up-front about their role in assessing eligibility for discretionary medical cards. The same applies to the fuller front office role. I refer to applicants who want help in filling out application forms and in establishing their other entitlements, including whether they are entitled to a long-term illness book if they are not entitled to a medical card.

To agree on the role of the guardian angel, we cannot, in Finglas or elsewhere, decide unilaterally how he or she will operate. I use the term "guardian angel" because the role was described as such by Deputy Connaughton. We must sit down with the people who are competent in this regard. We have been blocked from doing so for 15 months. We have issued an open invitation to IMPACT and SIPTU with a view to talking to their officials and the people they represent to agree on and seek their input into sizing the nature of the resource required.

Mr. Tadhg O’Brien

To answer Deputy Connaughton's question, the front office will be in Galway. There will be one associated with every primary care team in the country when we convert. Professor Drumm has been present at meetings of this committee on occasion talking about the reconfiguration. The front office will have a computer linked to Finglas. The front office official, be it a community welfare officer, clerical officer or otherwise, will be able to take the applicant through his or her problems. This is our aim. There would be no front office person in Finglas. That is the question on which the Deputy wanted clarity.

Rather than going to the local health office, does one go to the primary care team?

Mr. Tadhg O’Brien

We hope one will be able to go to the primary care team eventually.

What is to happen in the interim, during which there will be a hiatus?

Mr. Tadhg O’Brien

In the interim, one will go to the local health office. There are people employed not only to deal with medical cards but also to deal with any query. Any person who works for the HSE, be it a clerical officer or administrative officer, should be able to answer any query by the public, regardless of whether it concerns hospitals, primary care or other matters.

We have industrial relations issues at present.

That is not the reality according to my colleagues around the country.

Mr. Tadhg O’Brien

Not at the moment.

One goes back to the local health offices, which do not have the information and do not know why the applications have been declined. One ends up making numerous telephone calls and when one eventually gets through to somebody one is told some part of one's application form is not filled out correctly.

We have had very lengthy contributions by many members.

That is fine but let us have clarity and accuracy in the answers.

Let us hear the response.

Mr. Tadhg O’Brien

If the Deputy looks at page 5 of our statement, he will note we recently launched a new customer-focused facility that provides all HSE local health offices with visibility, for the first time, to the national database of medical card schemes, including historical records. They are allowed, for the first time, to track the current status of applications and reviews being dealt with in Finglas. This is new and positive. The local health offices currently have the power and the primary care teams will have the power to guide those with no on-line facility, of whom there are many, through the on-line application process.

Why did the HSE not route the over-70s through that system at the beginning?

Mr. Tadhg O’Brien

We had not got it in place.

In that case, the HSE put the cart before the horse and gave the system a bad name before starting.

Mr. Tadhg O’Brien

The bad name would have arisen when the industrial relations problems arose and the letters were sent to every member of IMPACT stating there is to be no co-operation with centralisation. I got the letter myself and the information is on IMPACT's website.

The statement looks great and Mr. O'Brien's and Mr. Burke's presentation thereof is even better but I need to know what they will do to solve the problem if someone over 70 has a difficulty tomorrow morning with his or her medical card. Clearly, nothing will change as a result of the statement or the delegates' presentation. Will the system change and when will the service be better? Will it be this week or next week? This is really what we want to know.

Mr. Tadhg O’Brien

The service will be better when we sit down with officials from IMPACT and the IMO.

For 18 months, we listened to Professor Drumm telling us continuously that the Irish Pharmaceutical Union was responsible for the awfulness of the service, which was actually quite good. It is trotted out at every hand's turn that the problem is always someone else's fault.

Mr. Tadhg O’Brien

We are not saying that.

I am anxious to let Mr. O'Brien finish.

A couple of specific questions have not been answered. Are we to have a vote at 6 p.m.?

If we let the delegates deal with the questions that have been asked, we can try, if time allows, to allow some supplementary questions. I ask that there be no more interruptions.

Mr. Patrick Burke

It is not everyone else's fault. I accept upfront that with any system there is a period within which there will be teething problems as it beds in. Some of those issues are my issues and it is, therefore, not someone else's fault. However, at the same time, I can demonstrate what has happened in the central office over 15 months, including the number of applications and reviews that have been processed, the number of cards that have been issued and the number of contacts staff have had with the public. In other words, there have been many positive developments there. I do not say it is everyone else's fault but I am setting out that there are circumstances that are pushing all of the public across the country to ring one office. If we have 40 people processing applications and eight are put on the telephone, at any point 40 calls could be holding and customers will be unhappy. We must address that issue before the end of April. We also have to address the fact that any application we receive must be dealt with inside 15 days before the end of April. We did not come here to say it is somebody else's fault. We have responsibilities and there is no point saying to the committee it is all our fault. There are other issues about which we have to be upfront and deal with.

I asked three specific questions, which have not been answered.

Can Mr. Burke deal with the specific questions?

If this is not dealt with by the end of April, what happens?

Can we have answers to the questions we asked first before additional questions are taken?

Mr. Tadhg O’Brien

Mr. Burke will answer some and I will answer others. With regard to the clarity required on the standardisation of discretionary cards, one county issues three per 1,000 head of population and another county issues 40 per 1,000. We are trying to standardise and get rid of anomalies. There is a need for discretion but the discretion in Donegal has to be the same as the discretion in Sligo and we need standardisation across discretion. Discretionary cards will continue but the staff in the HSE will know that there is not a difference in rent supplement between Donegal and Sligo. That is what we mean by standardisation.

Mr. Patrick Burke

When a card is due for review, a letter is dispatched to the client three months in advance of the review date. A reminder is sent to the client one month in advance of the review date. If we get a communication back from clients, they retain their eligibility until the application is assessed.

That did not——

Will Mr. Burke address his responses though the Chair in order not to provoke responses from members?

Mr. Patrick Burke

That is the policy. We had one instance in January of this year where we issued a renewal letter to clients. We also include an application form in all renewal letters we issue but we did not in these cases. When we sent the second letter advising the clients there was a month left, we were alerted to the fact that they had not received the review letter. None of those individuals lost eligibility and we sent the review letters. That is the standard. All the review letters are now posted up on the system and any HSE staff member who looks at the file on-line can read a copy of the letter issued to the clients. That is the policy.

A question was raised about the long-term illness scheme. Approximately 100,000 long-term illness clients are listed, while 68,000 clients use the scheme every month. The balance of the clients may have a medical card. Clients have eligibility under more than one scheme.

I have no disagreement with the list of suggestions made by the IMO. I have not seen it and, therefore, I am not sure what is in it but I have no difficulty in working through the list comprehensively and putting responsibility wherever it sits to deliver them. With regard to the communication with the IMO, the organisation wrote to the chief executive officer in March 2009. I responded in April on behalf of the chief executive officer and asked for a meeting on centralisation. I also proposed in that letter that we would have a two-item agenda. As well as dealing with medical cards, we would also deal with out-of-hours claims. That letter spawned 11 letters and no meeting ensued until 21 September. In the intervening period, there were 11 letters and two telephone conversations in which I outlined I wanted to meet about the two items on the agenda — centralisation of medical cards and out-of-hours claims. I met representatives on 21 September. I then met an IMO deputation locally on 25 November and agreed I would set up a separate forum for the local IMO representatives to discuss and work through any issues they might have regarding centralisation in those two local areas. That is a commitment I stand over. I have no difficulty working through whatever list is there and working through the issues. I have not seen it.

Was an analysis conducted? If so, who carried it out and where is the report?

Mr. Patrick Burke

The initial analysis of the medical card system was conducted by the Comptroller and Auditor General at the start of the decade. He looked at the architecture that existed for managing medical card registration three times. On each occasion he came back and suggested — he did not say it was over controlled — a system that had all of these databases around the country registering clients and trying to stay in sync with a national database made no sense. From that point in time, we looked at what was the best architecture and developed an IT system, which is an enterprise system. It was selected after a review internationally of all the systems to be used as the back end system for NIMIS, the national integrated medical imaging system. This is a comprehensive enterprise system and it is continually in development. We sat down earlier this year with some of our staff before the industrial relations difficulties kicked in and we asked them what they wanted to help clients on the ground and we have delivered all the functionality. However, the industrial relations difficulties became serious in September after the two local offices were centralised. We found that from September onwards the number of telephone calls we received escalated to almost 5,000 a day. They were unrelenting and that has not ceased.

I am perplexed by the reference to NIMIS. What has that to do with medical card applications?

Mr. Patrick Burke

Without going into a long dialogue regarding medical card applications over 30 years, a system was in place where each of the former health boards had its own medical card register. There was one national list, which was overseen by the former General Medical Services (Payments) Board. That is the list from which GPs have been paid since 1989 by agreement. There is one central list of clients who are eligible from which GPs are paid. On a monthly basis, all the old systems fed into that system. It also meant the local systems could request a plastic card to be issued. We identified in the course of the project a number of instances were plastic cards were requested but the registration never followed through. We have completed an analysis on that and that exercise will be tightened up quickly. If capitation arrears are due to a GP, he or she will get paid. There is no issue in this regard.

However, the issue is these are tight times. We will not get funding to fix architecture which is broken and which was judged to be broken in the earlier part of this decade. For that reason, the system that will be in place for registering clients is that single system with 3.2 million clients registered on it. It gives GPs, pharmacists, primary care contractors and hospitals one view of a client.

I do not understand where imaging comes into it. I thought that related more to X-rays and other procedures.

Mr. Patrick Burke

There is a significant project for the HSE to procure a national imaging system to hook together all the X-rays in all the hospitals across the country. As part of that imaging project, a central system had to be selected. The system in place in the HSE in Finglas is the system selected.

How many of the 500 employees across 100 offices does the HSE expect to be able to redeploy?

We will take three or four supplementary questions.

I am still not clear on whether the guardian angel can make the decision or whether he or she is just feeding information to Finglas, where the decision is to be made. That is a crucial question and I want absolute clarity on it.

Given the problems we have heard about today and the industrial relations unrest, is the HSE to go nationwide with the system for the under-70s medical card next month or the month after, as scheduled?

Is it the receptionist for the primary care team who will take the applications for medical cards?

Mr. Tadhg O’Brien

I will answer some of the questions and Mr. Burke will answer the others.

The local person will take the application. It will be done locally and will eventually be done through the primary care team. We will set up a standard regarding discretionary cards. The discretionary card will not be dealt with by some receptionists locally.

There are about 450 staff employed in the 32 local health offices. We hope approximately 150 staff will be required for Finglas and that the balance, 300, will be used for front-line services, such as manning primary care teams, clinics, and so on. The saving involves not having to employ the additional 300.

Who will deal with the applications locally? We still do not have an answer.

We are not asking who will receive the applications but who will make the decision thereon.

Mr. Tadhg O’Brien

Some 90% of the decisions will be made electronically. The discretion will be——

Mr. Tadhg O’Brien

By the computer.

Is that where the application goes?

Mr. Tadhg O’Brien

It will go electronically from local to national.

What will happen to the remaining 10% of applications?

Mr. Patrick Burke

We have decided to roll out the system nationally, with all applications coming to Finglas in April. We made that decision in November or December. The intention was to have our staff in place and the wherewithal to deliver the service. The current industrial debacle has prevented any transfer of staff and we have not been able to put them in place. This April, we will concentrate on making sure all the applications that currently go through Finglas are dealt with fully. We will roll out the on-line application system so any one of the 92% of clients we talk about can use it if he wants. The balance will continue to go through the local offices until we discuss, with IMPACT, SIPTU and others, the configuration for those guardian angels on the ground and what the front office will comprise.

In terms of the standard flexibility, who will make that decision? Will it be made in Finglas or locally?

We need to refine that question a little because it is quite clear there is a desire to have the decision made locally. However, it is not quite clear who the HSE envisages should make it locally. Who does the HSE want to make the decision in the local system?

Mr. Patrick Burke

To an extent, we are probably now jumping the gun. We said we want to have a conversation with the staff who currently do that exercise, the community welfare officers, to decide the scope——

They only do it in some parts of the country and do not do it across the country as a whole.

Mr. Patrick Burke

What we want to have is a standard service across the country. To have it delivered in each of the counties, we need to talk to the local officers who deliver it at present and agree on who should make the decisions, who should be involved and their role. We have been prevented from doing so for 15 months and need to do so. To answer all the questions that are being asked, we need to work through that process and come back with explicit answers as to how many officials will be in place, their role, their authority and the decisions they will make.

May I ask one further question?

Who does Mr. Burke want that person to be? Clearly, this will influence the outcome.

I do not believe he is going to tell us.

Having listened to Mr. O'Brien, I want clarification on the standardisation issue. If County Mayo has the same number of unemployed people as County Donegal, does Mr. O'Brien expect the percentage of discretionary medical cards issued in both counties to be similar? Is this the standardisation he is referring to?

Mr. Tadhg O’Brien

The reason for giving a discretionary card in Mayo should be the same as that in County Donegal. At present, the reasons discretionary cards are given are different across the 32 local health offices.

Those criteria——

Mr. Tadhg O’Brien

Historically, the system was built up from the former health boards and former county councils. What we want is a standardised approach to issuing discretionary cards.

Can Mr. O'Brien tell us what the criteria are?

Mr. Tadhg O’Brien

There are 40 different criteria. In one county, one might receive a medical card for one reason and in another county one might receive one for another reason. We want to standardise the system and get rid of the anomalies.

Has that formula been worked out yet?

Mr. Tadhg O’Brien


Will Mr. O'Brien let us know as soon as it has been worked out?

Mr. Tadhg O’Brien

We need to sit down with the staff.

Surely the HSE has to decide on that. The HSE cannot blame IMPACT or SIPTU——

Mr. Tadhg O’Brien

I am not blaming IMPACT.

——for the fact that it has not decided on the criteria.

I am sorry to harp on staffing. Of the 450 staff, Mr. O'Brien said 150 will be redeployed to Finglas and that the balance, 300, will be deployed in primary care centres, and so on. How many of the 450 staff will be left in the local health offices?

Mr. Tadhg O’Brien

Three hundred.

Three hundred will be left in the local health offices and not redeployed to primary care teams.

Mr. Tadhg O’Brien

That is where the local health officers will be.

I thank Mr. O'Brien.

Mr. Tadhg O’Brien

I reiterate Mr. Burke's invitation to members to come to Finglas to see how the system will operate. Doing so will possibly give them a better sense of how the system will work.

This is something the committee wants to deliberate on having heard presentations from every concerned party. We certainly appreciate the invitation to visit the office in Finglas. We might get to know the people in the office and will be happy to talk to them. We might know who to ring.

Are the members happy?

Is Mr. O'Brien saying the local area health office will be in a primary care premises?

Mr. Tadhg O’Brien

No, I am saying we will ultimately have 500 primary care teams. Each population will be assigned to one of those teams. In each team, we want somebody who will be able to assist the client not only with medical cards or long-term illness cards but with all aspects of health services.

Is that not nirvanamañana. We do not have 500 primary care teams and do not even have——

Mr. Tadhg O’Brien

We will have.

That is a debate for another day.

The reality is that patients cannot obtain their medical cards. They are not getting their medication and they are ending up in hospital. This will not be solved by our being told we will have 500 primary care teams some time in the distant future. The HSE has been referring to this since 2001 but this is 2010. On the basis of this statistic, we will all be dead and gone before we have the 500 primary care teams. My concern is that patients will suffer hospitalisation unnecessarily and cost the State more money in the process.

The IMO must still be confused about the list stating who is eligible. It knows some of its patients are eligible but they are not on the centralised list. I asked a question on this earlier. What is the answer?

Mr. Patrick Burke

There are two solutions. The simplest way of dealing with the issue is for the IMO and HSE to sit down and remove confusion from the equation. I have no difficulty reiterating what the contract states on how babies are dealt with and when they are put on the list. I have no difficulty stating whether a client is eligible or dealing with cases where individuals have plastic documentation. I have no difficultly working through the list of issues raised by the IMO to achieve absolute clarity on how the system operates.

With regard to patients wanting access to their medical cards, in the first two months of this year we issued 24,202 medical cards. In other words, medical cards are being issued and more were issued in the first two months of this year than ever before.

We should not conclude the meeting without paying tribute to people on the front line dealing with applications who work hard and do a good job. If the system is not working, the challenge for all of us is to make it work better.

I thank Mr. Burke and Mr. O'Brien for their presentations. Is it agreed to adjourn and return to a detailed discussion on this issue at our next meeting? Agreed. Unless there is any other business, we will adjourn until 20 April when we will meet the Minister of State at the Department of Health and Children, Deputy Moloney, for an update on mental health issues.

The select committee will meet at 2.30 p.m. on Tuesday, 30 March, with the Minister for Health and Children and the Minister of State at the Department of Health and Children, Deputy Barry Andrews, in attendance to discuss the Revised Estimates for 2010 — Votes 39 to 41, inclusive, and the Department's annual output statement.

The joint committee adjourned at 6.10 p.m. until 2.30 p.m. on Tuesday, 20 April 2010.