James Reilly (Dublin North, Fine Gael) | Oireachtas source

Yes. The report produced by PricewaterhouseCoopers suggested that somewhere between €60 million and €200 million could be saved through probity in the GMS, or primary care reimbursement service, as it is now known. That report was published 18 months ago, so obviously there has been a lot of action since then. None the less, a figure of €113 million in savings to be achieved was given to the Department by the Government. I am frankly concerned about what can be achieved here and about what can be achieved in view of the Haddington Road agreement. That is why I asked for the Taoiseach's Department and the Department of Public Expenditure and Reform to be involved in assessing and validating these figures and the impact these savings would have on the service. I want to reiterate - it is important that people understand this - that probity does not only relate to whether the person holding the medical card is eligible to do so, but also to the prescribing practices of doctors and out-of-hours claims made by doctors. One doctor claimed €180,000 and ended up settling for €15,000. There are issues with regard to pharmacy services as well. Therefore, it is not all about the question of eligibility for a medical card, by any means. I reiterate that people who are entitled to a medical card have nothing to fear.

I reject the Deputy's contention that discretion has been taken from the HSE. In fact, more discretion has been given to it, as there are now doctors to make sure that even more compassion is applied in assessing people and that every latitude is given to try to help people to qualify. As I said to the Deputy earlier, 49% of people who had their cards removed or failed to get a card were more than 200% over the threshold when everything was taken into account. I must re-emphasise that the medical card scheme never operated on the basis of medical conditions or illnesses; it operates on the basis of consideration of undue financial hardship. Clearly, medical conditions have an impact on financial hardship, and that is taken into account. Equity and consistency have been brought into the system because in the past people in some parts of the country got discretionary medical cards based on certain criteria while people in other parts of the country could not get them based on the same criteria. There is consistency in the system, but the rules have not changed.

The Deputy mentioned the issue of tax relief on medical insurance premiums. That is a taxation matter. He will probably ask whether I knew about it. I found out at the same time as all my other Cabinet colleagues. Is that unusual? I know of no Minister for Finance who has discussed his taxation measures with the Cabinet before deciding on them himself. This is a challenge for us as well; of that there is no question.

With regard to the increase in the prescription charge, that is not the direction in which I want to go. I still firmly have concerns about it, but given the options with which I am faced in order to raise €660 million, I would prefer, even though I do not like it one bit, to raise the prescription charge rather than to cut services. That is the choice I am left with. We do not like to be political here, but nobody in this room need be deluded as to why €660 million is needed from the health budget to get us out of the bailout and why we are in the bailout.

The Deputy asked me about the role of the three Departments. I think I have covered that already. I sought that because I want absolute clarity around these figures with regard to their achievability. I want absolute clarity about their impact on the service because if they are not achievable in this area of the budget, they have to achieved somewhere else in the budget. That is the reality and I have the agreement of the Taoiseach's Department and the Department of Public Expenditure and Reform on that.

Deputy Ó Caoláin asked if we had the necessary details in advance of the budget. In no other year have so many hours been spent going over this. There is a new chief financial officer and a new financial reform board in the HSE, and we had well over 30 hours of meetings, not including the hours of work those involved had done before they came to me and the hours we then put in with the Department of Public Expenditure and Reform. We have real information and the figures are real. I also want to clarify another matter. The idea of a black hole in health was something that had currency years ago. I can tell the Deputy there is no black hole there now. We now know where all the money is, how it is spent, where is going and how much we need. As I said previously - not here but in other media - we had postulated an increase in demand of 1% during the year, and asked for €190 million but got €90 million, and then the increase in demand ended up being 2%, which involved a cost of €360 million. The Deputy can recognise the challenges faced by the health service in trying to predict the future with absolute certainty.

The Deputy and the Irish people can be absolutely assured - I will ask the Minister of State, Deputy White, to elaborate on this - that the provision for the under fives is not a stand-alone initiative. This is a part of a key step on the road to universal health insurance. Even with full GP care available throughout the land, that will not end the inequity of the two-tier system. The only thing that can do that is universal health insurance and the delivery of that is something to which I and Government are committed. These are key building blocks towards that goal.

The Deputy asked where the figure of €113 million had come from. I have explained that already. As I said, this is the figure that we were given as a consequence of the Department of Public Expenditure and Reform's deliberations on that report.

On the issue of discretionary medical cards being harder to get, while the Minister of State, Deputy White, will want to deal with that, I have some detail on that in myriad of papers before me.

On 1 January 2010, there were 96,000 discretionary medical cards on the system. On 1 January 2011, there were 98,000 such cards. On 1 January 2012, there were 90,000 such cards. By 1 January 2013, the figure had fallen to 78,959. On 1 September, it was 75,000. I must point out that 22,584 of those migrated to full medical cards. As such, the Deputy's contention that a medical card is more difficult to get is not borne out by the facts and the figures.

Communication around these issues is needed, particularly in respect of probity and medical card reviews. We must review them. People move on. Sadly, people pass on. People leave the country, get jobs or so on, thereby changing their circumstances. At the beginning of an illness, the financial hardship can be quite severe. For some people, it can improve. Sadly, it does not for others. The cases where people have lost their medical cards are the ones where we are particularly interested in determining what changed in their circumstances. However, 49% of the people in question are 200% over the limit, taking all allowances into consideration, and 92% of people are more than 50% over the limit. It is a question of equity in the system.

The Deputy asked me about non-consultant hospital doctors, NCHDs, and sanctions. I will let Mr. Tony O'Brien and Mr. Barry O'Brien discuss those matters, but I have been clear - the sanctions are to be applied to those who have failed to deliver. Patients are not the ones failing to deliver, and neither are doctors. It is management. Let us not forget that management includes clinical directors. They are the ones on whom the sanctions will be focused.

Nursing home care was mentioned and the Minister of State, Deputy Kathleen Lynch, discussed that matter. I agree with her 100%. We must stop viewing long-term care as the only solution to these issues and focus more on trying to keep people at home. People are always attracted to resources. Before this meeting, I mentioned that a survey we conducted a couple of years ago had found that a third of people had never been assessed for home care before entering into long-term care. In the case of a further third, the survey was uncertain. There is a sense that many people who end up in long-term care should not have landed there in the first place. Once one enters, however, the chances of leaving are quite small. We have put in place an elderly care clinical programme so that elderly people who are frail when entering hospital have their medical problems addressed urgently and start their rehab from day one. If that takes a number of weeks, they will move to another facility, albeit not necessarily in the country. This will help us to get more people home instead of in long-term care before they need to be.