Oireachtas Joint and Select Committees
Wednesday, 10 July 2013
Committee on Health and Children: Select Sub-Committee on Health
Estimates for Public Services 2013
Vote 38 - Department of Health (Revised)
Vote 39 - Health Service Executive (Revised)
9:30 am
Jerry Buttimer (Cork South Central, Fine Gael)
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The sole purpose of the meeting is the consideration of the following Revised Estimates: Vote 38 - Department of Health and Vote 39 - Health Service Executive. I welcome the Minister for Health, Deputy James Reilly, and his officials. I invite the Minister to make his opening statement.
James Reilly (Dublin North, Fine Gael)
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I am accompanied by Ms Bairbre Nic Aongusa, assistant secretary of the Department of Health, Mr. Tom Byrne, chief financial officer, Health Service Executive, Ms Nuala Prendergast, principal officer, Department of Health, and Ms Laverne McGuinness, chief operations officer, Health Service Executive.
I am pleased to have the opportunity to address the select committee on the Revised Estimates for 2013 for my Department, Vote 38, and for the Health Service Executive, HSE, Vote 39. Copies of the Revised Estimates for the health Votes and briefing documents by subhead on the two Votes have been provided to Deputies. The annual Estimates of each Vote are being reconfigured along programme lines to ensure greater transparency in Government expenditure. The Department of Health is working towards the development of programme budgeting and changing the structure of the health Votes to reflect this. However, due to the fact that financial systems in the HSE are set up to account on a regional basis, they will have to be adapted to allow for this which will take some time.
In the interim, the appendices to the Revised Estimates for the health Votes have been constructed along programme lines, based on the national service plan and operational plan of the HSE, to provide a high-level programme breakdown of health expenditure.
Before looking at the Estimates in detail, I will make several general observations about the overall budgetary situation facing the health sector and also update the committee on significant developments in the health services since I last attended. The Government is committed to tackling Ireland’s very serious deficit problem in accordance with the broad fiscal framework of the EU-IMF memorandum of understanding.
Health expenditure in 2013 accounts for 27% of gross current expenditure. This represents 37% of total tax receipts and 88% of income tax receipts, meaning that fiscal realignment must, of necessity, impact on health sector spending. The challenges currently facing the health system at a time of growing demand means that the Government must press ahead with major health sector reform.
As the committee will be aware, the Government is embarking on a major reform programme for the health system, the aim of which is to deliver a single-tier health service supported by universal health insurance where access is based on need, not income. Under universal health insurance, everyone will be insured and will have equal access to a standard package of primary and acute hospital services, including acute mental health services. A new insurance fund will subsidise or pay insurance premiums for those who qualify for a subsidy.
There are a number of important stepping stones along the way and each of these will play a critical role in improving our health service in advance of the introduction of universal health insurance. I am pleased to say that significant work is already under way in respect of these initiatives which include the strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients, the work of the special delivery unit in tackling waiting times and establishing hospital groups and the introduction of a more transparent and efficient "money follows the patient" funding mechanism for hospitals.
In May, I announced a reorganisation of public hospitals into more efficient and accountable hospital groups to deliver improved outcomes for patients. This Government decision was informed by two reports, The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts and The Framework for Development - Securing the Future of Smaller Hospitals.
The reform of the health service, including the abolition of the HSE is a complex and sequential exercise. The Health Service Executive (Governance) Bill 2012 has now been enacted, which abolishes the current board and CEO structure and provides for the establishment of a new governance structure. As part of this reform programme, I am also proposing to change the funding arrangements for the health services. My Department has finalised proposals for legislation to disestablish the Vote of the Health Service Executive and fund the HSE from the Vote of the Office of the Minister for Health in future. As the committee can see, reforming our health system is extremely complex but I am pleased to say that we can demonstrate significant progress in a time of demonstrably reduced human and financial resources.
I would now like to address the Estimates for health in some detail. The Revised Estimate for 2013 for the Health Group of Votes provides for gross expenditure of €14.021 billion for health services. Of this amount, some €13.624 billion is for current funding and €397 million for capital funding.
Jerry Buttimer (Cork South Central, Fine Gael)
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Could members get a copy of the Minister's speech? Could someone give Deputy Ó Caoláin a copy?
James Reilly (Dublin North, Fine Gael)
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Acknowledging the significant pressures facing the health sector, the Government approved an increase of €150 million to the expenditure ceiling for 2013 which was extremely welcome but does not take away from the fact that further significant cost extraction is required with €781 million in savings to be achieved in 2013. The primary aim in targeting savings is to cut the cost of services and not the services themselves. This will be achieved largely through efficiencies and reconfiguration under the existing Croke Park agreement, the new Haddington Road agreement, new charging arrangements for private patients in public hospitals and curtailing the growing cost of pharmaceuticals. The required savings have been incorporated in the HSE service plan which I approved on 9 January and are recognised in these Revised Estimates before the committee today.
Vote 38, which relates to the Department itself, provides for gross expenditure of €244 million. This comprises €16 million capital and €228 million for current expenditure. While this is a slight increase on the outturn position for 2012, it represents a 25% reduction on the 2012 budget. All health agencies funded by my Department were required to achieve further efficiency savings this year, with the Department's administrative budget being reduced in line with the moratorium on recruitment and the provision for legal costs and statutory inquiries also reduced. The provision for the National Treatment Purchase Fund was also significantly reduced pending consideration of its future role in the context of the structural reforms set out in Future Health. Part of the fund was surrendered to the Exchequer as part of the overall cash reductions required and part was transferred to the HSE.
In addition, a sum of €30 million has been provided under the drugs initiative. The majority of this expenditure is allocated to local and regional drugs task forces. Last December, a number of measures were set out following a review of drugs task forces with the aim of better equipping the drugs task forces to respond to the current pattern of substance misuse and provide for the extension of their remit to include alcohol addiction. As measures to address the abuse of alcohol remain under consideration by the Government, the final report on the review has not yet been agreed. I do, however, anticipate that the final report will include further measures to improve management, oversight and control of funding allocated by the drugs task forces.
Vote 39 is the Health Service Executive Vote. The gross provision for the HSE is €13.774 billion comprising an Exchequer contribution of €12.312 billion plus appropriations-in-aid of €1.461 billion. As in recent years, in setting the Estimate for the HSE, tough decisions were taken in the context of the need to take corrective action in respect of public spending. The health service must, of necessity, contribute to the expenditure reductions required in 2012 but the Government's objective has always been to ensure that these reductions are achieved in a way that secures the best possible outcomes for those in receipt of services, with a particular focus on protecting services for the most vulnerable. To protect services, we need to reduce costs and improve productivity.
As with last year, the significant cost of drugs and medicines has been targeted for comprehensive savings measures. In recent years, a number of changes to the pricing and reimbursement system have been successfully introduced, primarily through pricing and supply agreements with the pharmaceutical industry. However, further efforts are required to control drug expenditure. Last year, a new pricing agreement was concluded with both the Irish Pharmaceutical Healthcare Association, IPHA, which represents the research-based pharmaceutical sector, and the Association of Pharmaceutical Manufacturers in Ireland, APMI, which represents the generic industry. The IPHA agreement, with a value of in excess of €400 million over the next three years, will deliver a number of important benefits, including significant reductions in the cost of drugs both for patients and for the State, timely access for patients to new cutting-edge drugs for certain conditions and reducing the cost base of the health system into the future. The APMI agreement provides that from 1 November 2012, the HSE will only reimburse generic products which have been priced at 50% or less of the initial price of an originator medicine. This deal represents a significant structural change in generic drug pricing and should lead to an increase in the generic prescribing rate. The reason I say that is because at the moment, many generics are nearly the same price as the brand leader when it comes off patent and, therefore, there is no real incentive for GPs to engage in that. It is estimated that the combined gross savings from the IPHA and APMI deals will be in excess of €120 million in 2013.
Jerry Buttimer (Cork South Central, Fine Gael)
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The Minister's ten minutes are up. If he has much more, could he please conclude?
James Reilly (Dublin North, Fine Gael)
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I will leave that up to the committee if it would like me to finish. I only have a small bit left to say.
Jerry Buttimer (Cork South Central, Fine Gael)
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Okay.
James Reilly (Dublin North, Fine Gael)
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The recently enacted Health (Pricing and Medical Goods) Act 2013 provides for the first time a radical change in the way prices are set and will lead to benefits for patients and the State finances. The legislation will promote price competition among suppliers and ensure that lower prices are paid for these medicines resulting in savings for taxpayers and patients. The Irish Medicines Board has commenced the process of reviewing an initial 20 groups of medicines, which have been prioritised on the basis that they cost the most to the State and patients, for inclusion in groups of interchangeable medicines.
The 2013 Estimate also provides for further reductions to professional fees paid to GPs and pharmacists under the Financial Emergency Measures in the Public Interest, FEMPI, Act 2009. Overall, these reductions will save approximately €70 million in a full year, savings which the Government believes are both necessary and proportionate. In the case of GPs, fees are being reduced by 7.5% overall, which will deliver savings of €38 million in a full year. The retail mark-up paid to pharmacists under the drug payment scheme, long-term illness scheme and other schemes is also being eliminated. This equates to a reduction of 7.67% in the average State payment to pharmacists and will save an estimated €32 million in a full year. It can be seen, therefore, that we did not just impose a straight across-the-board cut. We did it in such a way as to get rid of perhaps some of the historical anomalies in the system.
With regard to capital investment between 2013 and 2017, suitable and appropriate facilities are required to provide safe and cost-effective health care. Recent capital investment has brought about a significant improvement in the standard of facilities across all care programmes. Nevertheless, a significant proportion of the health care infrastructure is old and, therefore, generally unsuitable for contemporary health care delivery. This need is recognised in our programme for Government which states that "health capital spending will be a priority". Preparations are proceeding for the development of the new national children's hospital on the campus of St. James’s Hospital. In May, I also announced the relocation of the National Maternity Hospital to the campus of St. Vincent’s University Hospital. This addresses a key recommendation in the 2008 KPMG independent review that Dublin maternity hospitals should be located alongside adult acute services. Co-location of maternity hospitals with adult acute services is the optimal solution for the provision of hospital-based maternity services.
There was significant investment of taxpayers' money in health services during the good years but there has not been the improvement that the people have a right to expect. It is clear that if money could have solved this problem, having quadrupled the capital spend over 18 years, it should have been achieved before now. Reform is required and our reform agenda, while ambitious, will be delivered. The challenge over the next year will be considerable with between €800 million and €1 billion in savings required to enable us to maintain services and implement reforms.
I thank the Chairman and the committee for their attention and I commend the Estimates for the health group of Votes to the committee. I will be glad to supply any further information or clarification that members may request.
9:40 am
Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise to members that we did not receive the Minister's opening statement until 9 a.m. With regard to the briefing document, the committee secretariat asks departmental officials a week in advance of meetings to submit documentation. We received the briefing last Friday, which was then sent to members.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The background to these revised Estimates is the austerity cuts regime, which has resulted in reductions in health spending year on year. A sum of €781 million was cut in this year's budget, more than €750 million in budget 2012 and an additional €130 million in August 2012, and all that followed a cut of €1 billion in 2011. Along with other colleagues, I have said from the beginning that such cuts were unsustainable and would cause major damage to health services and that has proven correct.
In the week of the announcement of budget 2013, the Minister had to ask the Dáil for an additional €360 million in a Supplementary Estimate to prevent services collapsing before the end of 2012, showing once again the unsustainability of the level of cuts imposed. In a report to the Committee of Public Accounts, the Minister for Public Expenditure and Reform blamed the Minister for Health for the December 2012 Supplementary Estimate and the €360 million overrun. Among the savings as distinct from cuts to services not delivered were the promised reductions in the cost of drugs. This has not happened. Medical card holders were made to pick up the tab when their prescription fees were increased threefold. Both the Fine Gael and Labour parties vehemently opposed, rightly, the introduction of such prescription charges by the former Minister for Health, Mary Harney, but since taking office, the coalition has trebled the charges to €1.50 per item and increased the monthly maximum payment from €10 to €19.50. The Minister failed to deliver the promised reductions in the exorbitant price of medicines in the State and, instead, he is passing on the cost to patients with higher prescription charges and the increase in the threshold for the drugs payment scheme from €132 to €144 per month. This latter cut is yet another attack on families and individuals on the margins of poverty, with whom we are all familiar. These people's incomes are just above the threshold for qualification for a medical card. They must bear the full cost of GP visits and up to €144 per month for medication. They were hit with the full range of cuts in budget 2013, especially the PRSI increase and the child benefit reduction.
The health needs of older people, in particular, were attacked in the budget. People aged over 70 with an income of between €600 and €700 per week have lost their medical card and have received instead the GP only card. All Deputies across the board will testify to the fact that medical cards are being taken from people with serious medical needs because of the harsher and tighter application of the income threshold and little compassion or discretion is being exercised in cases I have come across. Only this week, my office was contacted by a man - I can submit the details of the case if requested - with a disability since childhood and with a serious bowel condition and consequent high medical expenses. He had long had a medical card but it has been taken away on income grounds. His appeal has been turned down and such experiences are increasing to the point that they are almost legion. They are not reflected in the dry figures in this Estimate but they are the reality on the ground that I have to contend with.
Government policy claims that primary care and community care are the bedrock of the health service. I agree but these Revised Estimates will result in a reduction of 8.6% in this area between 2012 and 2013. A Government that has pledged to extend free GP care to all and to expand primary care is going in the opposite direction and the figures confirm this. I will revisit this when the opportunity to ask questions presents.
The overall Estimate for the HSE in budget 2013 was €12.32 billion. The Revised Estimate provides for €12.312 billion. Will the Minister account for this difference? According to a quick calculation, this amounts to approximately €8 million. Last year's bout of austerity resulted in the cutting of 950,000 home help hours. The Minister of State at the Department, Deputy Kathleen Lynch, made a claim that there was a commitment to restore these services in 2013 but spending was reduced with the allocation under subhead C1, primary care and community-led demand schemes, being reduced by 8.6%. What is the position regarding the restoration during the remainder of 2013 of the home help hour cuts in 2012? Those cuts have caused significant hardship to many of those most in need. Will older people and people with disabilities whose home help hours were cut in 2012 have them restored during the remainder of this year as indicated by the junior Minister?
Age Action Ireland representatives at the pre-budget forum in Dublin Castle last Friday outlined the reality of cuts for older people. They said the feedback they received during their national consultation process in March was shocking with older people relating how they were going to bed early in the evening to stay warm or using hot water bottles to stay warm rather than turning on their heating or seriously considering the option of getting rid of pets because they could no longer afford to feed them. I support Age Action Ireland's call on the Government to increase the funding for vital community services, home helps, home care packages, day care and meals on wheels schemes, which are intrinsic to supporting people to manage at home, something I must contend with in my own family; to cease the counterproductive policy of reducing medical care eligibility for the over 70s medical card; and to consider options to increase funding for the nursing home support scheme.
Subhead C2 concerns long-term residential care. It is contingent on the passing of the Health (Amendment) Bill 2013, Second Stage of which was taken last week. I oppose the passage of the Bill. The briefing document states the funding available for long-term residential care was reduced by €20 million in 2013. What are the implications of that for the remainder of the year? What will the result be for the nursing home support scheme, the so-called fair deal? Has that been assessed in the context of the reduced number of nursing home places supported by the scheme? Has an impact assessment been carried out?
What has been said about older people can also be applied to people with disabilities in terms of the range of cuts affecting them, many of which are in the health area.
The Disability Federation lists the direct reduction in HSE funding for disability services, cuts to the housing adaptation grant schemes, which is a very serious matter, reductions in special needs assistants in schools, targeting of the mobility allowance and the motorised transport grant, the reduction in the number of personal assistants and home support hours available, cuts in the household benefits package, increased prescription charges, increases in the threshold of the drugs payment scheme, the rolling back of free GP care for all and certainly for people with special illnesses as an initial step, and the reduction in the respite care grant. These have all taken place on the Minister's watch and there is nothing in these Revised Estimates to give hope that any of that is being reversed.
Subhead B3 confirms the budget cut of 5% to the drugs initiative, cutting supports for local and regional drugs task forces. This has caused huge concern and uncertainty across all projects that are trying to address addiction, reduce the harm caused by addiction and assist people to move on from addiction. Services have been directly affected - for example, the hours when centres and contact points are open for people to seek help or avail of continuing support. Again, it is another regressive and short-sighted cut, and one that will cost the State far more in the medium to long term than the so-called saving made in 2013, as it will see more people with addictions requiring hospital care or other residential care, and more of the other social problems caused by widespread addiction. The evidence of that is almost daily demonstrated on the city centre streets of our capital city. It is creating untold concern and, for some, real and substantial fears.
These are the realities of life that present, and the consequences of the cuts the Minister has presided over. I am deeply concerned that, in the Revised Estimates he presents both in regard to the Department and the HSE, we are not looking at any turning of the corner.
9:50 am
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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When this Government was elected, there was a genuine feeling among the public that we were about to get a significantly improved health service. Of course, that was on the back of the Minister, Deputy Reilly, and the current Taoiseach travelling the country, making commitments in regard to improvements in the service. There is no doubt the previous Government had created serious difficulties for patients, people availing of services, staff and hospitals throughout the country. There was a genuine feeling that this Government was going to improve the situation. Of course, as often happens, the fact was a lot different.
Unfortunately, we have now arrived at a stage where the health services are at breaking point due to the huge austerity this Government has implemented since its election, with approximately €1 billion in cuts a year in 2011, 2012 and 2013, and I believe the Minister promised another €800 million to €1 billion in cuts in 2014. That is just on the expenditure side. Hand in hand with that, there have been huge staff reductions, with thousands of health care staff having left the system or been made redundant without being replaced. What we now have, as I said, is a system at breaking point. It is under-funded and understaffed. It is a system where the staff and all of our health institutions, hospitals and health centres are under pressure every hour of every day. Despite staff working above and beyond the call of duty, the service that is being provided to the public is simply not good enough. We now have a situation where, for example, yesterday, at the height of summer, some 230 patients were on trolleys in our emergency departments and some hospitals had as many as 19 or 20 patients on trolleys. That is now an ongoing situation in our acute hospital services.
On the community side, there have been significant cutbacks to the home help service, which, again, is an ongoing situation. We were told that people could appeal these decisions and that there would be a real appeals process. My experience is that there is paperwork but there is no proper appeals process or assessment of the needs of individual patients.
I raised the issue of the Fair Deal scheme at a previous meeting of the committee with the HSE. There has been an increase in the residents' contribution of 7.5% per year, bringing it to 22.5% from 15%. Of course, earlier in the year we had what I believe to be geographic discrimination against elderly people, whereby people throughout the country, with the exception of Cork and Dublin, had their applications for the Fair Deal held up.
The situation I am describing applies across the system. I would point to the example of the medical card system. As Deputy Ó Caoláin said, the prescription charge was at 50 cent and was to be abolished but we now find the Minister has increased it to €1.50, or €19.50 per month. There is also a very serious problem with the assessment of eligibility for medical cards, particularly for people who have health conditions. People who in the past held medical cards on medical grounds for long periods - years on end - now find those cards being withdrawn. I would instance the 65-69 age group, which I believe is being particularly and deliberately targeted by the HSE for the withdrawal of medical cards. This is happening on a daily basis. These are particularly people who have medical conditions and who are very marginally over the limit because they may have a small occupational pension. Of course, the medical card limits have not been increased since January 2006 and are completely out of date. This category of elderly people aged between 65 and 69 is being particularly targeted and their cards are being withdrawn on a daily basis because they are marginally over the limit, even though on medical grounds they have held cards for a significant number of years.
I draw the Minister's attention to a situation I have come across frequently lately, again in the area of medical cards. Children with disabilities who have held medical cards on medical grounds are having their medical cards withdrawn. While it is difficult to access GP services and medication, it is even more difficult for those children and their parents to access other services which are linked to the holding of a medical card by the child, so they are being deprived of other services. This is an issue I have asked the Minister to specifically look at because I have come across it on a number of occasions recently.
These children are being deprived of other services.
There are significant waiting lists - some are waiting years - for outpatient appointments for ear, nose, and throat, orthopaedic and audiology services. This needs to be addressed urgently. We need a commitment from the Minister to inform us when those on these waiting lists will be seen.
What is the status of the national children’s hospital? What is the timescale for this project’s development?
10:00 am
James Reilly (Dublin North, Fine Gael)
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Deputy Ó Caoláin quite rightly pointed to the reduction in our budget and staff numbers over the past several years. He contends this has done significant damage to the health service. He does not acknowledge that it has actually improved because reforms have been carried out.
A deal was done with the Irish Pharmaceutical Healthcare Association, IPHA, which will yield savings of €400 million over three years, greatly in excess of what was originally on the table. The Deputy referred to failures to save money on drugs and failures to obtain moneys owed by private insurers. We now have accelerated payments of €125 million from insurers last year, which more than accommodates the savings that were supposed to be achieved from the private patient charge and the reduced drugs savings.
Health is a demand-led service. That demand is created because people are growing older, many more people have medical cards because our economy is in such a state, and many more babies survive problematic births but require high-tech support in their early years. Our aging population means we will have more demand for chronic illness services in the future. By 2041, it is projected there will be an estimated 1.3 million to 1.4 million people over the age of 65 years. The greatest increase within that cohort will be among those over 80 years of age.
I reject the contention that we are travelling in the wrong direction in health policy. First, we will introduce free general practitioner care. Rather than spending much time overcoming legal issues concerning the cost of high-tech drugs for long-term illnesses, we have decided to approach that area in a different way. A paper will be going to the Government shortly. It will not only show our bona fides but give people something real. Up to 43% of the population, the highest number in the history of the State, is covered by medical cards, a fact contrary to the what the Deputy suggested. Another 1% is covered by the free GP card, meaning 44% of the population is covered. This shows that the figures are going in the right direction.
The home help budget in 2013 was restored to 2011 levels. The Deputy referred to a 8.6% reduction in primary care funding. That is not a reduction in home help funding. That is across primary care, where there are savings, to which Deputy Ó Caoláin alluded, on drugs, prescribing and fees paid to professionals.
I am not just telling the Deputy improvements have been made in the health service. I can show him these improvements. We had a 24% reduction in the number of people who had to endure long trolley waits last year. We have had a further 9.1% reduction this year, despite the prolonged winter. We have reached a target of 95% of endoscopies being carried out within 13 weeks, as well as the treatment of children for inpatient procedures within 20 weeks and the treatment of adults for same within nine months.
Deputy Healy contended that there has been a cut in the nursing home support scheme. Ms McGuinness will address that more comprehensively later. However, from the figures it can be seen that more than 22,000 people are being catered for. We need to reform that as well in terms of looking at more tiered supports for people who wish to stay at home, as most people do.
As for the number on trolleys, it was 569 in January 2011, averaging 400-plus per day. We brought that down to the point at which yesterday’s figure was 239, with 79 waiting longer than nine hours. On the same day last year the equivalent figures were 258 and 112. This day last year, there were 284 people on trolleys; today there are 204. I acknowledge that there are too many people who have to endure long trolley waits, but to try and say the numbers are going up is not just disingenuous but disrespectful to the people who have done so much hard work on the front line to make this possible. I thank them for the great work they do every day on behalf of our citizens.
The clinical programme for the frail elderly meets the needs of such patients when they are admitted to hospital, and they start rehab straight way to ensure they do not end up staying in hospital in the delayed discharge category. The stroke programme has meant that in 18 months we have gone from the bottom of the list in Europe to the top in terms of the number receiving thrombolytic drugs and therapy. That saves one life a day. The congestive heart failure programme is making life much better for our patients too. As for waiting lists for outpatient services, Deputy Healy does not acknowledge that this has been the first Government to quantify the problem and address it in a real and methodical fashion.
A memorandum will be going to the Government in the next week on the national children’s hospital. Our plan is to have a brownfield site on 1 January 2015 with full planning permission.
Billy Kelleher (Cork North Central, Fianna Fail)
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I apologise for not being here earlier but I was at the launch of a Fianna Fáil document on health system funding. I will give the Minister a copy of it later on because it maps out various funding options for the health services. I hope it will generate a discussion on this topic while we wait for the White Paper on universal health insurance.
10:10 am
Jerry Buttimer (Cork South Central, Fine Gael)
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Could I remind members about mobile phones and iPads? It would be helpful if they could be put on aeroplane mode.
Billy Kelleher (Cork North Central, Fianna Fail)
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I again apologise for being unable to attend for the opening remarks. We all accept the difficulties and pressures the Government is under in terms of cost reduction and trying to remain within the budget targets. Within that, medical cards, for example, are an issue. While the Minister refers to the fact that 44% of the population have medical cards, they are primarily getting them based on a financial assessment of means as medical cards are awarded under that. What is definitely happening in the system is that the discretionary element with regard to medical need is being grossly undermined. That area must be looked at. Previously, while there was no automatic entitlement, people who had cancer would get a medical card based on medical need. We now have a situation where people simply cannot get medical cards on discretionary medical grounds. That must be looked at. While we accept that there has been an increase in the numbers, it is primarily due to the downturn in the economy, as the Minister so eloquently tells me on a regular basis. This must be looked at in the context of the Estimates for the year to come because we cannot have a situation in which people with very serious illnesses who face massive costs and dislocation of their families cannot access the basic medical card on discretionary grounds. That should be revisited. The budget last year featured the withdrawal of 40,000 medical cards. When one looks at how they are being randomly picked for assessment, it beggars belief. It is certainly very random because we have situations in which letters are being sent to people asking them whether their financial or medical circumstances have changed. Clearly, any cursory look at their files would suggest that they have not changed. Is it necessary to send out such letters to those individuals? There might be some other method of profiling people in a better way, as opposed to this random selection process that seems to be happening with the withdrawal of 40,000 medical cards.
I welcome the decisions regarding high-tech drugs that the Government has decided to fund. In respect of the savings on drugs of over €440 million over three years, if one looks at the decisions that are being made, clearly there will not be as much of a saving over the next number of years as the Government had anticipated because there will be an increased cost due to the decision to cover these high-tech drugs that were not covered heretofore. So while the Government is pencilling in savings, I do not think they will be realised to the extent the Government hopes. Could the Minister comment on that issue? When one looks at the Croke Park agreement and the sacrifices staff have made under the FEMPI Acts and through changes in work practices and the pressures they are under, one can see that we need to acknowledge that there is huge pressure on front-line staff. There are huge pressures in our maternity hospital in Cork. It was originally recommended for 5,000 births a year, was built for 7,000 and is now at about 9,500 births per year. Many of the complex cases also come to Cork University Maternity Hospital because it has a good neonatal system and is a tertiary hospital. If one looks at the staffing levels on key front-line areas, one can see that the situation must be revisited very quickly. I accept the need for an embargo in broader staffing terms in the public service but in key front-line areas, it is too arbitrary at this stage. The Government must look at opening up that area, particularly in front-line emergency departments or maternity hospitals throughout the country and other key front-line services, because they are simply unable to cope with the huge pressure and stress. When one talks to individuals who work there, they say there is now a risk to patient safety. That is quite clear. Some very senior clinicians have come out and stated that they are concerned about work practices and pressures on front-line service providers and the impact on patient safety. That must be looked at before we have a tragic case on our hands in an emergency department or maternity hospital.
I know the Government has had legal difficulties with the roll-out of free GP care but the difficulty is that those legal difficulties were identified last year. We have now waited another year and still do not have a blueprint for how the Government intends to roll out its proposals for free universal GP care over the next two and a half years if this Government runs its full term. Will it be pencilled into the budget arithmetic in October 2013? Will the Government have a definitive blueprint of how it plans to roll that out? If some of those issues have already been referred to, I do not want the Minister to have to be repetitive. I can get the information from the blacks later on.
The Minister referred to us as criticising, advocating and highlighting, as an Opposition is sometimes prone to do. It is our duty to do that. At no stage have we been disrespectful to staff when we highlight inefficiencies and deficiencies in the health service. We are primarily targeting the policy decisions of the Government and criticising the fallout from them. I do not think any Deputy around here ever says that the people involved in the health service are doing anything other than giving 100% all the time, and sometimes above and beyond that in the call of duty.
Jerry Buttimer (Cork South Central, Fine Gael)
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I certainly think all of us would echo the sentiment that the staff in the HSE and the Department of Health do that. As we are under pressure for time, because the Minister and Deputies Ó Caoláin and Kelleher must be in the Dáil at 11.15 a.m., I ask speakers to be brief in their questions. Does the Minister wish to reply to Deputy Kelleher?
James Reilly (Dublin North, Fine Gael)
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Yes. We covered some of the issues raised by Deputy Kelleher so I will not go over them again. I will ask Ms Laverne McGuinness to answer his questions about discretionary medical cards, because I do not believe the assessments have been random, as well as issues raised by others about the nursing homes support scheme and the supposed cuts there.
Deputy Kelleher mentioned the drug deal with the IPHA, which will save €400 million. We have allocated €210 million which will possibly be taken up over that time for new drugs. That is still a saving of €190 million, which is far more than the amount in the original deal, around €125 million.
Deputy Kelleher also raised the issue of the moratorium on staff recruitment for front-line services. I have always said that we would maintain the moratorium but show flexibility with regard to front-line staffing when this has been fully assessed and methods and models of care have been examined. I return to my point that in some model 4 hospitals we have a ratio of nine nurses to one health care assistant while in others it is only 2:8, so there is much work to be done. We know that was done in Cork and in the UK before that. It related to the fact that when they screened out orthopaedic referrals, physiotherapists could deal with 50% of patients themselves rather than sending them on to the orthopaedic surgeon. There is much ongoing work to be done. My greatest criticism of the HSE in the past was the fact that a national organisation failed to bring uniformity to the system. One would find things being done very well in one hospital and it would not be transposed across the system to other hospitals. The new hospital groups will certainly address that in a major way as there will only be six CEOs to deal with rather than 49.
Deputy Kelleher said we had been waiting for the roll-out of free GP care for two years, which is true. We have already covered this, in that we said we would do it in respect of the long-term illness scheme and health technology assessment but, given the legal problems that caused and the complexity of the system one would be setting up just for a temporary phase, we made the decision to go in a different direction. We will come back with some very distinct proposals to the Government in the next number of months. I know Deputy Kelleher has waited two years, but the previous Government had 14 years and nothing happened. He will forgive me for throwing that at him.
Jerry Buttimer (Cork South Central, Fine Gael)
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Could Ms McGuinness be very brief? I want to go through each subhead. There is interference from a mobile phone.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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If Ms McGuinness is going to deal with the question of medical cards, we want to see it dealt with properly and fully because everyone around this table knows what is happening.
People aged between 65 and 69 are being targeted and their cards are being removed because they are marginally over the threshold but they have medical conditions because of which they have had cards for years. It is almost impossible to get a discretionary medical card on health grounds and in recent days children with disabilities who have cards are having them withdrawn. We need this dealt with fully, not briefly.
10:20 am
Jerry Buttimer (Cork South Central, Fine Gael)
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I fully agree with the Deputy and I share some of his sentiments. I propose we will deal with this under subhead C1, care programmes. We will take Vote 38, office of the Minister for Health - administrative subheads A1 to A8. Any comments or questions?
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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There is no end to the questions we could raise under these subheads but I am conscious of the time constraints. I wish to focus on subhead B3. If others wish to specify the subheads they wish to discuss, that might help to expedite the discussion. The Chairman can go through the list of subheads and we could have something to say on all of them but we are understanding of the time constraints and there may be areas we want to focus on. With regard the Department's Estimate, I wish to only address a matter under subhead B3.
Jerry Buttimer (Cork South Central, Fine Gael)
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In my role, I must go through all the subheads. I appreciate the Deputy's comments. I refer to subhead A7, consultancy services and value for money policy reviews.
Billy Kelleher (Cork North Central, Fianna Fail)
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We have raised this issue previously but the Minister says he does not want to comment on individual tax compliance and all that flows from that. Does this subhead cover people employed on a consultancy basis to head up the special delivery unit? Revenue is examining the contracts of individuals who come under this subhead. Will the Minister be informed when it has made a decision on this?
James Reilly (Dublin North, Fine Gael)
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The Department is currently in conversation with the Revenue Commissioners and we all know that these are private matters between the individuals and the Commissioners. It would be inappropriate for me to comment.
Billy Kelleher (Cork North Central, Fianna Fail)
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That is the key issue. If it is a matter between the individuals and the Revenue, why is the Department in discussions with the Revenue?
James Reilly (Dublin North, Fine Gael)
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Because there were queries from Revenue to the Department.
Jerry Buttimer (Cork South Central, Fine Gael)
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Any comments or questions on subhead A8, EU Presidency, other than to compliment the Minister on this role on the tobacco measure?
Billy Kelleher (Cork North Central, Fianna Fail)
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I would like to acknowledge the efforts the Minister made. We parked the Punch and Judy politics on this years ago but in the context of highlighting the issue of the flavouring of cigarettes and menthol cigarettes, I compliment him. Anything that discourages people and makes it more difficult for tobacco companies to encourage people to start smoking is welcome. I would like to put on record my party's appreciation of the efforts made during the Presidency.
Jerry Buttimer (Cork South Central, Fine Gael)
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There are no questions on subhead B1. Under subhead B2, grants to health agencies and other similar organisations from the national lottery and so on, when is it hoped to pay them this year? I have been contacted by the representatives of many organisations who say they are late and they are worried they will not get any grant. The Minister can come back to me on that.
James Reilly (Dublin North, Fine Gael)
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I will come back with a written answer.
Jerry Buttimer (Cork South Central, Fine Gael)
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Subhead B3 is the drugs initiative. I call Deputy Ó Caoláin.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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This provides for a 20% reduction in the provision of moneys to tackle the drugs crisis in our society. The 5% reduction relates to both the Estimate and the outturn and it equates to €1.524 million. It is in no way reflective of the required response to the ever increasing threat from drug addiction in society demonstrating itself not only in the larger population centres, but throughout the State. Huge concern is created by it and the impact it will have on local and regional drugs task forces and the ability to address this issue across all the various headings. Supply, reduction, prevention, treatment, rehabilitation research, etc., are the key pillars of address. This is an irresponsible reduction, given the gravity and the increasing reality of the threat drug addiction presents in our society. My request is that the Minister revisits this and withdraws the cutback. It is wholly inappropriate. The situation should be in the reverse.
James Reilly (Dublin North, Fine Gael)
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I ask the Deputy to withdrawn his contention that there has been a 20% reduction when it is a 5% reduction. I do not know where he got 20% from.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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5% is one twentieth.
James Reilly (Dublin North, Fine Gael)
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The Deputy said 20% at the outset.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I apologise if I said that wrongly.
James Reilly (Dublin North, Fine Gael)
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That is fair enough once we have clarity from members. There is a 5% reduction. We have a major problem with the drugs task forces and we are concerned about the drugs issue. There are 14 local drugs task forces which cover areas with the highest concentration of drugs activity. There are 12 in Dublin, one in Bray and one in Cork. There are also ten regional drugs task forces for the rest of the country. More than €19 million has been allocated to 209 local drugs task force projects and €8.7 million to 107 regional drugs task force projects.
However, further measures are required to improve management and control of funding. People will be consulted on changes to the number and boundaries of task forces. This is something we need to develop not just in this area, but also in primary care. We do not have good measurements of outcomes. We spend taxpayer's money and we need to know the money we spend yields results. We have a sense that certain things help but we have not been able to develop measurements of outcomes in the past. That is being examined now. All areas have had to take a budget reduction and this area is no different. I have no intention of changing the funding arrangements under this subhead but I would like to make sure we are achieving the results we should achieve, we are helping the people we should help and the money is being spent in a way that achieves the best outcomes for those who become addicted to drugs. It is a much broader issue than health, as there is also a law and order issue while supply and demand is a factor and education has a role. People must be educated that they should stay away from drugs because they can only cause harm and they do not know what they are getting. We have witnessed terrible tragedies in recent times.
Catherine Byrne (Dublin South Central, Fine Gael)
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This issue is close to my heart. I look forward to the final report and the measures that will be put in place. I come from an area that has been ravaged by drugs since my early childhood. The time for local and national drugs task forces is gone. The model needs to be broken and we need to consider something completely different. It is difficult to see the work done by some local drugs task forces. I have a problem with this and I agree with the Minister that we are not getting value for money. There needs to be a new way of helping people addicted to drugs in the community in order that they are not sent to offices for counselling and so on. They can have that but something has to be done under the remit of GPs and the HSE because drugs task forces have moved away from their original remit, which was to look after people and their extended families in communities with drug problems.
It has become a national business now, and I will say that publicly as I have said it locally. I honestly believe it is time to crack open the model and do something different. I look forward to seeing this report because I really want to know what is inside it.
10:30 am
Peter Fitzpatrick (Louth, Fine Gael)
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What kind of a crossover is there between the Department of Health, the Department of Children and Youth Affairs-----
Jerry Buttimer (Cork South Central, Fine Gael)
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This is subhead B3 on drugs.
Peter Fitzpatrick (Louth, Fine Gael)
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I am talking about drugs. For example, I brought a group yesterday to talk to the Minister, Deputy Frances Fitzgerald, about children and adults. With reference to drugs, I want to know what kind of crossover the Department of Health has with the Minister for Children and Youth Affairs and the HSE that would show the money is being spent in a proper way?
James Reilly (Dublin North, Fine Gael)
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There is a lot of co-operation at local level between the two Departments. Given the new Department has only been set up and the Bill for that will only be coming out this week, and given the new agency is currently being set up, there is a lot of co-operation between the Departments. The Deputy raises a very valid point, nonetheless, and we probably need to have a more formal arrangement to address these issues. With the Department of Education and Skills and the Department of Children and Youth Affairs, we have already appointed a principal officer across intellectual disability and obesity. I agree this is yet another area that needs to be addressed.
Billy Kelleher (Cork North Central, Fianna Fail)
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On subhead B3, the Minister is awaiting a report with regard to the drugs task forces and their effect, and there are some recommendations thereon. One of the key issues being discussed is the whole issue of alcohol and its abuse among young people. I know a debate is ongoing with regard to whether sports organisations should be able to avail of sponsorship from the drinks industry. At some stage, we have to make a decision as to what policy is going to be pursued by the Government in regard to trying to reduce the prevalence of alcohol abuse among young people. In that context, the drugs task forces are falling off the cliff to a certain extent in terms of being able to deal with the problems they are facing, there is no clear, defined policy as to what we are going to do in regard to alcohol abuse among young people and there is drift with regard to the prevalence of off-licences and the access to cheap alcohol. One can look at studies from countries around the world and see there is a direct correlation between the price and availability of alcohol and alcohol abuse among young people. When will the reviews be completed and when will a decision be made on what policy will be pursued with regard to the whole issue of sponsorship and the price of alcohol?
Jerry Buttimer (Cork South Central, Fine Gael)
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We are dealing with the Estimates.
Billy Kelleher (Cork North Central, Fianna Fail)
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I accept that.
James Reilly (Dublin North, Fine Gael)
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Deputy Kelleher has raised a very valid point. I do not accept that the drugs task forces are falling off the cliff. What we are doing is reviewing their role and effectiveness. As Deputy Byrne has made clear, many people have very serious concerns about their effectiveness and the way they are operating currently. We need to ensure that, at a time of very limited resources, we are getting value for money and getting the best outcomes for those for whom we are trying to provide the service.
Part of the complication has been the fact that alcohol is involved in the drugs task forces in terms of abuse of substances because, again, it is another drug. A policy from the Department is being considered by Government at the moment, and that will go to the Select Sub-Committee on Health very shortly.
We know there is a lot of angst among sporting organisations around the idea of sponsorship but, if the Chairman can afford me a minute to do it, I believe it is worth pointing out that the earlier people drink, the more likely they are to abuse it and to have a problem with it. We need to protect young people from the advertising of alcohol in so far as we can. Major sporting events are very often large family events. Children enjoy sport and we want it to be an integral part of their growing up. We would hope it would stay with them as a habit for life and we think that is a very positive thing to do for health. However, we do not want it associated with exposure to alcohol advertising at an early age. We can ask where the evidence is to support X, Y and Z, but all we have to do if we want evidence is to ask why drinks companies spend so much money advertising alcohol if it does not improve sales. Advertising alcohol to young people will encourage them, as the curious beings they are, to try it out and start drinking at an earlier age.
As I said, we know absolutely that there is evidence that the earlier a person starts drinking, the more likely they are to have problems. We have seen the report from Dr. Stewart, who came back here from Liverpool and who was shocked at the number of young people in their 20s he was dealing with who had liver failure from cirrhosis. Cirrhosis does not develop in a year but over a number of years of heavy drinking, so these people in their 20s had to have started drinking heavily in their teens.
I believe very much that we have an obligation and a responsibility to protect our children, the next generation. My view on advertising at sporting events is well known. I am absolutely supportive of the Minister of State, Deputy White, in this regard. While I know others may have different views, the Government will make its decision in due course, and that due course is not long away.
Peter Fitzpatrick (Louth, Fine Gael)
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We now turn to subhead C - expenses in connection with the World Health Organization and other international bodies. Are there any questions or comments? As there are no questions, we move to subhead D - statutory and non-statutory inquiries and miscellaneous legal fees and settlements. Are there any questions or comments? As there are no questions, we move to subhead E1 - developmental, consultative, supervisory, regulatory and advisory bodies. Are there any questions or comments? As there are no questions, we move to subhead E2 - Food Safety Promotion Board. Are there any questions or comments? As there are no questions, we move to subhead E3 - the National Treatment Purchase Fund and special delivery unit. Are there any questions or comments? As there are no questions, we move to subhead E4 - Ireland-Northern Ireland INTERREG. Are there any questions or comments? As there are no questions, we move to subhead F1 - payments in respect of disablement caused by thalidomide. Are there any questions or comments? As there are no questions, we move to subhead F2 - payments in respect of persons claiming to have been damaged by vaccinations. Are there any questions or comments?
Denis Naughten (Roscommon-South Leitrim, Independent)
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On subhead F2, the briefing note we have received on Vote 39 is a significant deviation from what we have had up to now. I would be grateful if the Minister could clarify this. As he knows, Deputy Micheál Martin had a report commenced in-----
James Reilly (Dublin North, Fine Gael)
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Is the Deputy referring to Vote 38 or 39?
Denis Naughten (Roscommon-South Leitrim, Independent)
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I am sorry, I meant Vote 38. As the then Minister, Deputy Martin, commenced a report in 2002 that culminated in the publication of the expert group report on introducing a no-fault vaccine compensation scheme. It is an issue we have addressed at the committee on a number of occasions. Up to now, subhead F2 was to deal with that and, sadly, it has not been dealt with. I am disappointed by that. If the Minister cannot brief us today, he might brief us as to what is the timeline for this.
I note that the explanation for this Vote refers back to the previous expert group which was established in 1977 and which found in the early 1980s that 16 children had, in all probability, been profoundly brain-damaged by the administration of the three-in-one vaccine, in particular the whooping cough element of that. Fifteen of those 16 sets of parents took a £10,000 ex gratia payment at that time. Can the Minister tell me that what we are talking about here is providing additional supports to those particular children, who are now adults? We have to look in a fair-minded way at the offer that was put to those parents, many of whom were under severe financial pressure at that time. Of course, one of those parents did not take the compensation. Mrs. Margaret Best went on to win her High Court case against Glaxo Wellcome on behalf of her son, Kenneth Best, and got substantial compensation on foot of that.
Are we now considering revisiting the once-off payment that was made by the then Minister, Dr. Michael Woods, to those 15 parents, or are we talking about some other overall scheme that has been promised for a long time but has not moved along?
10:40 am
Billy Kelleher (Cork North Central, Fianna Fail)
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Does the issue of narcolepsy as it relates to the vaccine form part of the new report on damage by vaccines? What is the position on that issue and has funding been provided? The Minister stated supports were being made available in the context of education, the provision of medicines, etc., but I understood a compensation package would also be provided for children who suffered from narcolepsy after taking the vaccine. Is that package to be found under a different subhead or has it not been included?
James Reilly (Dublin North, Fine Gael)
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Ms McGuinness can deal with the question on narcolepsy in more detail. It is not covered under this subhead, but proposals on how to deal with it are being put together for consideration by the Government. There is no question or doubt that people have suffered as a consequence of the vaccine which was given and taken in good faith.
That brings me to Deputy Denis Naughten's inquiry. This subhead keeps the issue open for possible future use. I have asked the Department to explore with the State Claims Agency the idea of addressing the issue of vaccination. As the Deputy knows, I share his strong views. Vaccines are given, taken and manufactured in good faith and problems arise in small numbers. Where they do, people should be looked after. It is not right or just that they should have to go to court and mortgage their homes to get services for their children. The State should provide. That is my personal opinion. This must be done in a way that is cost effective from the State's point of view and be discussed at Government level generally.
If we want to derive the maximum benefit from vaccination programmes, 95% of people must be vaccinated in order to protect us all. One of the great achievements of medicine in the past 200 years was the eradication of smallpox through vaccination. We rarely see a new case anymore, nor have I ever seen a case of tetanus in this country, although I saw one in Haiti while I was there. We want people to feel safe and be responsible, not just for the protection of their children but also of their broader communities. Where events occur that do not arise as a result of negligence, people should be looked after by the State. The question of how to do this is being explored with the State Claims Agency. I will revert with more details when I have them.
Jerry Buttimer (Cork South Central, Fine Gael)
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I will allow Deputy Denis Naughten in briefly, as we are under pressure for time.
Denis Naughten (Roscommon-South Leitrim, Independent)
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There is a deviation in subhead F2. Until now the subhead had been kept open in the light of the recent expert group's report and the report that had been referred to the State Claims Agency. However, the explanation for subhead F2 refers to the expert group report of 1977. That is a deviation from the Votes presented to us previously. Is it the Department's intention to revisit the one-off ex gratia payment made in the 1980s to the 15 children? Is this the reason for the change in the documentation presented to us today?
James Reilly (Dublin North, Fine Gael)
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I will let Ms Nic Aongusa explain that technical issue in more detail.
Ms Bairbre Nic Aongusa:
The briefing note provides an example of the use to which the subhead could be put. Legally, the key determining factor in the use of money under any subhead is the description. In this case, the description is "Payments in respect of persons claiming to have been damaged by vaccination". Currently, there is €1,000 in the subhead, as it is a holding subhead until it can be used, if necessary.
Denis Naughten (Roscommon-South Leitrim, Independent)
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There is no significance to the fact that it refers to one expert group rather than-----
James Reilly (Dublin North, Fine Gael)
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Ms McGuinness might discuss the narcolepsy issue.
Jerry Buttimer (Cork South Central, Fine Gael)
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Subheads F3 and F4 relate to the Hepatitis C Compensation Tribunal Acts. Subhead G relates to the dissemination of information, conferences and publications in respect of health and health services. Subhead H relates to grants in respect of building and the equipping, including ICT, of agencies funded by the Department. Subhead I relates to appropriations-in-aid. As there are no questions or comments on these subheads, we will move to the corporate and administrative subheads of Vote 39 - Health Service Executive. We will take subheads A1 to A3, inclusive, together.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Does the Chairman not put the proposition on Vote 38 at this point?
Jerry Buttimer (Cork South Central, Fine Gael)
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Not until the end. There are no questions or comments on subheads A1 to A3. Subheads B1 to B4, inclusive, relate to the HSE's regions. Subhead B5 relates to grants to other health bodies, including voluntary and joint hospital boards. Subheads B6 and B7 relate to other services. Subhead B8 relates to payment to a special account established under section 13 of the Health (Repayment Scheme) Act 2007. Subhead B9 relates to payment to a special account established under section 4 of the Hepatitis C Compensation Tribunal (Amendment) Act 2006 - insurance scheme. Subhead B10 relates to service developments. Subhead B11 relates to payments to the State Claims Agency in respect of costs relating to clinical negligence. As there are no questions or comments on these subheads, we will move to the care programme. Subhead C1 relates to the Primary Care Reimbursement Service, PCRS, and community development-led schemes. A comment was made about medical cards.
Ms Laverne McGuinness:
Deputies Billy Kelleher and Seamus Healy raised various queries. Some 1.87 million people are covered by medical cards, 68,000 more than were covered last year. The determining factor, in the first instance, for a medical card is a financial assessment. In the event that people marginally exceed that assessment figure, they can either qualify for a general practitioner, GP, visit card or, where they have medical conditions, apply for a discretionary medical card. A full review is being carried out of the discretionary medical card system to ensure medical doctors examine the assessments and clients and that it is not just a managerial or administrative function. A doctor is heading up the review process and a medical doctor engages locally in each of the regions. There are 59,000 discretionary medical cards and more than 19,200 discretionary GP visit cards. These are significant numbers.
A person is not automatically entitled to a discretionary medical card if he or she has cancer and is above the financial threshold. A person is so entitled if it is life-limiting cancer, in which case we grant the card within 24 hours as an emergency measure for a period of six months.
Deputy Billy Kelleher mentioned random reviews of medical cards. A number of reviews are being conducted. Regarding this year's changes to the income thresholds for the over 70 year olds and the adjustments for persons aged less than 70 years, a review is being carried out of those involved. However, it is not random. It is actually based on a-----
Jerry Buttimer (Cork South Central, Fine Gael)
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I am sorry, but does Ms McGuinness have an iPad or a mobile phone next to her? It could be causing interference.
Ms Laverne McGuinness:
I apologise. In addition, there is public accountability for the money spent on medical cards to ensure everyone who has one is so entitled under the eligibility requirements. If there is a change in circumstances, for example, a salary increase, the onus is on the medical card's receiver to notify the PCRS and have a reassessment made, as he or she may no longer be entitled to a medical card.
To ensure probity, we initiated a random review this year of 1,500 medical cards, which takes in people over 70, those under 70 and discretionary medical card holders.
We were obliged to do that as part of our public accountability and we will be sitting before the Committee of Public Accounts to ensure that we are discharging our obligations in that regard. Discretionary medical cards have not been targeted, per se, as part of our random review of 1,500 medical cards. The other measure we are considering is the idea of inactive cards, and if somebody has not used a medical card for 12 months, we are writing to ask if the person is still resident in the State and needs the card. Those people would retain eligibility for a period of three to six months after this but after that we have an obligation to take back the card. This will ensure that the people who most need the cards get them.
As I indicated, 43% of the population is covered by medical cards, and at the request of the Minister we put in place a process where a medical doctor would consider the assessment for discretionary medical cards. In previous years there was a decentralised process which meant there could be inequities throughout the country; this means people may have been getting discretionary medical cards in some parts of the country and not in others because of the rule set, which has now been standardised. There will be equitable access for all people.
10:50 am
Billy Kelleher (Cork North Central, Fianna Fail)
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The indication is that there are 59,000 discretionary medical cards given on medical grounds.
Billy Kelleher (Cork North Central, Fianna Fail)
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How many were there last year or the year before? Has there been a decrease? The difficulty that I and everybody in the House have is that the information is not what is reflected on the ground. We seem to be in a position where it is almost impossible for people to get a medical card on discretionary grounds. It is getting more difficult, although I accept there is no automatic entitlement. If a person has contracted cancer and is going through treatment, that person would usually have got a medical card on discretionary grounds, but that is not now the case. Perhaps I am the only one with experience of such a case but listening to the debates in the House and considering parliamentary questions, there seems to be a disconnect between policy and what is happening on the ground. How many discretionary cards are there now and what was the number in previous years?
Ms Laverne McGuinness:
There are currently 59,000 discretionary medical cards, with 19,200 GP visit cards. Somebody who may not qualify for a discretionary medical card may get the discretionary GP visit card. I will have to revert to the Deputy with regard to the trajectory of numbers and deviation from this time last year. I will submit that report to the committee.
Jerry Buttimer (Cork South Central, Fine Gael)
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We have a quarterly meeting on 25 July with representatives of the HSE and the Minister. What is being articulated this morning is the common feeling on the ground.
Billy Kelleher (Cork North Central, Fianna Fail)
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It is every Member.
Ms Laverne McGuinness:
Okay. It is correct that in the past clients with cancer, irrespective of incomes, may have got discretionary medical cards. An entitlement to a medical card is primarily on the basis of financial assessment but if there are significant medical conditions and the client is marginally over a limit, there would be another assessment. There is no automatic entitlement on the basis that the maximum that anybody must pay for the drugs is €144 in a month. There is no automatic entitlement if a person has cancer, unless it is life-limiting.
Jerry Buttimer (Cork South Central, Fine Gael)
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Given that we are going to be caught for time this morning, I propose that at the quarterly meeting we have a specific section dealing with the medical card issue. It is not fair for committee members to have to rush the matter this morning, as it requires more discussion than we can have in the brief time available this morning.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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From my experience and that of other Members in the Houses, as well as the response from Ms McGuinness, it seems clear that people with medical conditions are being targeted in order to implement a reduction of 40,000 cards that was in last year's budget.
James Reilly (Dublin North, Fine Gael)
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I should say-----
Jerry Buttimer (Cork South Central, Fine Gael)
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I will allow the Minister to speak again.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Ms McGuinness has indicated that a doctor considers these applications but that has always been the case, or at least it was always the case in south Tipperary. The cards were granted by a doctor. It is now certain that it is almost impossible to get a discretionary card on medical grounds and unfortunately, the only way to get a card urgently is if a GP certifies in writing that a condition is terminal. That is outrageous.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I raised this issue in my opening remarks and I instanced a case only this week where a person with a disability since childhood, having had a medical card while experiencing very serious associated issues, including a bowel condition, and high medical costs, had the medical card taken away on income grounds. We are not talking about massively exceeding thresholds but rather people who are relatively or marginally in excess of the qualifying figures. It is a harsh process and if a person is dependent on the card, the loss could have the most serious consequences. It delivers a very serious blow to such people and their families, with the intimation being that we almost do not care as a society. That is not good enough. I also know of a case this year of somebody confined to a wheelchair from early on who has had a medical card. That person has a work opportunity within a non-governmental organisation with limited income levels and that person has lost the medical card as well. The person is serving peer groups of people with disabilities, so it is a crazy decision.
Jerry Buttimer (Cork South Central, Fine Gael)
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Will members accept the proposal that part of our quarterly meeting on 25 July will be devoted to this issue? I am aware that Deputies and the Minister will have to go to the Dáil.
Denis Naughten (Roscommon-South Leitrim, Independent)
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I echo everything that has been said, as it reflects my personal experience in dealing with the issue over a long number of years. I ask that Ms McGuinness, in advance of the quarterly meeting-----
Jerry Buttimer (Cork South Central, Fine Gael)
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Will the Deputy submit the request to the clerk so that he can contact Mr. Mitchell in the HSE?
Denis Naughten (Roscommon-South Leitrim, Independent)
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I am seeking that the full detail be circulated to the committee. Nobody knows what I am asking for yet so, with all due respect, let me ask for it first.
Jerry Buttimer (Cork South Central, Fine Gael)
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There is a process to go through.
Denis Naughten (Roscommon-South Leitrim, Independent)
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I ask for a full explanation as to how a discretionary medical card is issued. In our region in the west, they are only given with financial exceptions but it now seems they are being given on medical exceptions as well. Could we have a full explanation of how a medical card is assessed and particularly how a discretionary medical card is assessed?
There is a question regarding subhead C1 and a proposal that has been put to the Minister in the past. A Minister of State, Deputy White, is examining the matter, which is the establishment of a national home care budget for children with a life limiting condition. Each primary, community and continuing care body does this and taking children out of hospice or hospital beds would save two thirds of the budget and be far more effective. If we have a national fund, it could be better spent by using the same amount of money and giving better quality of delivery. Has any progress been made in that regard?
James Reilly (Dublin North, Fine Gael)
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I will confine myself to the issue raised by the Deputies around the medical card scheme. I contend with Deputy Healy that it has not always been the case that they have been given by a doctor, and the discretionary medical card-----
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I stated it was so in south Tipperary. Do not attribute a comment to me that I did not make.
James Reilly (Dublin North, Fine Gael)
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Let me finish.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The Minister should not attribute a comment to me that I did not make.
11:00 am
Jerry Buttimer (Cork South Central, Fine Gael)
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I know it is warm outside and we are all under pressure to get things done.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The Minister should be careful about what he says.
Jerry Buttimer (Cork South Central, Fine Gael)
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Can we finish the Estimates? Please allow the Minister to speak and I will allow members back in later.
James Reilly (Dublin North, Fine Gael)
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The discretionary medical card emanates from discretion that was conferred on the CEOs of health boards. It was at the CEO's discretion, not a doctor's discretion. The cards were given out for all sorts of reasons. In some regions, anybody who had cancer would get a card. As we all know, in the past the word "cancer" struck terror into people's hearts and the prognosis was very poor, but cancer nowadays is a very different condition. It ranges, sadly, from a desperate diagnosis to often being not such a bad diagnosis at all. I set up the system, and requested that it be put in place, whereby discretionary medical cards were based on medical grounds. A team of medical doctors, unrelated to the patient, assess the situation and decline or give a discretionary medical card on a medical basis. When the HSE was formed the CEOs of health boards were no longer there so there was a question over who had the discretion. Perhaps in south Tipperary the discretion might have been devolved to a doctor. I find it hard to believe that it always was.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Always.
James Reilly (Dublin North, Fine Gael)
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I doubt that.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Always.
Jerry Buttimer (Cork South Central, Fine Gael)
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I give a commitment that we will return to the matter at the quarterly meeting.
Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The Minister can doubt me if he likes, but it has always been done that way.
James Reilly (Dublin North, Fine Gael)
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A new system is in place. I have no issue with Deputy Naughten's call for a clear and transparent description of how it operates, because this is only fair and proper. In the past, different criteria were used in different parts of the country. As a result, some people received medical cards who did not really need one but appreciated it, while other people could not get one even though they desperately needed one.
Jerry Buttimer (Cork South Central, Fine Gael)
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I take the point made by Deputy Healy. I have given a commitment that a specific part of the quarterly meeting scheduled for 25 July will be dedicated to the matter.
Subhead C2 refers to long-term residential care.
Denis Naughten (Roscommon-South Leitrim, Independent)
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I asked Ms McGuinness a question on subhead C1. I ask her to forward the details to me if she cannot answer me now.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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While I appreciate the time situation, I must protest strongly that the timing of the meeting was wrong.
Jerry Buttimer (Cork South Central, Fine Gael)
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So did the Chair.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It is very difficult-----
Jerry Buttimer (Cork South Central, Fine Gael)
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Let me make it quite clear that the Chair did not engineer today. The Chair made it quite clear to those involved that he thought it was an inappropriate day to have a meeting and we tried to change it. I accept that it was not the correct way to do business. I ask the Deputy not to infer that the Chair or the secretariat were involved, because we were not.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I made no such inference.
Jerry Buttimer (Cork South Central, Fine Gael)
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Okay. We will discuss subhead C2 now.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I know, but the clock will not allow us to address the subhead properly.
Jerry Buttimer (Cork South Central, Fine Gael)
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Unfortunately not.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I have raised the matter in my opening remarks. Subhead C1 relates to primary care and community-led demand schemes, which have seen a reduction of 8.6%. My particular area of concern relates to the 950,000 home help hours that were removed. The Minister, in his response, talked about restoring the hours to the 2011 figures and the Minister of State, Deputy Lynch, gave a commitment to restore the 2012 level of home help hours. Will those same home help hours be restored during the remainder of this year, 2013, to the same older and disabled people who had them removed from them in the first place?
Ms Laverne McGuinness:
With regard to home help, there was a reduction in outturn in 2012. The Minister gave a commitment and we have put in our service plan a commitment to reach the full target of home help hours in 2012, which was 10.3 million hours. The same is in place for the service plan for 2013. There is a full commitment to the restoration of budget in that regard. That is there and in place.
I will explain what happens with home help hours. People's cases are reviewed; one cannot say that the same person will receive home help hours continuously or on an ongoing basis. Some people only need the service for a period. For example, a person might be at home or in hospital for a period and might need the service for six months or three months. There is a continuous process of review. Some people might need more hours. One cannot say that one will give the hours to the same people for the same period on an ongoing basis. We can emphatically say that the same number of hours and the same budget have been committed to in 2013 as were provided for, in full, in 2012.
Denis Naughten (Roscommon-South Leitrim, Independent)
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May I comment?
Jerry Buttimer (Cork South Central, Fine Gael)
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Very quickly, because the clock is against us.
Denis Naughten (Roscommon-South Leitrim, Independent)
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Earlier the Minister made the point, in his response, that the stroke programme saves a life a day. That is a great success story for the health service. The programme has also taken about 160 people out of the nursing home system per annum, which has saved, to date, about €25.75 million. Savings have been made in the nursing home budget but the actions are taken in the acute hospital budget. I believe these should be linked. At least some of the savings made in the nursing home budget should be moved back into the acute hospital budget because a roadblock is preventing the roll-out of the stroke programme across the country. Funding is part of that issue. If some of the savings could be released specifically to the stroke programme, it would save the long-term residential care budget a significant amount of money.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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My comment relates to subhead C2. Earlier I made reference to the Health (Amendment) Bill going through the Houses. Its briefing document states that funding available for long-term residential care has been reduced by €20 million in 2013. Earlier, the Minister made a point about other measures with regard to outcome assessments, which is fair enough. Has any evaluation been made or is an impact assessment being done on the cuts and the long-term residential care supports?
James Reilly (Dublin North, Fine Gael)
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I will let Ms Bairbre Nic Aongusa answer.
Denis Naughten (Roscommon-South Leitrim, Independent)
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Sorry; it is about €160 per person per year, which represents about €25 million to date in savings.
Denis Naughten (Roscommon-South Leitrim, Independent)
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Yes.
Ms Bairbre Nic Aongusa:
The overall target of savings for the health service is €721 million for this year. All of the savings are required in order to meet the overall savings. To say that the €25 million is actual cash that can be transferred from one budget to another is a misunderstanding of the way the budget works.
Denis Naughten (Roscommon-South Leitrim, Independent)
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That was not the point I made. There are savings to be made.
Jerry Buttimer (Cork South Central, Fine Gael)
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I will not allow a debate. Sorry, Deputy; we are moving on.
Denis Naughten (Roscommon-South Leitrim, Independent)
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Further savings could be made if some money was released back.
Jerry Buttimer (Cork South Central, Fine Gael)
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Subhead C3 is on children and family services.
Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Is an impact assessment being done?
James Reilly (Dublin North, Fine Gael)
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We will have to get back to the Deputy, because his question of fact requires quite a long answer and we do not have time.
Jerry Buttimer (Cork South Central, Fine Gael)
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Will the Minister forward the information to the Deputy?
James Reilly (Dublin North, Fine Gael)
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Yes.
Jerry Buttimer (Cork South Central, Fine Gael)
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Is subhead C3 agreed? Agreed. Are subheads D1 to D4, on capital services, agreed? Agreed. Is subhead E on appropriation-in-aid agreed?
Denis Naughten (Roscommon-South Leitrim, Independent)
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I wish to comment on subhead E. As the Chairman will know, I flagged an issue when we set the agenda for today's meeting. I refer to the EU directive on cross-border treatments, which is under the remit of refunds from the member states of the European Community. The directive will kick in from 25 October and potentially has great implications for the health service for this year and, significantly, next year. We do not yet know how the legislation will be implemented. We do not know whether it will be through regulation or primary legislation, because the Department has not been able to indicate either way. The directive is a significant piece of legislation that needs to be enacted in the State by 25 October. Has provision been made for it in the Estimates? What mechanism is the Department using to implement the directive?
James Reilly (Dublin North, Fine Gael)
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I will revert to the Deputy. I know some people have said we cannot give any dates, but I can say that the legislation will be ready very shortly. It may miss the deadline by a small number of weeks but it will be ready this year.
Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise to members of the sub-committee for the unacceptable timing of this morning's meeting. There was a clash of meetings this morning and we will liaise with the Departments regarding the matter. I thank the Minister and his officials for assisting the sub-committee with our consideration of the Revised Estimates.