JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 24 May 2012

Processing of Medical Card Applications: Discussion with HSE

Chairman

This meeting follows our meeting with HSE officials in Finglas and the only issue on the agenda with the HSE today is the processing of medical cards. There will be an opportunity at the quarterly meeting with HSE officials in June to raise other pertinent issues. We had a thorough visit to the Finglas facilities and we were given a very interesting and informative presentation. We had a good opportunity to interact with staff and I thank the HSE staff in Finglas for their courtesy on the day. We agreed at the time to have a follow-up meeting, at which an update would be provided to members on the backlog of medical card applications.

I begin by reminding witnesses they are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable. I remind members of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.

I welcome the delegation and ask Ms Laverne McGuinness, national director of integrated services for the HSE, to make her presentation.

Ms Laverne McGuinness

I thank the committee for the invitation to attend today's committee meeting. I am joined by my colleagues, Mr. Paddy Burke, from primary care reimbursement services, PCRS, and Mr. Dave Moore.

The primary care reimbursement services section manages a wide range of primary care services across 12 community health schemes, including the medical card scheme, for a population of over 3.4 million people. These services are provided by more than 6,660 primary care contractors and involve 77.9 million transactions annually at PCRS, with an associated expenditure of €2.5 billion. As of 1 April 2012, there were 1,758,774 medical cards and 126,449 GP visit cards in circulation. That is an increase of 151,991 on the January 2011 figure. Comparing the figure to that of 2005, there has been an increase of 740,140 cards in circulation, or 65%. In 2011 a major change programme was initiated, planned and developed by the HSE to centralise medical card application processing in the primary care reimbursement service, PCRS, effective from 1 July that year. The purpose of the centralisation project was to provide for a single uniform system of medical card application processing, replacing the different systems previously operated through more than 100 offices across the country; to streamline work processes and reduce the number of staff involved in medical card application processing from approximately 450 to 150; to ultimately ensure a far more accountable and better managed medical card application processing system. I have circulated to committee members a written report on the medical card centralisation programme. The report sets out in greater detail the progress made since centralisation and also since the committee visited the PCRS in March.

I will confine my opening remarks to a short update on a number of key matters addressed in the report which will be of particular interest to the committee. Centralisation commenced in July 2011. This was a very significant change programme which involved the redeployment and training of significant numbers of staff and considerable changes to processes which had not been standardised previously. While considerable progress has been achieved in improving the medical card system, it must be acknowledged that during the first six months after centralisation, a significant backlog in processing applications accumulated. This caused difficulties for applicants which the HSE very much regrets. During February 2012 the HSE conducted a planned review of the first six months of the centralised operation. One of the first actions taken was to address the backlog of applications received between July and December 2011, which stood at 57,962 in January 2012. This figure includes applications which were incomplete, as well as those which were complete. The backlog was successfully cleared to zero by the end of April.

As part of the six month review, PricewaterhouseCoopers, PwC, also undertook a high level assessment of possible excess registrations on the medical card register. In its analysis PwC indicated a range of potential exposures if such excess registrations were to be substantiated; however, it also stated this preliminary assessment should be treated with caution and that it was only indicative in nature. A forensic analysis of the medical card database is under way and this analysis is scheduled to be completed by the end of August. The committee will also be aware that the Committee of Public Accounts has raised the issue of payments to general practitioners, GPs, in respect of deceased medical card holders. The HSE is undertaking a comprehensive analysis of the historical overpayments of €1.48 million referenced by the Committee of Public Accounts. This analysis will be completed by the end of May, following which the issue of overpayments will be followed up with GPs.

The report which has been provided for the committee also describes the significant programme of work under way to implement the recommendations of the review. In particular, we are improving the experience of service users through initiatives such as simplifying the application form and guidelines and enhancing the online application process; streamlining other medical card processes such as standardising the period of eligibility, simplifying the emergency medical card and medical card renewal processes to make them more customer friendly; improving the overall controls in place for such a significant level of State expenditure; appointing a new head of customer services to the PCRS who will take up the post in the middle of June.

While there have been some teething problems, most have now been addressed and the medical card centralisation project is proving to be a success. A total of 96% of completed applications and reviews are processed within the target 15 day turnaround time. As indicated to the committee at the last meeting, the statistics for medical card application processing are published weekly on medicalcards.ie. I am confident that the improvement initiatives which are being progressed and which my colleagues, Mr. Burke and Mr. Moore, can further outline will deliver a more streamlined and user friendly service to the public. I take the opportunity to thank the committee for its continued support of the HSE’s efforts to improve the medical card system and, in particular, we appreciate the time taken by the committee to visit the PCRS in Finglas last March. My colleagues and I will endeavour to answer questions members of the committee might have.

Chairman

I thank Ms McGuinness for her presentation and the information she has provided for the committee. All of us have constituents who need access to medical treatment and care. It must be said - I will refer to this again in the question and answer session - that it is a very frustrating process - even since our visit to Finglas and notwithstanding the great courtesy shown to us as parliamentarians - whether it be the online service, in dealing with incomplete applications, in forms being lost and the variety of barriers that confront applicants. It is important to put at the forefront of our discussion that we are discussing not a medical card reference but a person. Often a person is already tense about his or her personal circumstances and fears that he or she will be disconnected from access to a doctor or treatment. It is important to put the matter in context.

Deputy Caoimhghín Ó Caoláin

I join the Chairman in extending a warm welcome to Ms McGuinness, Mr. Burke and Mr. Moore. I, too, was a participant in the visit on 2 March to the new centre at Finglas. Like the Chairman, I appreciate the welcome and courtesy shown on that occasion. It was very informative and hugely helpful in understanding the volume of work being addressed and the significant team of people who were obviously working very hard to deal not only with the throughput but also, at that time, the backlog that had built up. I welcome the statement that to all intents and purposes the backlog has been addressed. I use the word "addressed" carefully because it may not be the case that everything has been determined. That is the difference. It might have been addressed in so far as further information was sought and some action has been taken. I expect that is the case, but I accept that the overwhelming bulk of the backlog has been addressed, for which the words "well done" are due.

It would be remiss of me not to reflect my appreciation of the Oireachtas helpline. I have expressed this before and recall saying it during the visit to Finglas. It is important that it be known by their work colleagues that those with whom we are in first line engagement have, in my experience, been very helpful at all times. However, I wish to make the case for its extension. However - I have expressed this view previously - a helpline is not enough. We are coming from a situation where we had direct access to the community welfare office system throughout the State. We were dealing with people who had, at least, as intimate a knowledge of their local community as we had as local representatives. I urge that favourable consideration be given to the appointment of a small dedicated help desk, with one to three staff, to deal with correspondence and provide for the opportunity of one-to-one engagement. That is hugely important because there will be situations and cases not provided for in terms of the construction of the application or review form. Rather than have a vexatious and an elastic period of time in which to receive an answer or decision in such situations, that would be of huge help to elected representatives, and I urge that it be taken on board. If anything can be said in that regard, I would welcome it.

We miss the community welfare office system. Community welfare officers also deserve acknowledgement of the role they have played but which they no longer have. Their knowledge was hugely important in helping the decision making process on many occasions, certainly in my experience. We accept the new situation, the Finglas centre is in place and it would be pointless to argue for a reversal and we have an obligation to work with the new system to ensure it works as efficiently and effectively as possible. I commit to doing that.

I have reflected before on the disconnect between the administration of a service and the appeals process. The area office appeals service deals with medical card holder who wish to appeal the decision made by Finglas centre which issues the medical card. In my experience the area office appeals office and the Finglas centre can have almost parallel engagement on particular cases. I wonder if that can be addressed?

I want to comment on the information provided on overpayments. Some general practitioners may have medical card holders on their system who are now deceased or who no longer reside in the jurisdiction. The payment for these medical cards would no longer apply. With the exodus of approximately 1,500 people per week I suggest there should be some methodology to factor this into the system rather than pursue the GPs for overpayments afterwards. Can we amend the system to flag up people who have died or left the country so that their medical card is no longer active and will not be a charge on the health services in order to avoid overpayments from our straitened budgets? Some means has to be found to establish who should take on responsibility for this role. Will the delegates please comment on this?

Deputy Denis Naughten

I welcome the delegation from the HSE and I compliment them in dealing with the substantial medical cards backlog, which is now being addressed. I acknowledge the role of the staff who man the helpline for Oireachtas Members as they have been more than helpful in dealing with issues and ensuring that the backlog was been dealt with.

We are experiencing teething issues with the new system. I have come across a number of problems where the GP will extend the medical card and see the patient, however, when a patient goes to the hospital and presents a medical card that has been extended, the hospital system has a difficulty in accepting it. Again I welcome the change in policy applying to the medical cards of persons over 16 years; and their card will be renewed until their parents' medical card is due for renewal again. That is a welcome development. I have come across a case where the hospital is not recognising that change in the system.

The problems we are now facing relate to more complex medical issues, where the medical costs are being dealt with on top of the basic means costs. It would probably help if the PCRS could write out to GPs and outline exactly what information would assist them in making a determination. There is a significant variation of the quality of communication we are receiving from GPs to submit to the PCRS. When it is very good the application is processed quite quickly, others provide just a list of the medication prescribed, which is a pointless exercise, and draws us into a spiral that is delaying the whole process.

Ms McGuinness mentioned ineligible and inactive medical cards and that these figures needed to be treated with extreme caution. The figures were not provided to us. Will she give an indication of what she suspects is the level of ineligible or inactive cards, and the potential exposure to the Exchequer? I understand that an audit is being conducted but could we get an idea of the global potential cost? When does she expect the audit to be completed? When we last met, the committee members were quite critical of PricewaterhouseCoopers, an outside consultant, being brought in but it has clearly carried out some work and has identified a problem. What is the scale of the problem?

I wish to raise the issue of the appeal process. There was a backlog in dealing with appeals. In the report it was stated that the backlog would be cleared by April of this year. Has the backlog been cleared? While I accept that people retain their eligibility until a determination is made on the appeal, the difficulty is the hardship for people applying for a card for the first time. They are not eligible for services until there is a determination made on the appeal. Could we ensure that those applications are fast-tracked through the system to avoid a delay in denying them access to very important support?

Will Ms McGuinness revert to me if she does not have an answer to the question of eligibility of persons aged under 25 years? Initially, persons aged under 25 years who were in receipt of the legal maximum payment of €100 per week, which was less than the €184 that everyone else received, were denied access to a medical card. Following the Ombudsman's intervention that changed and people who reside outside the family home in receipt of €100 a week will get the medical card but those who reside in the family home will not get a medical card unless their parents have a medical card. Is that not an incentive to force people out of the family home, getting them to apply for rent supplement and putting further additional costs on the Exchequer? Will the delegates clarify that?

Deputy Charlie McConalogue

I thank Ms McGuinness, Mr. Paddy Burke and Mr. Dave Moore for their update. I commend them and the staff for their work on reducing the backlog in issuing medical cards as I am sure it has not been easy for them. It was unfortunate the way things went. As we all know many were left in a very difficult situation, and lessons must be learned. A very strong effort to put things back on track was made and I welcome that 96% of applications are dealt with in the target timeline. As Deputy Naughten stated, many people are applying for the medical card for the first time and at this very stressful time it is key they get an answer quickly.

I wish to raise the issue of GPs charging medical card holders additional charges when they carry out bloods tests. This is becoming an issue, and when a trend starts for one service, this could expand in time and apply to other services. We should avoid charging medical card holders for this service and I would like the witnesses to comment on it.

Deputy Robert Dowds

I thank the delegates for appearing before the committee today. I too found the visit to the medical card facility in Finglas beneficial. I have three questions. Are the delegates satisfied that the new HSE system of operation is an improvement? Is the old medical card valid for use until the new medical card issues? Are there still cases in which forms have been lost? I encountered a case earlier this week in which a person alleged that their application form had gone missing. The person in question had to apply again. Is that a common problem or was that case a one-off? Like Deputy Ó Caoláin, I would like to know how medical cards are taken off the system after the medical card holders in question have died. Does the HSE depend on the goodwill of doctors to pass that information on?

Deputy Catherine Byrne

I thank the delegates. I was very impressed when we toured the HSE facility in Finglas. From the moment we entered the door, we had a sense that the staff there were very committed to the work they were doing. The first staff we met were the people who were sorting the mail. I was overwhelmed by the amount of mail that was lying in boxes to be dealt with in a single day, rather than a month. The staff in every section of the centre extended great courtesy to us even though we were looking over their shoulders to see what they were doing. The system out there shows that when people really want to get a job done, it can be done. It has already been pointed out that there has been a significant reduction in the number of applications waiting to be dealt with.

I welcome the extension of medical card eligibility to people who are terminally ill. It is right that such people should not have to go through a long process. It is a difficult time not only for the person who is terminally ill, but also for the members of his or her family. They should not have to be constantly on the telephone trying to contact people to make sure the person who is dying is covered by a medical card. I welcome the changes in the medical card system in that regard, as set out in the report.

Are general practitioners and pharmacists aware that a person whose medical card has expired, but who is attempting to appeal or renew it, can continue to avail of medical card services? In the last two or three days, I have been contacted by two people who have gone to their local pharmacies to buy prescriptions across the counter. I wonder why that is happening. Do the general practitioners in such cases not know that the medical cards of the people in question have gone in for renewal?

I would like to ask Ms McGuinness about the appeals process, which I have read about. How many appeals are under review at the moment? How long are those appeals taking? The developments of the last couple of months have been a huge credit to the staff of the HSE. I refer particularly to the people in the back rooms who open the envelopes and put the applicants' details onto the computer system. It is up to the public to send those details in. When people ring me about medical card issues, I constantly go through a list of things with them. I ask whether they have everything that is needed and I remind them to send those details in. If people do not send in the correct information, it can take a long time for their applications to be dealt with.

Since I visited the centre, I have examined the process and the way the forms are filled in. I compliment the HSE on the way the forms are presented and the ease with which they can now be filled in. Deputy Naughten mentioned that it can be difficult for people to fill in these forms. In many cases, the information they get from their doctors is insufficient. I agree with the Deputy that more general practitioners need to be encouraged to provide the proper information. It is sometimes very scatty. I thank the delegates again. I ask them to pass on our thanks to the staff of the centre in Finglas.

Chairman

On behalf of the committee, I would like to acknowledge publicly the courtesy, efficiency and genuine warmth of the staff of the Finglas centre on the day we visited them. It must be noted that they were helpful and informative even though we were in their working space. It would be remiss of this Oireachtas committee not to acknowledge that. There has been a substantial growth in the volume of medical card applications. The quantum of paperwork has also increased. It is fair to give great praise to the staff at the front line of the service. I assure Mr. Burke and his staff that we are satisfied with the information that is provided in the answers that are given to public representatives. It should not all be seen as negative. There is positivity as well. We are appreciative of what the staff are doing. We thank them for the courtesy they showed us the day we went to Finglas.

Ms Laverne McGuinness

I greatly appreciate the committee's positive comments, particularly with regard to our back-office staff. Believe it or not, when our service is the subject of public criticism, our clerical officers and our porters at the front door are among those most affected. I thank the members for their praise, which will act as significant motivation for our staff. We will convey the committee's appreciation to them today.

Some of the questions that have been asked are quite common. Deputy Ó Caoláin asked about the backlog, which has been addressed in full. The figure of 57,000 outstanding applications that he mentioned relates to the period between 1 July and 31 December 2011. That has been cleared. Approximately 50% of the applications in question were incomplete. The team in Finglas was given the task of contacting the applicants in question by telephone to get the additional information that was required. We are satisfied that those applications have been completed comprehensively now.

Chairman

When Ms McGuinness says they "have been completed", does she mean that the result has been given?

Ms Laverne McGuinness

Yes, the result has been given to all of them. Either they have cards or they have been refused. All the results have been given. The applications have not been piled onto another list. We are delighted with the members' comments that the Oireachtas helpline is working. We hope to improve it when we appoint a new customer services manager, who is to be transferred from within the public sector. When the person in question starts in June, we hope to hold interviews and meetings with the various representatives. That will be linked up with the helpdesk. There will be a small front-of-house office that will deal with various queries, particularly the exceptional cases that arise in day-to-day life, as we all know.

Chairman

Will the new head of customer service be transferred from an existing position? I know a new post is being created. Will there be an extra cost to the Exchequer?

Ms Laverne McGuinness

I was making it clear that there will be no extra cost to the Exchequer.

Chairman

Okay.

Ms Laverne McGuinness

The person in question will come from within the public sector. It is one of the transfers that are provided for under the Croke Park Agreement. The person in question, who will be based in Finglas, will set up a front-of-house office in order to improve customer relations. Before now, it was primarily a back-office function. We accept that a gap exists in this regard. We are trying to provide what is missing to tie all the pieces together. That person will start in June.

I will ask Mr. Burke to respond to the question that was asked about the appeals office. A question was also asked about the payments that have been made to general practitioners in respect of deceased owners of medical cards. This issue was addressed when the primary care reimbursement service was centralised in Finglas. We can now ensure that a payment which is made to a general practitioner in respect of a deceased patient is automatically reclaimed back as far as the relevant date. That has been happening on a continuous basis since the centralisation took place. Historically, the primary care reimbursement service did not have visibility of the €1.4 million figure that has been mentioned because the centralised system was not in place. Mr. Burke is carrying out a full extensive analysis of what is actually entailed in that regard. We will seek to take that money back from the general practitioners in question. The analysis will be completed by the end of May. The figure in question relates to the historic position as opposed to the position going forward. We have addressed what will happen in this regard in the future.

Deputy Naughten asked about people over the age of 16. We have addressed that. They will stay on their parents' medical cards as long as their parents maintain their eligibility. Reference was also made to people having to go back to doctors when additional medical information is sought in respect of discretionary medical cards. A medical officer in the primary care reimbursement service is now available to look after the whole discretionary medical card process. We are standardising the process. We hope to be able to simplify it and make it easier. We will also put a customer services person in place. We will link those officials together and thereby ensure that when we contact a doctor to ask him or her to specify the condition the applicant has, we will get sufficient information to make a determination on that person's medical card application.

Deputy Denis Naughten

The point I am making is that something should be communicated to the doctors. There is an ongoing historic problem in relation to the quality of the material one gets from one's doctor.

Ms Laverne McGuinness

We are just completing standardisation of the discretionary medical card criteria and we will communicate with doctors in that regard.

Chairman

On that issue, the application form has been redesigned to be more simple and user friendly.

Ms Laverne McGuinness

The application form, of which I have a copy with me, will be much easier to understand once it has been completed. We had the form assessed by the National Adult Literacy Agency, NALA. Under the new form, only one item of income information will be sought.

Chairman

Is the HSE on schedule to meet the June target date for the introduction of the new form?

Ms Laverne McGuinness

Yes, the introduction of the card is on target. We have also had service users involved in the process. The next issue to be addressed will be eligibility.

Chairman

Will an advertising campaign be launched to educate and inform people about the user friendliness of the new form?

Ms Laverne McGuinness

What we are developing as part of a plan is a communications piece which has been missing to date. Communication will be made with members of the public on the simplified medical card and what they need to do if they have specific difficulties. The HSE customer services personnel will be at the centre of this process.

Chairman

As we have a vote in the Dáil, I propose that we suspend briefly. Is that agreed? Agreed.

Sitting suspended at 12.15 p.m. and resumed at 12.30 p.m.

Chairman

I apologise to the delegates that we had to interrupt the meeting for a vote. Ms McGuinness was in possession.

Ms Laverne McGuinness

There are still a couple of questions with which we must deal. We were asked what the position was on appeals. In line with good governance, the appeals process is carried out separately from medical card application processing in order to ensure appropriate segregation of duties. On the number of appeal applications reviewed, at the time the centralisation process was introduced there were 2,184 appeals waiting to be dealt with, but by 8 or 9 May, this figure had been reduced to 376. The appeals unit has been working interactively with the medical card section to reduce the number of appeals and it is anticipated that the appeals will be cleared in the next few weeks. To date, the number of appeals has been reduced from 2,184 to 376.

Deputy Denis Naughten asked about the involvement of PricewaterhouseCoopers which we had engaged to support the review being carried out. The cost involved was in the region of €35,000, as it was a significant engagement and PricewaterhouseCoopers had carried out a piece of work within a short number of days in looking at the issue of eligibility and whether medical cards should be issued. They came up with a wide range for the figure which, as they clearly stated in the report, cannot be relied upon unless a substantial piece of work is carried out, and the report was furnished to the committee. That substantial piece of work is currently being carried out with Mr. Burke and will be completed in August.

Chairman

What do you hope to achieve by that analysis?

Ms Laverne McGuinness

There are two pieces to that. The analysis will first focus on people who may no longer be living in Ireland, as they have emigrated and are no longer eligible for a medical card. That is the historic piece. Taking on board what the committee has said, we are also dealing with the day-to-day elements as the medical cards are reviewed. We are checking to see whether people are eligible and whether they have activity on their cards. If there is no activity on their cards at the time of renewal, we will write to them and stop the medical card after a number of months. For example, if they are no longer in the country, we will stop their medical card eligibility. As there was no centralised base for that historically, this is again the historic piece that is being examined as part of the verification process.

Deputy Denis Naughten

Ms McGuinness is saying that the activity is examined at the time of renewal. However, someone could have his or her medical card renewed now and emigrate in July. Is there any examination of such cases at the moment?

Ms Laverne McGuinness

It is a continual process. We look to see if there is activity on a medical card. By "activity", I mean whether there has been a payment to the GP or pharmacist. That is taking place on an ongoing basis. Perhaps Mr. Burke can elaborate on that process.

Mr. Paddy Burke

The objectives of centralisation were to provide a uniform system for patients and to provide a fully accountable system. The fact that it is now centralised means that it is audit rich from that perspective. We can analyse what is happening in this area. As cards come up for review and if there has been no activity, we write to the patient several times. If we get no response, we will also write to the GP stating that there is a patient on his or her list who we have not been able to contact, and ask for any change of address or whatever. We have now provided a function whereby the address can be updated. We are constantly looking back over activity and eligibility. When that work is finished, it will identify a harder space, but it will also be very clear about the analysis that we bring to bear on managing all of this. We have centralised it and we now have a fully accountable system.

Deputy Denis Naughten

Can the activity be examined in the interim three or four year period?

Mr. Paddy Burke

Absolutely.

Deputy Denis Naughten

Does the skill set not exist at the moment to do that?

Mr. Paddy Burke

Yes it does-----

Deputy Denis Naughten

Yet only at review and renewal.

Mr. Paddy Burke

No. We are continually looking back at activity over the last six, 12, 18 and 24 months.

Chairman

Given that both yourself and Ms McGuinness have spoken about accountability and a better managed medical card processing system, is it fair to say that this is not necessarily the case from the point of view of the service user, namely, the patient and those attending a GP? From our own experience, we consider that the ordinary person struggling with the system finds it chaotic and frustrating. I fully accept what you are saying to us this morning but for us it is about access for the person to a system that is simpler, streamlined and more user friendly. It is very frustrating for people who have not necessarily received the same one-on-one assistance that we have received. It is my worry that this will continue to be the case, even though I fully accept that vast improvements have been made.

Mr. Paddy Burke

It is important to state that in the last few months, as well as dealing with the daily work and the evidence we put on the website in respect of the number of completed applications dealt with, we have been focused in the short term on dealing with the backlog. We have an interim plan which deals with quite a number of issues, such as the communications strategy, and we also have a customer services manager in place. The customer service manager should draw all of that together. There is also a number of other initiatives that we have begun, such as reviewing the national assessment guidelines and figuring out how we can make the journey of the applicant through that much easier and targeted for each individual circumstance. There is no one size fits all.

We have moved from dealing with the backlog and the normal day-to-day work to the interim and long-term work, such as how we deal with scanning the documentation and so on. Our focus is to make sure that the experience of the applicants gets better. The vast majority of the applicants are getting a good experience. Our difficulty is that there are still challenges for us at the tail-end of things. We accept that and we are addressing that in the interim plan.

Deputy Denis Naughten

Ms McGuinness mentioned that we received a report on the study by PricewaterhouseCoopers. I do not recall receiving that report. I am not sure if other committee members received it but I certainly did not. Can she give us even an indication of the range of the potential liability? This is taxpayers' money. I am sure it is a larger factor than the number of deaths. What kind of figures are we talking about here?

Ms Laverne McGuinness

The report was sent in to the joint committee. We can check on the date. It was not with this report as it went in earlier. It came out as part of an update we provided to the joint committee. It was not for this particular meeting, but it was sent in by PricewaterhouseCoopers.

I can give the Deputy the figure as it is in the report but it needs to be treated with extreme caution. PricewaterhouseCoopers has a disclaimer on the figure and there are many caveats to it. The range is between €65 million and €210 million. That is a very significant range and PricewaterhouseCoopers is stating clearly that the figure cannot be relied upon without further substantiation and detailed analysis. The company only spent a couple of days carrying out that piece of work. The analysis is being carried out now.

Deputy Denis Naughten

It is clear then from the centralisation that there could be huge potential savings.

Ms Laverne McGuinness

There could be such savings on the historical aspect. We are looking at that regarding the probity. We are dealing with the day-to-day issue and we need to look back and take back the savings to the Exchequer. That is our mantra.

Deputy Byrne asked a question about the continuation of eligibility. If a person has a medical card that is being reviewed that eligibility continues provided the person is engaging with the system. We do not really understand why hospitals would not be providing the services in respect of medical cards but we will certainly get the message out. The last question was about some GPs charging for phlebotomy tests and blood tests. They should not be charging if the patient has a medical card. We will again write out about that but there should be no charge.

Chairman

Has that been communicated to GPs?

Ms Laverne McGuinness

Yes it has but it will be communicated again to them.

Mr. Paddy Burke

I know that the Minister has written to them as well, stating that there is no charge for any service provided under the contract to a person who is eligible for services. The routine taking of bloods is something that is typically done by the practice nurse and the HSE pays a subsidy to the GPs for a practice nurse. We have been very clear on that but if we need to get another message out we can do so.

Deputy Catherine Byrne

I asked a question about the number of appeals and the amount of time involved. I am not sure if it was answered before I came back into the room. I apologise for this.

Ms Laverne McGuinness

I did, but I will call it out again. The number of appeals at the time of centralisation was 2,184. Our appeals process is separate to the issuing of the medical cards. That has to be the case in order to have it under control. It was reduced to 376 by 9 May and it is hoped to have it cleared over the next number of weeks.

Deputy Robert Dowds

I asked a question about finding out whether cards are still valid, for example, when somebody has died. Is this done simply on the basis of whether the card is being used?

Ms Laverne McGuinness

Perhaps the Deputy missed the answer to that. As and from the date of centralisation, July 2011, we have direct communication with the registrar and we know whether a person has died. If a GP has been paid, even for a month or two, we reclaim the payment. The figure of €1.4 million relates to the historic backlog which is being addressed.

Deputy Robert Dowds

Automatically.

Ms Laverne McGuinness

Yes.

Senator Colm Burke

Ms McGuinness has stated the HSE removes a person's name once notification of death is received from the General Register Office. I know of a case in which it took six years to register a death because as I understand, it is the family that must register the death. The person concerned had died in hospital and the information had been given to the family but they did not register the death. It was six years before I eventually persuaded someone to sign on the dotted line to receive a death certificate. This is an issue I ask Ms McGuinness to check to ensure all deaths are registered.

The second issue I wish to raise concerns the increase in the number of medical cards and GP-only cards. It is probably a reflection of the economic downturn, but there are close to 2 million people who either have a GP card or a medical card, or four out of every nine people in the country. There are extreme budgetary pressures and some €13.4 billion was expended on health care last year. Some €13.317 billion was raised in income tax, which means that literally every cent went on health care. Considering the significant increase in the numbers of GP-only cards and medical cards, where can efficiencies be achieved? The report is very detailed and sets out where efficiencies are being achieved in the administration of medical cards. Can efficiencies be achieved in other areas to stay within budget? What has been the cost of the report and the amount paid in fees to PricewaterhouseCoopers for its analysis?

Almost 2 million have a medical card or a GP-only card. This involves a significant amount of personal information. I have referred previously to the Danish system under which every individual has a patient medication card. The HSE has access to the details of nearly 40% of the population. Would it be possible to introduce a patient medication card which would remove the need for much of the paperwork involved? For example, under the Danish system prescriptions are not issued because the information is placed in a person's file which can be accessed by the pharmacist. I understand 27% of all prescriptions written in hospitals are misunderstood or that it is necessary to contact the prescriber to clarify the prescription. A patient medication card system would allow for prescriptions to be written and placed in a patient's file which could be accessed by a pharmacist. We should aim to set planning targets for the future.

Senator David Cullinane

I apologise in advance if any of my questions has already been aired, but I was voting in the Seanad.

I welcome the report and the changes made. The Chairman referred to the frustration of many users because of what I regard as failures of the system, some of which are being corrected. However, people have come to my office to complain about cases in which information has been lost when it has been posted. It could be supporting medical information, payslips or general paperwork accompanying an application. A significant level of information has been lost. I note that a new scanning document management system has been installed and hope this will make a difference. However, in the past few days I have been informed about a number of cases in which applicants have been left frustrated. For example, a person may telephone the HSE and be given verbal confirmation that the supporting documentation has arrived only to be informed a few weeks later by telephone that it has disappeared. I do not understand how it can be mislaid or lost, but from what I have been told, it seems great volumes of documentation have been lost within the system. I ask the delegates to explain how the new system will change things for the better and prevent this from happening. In many cases, I have scanned information and sent it to the HSE and there has been no problem; therefore, I see the logic in scanning documentation, but up to now, the mislaying of documentation has been the source of deep frustration for many. They have had to revisit their doctor and compile all of the information a second time.

Chairman

On the same point, a person came to me last week who had applied online for a medical card and received a letter assigning a reference number. When the person concerned followed-up on the matter, she was informed there was no record of her application and that she had to reapply. I have a copy of the letter in front of me. This is the case of an ordinary person who applied online. I can provide the delegation with a copy of the documentation after the meeting. The system must be made simpler in order that people can track their applications and understand the process. I accept some people may not be computer-literate and may have difficulty, but this should not be a barrier to tracking an application.

Deputy Caoimhghín Ó Caoláin

I wish to follow up on one response from the delegates for which I thank them. I refer to the customer services person, as he or she was so described. This is a welcome development. Customer services person suggests access to the service is open to all, that this is a front desk job which the HSE is considering creating. It is certainly a service which is needed. However, the focus of my query is on the less than straightforward cases which elected representatives must often present or articulate. A customer services desk in many other settings is not always the most appropriate place at which to deal with such matters as such conversations require a private space in which one can deal with a person who knows the system. Those who operate the helpline or the Oireachtas contact line are not in a position to give such a service; they can only supply a certain level of information. The proposed system will require someone - it may not be a full-time role as the person concerned may have other roles to perform - to act as a designated person - or persons as the case might be - to help Oireachtas Members, or even councillors who are elected representatives and just as likely to have to deal with such cases as Oireachtas Members. This would be a very helpful development to streamline the system which would result in more timely and helpful conclusions and decisions for all our sakes.

Deputy Denis Naughten

I wish to return to my question about the appeals system. Would it be possible to have a separate system for those appealing a decision not to renew a medical card as opposed to those appealing a decision on a first application for a medical card? The delay in the appeals process is causing significant hardship for those appealing a decision on a new application. The target date of the end of April was not achieved and it is to be hoped it will be achieved by the middle of June. What is the timeline for processing standard appeals? How long does it take to make a decision on such appeals?

Chairman

I seek clarification. Was the backlog cleared by issuing decisions on all applications or was it done by writing to applicants for further information, some of which had, in fact, already been provided?

Ms Laverne McGuinness

Decisions were issued in all cases; it was not simply a case of seeking further information and pushing applications down the queue. Applicants who were not entitled to a medical card did not receive one and vice versa. In cases in which insufficient information had been supplied, we went back to the individual applicants.

Senator Colm Burke asked about payment to PricewaterhouseCoopers and ensuring value for taxpayers' money. The sum we paid in respect of the report in question was €35,000, in return for which the company supported us in undertaking the process to the required level of objectivity. The Senator also referred to the increase in the numbers of medical cards issued in recent years. The service plan for 2012 provides for the issuing of between 100,000 and 105,000 new medical cards, which is in line with the eligibility guidelines. The statistics are interesting in breaking down the increase across age cohorts. For example, between 2005 and 2011 there was an increase of 108% in the number of medical cards issued to persons aged between 35 and 44 years and an increase of 107% for the 25 to 34 year age group. The numbers are staggering when one considers the increases between 2007 and 2012, with a 182% increase in the 25 to 34 year age group and a rise of 128% among those aged 35 to 44 years.

Deputy Denis Naughten

I asked a question about the provision for those aged under 25 years.

Ms Laverne McGuinness

That matter will be examined in the context of the eligibility and guidelines review. I agree that there is almost an incentive for people to move out of home in order to avail of the allowance and so on.

Deputy Denis Naughten asked about the appeals process. I will check with the appeals office and forward a written response to the Deputy in that regard. Deputy Ó Caoláin had several questions about customer services which may not be the best terminology to use. To clarify, we are not talking about a full-house customer services operation, rather an individual will be appointed who will oversee a number of staff whose job will be to do exactly as the Deputy suggested, that is, link in with Oireachtas Members, manage exceptional cases, oversee connectivity between call centres, carry out our communications protocol and have oversight in addressing spikes in the system that must be addressed. It will essentially be an escalation forum, in other words, not every single query will go through it, but it will deal with more exceptional cases and provide for an overall link and connectivity between all of those involved in the process. The person appointed will engage with Members to ascertain how best they can be assisted in their work. It is about providing assistance for the Oireachtas and members of the public who are seeking medical cards. That is where the focus will be.

Chairman

I hope it proves to be of benefit not only to Members but also to the public.

Ms Laverne McGuinness

That is the objective.

Chairman

People deserve to be treated with respect and have access to a first-class system. In fairness, the delegates have been proactive in their endeavours in this regard. Despite members' misgivings and concerns, we are overwhelmingly impressed by the positivity of Ms McGuinness and her staff in seeking to address this issue. Other branches of Health Service Executive management would do well to look to their example to make the service more user-friendly and accessible. It must be more people-centred rather than just being about politicians.

Ms Laverne McGuinness

The objective is to make the process more accessible to the public and ensure information is available to the Oireachtas. We are seeking to marry the two objectives. One of the issues is that the medical card application form had not been revised for years. We have devised a draft which is far more user-friendly and have been through it with a fine toothcomb. We are, however, still receiving feedback on it. It is all about seeking to establish a front-of-house interface with the public, with clear guidance on the information sought and easy access to the process for applicants.

Senator David Cullinane

I asked about tracking paperwork and documentation.

Ms Laverne McGuinness

Part of the problem was that we were receiving more documentation than was needed. A significant factor in this regard was the processing of reviews, whereby all of the documentation was sought once again in respect of each renewal. We have since refined the system such that there are two separate processes, one for renewals and one for new applications. While this reduces a great deal of duplication, it cannot, however, prevent documents from getting lost, which is where the new document scanning system comes in. The system is not entirely error-free at this time but it is a vast improvement.

Mr. Paddy Burke

A significant factor in the backlog was that people whose applications were not dealt with proceeded to submit them a second, third or even fourth time. Some of the documents were occasionally misfiled. To illustrate the progress we have made, we have used the example that an airline will sometimes mislay an item of luggage. We have reduced such errors in order that they are now the exception rather than the rule. Cases of missing documentation are brought to our attention and dealt with as a matter of urgency. We have begun, as Ms McGuinness said, to specify a new document management system which will not only provide an audit trail but also assist with appeals by allowing us to access and move information much more quickly.

Members have observed that it can take up to six years to register a death certificate. It is important to note that we do not rely solely on the death event publication service in this regard. GPs have the functionality to register a death and remove a patient from the register. Several thousands have been registered in that fashion in recent years. Individuals can contact us directly to notify us of the death of a family member. We also have our own staff who monitor these matters. In other words, there are multiple means by which deaths can be notified. We operate a register of more than 3.5 million persons, including 2 million medical card holders and 1.3 million who are part of the drugs payment scheme, suffering from long-term illnesses and so on. While a death may occasionally be missed, we have very good interfaces. Deputy Caoimhghín Ó Caoláin asked how we might be more proactive in this regard. The Minister has given a commitment that the question of data sharing between ourselves and other State agencies will be underpinned by legislation due to be brought forward later this year. It will provide additional support.

In regard to complex medical issues, we are in discussions with the Irish Medical Organisation on the design of a standard document to collect the additional medical information we require for review by our medical assessors.

Senator Colm Burke

I asked about patient medication cards.

Mr. Paddy Burke

We talked about the process of reform being undertaken in steps, one of the largest being the centralisation of all data in one place. I referred to the index containing more than 3.5 million clients. These are all building blocks in moving towards electronic prescribing. The gathering of data in this way makes them amenable to audit and policy decisions. Our focus has been on centralisation, addressing the teething issues and clearing the backlog and, in the interim, dealing with customer services, communications, document scanning and so on. The architecture of the system means data are now available to policymakers for analysis in terms of medication cost management and so on.

Ms Laverne McGuinness

To clarify the statistics I provided, the respective increases of 182% and 128% from 2007 to 2012 relate to doctor visit cards for the relevant age groups, while the increases of 107% and 108%, respectively, relate to medical cards. I did not make that distinction.

Chairman

I thank the delegates for attending the meeting and engaging with members. We very much welcome the initiatives taken by them and their staff. It is welcome also that the primary care reimbursement service, PCRS, will have a new head of customer services, which is an important departure. I thank Mr. Burke for his courtesy to the members of this committee. When he receives the report on the forensic analysis we might have a further discussion on it if we can arrange that. We are appreciative of the efforts the staff in Finglas make and of their courtesy to us during our visit. This is about the customer, and all of us must make the service more customer centred.

Mr. Paddy Burke

I will pass on the Chairman's kind comments to the staff. I acknowledge that we are lucky in that we have a very good staff. I thank the committee members also. Mention was made a number of times earlier that centralisation has occurred. We must work together to ensure we move on and make it a better experience. Today is probably the end of the beginning. We have quite an amount of work to do but the fact there is a commitment on the part of everyone to support it is very good news.

Chairman

It is worth putting on record that 1,885,223 people have medical and GP visit cards. That involves a great deal of procedure and interaction but I repeat that it is about making the process easier, more accountable and transparent. I thank the witnesses for attending. I thank Mr. Ray Mitchell also for his co-operation.

Members will be glad to hear that the committee will not sit next week. They will be canvassing for the referendum.

The joint committee adjourned at 1.05 p.m. until 11.30 a.m. on Thursday, 7 June 2012.