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Tuesday, 1 Apr 2014

Priority Questions

General Practitioner Services Provision

Ceisteanna (96)

Billy Kelleher

Ceist:

96. Deputy Billy Kelleher asked the Minister for Health the action he proposes to take in view of the negative response of general practitioners to their proposed new contract; and if he will make a statement on the matter. [15121/14]

Amharc ar fhreagra

Freagraí ó Béal (12 píosaí cainte)

We have attended meetings at which general practitioners expressed concern about the contract the Government has proposed in the context of the roll-out of universal general practitioner care for children aged under six years. This is not universal care in the sense that somebody will have to pay for it at some stage. Persons with severe intellectual disabilities and serious and life threatening illnesses will pay for it. We seek clarity on the Minister's proposals.

The Government's vision for primary care is the development of a single tier system in which access is based on medical need, rather than ability to pay. The Government is, therefore, committed to introducing a universal general practitioner service without fees, on a phased basis, in its term of office. The word "universal" has the meaning of applying to everybody and does not touch on the issue of how care is funded. It means simply that everyone has access. As such, the distinction drawn by the Deputy is incorrect. Perhaps we will return to that issue.

The orientation of health systems towards primary health care and general practice has advantages in terms of better population outcomes, improved equity, access and continuity of care and lower cost. As announced in the budget, the Government has decided to commence the roll-out of universal general practitioner services by providing all children under six years with access to a GP service without fees. The decision to commence the roll-out with this age cohort is in accordance with the recommendation in Right from the Start, the report of the expert advisory group on the early years strategy. Universal screening and surveillance services are already made available for children in this age cohort. Evidence suggests that a high quality primary care system with universal access will achieve better outcomes for young children.

The implementation of this measure will require primary legislation, which is expected to be published shortly. The necessary administrative arrangements will be made when the specifics of the legislation are known. The introduction of this service also requires a new contractual framework to be put in place between the Health Service Executive and individual general practitioners.

As Deputies are aware, a draft contract is currently the subject of a consultation process. In excess of 280 responses were received by the Health Service Executive during the consultation process. These responses are being examined and a report will be published in due course.

While there has been some negative reaction to the draft contract, I am pleased to say the Irish Medical Organisation, the primary representative body for general practitioners, has confirmed it is supportive of Government policy to introduce GP care free at the point of access, albeit conditional on the provision of adequate resources and full and meaningful negotiations with the IMO. I welcome this response and I have assured the IMO, most recently in my letter of 26 March, that the Department and the HSE are prepared to engage meaningfully with it in negotiations on all aspects of the scope and content of the proposed contract. I have also explained that there will be an opportunity for its input on the fee structure, which will be addressed by means of a complementary consultation process.

Additional Information not given on the floor of the House

I trust the IMO will accept my invitation to commence negotiations with the Department and the HSE. This will afford it the opportunity to obtain clarification from the Department and the HSE on any aspect of the draft contract and to raise any other issues which it may have in that regard. I am confident a process of open discussion has the potential to significantly enhance the draft contract for patients, GPs, the HSE and the Department, thus helping to progress our common goal of free GP care at the point of access.

The Minister of State said at the outset that he has a vision for primary care, but it became clear as he neared the end of his reply that he has no vision because there are no actual plans in place to deal with what the Government committed to in its programme for Government. It is evident there has been no increase in funding in respect of primary care and that the continuing withdrawal of discretionary medical cards is what is funding the roll-out of free GP care for children aged under six years. For this not to be the case would have required the Government to increase the budget over and above what is currently provided. The Government has not done that. There has been a systematic reduction in terms of the availability of discretionary medical cards to people who held them based on illness and need owing to medical conditions.

The Minister of State said a consultative process was in place. There has been no consultation with GPs. The contract was published by the Minister, the Minister of State and their officials with no consultation on the matter. Had there been some consultation there might have been an embracing of the contract. As I understand it, there has been no embracing of this contract by GPs. It is an onerous and restrictive contract which forces GPs to choose between people who hold medical cards and those with discretionary medical cards, granted to them based on illness and need rather than age.

What Deputy Kelleher said is incorrect. The Government has a clear plan in relation to the implementation of access to free GP services for children under six years of age. The legislation in this regard will be published shortly. I look forward to hearing the Deputy's response to that legislation because I am anxious to know whether he supports the initiative. The IMO has indicated it supports it, although it has raised reasonable concerns which I am anxious to discuss with it.

The Deputy is also wrong on the budgetary issue because €37 million has been voted specifically for this measure. The Deputy is also wrong in his commentary about discretionary medical cards being granted to people based on medical need. The Deputy knows well that there is no such thing as a discretionary medical card based on medical need but that people may apply for and the HSE may grant a discretionary medical card in circumstances where a person has to meet expenses in respect of their medical condition.

I look forward to meeting the IMO. It has been suggested there has been no attempt by me to ensure such a meeting takes place. I have written twice to the IMO. I am engaged in correspondence with it, which I could read into the record of the House if I had time. I have made it clear to the IMO in that correspondence that I look forward to meeting it. I have extended three invitations to the IMO to meet me to negotiate on the contract. There will be consultation and negotiation but people have to attend a meeting for this to happen.

Not only is the Minister of State playing with words, he is playing with people's lives when it comes to discretionary medical card withdrawals. Time and again when we have raised the issue of discretionary medical cards in this House, the response has been that there is no such entity as a discretionary medical card. Up until last year, every HSE service plan made provision for discretionary medical cards. Provision in that regard was always included in the HSE budget. We now find it has been removed from the lexicon of the Department in terms of primary care funding. While provision was always made for discretionary medical cards, they are now being systematically withdrawn.

Last Sunday week was International Down's syndrome day. Families of children with Down's syndrome are time and again highlighting that they are unable to obtain or renew discretionary medical cards. Some 50% of families in this country have lost or cannot get a discretionary medical card based on medical need. That is a fact.

The Deputy is making up figures or pulling them from the sky.

The Deputy asked a question to which I have responded. If he wants to have a discussion on discretionary medical cards I am happy to do so.

There is no mention of that in the Deputy's original question, which refers to what he calls the "negative response of general practitioners to their proposed new contract".

I clarified what I meant.

It is interesting that Deputy Kelleher almost always moves off the subject of free medical care for those under six years of age, even when the question he tables refers to them. The Deputy spent no time discussing those to whom I refer and instead tried to deflect the House's attention towards another matter.

What about the position with regard to those with long-term illnesses?

We are quite happy to discuss discretionary medical cards. The Deputy is wrong. There is no systematic policy, or anything like it, to remove discretionary medical cards. The Deputy is well aware of what I meant when I stated there is no such thing as a discretionary medical card. A medical card is a medical card. Regardless of whether one applies through the means-tested system or the discretionary system, what one will obtain is a medical card. The cards relating to both systems are the same. The Deputy knows what I am talking about and it is he who is playing fast and loose with the facts.

Ambulance Service Provision

Ceisteanna (97)

Caoimhghín Ó Caoláin

Ceist:

97. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will take immediate action to increase the number of ambulances and the number of trained ambulance personnel to ensure proper emergency cover across the entire State in view of the dangerously inadequate ambulance service cover across large areas of the Twenty-six Counties at present; and if he will make a statement on the matter. [14989/14]

Amharc ar fhreagra

Freagraí ó Béal (24 píosaí cainte)

I ask the Minister to outline the immediate action he will take to increase the number of ambulances and trained ambulance personnel to ensure there will be a proper ambulance service in which citizens can have complete confidence in times of need.

I assure the House that the national ambulance service will continue to modernise and reconfigure its services to ensure emergency pre-hospital care is delivered in an appropriate and timely manner. In that regard, additional funding of €3.6 million and 43 staff have been provided under the national service plan for 2014. Including Dublin Fire Brigade emergency ambulances, our total fleet now numbers 534 vehicles. This represents an increase of 77 on the number of vehicles we had four years ago. I understand a number of emergency ambulances will be upgraded this year.

A significant reform programme is under way to provide a clinically driven and nationally co-ordinated system that will be supported by improved technology. Ongoing performance improvement projects include the single national control system, which is to be completed next year; the intermediate care service, which transports patients between facilities and allows emergency vehicles to focus on emergency situations; the move to on-duty rostering and the development of a national rostering system; and the emergency aeromedical support service, which flew 368 missions in 2013. One third of the latter involved time-critical transfers of ST segment elevation myocardial infarction, STEMI, heart attack patients to primary percutaneous coronary intervention, PCI, units.

I also draw the Deputy's attention to the three separate reviews of ambulance services that are under way. The Health Information and Quality Authority is examining the governance arrangements for pre-hospital emergency services, the HSE and Dublin City Council have commissioned a joint review of Dublin ambulance services to determine the optimal and most cost-effective model of ambulance services delivery for the city, and the national ambulance service is undertaking a comprehensive capacity review to determine the level of resourcing - in terms of staff, vehicles, skills and distribution - that will be required to deliver a safe and effective service now and into the future. These reviews will inform the development of a modern, clinically driven system, properly resourced, for appropriate and timely services to the benefit of patients.

We need fewer reviews and more action. That is the bottom line in respect of this matter. The "Prime Time" programme exposed the extent of the crisis relating to the ambulance service. That crisis is a direct result of cuts introduced under the stewardship of this Government and the one preceding it. Does the Minister share the huge public concern that exists with regard to the total inadequacy of the emergency ambulance cover available across huge swathes of this country? I refer here to the provision of ambulance services and the number of trained personnel and not to the quality of those working at the coalface within the ambulance service and who deserve great plaudits. Is it acceptable that ambulances often arrive too late and that people, including those I have known and who were dear to me, have died as a result? Is it acceptable that the target times set by HIQA are not being met? The times to which I refer have been changed and increased by the HSE. Is it acceptable that last year only one in every three people with life-threatening conditions was responded to by the ambulance service within the target times set?

I will address the specific issues. Since 2011 the HSE has been implementing response time standards on a phased basis in tandem with planned service improvement. In 2013 the HSE target for patient carrying vehicles to respond within 19 minutes was 70% for echo calls, that is, life-threatening cardiac and respiratory incidents, and 68% for delta calls, that is, life-threatening other than cardiac and respiratory incidents. For 2014 the target is 80% for both call types. It is important to remember that there have been over 1,000 extra calls per month in the past year. To say that we have been instigating cutbacks is utterly untrue. There has been a rationalising of control rooms towards one national system, which is ongoing. This is delivering improved technology to improve response times. The amount of investment in the past three years has been up year-on-year. In 2012 it was €128.7 million, in 2013 it was €135.1 million and in 2014 it was €137 million.

I assure the Minister that the points I have made are absolutely true. What we are seeking is an explanation of what the Minister is going to do about this crisis situation. Will he significantly increase the numbers of trained personnel and ambulances? When is he going to do this? What will he do in respect of HSE mismanagement of the service? This includes, for example, the scandalous use of rapid response vehicles as personal cars for managers. They are sitting outside their homes for long periods or in fleets at specific meetings that have been called having been driven there from different parts of the country and remaining for long periods out of service to the ambulance provision.

Is the Minister aware of the serious concern in the city of Dublin that the HSE is lining up to take control of the Dublin Fire Brigade ambulance service? This arises against the backdrop of a serious lack of confidence not only in the city but throughout the country in the HSE's capacity to provide a state-of-the-art and fully reliable ambulance service.

The people of this city do not want that change to arise. What can the Minister indicate to them about what he is going to do? When the Minister is citing figures he should examine the comparative situation in the North of Ireland and Scotland. He would find that we fall far short of those standards.

Again, the Deputy across loves to talk about crises and doom and gloom and has engaged in shroud-waving on several occasions.

The Minister should answer the question.

Sorry. I do not-----

He should answer the question without his nonsense. This is a very serious matter.

Deputy Ó Caoláin is not proving to be a very serious contributor if all he can do is shout instructions across the Chamber.

All the Minister can do is bluster his way.

There is no bluster.

He should answer the question.

No, sorry, Deputy.

Would you ask him to answer the question, a Leas-Cheann Comhairle?

Could we have order, please?

I will answer the question and I will keep the people informed of reality and the facts, not Deputy Ó Caoláin's bluster and shroud-waving. We have had quite enough of it over the years.

I am telling the Minister that any shroud-waving on my part is a result of the loss of a member of my family and it applies equally to all those who have experienced loss of life because of poor ambulance response times.

Good. I am glad that Deputy Ó Caoláin has acknowledged that it is shroud-waving.

This is a very serious matter.

I want order, please. The Minister to reply.

The response vehicle situation is currently being reviewed. I wish to inform Deputy Ó Caoláin again of some facts that do not quite fit the picture he likes to portray. Over 600 calls have been carried out this year already by those vehicles and over 230 of these were out-of-hours calls responded to by officers who had these vehicles at their homes and who were able to respond in an out-of-hours situation. That is what they are there for. I am not saying, no more than anyone in the service is saying, that the service could not be improved. We have these reviews to inform us of how to further improve the service to the benefit of patients and citizens. We will continue to do that.

Vehicles are important in themselves and ambulances are rather important too. Getting an ambulance to a patient is a priority. However, the core priority is getting treatment to the patient. There is a major emphasis now on the pre-hospital emergency care situation in order that the patient gets treatment and is stabilised as early as possible. This allows for them to be transferred to hospital in a safe fashion.

Hospital Staff Recruitment

Ceisteanna (98)

Tom Fleming

Ceist:

98. Deputy Tom Fleming asked the Minister for Health the number of hospital consultants' posts currently vacant; how widely medical consultant positions are advertised throughout the world by the Health Service Executive; the reason the salary scales applicable are not specifically included in advertising; and if he will make a statement on the matter. [15156/14]

Amharc ar fhreagra

Freagraí ó Béal (8 píosaí cainte)

How many hospital consultants' posts are vacant? How widely are medical consultant positions advertised across the world by the HSE? Why are the applicable salary scales not included in advertising?

I thank the Deputy for his question. It is Government policy to move to a consultant-delivered service. I am pleased to inform the House that, since the establishment of the HSE, there has been a significant increase in the number of whole-time equivalent, WTE, consultants by 723 from 1,947 in January 2005 to 2,670 in December 2013. However, there are some specialties in which there is an international shortage and that have been traditionally difficult to fill regardless of the salary scales. There are also some hospitals to which it has historically been difficult to attract applicants, in particular smaller hospitals that have onerous rosters due to a limited number of consultants. The establishment of hospital groups will help to address this issue, as they will allow doctors to be appointed as group resources instead of to just single hospitals.

The Public Appointments Service recruits permanent consultants on behalf of the HSE. All of these posts are advertised on www.publicjobs.ie, in the national newspapers, in medical journals and also on occasion through professional social networks. The terms and conditions are included in the information that accompanies these advertisements. Clearly, these include pay. They specify the types of contract being offered, for example, type A or type B, the applicable new entrant salary scale and the condition that serving permanent clinical consultants in the Irish public service are to retain the salary scales to which they were subject before these appointments.

Notwithstanding the need to reduce the numbers employed across the public service in order to meet fiscal and budgetary targets, the HSE has the capacity to recruit consultants. Arrangements are in place in the HSE to allow the recruitment of front-line staff where there is an established service need.

The HSE has advised that 34 hospital consultant posts are vacant. A further 219 consultant posts are filled by temporary or locum appointees. It should be noted that consultant posts take a number of months to fill, as applicants may be finishing training programmes or working abroad gaining additional experience at the time of their applications and, of course, are duty-bound to finish out their contracts.

Additional information not given on the floor of the House

The ability of the public service to attract and retain high-quality consultants shapes the extent to which the HSE can maintain and develop the range of health services required. As such, I set up a group under the chairmanship of Professor Brian McCraith last July to carry out a strategic review of medical training and career structures. The group submitted an interim report focused on training to me in December and is now progressing examination of the career structure to apply on completion of specialist training with a view to reporting to me shortly. Broader issues relating to recruitment and retention of non-consultant hospital doctors, NCHDs, and consultants will be given further consideration on receipt of this report.

I thank the Minister for his reply. To put this issue in context, Kerry General Hospital has advertised numerous times for consultant radiographers.

There are two vacant posts and the hospital recently received one application. For years, this service has been provided by private contract at an increased cost of approximately 40% compared with filling the posts within the hospital. This is a time of scarce resources when we must get value for money. Will the Minister streamline the advertising process? Are we reaching out universally to recruit suitable and qualified applicants?

Just for clarity, and I am not in any way trying to be difficult, but the Deputy mentioned radiographers. They are the people who take the pictures and are not consultants per se. Radiologists are the consultants who read the pictures.

I will conclude my answer. The ability of the public service to attract and retain high-quality consultants shapes the extent to which the HSE can maintain and develop the range of health services required. As such, I set up a group under the chairmanship of Professor Brian McCraith last July to carry out a strategic review of medical training and career structures. The group submitted an interim report focused on training to me in December and is now progressing examination of the career structure to apply on completion of specialist training with a view to reporting to me shortly. Broader issues relating to recruitment and retention of non-consultant hospital doctors, NCHDs, and consultants will be given further consideration on receipt of this report.

I do not profess to be familiar with the specific problem in Kerry, so I apologise. Sometimes, hospitals that are geographically isolated experience difficulty in attracting consultants and NCHDs.

The group hospital scenario helps to address that, as they can be part of a group and move around through the hospitals, thus making themselves available to the broadest range of individuals within the service.

A recent report stated that less than one third of consultant posts advertised since 2012 have been filled. This is alarming, to put it mildly. The figures show that just 36 of 104 consultant posts have been taken up at this stage. The Public Appointments Service has confirmed that it received no applications for some consultant posts and it has re-advertised a number of times. A recent "Prime Time" programme on RTE provided the information that one locum in a certain hospital was paid up to €300,000 for services in a 12 month period. We must move with more urgency towards getting the overall situation back to normality.

The number of consultants has been increasing year on year, and that has been the case for the past number of years. In 2011, there were 2,470; in 2010 there were 2,410; in 2012 there was a further increase to 2,510 and last year the figure increased to 2,560. Year on year we are not only replacing those who are leaving but also adding to the total number. However, I must return to the point that there are certain areas and certain specialties that pose difficulties and we are examining innovative ways of trying to address that. The McCraith report will help in that regard.

The new salary scale, which starts at anywhere between €116,000 and €122,000 is a considerable sum of money and compares extremely favourably with the UK, where the starting salary is £80,000 or €100,000. People are wont to compare immediately with America, Canada and the wealthier nations, but that salary is for somebody who is just finished their training to be a consultant. I do not expect a consultant who has worked abroad as an associate professor of cardiology or whatever for ten years to come back here and start on that salary rate. That would not be appropriate. In all walks of life, people get paid a certain amount more for the additional experience they have.

Children in Care

Ceisteanna (99)

Colm Keaveney

Ceist:

99. Deputy Colm Keaveney asked the Minister for Health his response to the criticisms of child and adolescent mental health services in the recent report by the Ombudsman for Children entitled A Meta-Analysis of Repetitive Root Cause Issues Regarding the Provision of Services for Children in Care; and if he will make a statement on the matter. [15122/14]

Amharc ar fhreagra

Freagraí ó Béal (6 píosaí cainte)

The object of this question is to elicit a response from the Minister to the several criticisms and observations made by the Ombudsman for Children in a recent report, A Meta-Analysis of Repetitive Root Cause Issues Regarding the Provision of Services for Children in Care. Will the Minister respond to the observations made by the Ombudsman for Children in section 4.6 regarding concerns with respect to the inter-professionalism and multi-agency collaboration with the Child and Family Agency?

I note the report referred to by the Deputy which was published recently by the Office of the Ombudsman for Children. A significant part of the report refers to services provided by the Child and Family Agency, and my colleague, the Minister for Children and Youth Affairs, has recently responded to the issues raised in the report. As a number of the report's recommendations relate to the HSE child and adolescent mental health services, CAMHS, and the need for improved inter-agency co-operation with the Child and Family Agency, I have asked the executive to consider these and determine the steps necessary to address the issues identified.

The HSE child and adolescent mental health services are benefiting significantly from the funding provided by the Government for mental health services, which amounts to €766 million in 2014, including additional funding of €20 million this year, as part of total additional funding of €90 million over the period 2012 to 2014, inclusive. By the end of 2014, up to 1,100 new posts will be put in place to strengthen community mental health teams for both adults and children, and develop other specialist mental health services.

A Vision for Change recommended the establishment of 99 multi-disciplinary child and adolescent mental health teams to provide acute secondary mental health care in the community. There are now 61 CAMHS teams in place, compared to 54 in 2008. The additional funding in 2012-14 is being used in part to expand and enhance the skill mix of these teams. Approximately 230 new posts were allocated to CAMHS over 2012-13 and recruitment is well advanced. The increasing demands being placed on our child mental health services were reflected in the 14,000 or so referrals received by CAMHS teams in 2013. This was nearly 1,000 or 8% more than projected in the HSE national service plan last year. However, the target of 70% of referrals being seen within three months was maintained.

I accept that there are specific additional risks of developing mental illness associated with children who are within the care system and that a proportion of the children attending CAMHS services are in contact with, or in the care of, the social services. A comprehensive protocol is in place between the HSE and the Child and Family Agency to ensure that the needs of children in the care of the State have access to CAMHS services in the same way as any other child with a mental illness, prioritised on need.

I thank the Minister for his response. Can he confirm that there will no longer be a situation where a child in care has a social worker in one area while relying on child adolescent mental health services in another area? Will the child be guaranteed to have a seamless access to a service? Several serious communications issues were identified in that report, including a case where the child adolescent mental health services failed to monitor a child's health status for over seven months. Can the Minister categorically state today that this is being addressed? I welcome the fact that he has asked the HSE to consider the report. The report found that where a child had been initially assessed in one area, she had been refused an assessment in another area, even though she was under the care of the HSE. Has this practice stopped since the Minister referred this report to the HSE?

The final issue was the most serious and may have implications not just for those in care, but also for those presenting to CAMHS. The report stated that "CAMHS does not work with children with an intellectual disability, and disability services do not work with children with mild intellectual disability." When are we to expect a response from the HSE on that reference in the report?

I anticipate that the response to the last issue will come fairly soon. I would like to apologise; this is the area of the Minister of State, Deputy Lynch, who is unavailable to us today due to a family bereavement. I am here in her stead. I remember that when I was on the benches across and we were discussing child care, it was about the terrible tragedy of so many deaths in care in the past. I am glad to see that that situation has greatly improved even though we still need to work on it.

We also continue to work on the admission of children to adult facilities, because nobody in this House thinks that is appropriate. New services are being put in place. In 2008, 25% of admissions of children to the HSE inpatient acute services were to age appropriate child and adolescent units. By 2013, this had increased to 68%, so clearly we have more road to go.

What actions will the Minister be taking with respect to the report, specifically on the issue of CAMHS? Will those who have the responsibility for children be committed to playing a full-time role in collaborating with the new agencies, especially in respect of the parenting of children in the care of the State? The report notes that the Child and Family Agency has been created, and we welcome that. However, there is a concern that the agency will not have the same reach in terms of its responsibility for services under the direct control of the HSE. The lack of control by the agency primarily relates to CAMHS. CAMHS does not come under the new Child and Family Agency, and neither does the public health nurse. However, we have a system with respect to the welfare of children in this country under a multidisciplinary, multi-agency environment and I have concerns, as has happened in the past, that children will fall through the cracks of the bureaucracy again.

We all share the Deputy's concerns that children might fall through the cracks and we must guard against that when we have so many people involved in their care and well being. In September 2012, access protocols for CAMHS services were approved by the HSE, with effect from 1 January 2013.

The protocol reiterates the position of children accessing services in line with the Mental Health Commission's protocols, including children being referred for the first time to the mental health service from outside their geographic area. In effect, all children requiring secondary care mental health services are seen on the basis of clinical requirement. Children in care are provided with child and adolescent mental health services on the same basis as all other children in the population. A comprehensive protocol has been developed between the HSE and the Child and Family Agency to ensure the needs of children in the care of the State are met when it comes to accessing health services, including mental health services. This reinforces the position that child and adolescent mental health services are available to children in the care of the State in the same way as they are available to any other child with a mental illness. Basically, it is prioritised on the basis of need. This protocol is at an advanced stage of discussion pending agreement.

Neuro-Rehabilitation Policy

Ceisteanna (100)

Caoimhghín Ó Caoláin

Ceist:

100. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will respond to the findings of the latest survey of persons with neurological conditions carried out by the Neurological Alliance of Ireland which finds that 42% of medical card holders surveyed have had their medical cards withdrawn and that 50% of those applying for a medical card have been refused; if he will respond to the other findings showing the damaging effect of Government cutbacks; and if he will make a statement on the matter. [14990/14]

Amharc ar fhreagra

Freagraí ó Béal (6 píosaí cainte)

What does the Minister of State intend to do in response to the Neurological Alliance of Ireland's latest survey of people with neurological conditions, which found that 42% of medical card holders have had their medical cards withdrawn and 50% of those applying for medical cards have been refused?

As the Deputy has indicated, his question refers to a recent report compiled by the Neurological Alliance of Ireland. Neuro-rehabilitation health services are provided across a range of settings by different organisations and by many health professionals and carers. The Government has set out a four-year plan with a series of recommendations under the national policy and strategy for the provision of neuro-rehabilitation services in Ireland, which is running from 2011 to 2015. The HSE is committed to working with the national clinical programme for rehabilitation medicine to develop services based on the recommendations of this strategy. In this regard, the number of rehabilitation medicine consultants nationally increased from seven to 12 in 2013. Specialist inpatient and outpatient units have been identified to operate in each of the four current HSE regions, with clinical governance and expertise to be provided by the National Rehabilitation Hospital. An early access rehabilitation unit for Dublin and mid-Leinster, based at the National Rehabilitation Hospital, was set up in April 2013. This has delivered a significant increase in the throughput of patients treated.

I will use the remaining time available to me to address the question of medical cards, which was mentioned by the Deputy. I can refer to some of the other matters if necessary. The Deputy will be aware that under the provisions of the Health Acts, medical cards are provided to people who, in the opinion of the HSE, are unable without undue hardship to arrange GP services for themselves and their dependants. There is not and never has been an entitlement to a medical card based on having a particular disease or illness. The assessment for a medical card is determined primarily by reference to the means, including the income and expenditure, of the applicant and his or her partner and dependants, based on the HSE's income guidelines. The HSE routinely examines applications for indications of medical or social circumstances which might result in undue financial hardship in arranging medical services. In such circumstances, it may exercise discretion to grant eligibility for a medical card on this basis. The Government recognises that neurological illness or injury has significant implications for the individual and his or her family. It has an impact on his or her social, educational, vocational and recreational participation. Waiting times, access, treatment and quality of care are priorities for reform for this Government. Despite the budgetary constraints we face, the Government is determined to create a new health service that can better respond to the needs of the Irish people.

I welcome the long-overdue establishment of the implementation group for the national policy and strategy for the provision of neuro-rehabilitation services. Is there a timeframe for the work of that group? I have no doubt that the Minister of State is well aware of the huge challenges facing people with neurological conditions. In that context, is he concerned by the results of the latest survey compiled by the Neurological Alliance of Ireland? As I outlined in my question, the alliance has reported that a phenomenal 42% of the medical card holders surveyed have had their medical cards withdrawn and 50% of those applying for medical cards have been refused. I do not have to remind the House of the reality of the impact of the withdrawal of medical cards. I do not believe any discretion is being employed in relation to these matters. There is an overwhelming body of evidence to suggest that no discretion is being employed in the health services when people seek to have medical cards renewed or issued. Does the Minister of State think this is acceptable in this area, leaving aside all the other areas of concern? What does he intend to do about it?

I would like and the Government intends to ensure that universal access to GP service is available - universal meaning access by everyone in the community, including those with an illness or condition. That is the way we intend to address at least part of the issue the Deputy raised. I cannot answer directly the Deputy's question on the timeframe, but I will certainly access that information and get back to him on it.

I respectfully disagree with the Deputy on the exercise of discretion. Whereas I, as a Minister of State, cannot be across every individual aspect of the manner in which this service is operated and managed, I know that there is a system in place for the exercise of discretion. I know that because I see it in requests that come in from Deputies for issues to be addressed and for me to ask the service specifically how particular applications are dealt with. I know discretion is exercised in a manner that has been explained to this House on a number of occasions in respect of persons who are over the income limit. It is an income and means-based system; it is not an illness-based system.

There is strong evidence. I was not aware that the Minister of State was a conduit in terms of appeals over the exercise of discretion regarding medical cards - that is certainly a point of interest to me. What will the figures be for 2014? The survey relates to last year. I specifically focus on people with neurological conditions, which is an area of major concern. The survey also indicated that 68% of those surveyed were affected by changes to the mobility allowance; 64% by cuts to home-care packages; 59% by reductions in home-help hours; and 54% by reductions in HSE transport services. As I have only recently engaged with people with neurological conditions, I can assure the Minister of State that they are suffering greatly and it warrants special attention on his part.

We were promised a replacement for mobility allowance and the motorised transport grant that have been closed to new applicants. What has happened to that commitment? When will the Minister of State introduce a replacement to the mobility allowance and the motorised transport grant?

A group is looking at the matter of the mobility allowance. We can certainly ensure we get a progress report to the Deputy and to the House as soon as possible.

I want to ensure the Deputy has not misinterpreted what I said. He used the word "conduit". Neither the Minister for Health nor I have any role whatsoever in the allocation of or appeals over medical cards, discretionary or otherwise. However, in the normal run of events people raise the issue with me and the Department as to how the system operates. My knowledge of how the system operates tells me without doubt that there is the exercise of discretion in circumstances where people's income is above the limits set out in the guidelines but who may have an illness or condition that will affect their resources, means or ability to provide in respect of their health.

There is no question of any targeting. I have made this point previously to Deputy Kelleher. Records in the PCRS do not categorise applicants in accordance with their medical condition. The system is not set up in such a way as to categorise people in accordance with a particular illness or condition, such as a neurological condition. It would be perverse to seek to target people with particular conditions. Even if anyone wanted to do it, which would be amazing, they could not do it because the system is not set up that way. People with particular disabilities, diseases or conditions cannot be and are not targeted for review.

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