Wednesday, 14 May 2014

Ceisteanna (6, 7, 9, 12, 16, 18, 21, 23, 31, 35, 39, 42, 45, 48, 58)

Billy Kelleher

Ceist:

6. Deputy Billy Kelleher asked the Minister for Health to explain the action he is taking to address the persistent fall in the numbers of discretionary medical cards; and if he will make a statement on the matter. [21249/14]

Amharc ar fhreagra

Billy Kelleher

Ceist:

7. Deputy Billy Kelleher asked the Minister for Health if he will direct the Health Service Executive to take water charges into account when considering whether to award a medical card; and if he will make a statement on the matter. [21253/14]

Amharc ar fhreagra

Robert Troy

Ceist:

9. Deputy Robert Troy asked the Minister for Health to outline his views on the automatic granting of a medical card to children with Down's syndrome; and if he will make a statement on the matter. [21272/14]

Amharc ar fhreagra

Billy Kelleher

Ceist:

12. Deputy Billy Kelleher asked the Minister for Health to outline the consultations he has had with the Department of the Environment, Community and Local Government with regard to charges for persons with high water usage owing to certain medical conditions; and if he will make a statement on the matter. [21250/14]

Amharc ar fhreagra

Timmy Dooley

Ceist:

16. Deputy Timmy Dooley asked the Minister for Health to explain how he will address the current and persistent concern regarding the withdrawal of discretionary medical cards; and if he will make a statement on the matter. [21274/14]

Amharc ar fhreagra

Brendan Smith

Ceist:

18. Deputy Brendan Smith asked the Minister for Health to explain how he proposes to address the continuing concerns regarding discretionary medical cards; and if he will make a statement on the matter. [21254/14]

Amharc ar fhreagra

Catherine Murphy

Ceist:

21. Deputy Catherine Murphy asked the Minister for Health to set out the evaluation carried out to determine the cost implication to the Health Service Executive of withdrawing a discretionary medical card where the patient concerned is likely to go on to require acute hospital care for a chronic condition; if he has readily available figures to demonstrate that the economic saving of taking away medical cards from persons is not more than eliminated by the resultant reliance on acute hospital services; and if he will make a statement on the matter. [21121/14]

Amharc ar fhreagra

Barry Cowen

Ceist:

23. Deputy Barry Cowen asked the Minister for Health if the impact of property tax and water charges will be taken into account when assessing persons for medical cards; and if he will make a statement on the matter. [21270/14]

Amharc ar fhreagra

Colm Keaveney

Ceist:

31. Deputy Colm Keaveney asked the Minister for Health if he will reconsider his policy on discretionary medical cards in respect of children with Down's syndrome; and if he will make a statement on the matter. [21120/14]

Amharc ar fhreagra

Niall Collins

Ceist:

35. Deputy Niall Collins asked the Minister for Health to outline how he has intervened to protect persons whose medical conditions necessitate above average water consumption from the financial hardship that may result from the introduction of water charges; and if he will make a statement on the matter. [21267/14]

Amharc ar fhreagra

Michael Moynihan

Ceist:

39. Deputy Michael Moynihan asked the Minister for Health if he will introduce new guidelines for the awarding of medical cards on a discretionary basis; and if he will make a statement on the matter. [21261/14]

Amharc ar fhreagra

John Browne

Ceist:

42. Deputy John Browne asked the Minister for Health if he will consider the introduction of an automatic entitlement to a medical card for children with Down's syndrome; and if he will make a statement on the matter. [21264/14]

Amharc ar fhreagra

Robert Troy

Ceist:

45. Deputy Robert Troy asked the Minister for Health to set out the number of discretionary medical cards the Health Service Executive expects to issue in 2014; if the downward trend of the past three years is likely to be reversed; and if he will make a statement on the matter. [21273/14]

Amharc ar fhreagra

Seán Ó Fearghaíl

Ceist:

48. Deputy Seán Ó Fearghaíl asked the Minister for Health if he has brought to the attention of the Department of the Environment, Community and Local Government the health conditions that require water usage above the normal individual consumption level; and if he will make a statement on the matter. [21269/14]

Amharc ar fhreagra

Barry Cowen

Ceist:

58. Deputy Barry Cowen asked the Minister for Health to outline the engagement he has had with the Department of the Environment, Community and Local Government with regard to the possible impact on the health needs of persons of the introduction of water charges; and if he will make a statement on the matter. [21271/14]

Amharc ar fhreagra

Freagraí ó Béal (46 píosaí cainte) (Ceist ar Health)

Are the questions grouped?

They certainly are.

There are several of them. Are we reverting to type?

The fact is that time will be taken up with this question.

I will cut to the chase on the issue. The culling of discretionary medical cards has already been referred to in Priority Questions, Private Members' business and in the House for the past two years plus. Can we have an acceptance from the Government side that there is a major problem? It has been acknowledged in the Fine Gael Parliamentary Party. I wish that the Labour Party would acknowledge it as well and then we might get some traction for change, not necessarily in the policy but in the practice of how discretionary medical cards are assessed and awarded.

I propose to take Questions Nos 6, 7, 9, 12, 16, 18, 21, 23, 31, 35, 39, 42, 45, 48 and 58 together.

At the outset, let me again put on the record of the House that there is no policy to abolish the awarding of medical cards on discretionary grounds or to target any patient group. I welcome Deputy Kelleher's belated acknowledgement that there is no such policy in existence.

It is the practice.

We will come to the practice. Neither has there been a change in the rules of awarding medical cards on discretionary grounds. The medical card scheme continues to operate such that those who suffer undue financial hardship, as assessed according to the published HSE guidelines, in the arranging of general practitioner services are awarded a medical card.

While the number of medical cards issued on discretionary grounds has fallen in recent years, this is not as a result of a change in policy or a deliberate targeting of discretionary cards. Rather, it is attributable in the main to the fact that many people - I can give the figures again - who previously were marginally over the qualifying means thresholds have subsequently been granted medical cards because they now fall under those means thresholds. Of the discretionary medical cards in circulation in 2011, approximately 6% have subsequently been refused a discretionary medical card on review. While the number in this regard may be small, I in no way underestimate the difficulties caused for those who are considered or found to be ineligible.

However, the legislation is clear that qualification for a medical card is means-tested. As a result, some people have been found to be ineligible because their net income is in excess of the means thresholds, sometimes by hundreds of euro per week. As I outlined previously, the HSE is currently examining how individuals who are not entitled to a medical card could still receive services that meet their needs. The issue is being addressed in a manner that includes all of the services and supports provided by the HSE with as much flexibility as is available and at a local level.

All medical card and GP visit card holders are subject to a periodic review of eligibility to determine whether they remain eligible. The change in the number of existing cards will be dependent on the extent of ineligibility detected. Given that medical card eligibility is assessed on an individual basis it is difficult to estimate the number of medical cards that may be awarded on a discretionary basis.

It is important to note that where a medical card is withdrawn, irrespective of its having been awarded based solely on means or where the HSE has exercised discretion, it is not withdrawn due to the cost implications for the HSE. In accordance with the Health Acts, a medical card can only be withdrawn due to eligibility not having been established.

The medical card system is founded on the test of undue financial hardship in arranging GP services. Assessment for a medical card is determined primarily by reference to the means, including the income and reasonable expenditure, of the applicant and his or her partner and dependants. In the case of a child, the parents' income and reasonable expenditure is assessed. Under the legislation there is no automatic entitlement to a medical card, nor has there ever been, for a person with a particular disease or illness.

Determination of eligibility for a medical card is the responsibility of the HSE. I will outline the matter of practice that I was asked to address. The HSE has produced national assessment guidelines to provide a clear framework to assist in the making of reasonable, consistent and equitable decisions. The guidelines do not provide for expenditure associated with property taxes or water charges to be included in the determination of means of the applicant. On the issue of water charges, the Department of Health has not been involved in discussions on the exempting or capping of water charges for certain medical conditions but it is available to do so.

As I remarked earlier, one of the consequences of the transition to a nationally consistent system of assessment has been difficulty at renewal stage for higher income households or persons on relatively higher income, even where an illness or disability is involved. On the initiative of the Minister for Health, the HSE established a panel of community medical officers to assist in the processing of applications for medical cards where the income guidelines were exceeded but where there are difficult personal circumstances, such as an illness or physical disability that may have an impact on the financial situation of the applicant. The medical officers review evidence of necessary medical expenses provided by the applicant. As appropriate, he or she liaises with general practitioners, hospital consultants and other health professionals such that the costs relating to the health circumstances of the applicant can be taken fully into account.

At the request of the Minister, Deputy Reilly, the HSE is currently examining how individuals who are not entitled to a medical card could still receive services to meet their needs. As I said earlier, this examination relates to all of the services and supports provided by the HSE with as much flexibility as is available and at a local level. Additional information will be provided and local information points will be established at major health centres throughout the country, where members of the public can obtain comprehensive information and support in accessing their full range of supports from the health services. Appropriate notice is also being considered as part of this review for existing medical card holders who may no longer be eligible on renewal but where serious medical conditions or profound disability continues to exist in the household. The objective is to maximise the supports available for patients and families.

The Government is fully aware of the difficulties caused for those who are considered ineligible. Indeed, one of the key goals of the reform of the health system is to ensure that people receive health care according to their particular needs rather than based on their income. Historically, eligibility for health services in Ireland has been based on a person's means. This, I believe, is an anachronistic and inappropriate basis for a health system and is far from any comparable modern health system of any European country. It underpins the importance of moving towards a health system based on universality of access. These major reforms take time and, in the meantime, I look forward to seeing proposals from the HSE on how individuals who are not entitled to a medical card could still receive care that meets their needs under the existing health legislation.

Four Deputies present have questions, namely, Deputy Kelleher, Deputy Troy, Deputy Catherine Murphy and Deputy Keaveney. Deputy Ó Caoláin has indicated, if we have time.

What time do we have?

You are entitled to two minutes each.

I cannot elicit information on whether there has been change in policy or in practice. However, I do know one thing: there has been a change to many people's lives. These are people in our communities who have had their discretionary medical cards withdrawn or who applied on a discretionary basis but were not granted a card. Last night in the Dáil debate I remarked on the advocacy groups, who represent and advocate for people, which have been consistently highlighting this. The Jack & Jill Children's Foundation, Down Syndrome Ireland and many other organisations, including the Irish Cancer Society and others, have consistently said that there is a change either in the practice or the policy. Either way, it is making a major impact on people's lives in a negative way.

The former Ombudsman, Emily O'Reilly, stated clearly in her report in 2013 that while there was no discernible change in terms of policy, the way the scheme was implemented and the way discretion was assessed had been tightened to the point where it was more and more difficult for officials to grant a card on a discretionary basis. Therefore, there have been changes. I said last night and I repeat: the Minister of State is asking the old and the sick to pay for the health and the wealthy and that is simply wrong.

Deputy Kelleher alleges there has been a change in policy, then he agrees that there is no change in policy and then he says he is unsure whether there has been a change in policy.

We are in the Dáil now, we are not in the Four Courts.

There has been no change in the policy. It has been made clear that there has been no change in the policy. What has happened is that we have had a standardisation of the application of the procedures and the guidelines and the HSE has, in fact, published these. I believe that is a good thing and I invite Deputy Kelleher to agree with me that this is a good thing in order that we can ensure we do not have a repeat of the significant disparities that have existed for so long throughout the country with regard to awarding medical cards based on discretion.

With regard to the spread throughout the country of medical cards granted on the basis of discretion, will Deputy Kelleher comment on the fact that in his county of Cork, the number of discretionary medical cards is 71% above the national average whereas in County Meath it is almost 70% below the national average? How can it be that over the years Cork, Limerick, Tipperary, Laois, Offaly, Clare and Waterford have had a higher number of medical cards awarded on discretionary grounds than some other counties? These are not small differences but huge disparities. It is not fair we have a system which is not transparent. I do not know whether the Deputy and his party would prefer to have a system without transparent rules whereby people have access to services through another method.

I believe in having a rules-based system and applying it fairly, transparently and honestly. This is what we want to achieve.

The Minister of State can dress it up anyway he wants. It confirms to me that many Dublin-based Deputies must not have clinics because the hard facts and evidence coming to every clinic the length and breadth of the country, which any Deputy of any political party or none will cite, is that these discretionary medical cards are being culled at an alarming rate. I spoke recently to a woman who had had a mastectomy and her medical card was culled. As my colleague stated, according to Down Syndrome Ireland, the mother of a young boy was asked to prove he still has Down's syndrome. Cancer patients and people with motor neurone disease are also affected. The list goes on and on. Whatever way the Minister of State wants to dress it up, the simple hard facts of the matter are people with a medical need for a discretionary medical card are being deprived of it. The Minister of State speaks about establishing information units to inform people of their entitlements. How much will these information units cost? Why can people not be given their entitlements? Their medical conditions cause them enough anxiety and worry without putting them through more anxiety and worry appealing and re-applying for medical cards which ultimately they do not get.

People are entitled in certain circumstances to a medical card and nobody will lose or has lost a medical card who is eligible for it and is entitled to it. This is absolutely the case.

Anybody who is eligible for a medical card under the system and guidelines will get it. If there are any circumstances where a Deputy suggests those eligible for medical cards do not have one, we need to know about it because if they are eligible, they will receive it. As I indicated, we had a system which had huge disparities throughout the country. We now have a fair system. Surely it is much better to have a fair, consistent and clear system in order that people know where they stand. This is the type of system I want to see.

That is not what we have.

I am not sure if it is the type of system the party opposite wants to see. Historically it is not how they did business.

Is taking from the vulnerable and sick fair?

This is how we should do business in future. We should make sure we have a proper rules-based system and do as the Minister and I have sought to do, which is take steps to ensure services are in place to support people who have lost out on a medical card on which they relied for a number of years, and make improvements in the services where they are needed, particularly with regard to access to and information on the services, in order that there is proper interaction between the primary care reimbursement service, PCRS, and services on the ground. I accept we have not done enough to achieve this and there are gaps in services which need to be filled. This is where we are concentrating our efforts, to ensure people get the services they need.

We can only say what we see ourselves. A particular case which I believe highlights it very well is that of a family with a little girl who has cerebral palsy. She has just turned five. A little over a year ago, after providing very significant information, she received a medical card on discretionary grounds which was issued for three years but was reviewed less than a year later and is now on a very short extension. The same very extensive information is being sought as was provided previously. This is not just about the child going to a GP. The mother, who went public, stated the child has had a card since she was 13 months old. The child cannot swallow and is fed through a tube. The food delivered is covered by the medical card, as is her €4,000 chair which must be adjusted regularly as she grows. She needs physiotherapy to massage her legs and ensure her spine is not damaged from being in the chair all of the time. The children's hospital in Crumlin did not let her leave until she had a medical card. She receives occupational therapy. All of these services are provided on the medical card. This family requires the State to support the child, who could end up being in hospital because she is at risk if she is not properly cared for and resourced. It is not just about going to the doctor once or twice a year. It is everything else which goes with it. These families are being put through absolute purgatory. At the very least until services are in place there needs to be an extension on these cards where such children are at risk.

Deputy Murphy referred to services. It is very difficult to comment on an individual case but I entirely trust Deputy Murphy with regard to the veracity of what she stated regarding the case. The point is the services which the individual needs, such as access to physiotherapy, equipment, various devices and a wheelchair, and this is what we must ensure the person gets. We are inclined to reduce this entire debate to an actual physical card. I know that traditionally it has been the gateway to all of these services, but we want to ensure that services are there irrespective of holding a medical card on the basis of need. I will not trespass for a moment on the individual and family, even though we have not stated who it is. In circumstances where a family's means are above, perhaps significantly so, the income test, it still should have access to the services. This is what we seek to do.

An issue which comes up in many cases, and I am not stating it is in this particular case, is people do not realise that even if they do not qualify for a medical card, they may qualify under the long-term illness scheme, which is hugely important and people need to know about it. I am not speaking about the case raised by Deputy Murphy. I am making a general point that there seems to be a gap in the information flow to people. They may not be entitled to a medical card but they may be entitled to other services and we need to join up all of this.

I am loath to reference anecdotal evidence from canvassing on doorsteps in light of the Minister of State's previous comments, but I refer him to a senior official of the HSE who last week stated in Galway that the removal of discretionary medical cards is indefensible. We have a Minister of State defending what he regards as a fair gateway to aids and appliances through providing a medical card. The Minister of State is continuing a crusade of removing medical cards from the most vulnerable people. I refer him to the Coyle family whose child's medical card was removed. Alexander cannot walk, talk or go to the toilet and takes 31 medicines and interventions a day. The Minister of State's crusade has taken away Alexander's medical card. The language he uses is vis-à-vis what has been issued, but he does not state what has been culled in the reissue. Clearly, there is an inconsistency between his language and that of John Hennessy who stated these actions are indefensible. What is going on is immoral. What is being done to people who cannot defend themselves is immoral. Parents of children with Down's syndrome are written to and asked whether there is any sign on the horizon that the child is any better. This is insensitive and equal to the merit of the Minister of State's crusade to rob vulnerable people of a discretionary medical card.

It is true some of the decisions made in respect of the mechanics of how the process is implemented, some of the overbureaucratising of the process, some of the delays which have happened and some of the mistakes which have happened in the implementation and administration of the system are indefensible. There is absolutely no doubt about this in my mind and I have no difficulty repeating the word here that it is so. People accuse me of being legalistic about this, and perhaps I am a little too legalistic sometimes in my style-----

Just be human for a day.

-----but the Oireachtas makes the laws. The Minister does not make the law, the Oireachtas does, and we must carry it out. No Minister or HSE-----

Who resourced discretion?

The Deputy is very excitable.

I always get excited.

The Deputy should understand that no Minister or the HSE can award directly a medical card outside the legislation this House has passed.

While the Deputy stated he was reluctant to bring up individual cases, he then of course went on to so do. However, I can tell him that in respect of the particular court case to which he referred, the HSE has been in touch with that family in a sensitive fashion. It is dealing with those issues as best it can within the available resources, entitlements and eligibility that are in place. I believe the family would appreciate that.

Perhaps the Minister of State could get a little excited sometimes, because the passion is what is missing.

More than that.

I will paraphrase what the Minister of State said a few moments ago, which is that one must ensure the services people need are what they get. Yet he has placed people not on a pathway to those needs and services but in a maze in which they are unable to find how to get to the end point. This is absolutely unacceptable. Moreover, in the Minister of State's earlier response to me - when I thought I had another opportunity to reply regarding my priority question on this very issue - he spoke about the context of elections. The Jack & Jill Children's Foundation is not standing in the local and European elections but has described the current medical card system in Ireland as being broken and lacking in humanity. It has described it as being unjust and inconsistent and as a hellish lottery. Has the Minister of State read the correspondence from the specialist nurses in the Jack & Jill Children's Foundation? Has he looked at the case put by the Aoibheann's Pink Tie organisation on behalf of children with cancer?

Thank you Deputy.

Make no mistake about it-----

Sorry Deputy, please.

-----I am asking the Government to recognise the hurt and pain that exists, of which its backbenchers must be at least equally aware as are Members on this side.

I do recognise the pain, the difficulties and the dilemma that families face in these circumstances. I also understand and am aware of many individual cases in which people have felt confronted by such a situation. I also accept what the Deputy has just stated, which is that sometimes, it can appear to be quite a maze to people who perhaps are faced suddenly with a situation in which they need access to services through a medical card or otherwise. I accept this and do not disagree with the Deputy's use of the word "maze" sometimes regarding the bureaucracy or that there are inconsistencies in the system. The Deputy undoubtedly is correct when he said that and this system must be reformed.

At present, the long-term illness system is based on illness while the medical card system is based on means. There are huge inconsistencies about which nothing was done historically and the Government now is moving towards a universal system. This is a time of transition and I accept it is extremely difficult to defend some of the things in the existing inadequate system, while at the same time the Government is trying to reform it. I sought the support of the Opposition and while the Government received some support from Sinn Féin with regard to the under-sixes, there was very little support from elsewhere and very few alternative proposals from Fianna Fáil on any of these matters, other than just attacking.