Mr. Tony O'Brien:

Thank you Chairman.

Part of the challenge is the introduction of new work patterns for NCHDs and consultants, transfer of work currently done by NCHDs to other grades and the reconfiguration of acute hospital services. We have accelerated progress in reducing hours in 2013. Data based on hospital site visits indicates that as of September, 76% of NCHDs were compliant with a 24 hour shift and a further 6% worked no more than 26 hours continuously. It underlines continuing progress when compared to the date for the first six months of 2013.

As part of the ongoing engagement with the IMO, the proposals of 27 September reflect a significant level of agreement between the IMO and health service management. They include implementation of a maximum 24 hour shift by 30 November - other than in exceptional circumstances - with full implementation by 14 January 2014, full directive compliance by 31 December 2014, a joint IMO and management verification and implementation at national and local level and referral of a range of other items to the Labour Relations Commission. One issue remaining between the sides was the matter of sanctions, and the HSE has put proposals to the IMO to resolve this issue. The HSE and IMO have now concluded negotiations facilitated by the LRC, and yesterday the IMO's NCHD committee agreed to put resolution proposals to a ballot of members. It is hoped that this will lead to a final resolution of the dispute.

I would like to turn to the issue of medical cards, and I am conscious that much of the information on this has been covered in the Minister's speech. With your permission, Chairman, I will exclude a few sections which may make things a little harder to follow. I welcome your suggestion of a further visit by the committee to PCRS and we look forward to hosting that in due course. In advance of today's meeting, an update report on medical cards was circulated.

I must re-emphasise that the medical card scheme does not provide an automatic entitlement to a medical card for individuals with a specific illness. It is important to clarify that there is only one medical card, as there seems to be an impression that there are two or indeed three types of medical cards. A medical card is either approved on foot of a means assessment, which meets the current financial guidelines, or where the applicant does not meet the income guidelines but there is undue hardship as a result of the medical or social circumstances. The Minister has already described the procedures that are in place.

Earlier this year the first €50 of travel to work costs became disallowed for the purposes of these calculations, as did the costs of servicing loans related to home improvements.

This followed a budget decision in 2012. Changes in the thresholds for medical cards for the over-70s, with substitution by GP visit cards, were implemented by the Oireachtas in April this year. These are the only changes to affect or limit standard eligibility. The assessment guidelines used in respect of medical cards issued in the case of an assessment of undue hardship for otherwise ineligible recipients have not been altered by the HSE since 2009.

In February 2012 the HSE reached agreement with the Irish Medical Organisation in respect of new flexibility around reinstating and prolonging eligibility in certain cases. Under this arrangement GPs in certain circumstances can extend the period of eligibility for a medical card where a vulnerable person has been unable to engage with the HSE to renew his or her application. It also allows a GP to reinstate eligibility if a patient presents for medical care who has had his or her eligibility removed, for example, owing to lack of a response to the review process or because of a change of address. It also allows GPs to add a newborn baby to their GMS list where the baby's parent holds a medical card. I emphasise again that the assessment procedures used to determine eligibility for medical cards and GP visit cards have not changed. Rather, through the centralised processing of applications since 2011, where discretion is exercised, they are applied equitably and consistently, based on standard operating procedures, with medical officers assessing medical evidence of cost and necessary expense. This ensures people with a serious illness and an income within reasonable reach of the qualifying scales can qualify. This becomes progressively more difficult as incomes increase to multiples of the qualifying scale.

It is important to correct the impression that medical cards are issued automatically or irrespective of means to those with serious medical conditions since there is no such automatic entitlement. It is also important to stress that the medical card system is founded on the undue hardship test and that the Health Act 1970 provides for medical cards on the basis of means. The HSE must, of course, operate within the legal parameters as set out in the Act, while also responding to the variety of circumstances and complexities faced by individuals who apply for a medical card.

I assure all citizens eligible for either medical cards or GP visit cards that the health service will not change its eligibility assessment guidelines. My colleagues and I are as committed to ensuring all those legally entitled to medical or GP visit cards are able to avail of them as we are to fulfilling our absolute obligations to ensure those who are not so entitled neither receive nor retain them. To put this in context, between January and September this year, 289,000 families with 428,000 individuals were reviewed. Some 2.3% were not renewed based on an assessment against guidelines; 87% were renewed, while 8.3% did not respond, resulting in the suspension of eligibility. The probity figure of €113 million which featured in this week's Estimates has no impact on the definition of eligibility or our approach to assessment in each case.

Turning to service plan activity, the HSE has seen significant and extended pressures on services in the first seven months of the year. This has required us to respond, including with additional capacity. The number of emergency admissions was up by 6,842. The number of elective admissions was broadly level with that last year. The level of GP out-of-hours contact remained high, at nearly 567,000. At the end of July, 1,991,148 people were covered by either a medical card or a GP visit card, which is 1.36% above the figures for July 2012. In July 2013 a total of 23,166 persons were supported under the nursing home support scheme, compared with 22,950 one year earlier.

In setting out the financial position it is important that it be considered within the following context: there were significant pressures on our services which impacted on our costs, as well as our ability to fully sustain the very important improvements made last year in areas such as access times to scheduled care. The total reduction in HSE budgets or costs is €3.3 billion, or 22%, since 2008, while the reduction in staffing levels is over 11,320 whole-time equivalents since the peak employment levels in September 2007. In Vote terms, at the end of August there was a cumulative net current deficit of €70 million. In income and expenditure terms, there was a cumulative net deficit of €75 million at the end of July. By comparison, for the same period in 2012, the cumulative net deficit was €298 million. The HSE is not flagging new concerns beyond those set out within the national service plan for 2013.

The 2014 public expenditure estimates indicate health sector measures totalling €666 million, net of demographic and other pressures. The HSE has already commenced the preparation of a service plan for 2014. Preparing the plan will be very challenging for the HSE. I thank members for their attention.