Oireachtas Joint and Select Committees
Wednesday, 9 December 2015
Joint Oireachtas Committee on Health
Medical Cards: Health Service Executive
I welcome members and witnesses to this afternoon's meeting. We are joined today by Mr. John Hennessy, who is the national primary care director of the HSE; Ms Anne Marie Hoey, who is the assistant national director in primary care reimbursement and eligibility in the Primary Care Reimbursement Service; Ms Siobhán McArdle, who is the operations manager in the Primary Care Reimbursement Service; Mr. Kieran Healy, who is the head of customer service in the Primary Care Reimbursement Service; and Mr. Ray Mitchell of the parliamentary affairs liaison division of the HSE. I thank Mr. Mitchell for all the work he has done in liaising with the committee during the 2015 calendar year. This is not our last meeting of the year, as we will have another one tomorrow. Mr. Mitchell is always available to the committee to help to co-ordinate our meetings.
This afternoon, we will consider developments in the administration of the medical card service over the past year. I welcome Ms Anne Marie Hoey, who has taken up her duties in the role previously held by Mr. Paddy Burke. I thank her for being in attendance this afternoon. We had hoped to have this meeting earlier, but there was a mix-up with the dates. That has been rectified today.
I wish to advise witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of the evidence they are to give this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable. Members of the committee are reminded of the long-standing parliamentary practice and rulings of the Chair to the effect that they should not comment on, criticise or make charges against a person or persons outside the House or an official either by name or in such a way as to make him or her identifiable. I invite Ms Hoey to make her opening remarks.
Ms Anne Marie Hoey:
I thank the Chairman and the members of the joint committee for inviting us to attend today's meeting. The Primary Care Reimbursement Service and national medical card unit delivers a wide range of primary care services across 12 community health schemes, including the medical card scheme, to a population of over 3.66 million. These services are provided by more than 7,000 primary care contractors and involve 77 million transactions, with an associated expenditure of €2.397 billion, each year. As of 1 December last, some 1,729,000 medical cards and 409,000 GP visit cards were in circulation. Since 1 December 2005, there has been an increase of 573,273 people with eligibility under the GMS scheme. This represents an increase of 33.2% on the 2005 level. Since 2011, the national medical card unit has provided a centralised medical card assessment and processing service. This enables a single uniform system of medical card application processing. The unit replaced the different systems that previously operated through more than 100 offices across the country. It enables a streamlined and standardised work process and ultimately ensures a more consistent and accountable medical card processing system.
It is important to note that the administration of the health service requires achieving a balance between ensuring those who meet the criteria for full or limited eligibility under the GMS scheme receive their medical cards or GP-visit cards in a timely manner and are treated in a sensitive and compassionate manner at all times, and ensuring there are processes and controls in place to ensure there is robust accountability for the expenditure of public funds. In the summer of 2014, the HSE commissioned two reviews: the medical card process review, which was undertaken on behalf of the HSE by Prospectus-Deloitte; and the report of the expert panel on medical need for medical card eligibility. Both reports were publicised in November 2014 by the Minister for Health, Deputy Varadkar, and the Minister of State with responsibility for primary care, mental health and disability, Deputy Kathleen Lynch.
I will confine my opening remarks to a short update on the progress in implementing the recommendation of those reports. This will be of particular interest to the committee. The recommendations contained in the reports fall broadly into a number of key areas, the first of which relates to communications. During 2015, the national medical card unit has engaged in communications to gain a full understanding from our customers of their experience of making an application for a medical card. A randomised survey was undertaken in June involving 900 customers who had made applications for medical cards in the previous 12 months. Some 75% of those surveyed were granted eligibility and 25% of them were not.
The overall summary of the responses demonstrated a very good level of satisfaction with the service. The majority of respondents, regardless of their outcome, found the information on the medical card website appropriate and helpful. Respondents found the advice they got from local health offices supportive and found their telephone interaction with the national medical card unit, NMCU, to be very good. The survey found that 86% of applicants completed their application form without assistance. Of those who required assistance with the application process, 14%, the main sources of assistance was the HSE local health office, the GP surgery, the public representative's local office or by direct contact with the NMCU contact centre at lo-call 1890 252 919.
In responding to the findings of the customer survey and the national medical card process review report, the NMCU has commenced a further series of briefing sessions on the medical card scheme with public representatives and their staff, local health office staff, medical social workers and allied health professionals within the acute hospital groups and with GPs and their staff. These briefings will continue throughout the country in 2016. Briefing sessions have also been undertaken to date with a number of other stakeholders, including each of the four regional fora and the national patient forum. The findings of the customer survey will inform the development of a strategy for the NMCU which will be finalised in the first quarter of 2016 following a public consultation process.
The second area I want to touch on relates to the medical card application process. The medical card process review report of 2014 made a number of recommendations to improve the processing of medical cards at the NMCU. In implementing these recommendations, the NMCU has carried out a review of the processing of medical cards at all stages using a Lean methodology, and the NMCU continues to implement recommendations arising from this initiative. The unit has introduced real-time analytics to enable the unit to manage effectively the throughput of applications and amendments required by applicants to their applications, which can include change of doctor and the addition of new babies, and we receive up to 19,500 pieces of post per week. The NMCU has developed a quality control division, undertaken continuing training and development of its staff, and extended its utilisation of information technology through initiatives such as an online registration process for GP-visit card schemes and the internal scanning of customer documentation.
On information technology, our ICT systems are continually being improved and refined to support the processing of medical card applications. The NMCU has initiated two major ICT-based projects to be delivered in 2016. The first of these is an enhanced online application system whereby applicants will be able to apply online and attach any supporting documentation required. The turnaround time for applications received online will be enhanced. This service development will significantly improve the overall experience of customers. The second project relates to the enhancement of the interface with the Department of Social Protection in regard to payments made by that Department to medical card applicants, obviating the need for customers to provide details of Department of Social Protection payments with their applications in future.
On the clinical advisory group, CAG, following a recommendation in the report of the expert panel on medical need for medical card eligibility to consider medical conditions and their prioritisation or suitability for medical cards, the CAG was established by the director general of the HSE in January 2015. The group is working on developing an assessment approach to support the existing medical card application process which will enable the medical officers and deciding officers at the NMCU to gain a more comprehensive understanding of the burden of illness on an individual or a family. This refinement is being tested and validated with customers with a view to it being recommended to the HSE in the first quarter of 2016. Since September 2014, the number of medical cards awarded on the basis of the exercise of discretion has risen from 71,222 to 95,887 on 1 December 2015. Eligibility awarded on the basis of the exercise of discretion is currently not reviewed, pending advice from the clinical advisory group.
Further recommendations from the report of the expert panel have been implemented, including the granting of a medical card and a GP-visit card to the individual with the index condition only in the family. Eligibility granted to applicants certified clinically as being terminally ill is no longer subject to an eligibility review. Medical cards for children under 18 with a diagnosis of cancer and where a means test is not conducted were introduced in July of this year. Three further new schemes were introduced at the NMCU in 2015: the GP-visit card scheme for children under six, the GP-visit card for people over 70, and eligibility in accordance with the Redress for Women Resident in Certain Institutions Act 2015. A user-friendly online registration system is available for the GP-visit card scheme for children under six and the GP visit card for those over 70. To date 204,251 children and clients have registered for the under-six scheme and 47,594 people have registered for the GP over-70 scheme.
I thank the committee for its continued support of the HSE’s efforts to improve the medical card system. I and my colleagues will endeavour to answer any questions the committee may have.
I welcome Ms Hoey and her colleagues. On the figures for those who have taken up the under-six and over-70 schemes, 204,000 and 47,000, respectively, does the primary care reimbursement service, PCRS, have projected figures? How far short of what was expected are these figures? Is it the case a significant number may not have taken up the scheme to date? This information would be helpful.
I welcome the advances signalled in the area of information technology. The enhanced online application system is welcome. I also welcome the interface with the Department of Social Protection, which will eliminate the need for applicants or clients to provide details of their social protection payments. These developments are to be delivered in the coming year and are welcome.
The expert panel made a number of other recommendations in its report published in September 2014. I note medical officers and deciding officers at the NMCU are being enabled to gain a more comprehensive understanding of the burden of illness on an individual or family. This will be very much part of the assessment. Is it the case that the NMCU is seeking the green light for that refinement in 2016 from the HSE? The other two initiatives are current and, I presume, approved, but Ms Hoey said this refinement is being tested with a view to it being recommended to the HSE in the first quarter of 2016. What has the pilot programme shown and does the NMCU anticipate a favourable response to the recommendation?
Removing the means test for medical cards for children under 18 with a diagnosis of cancer is a welcome and important development. Does the PCRS have an opportunity to encourage further consideration of the medical need assessment rather than means or income stream assessment?
That is the case currently and I would argue it should be expanded.
The thresholds for qualification have been parked for many years. Although the representatives from the HSE, in their opening remarks, indicated that there has been a significant increase in the number of people who have medical cards in the ten years since 2005, has the qualification threshold increased over that period of time? I doubt that it has but the delegates can correct me if I am wrong. The threshold figures are unacceptably low in respect of the full medical card and the GP-visit card. Does the primary care reimbursement service have the wherewithal to recommend or would it even consider recommending that this particular barrier to access be revisited? I would much rather assessment on the basis of medical need. However, would the service recommend an increase to the thresholds if the alternative option of assessment based on medical need is not possible?
I also wish to deal with capacity in Finglas and the post office, PO, box number. We will have the anticipated addition of children from six years to 12 years in the last quarter of 2016 to the scheme. This is clear given the funding of €10 million for a scheme that would cost €39 million over a 12-month period. With the addition of the under-sixes and those over 70, does the HSE have the physical capacity and office space to accommodate the movement towards, it is hoped, at least, initially, universal free GP access? This will be done incrementally and will add additional work throughput. Does the HSE have the necessary physical space and staffing? What will the impact of schemes for the under-sixes and the over-70s be? Does the HSE anticipate more in terms of need?
Are the 2014 figures relating to the primary care reimbursement service available? The only figures I can access are those from 2013. What is the status of the 2014 figures relating to the performance of the funding stream to general practitioners, for example, through the primary care reimbursement service? Are the delegates in a position to answer the question? Perhaps I am wrong but I was endeavouring to establish this recently and was unable to isolate the information I needed. Are the delegates in a position to help me in this regard?
I thank the delegates for today's report. I am responding positively to the elements I believe are welcome and will make a difference and I am trying to be encouraging in respect of the areas I would like to see the service develop.
I welcome the HSE representatives and thank Ms Hoey for her presentation. As the public representative with the highest number of contacts with the medical card unit, I wish to compliment the staff there. They are always courteous and helpful and that applies across the board. As a former public servant and as a trade unionist who represented public servants for more than 30 years, both locally and nationally, I would expect no less.
This service should never have been centralised. It is uniquely appropriate that this service would be locally based. The public, applicants and their representatives should be able to have face-to-face access to officials dealing with the applications. This is the biggest difficulty with the current system. There is no method for an applicant or anyone acting on behalf of an applicant to have direct contact, be it face to face or over the telephone, with the official dealing with an application. This should be possible and, if available, would solve a huge amount of the current problems affecting the system. Is this being considered by the HSE?
I welcome the clinical advisory group and the examination of the burden of illness on an individual or family. The issue of applications for a discretionary medical card on the basis of medical need has been difficult from the beginning. There is no doubt the situation has improved but this area of the system needs to be dealt with urgently. I would like to see the proposal being brought forward sooner rather than later. It is still one of the areas in the system which is particularly difficult for applicants and their families. Currently, when dealing with the renewal of a medical card, a review form is sent to the medical card holder. It would be helpful if a medical certificate could be forwarded with the review form where the application was granted previously on a discretionary basis given the medical need. This would short-circuit the need to send the certificate later and avoid further delay.
The system whereby cards are made available to individuals with a terminal illness is working well but it can give rise to difficulties for applicants, their families and some doctors who do not wish to certify an illness as being terminal. The situation could be helped by having direct personal contact between GPs or individuals acting on behalf of applicants and the person dealing with an application. This has occurred in the past because I have been involved in such cases. I was able to speak to officials and the process was accelerated and the applications in question ultimately proved successful. This contact is vitally important and its availability needs to be widened.
There appears to be a difficulty in terms of the self-employed, particularly those with small incomes. The delegates may not have an answer to my question today but they might revert to the committee with it. I understand the HSE takes one view but the Revenue Commissioners take another one and, to date, the twain have not met. The Revenue Commissioners say the form 11 is a single-sheet form but the HSE say it is a multi-sheet form and we have stalemate. Perhaps the delegates will examine the issue and revert to the committee on it.
I understand the unit gets 19,500 items of mail per week but I receive regular complaints about information not being received even though they have been sent by registered post.
What is the situation in that regard?
Like Deputy Ó Caoláin, my understanding is that thresholds have not been increased since January 2006. They need to be reviewed.
We raised the question of refunds for the taking of bloods by general practitioners, GPs, with the former Minister for Health, Deputy Reilly, who solved the problem and medical card holders who were charged for the taking of blood by their GPs were refunded. That seems to have come to a halt again. Could that be clarified?
I thank Ms Hoey for the presentation. According to the report, "Eligibility granted to applicants certified clinically as being terminally ill is no longer subject to an eligibility review". I have come across cases where to my surprise applications were refused. I accept that people were over the qualifying criteria, people aged over 70. The same discretion does not seem to have been applied. In two or three cases the application was refused and a GP only card was issued. In one case there were reports from four consultants indicating that this person had serious medical difficulties. It is great to be able to talk to someone in the unit but we do not get to talk to the person who makes the final call. I am concerned about how decisions are arrived at. I know of two or three cases which should have got over the line. In one case, the person has died since. I made the call six months ago and all my information was correct but the person was refused a medical card. Can Ms Hoey clarify how the call is made and what discretion there is to make it?
On page 2 of the presentation there is a reference to 86% of applicants being successful and not needing help. People coming to my office need help. The most common complaint I get is that the application is sent back and they have to start all over again within three months, getting bank statements and so on. They find that very difficult.
It always surprises me to read that 1.729 million people have medical cards and 573,000 have the general medical service, GMS, card. That is 2 million of the 5 million living in Ireland. It is a large number but sometimes when I am knocking on doors or am in my office listening I get the feeling that nobody has medical cards.
Ms Anne Marie Hoey:
Deputy Ó Caoláin asked about the numbers projected in respect of cards for those under six and the over-70s. When the schemes went live, it was projected that 276,000 children under the age of six would be eligible for the scheme and approximately 40,000 people aged over 70. A total of 204,000 under sixes have registered for the scheme. Children under six continue to register. The number of people over 70 has exceeded the initial projections. The uptake for registration for that scheme was very positive from the beginning and more people turn 70 every month so the numbers have increased.
The assessment tool is being developed by the clinical advisory group. It will be designed to try to enhance the current process by enabling people to describe the burden of illness as it affects the individual or the family. It will support the existing application form without overburdening people with additional work to complete that. To date the assessment tool has been tested at a couple of focus groups and is due to be further tested at focus groups with patient representatives next week. My understanding is that the clinical advisory group will take on board the feedback from the focus groups and in its report in quarter 1 of 2016 will recommend to the health service executive, HSE, that it be adopted for use.
The card for children under the age of 18 diagnosed with cancer was implemented last July. The clinical advisory group made that an interim recommendation but, as its work progresses, it will take into account how that burden of illness is assessed for all cohorts.
The thresholds are set by the Department of Health and the national medical card unit in the HSE implements those thresholds. In respect of capacity in Finglas if GP-visit care is extended from under six to under 12-year olds, approximately 93% of people registered online over the past few months for the card for under sixes, which reduces the volume of paper work for us to process. If that trend continues with the extension of the card, that reduces the number of staff needed to process paper applications. I am confident that we will have capacity, albeit with a small uplift.
Deputy Healy asked about centralising the service and having face-to-face contact. We work on that continually in our interaction with the community health organisations. The centralised system has benefits but we cannot do that in isolation. We have to work with local areas and the intelligence available there. Members of the public go to their local areas for advice and support in completing application forms.
We are holding meetings throughout the country with local health office staff, with GPs and with local representatives and their staff to ensure everybody is fully briefed on the scheme, how it operates and can provide the most up-to-date advice and information to members of the public who come to local offices.
Ms Anne Marie Hoey:
My apologies, I thought the Deputy was talking about the local office. For individuals who want to speak to somebody about the processing of an application, the first point of contact would be through our call number. If a query cannot be resolved at that stage, it will be transferred to our customer relations department which is managed by Mr. Kieran Healy.
Deputy Seamus Healy welcomed the burden of illness initiative. The plan is for the clinical advisory group to bring that recommendation forward in quarter 1 of next year.
On the review form and the medical form going out together, we take that as a very positive recommendation. I would certainly take that away with me.
In the context of self-employment and form 11, we have them working and realise there can be some differences in understanding in respect of the form. We have been working with Revenue to resolve the matter and have a common understanding. We are confident at this stage that we do have a common understanding, which we will certainly impart to any applicant in terms of exactly what is required. We do not want to overburden people unnecessarily on that.
Regarding documentation not received, we have made a number of improvements to address the issue. I mentioned earlier that we have undertaken a lean methodology looking at all of our processes. We are putting in place very robust systems for the management of the volume of documentation which we receive on a daily and weekly basis. Over the summer months, we also introduced scanning whereby all additional information received into the unit is scanned at the point of entry and linked with the person's application, cutting down on unnecessary handling of documentation by any more people than would be necessary.
Senator Colm Burke referred to people who are terminally ill. Obviously, I am not familiar with the individual circumstances of the cases but am happy to discuss same with him offline. On the question of how decisions are arrived at, we take into consideration all information that is provided to us, which can include comprehensive medical reports or reports from hospital social workers. Some reports can be much more explicit than others. Sometimes we may not know the full circumstances. Our medical officers will make contact with the person's general practitioner or public health nurse, depending on whether the person is in a hospital or community setting, and try to gather all the information on that patient and take it into consideration. The medical officers with all of the information and deciding officers with all of the financial information will then come to a decision. The numbers for discretionary cards over the last year would indicate that we are applying a very sensitive and compassionate approach to all of the information that is presented to us.
Deputy Mitchell O'Connor mentioned the numbers that did not require help. The survey was undertaken in June of this year and was of 900 people who had made applications over the previous year. The results of the survey indicated that a number of people said they did not need help; nevertheless, those who said they did need help identified the most likely places where they would get it. That is why we are embarking on the briefing sessions throughout the country with all of the various cohorts to make sure that anybody who is contacted for information has the most up-to-date information available to them.
Mr. John Hennessy:
I think the last published figures were for 2013. The question about charging for bloods and phlebotomy was raised by Deputy Seamus Healy. We are all aware of that problem. There are general practitioners out there who are charging medical card holders. Our position on it is pretty clear. We believe it is not permitted under the contract and is not an appropriate way for general practitioners to deal with the issues and concerns they have. We have written to all general practitioners, I think twice in the last two years, to remind them that they are not permitted to charge medical card holders under any circumstances. Where clients and patients have brought this to our attention, we have refunded them and, in turn, withheld the amounts from the future payments due to those particular general practitioners. It is a matter with which we are dealing under the negotiation process for the contract review with the IMO under the framework agreement. It is not something I think is appropriate in terms of an approach to negotiating a new contract. I say that with particular reference to the fact that medical card holders are the most disadvantaged sector of the community. It is not at all appropriate that they would be charged. We can remind general practitioners again of their obligations under the contract in that matter.
Mr. John Hennessy:
A matter that came up in respect of the burden of illness was mentioned in a number of the Deputies' comments. The first report of the clinical advisory group is being worked through at the moment. The first report made eight recommendations and we have been dealing with them. The first was the approvals for medical cards for children with a cancer diagnosis. Other recommendations called for more flexibility in reviewing eligibility and we are working through those. The operation of the long-term illness scheme, which is a bigger issue, will require closer liaison with the Department of Health. Extension of services to public health nursing and home support outside of medical card eligibility is also being addressed, but is a more medium-term issue. The review arrangements for discretionary medical cards and non-medical benefits are both being worked through by the primary care reimbursement service, PCRS, at this time. We anticipate a further report from the clinical advisory group shortly, which I am sure will address other issues in respect of the burden of illness. Members will recall that the issue is a notoriously difficult one to grapple with and was of particular difficulty for the Keane review group in the first instance. It has not gotten any easier but we are still grappling with measures that will hopefully improve the situation for applicants with critical and serious illness.
I thank Ms Hoey and congratulate her on her appointment. She said that the discretionary medical cards have increased by approximately 25,000 since 2014. Has she any figures on how many people would have applied and did not get one? On the over-70s who do not qualify for the general practitioner card, many of whom contact me quite often, under the discretionary medical card people are being told to apply again but for the under-70s section rather than over-70s. Does Ms Hoey understand what I am saying? Are there figures available in respect of people who are over 70, who are turned down and who then told to reapply but for the under-70s section?
I welcome all the representatives from the HSE. It is worth saying that over 1.7 million medical cards and over 400,000 general practitioner cards have been issued. Over 200,000 children have been registered for the under-six scheme to date and nearly 50,000 people have registered for the over-70 scheme.
Much work has gone into that and the service should be congratulated on it.
When I became a Deputy in 2011, there were over 100 offices across the country processing medical card applications. The centralised, uniform medical card application system seems to be working and to be a lot more organised than the old system. It had a very shaky start in 2011. Members of this committee visited the centre in Finglas twice in recent years and have seen at first hand the work that is being done.
It was stated 75% of applicants were deemed eligible for medical cards and 25% were not. I am very impressed with this rate. It was also stated that from 2005 to 2015, there has been a 33% increase in the number of medical cards and GP cards. Could the witnesses provide a comparative analysis of the figures? Some 86% of applicants completed their forms without assistance. To me, this seems to be a very high number. It was stated 19,500 items of information are received in the post every week. This seems to be an awful lot of paperwork each week. How many staff are working on this?
The number of discretionary medical cards has jumped from 71,000 in September 2014 to over 95,000 in December 2015. I welcome that increase. Deputy Byrne asked how many people were refused discretionary medical cards during that period.
The medical card service has come a long way. For a long time, every time one looked at a newspaper or listened to a radio programme one encountered medical card problems. It does not seem to be a major problem now. I commend the staff involved. It is nice to see the HSE doing a great job; I am not going to say it does not normally do a good job. Sometimes it is nice to get a wee clap on the back. The difference between a clap on the back and a kick on the backside is only six inches. Well done.
I thank the delegates for their presentations. I attended a briefing they gave in the audiovisual room recently at which many issues were covered. I will not go over many of the issues that were raised today. I welcome the positive aspects of the presentations.
I wish to refer to a couple of small points on medical card renewals. There seems to be a problem affecting people on community employment, Tús or back-to-education schemes. Some such people have come through our doors. It has taken them quite a while to sort out their problems. Even if they take up the schemes, and even if they take up employment, they should be entitled to keep their medical card. I have encountered a few people who have been without a card for a few months.
With regard to terminal illness, I agree on the point on doctors not being inclined to produce a letter. I encountered a case recently in which a person was asked for a land valuation. He had only 31 acres but, given his illness, he would be unable to work that land. It took quite a while to sort this out. This brings me back to the issue of direct contact and the ability to speak to a decision-maker face to face. Had I been able to speak to a decision-maker at the time, we could have sorted the problem within a day. We have been harping on about a dedicated line for public representatives for a long time. We just cannot seem to tie this down with the service. There is such a line for almost all other Departments we deal with. Will we ever have it?
I thank the delegates for attending. As with Deputy McLellan, I was at the briefing in the audiovisual room. I note a real sense of calm and, more important, control over what was obviously very much out of control not so long ago. That is a real credit to all the staff, particularly those in Finglas. There was a lot of stress among those staff, just as there was among those at the other end of the system. From what I hear, there is a real sense of camaraderie and of being listened to. It is a real pleasure to be where we are. Well done. I hope that does not sound patronising.
One of the clinical advisory group recommendations that was taken on board this year concerned cards for those under 18 with cancer. It is very welcome. How did we do that without changing the legislation? With regard to other ailments, the legislation had to be changed, yet we were able to proceed without changing the legislation for the under-18s. Did we just grant them discretionary medical cards? Did we change the discretionary route we use? If so, do the delegates envisage a stage where we could deal with 19-year-olds, 29-year-olds or 59-year-olds with cancer or other illnesses in the same manner? I am quite sure treatment is as financially taxing on the family of a 29-year-old as the family of a nine-year-old. Could the delegates outline what has been achieved?
I have three issues to raise. I join colleagues in congratulating the primary care reimbursement service on the good work it has been doing.
The first issue concerns the justice aspect. If somebody is declared bankrupt, his income drops. While he may have a very good job, a certain amount of his income is taken away by the financial institutions, thereby resulting in a net income that is quite low and which can remain so for at least eight years. I am told gross income is taken into account in a medical card application, which does not reflect the reality. It might be an issue that has not come across the delegates' bows yet but they might examine it. The incidence of this problem is increasing and it is causing hardship for people. Some have informed me the gross income is taken into account by the service, not the real net income after the banks or financial institutions have taken their cut.
Second, I understand that in the case of people under 23 who are living at home and who wish to apply for a medical card, it is the whole family that makes an application. There is no way in which the individual can make an application on the form as it stands giving the household income. One way out of this might be to have a different form for such people so that the household income could be included initially rather than having to make two applications. The current methodology is quite cumbersome.
Third, where somebody with a serious illness and who requires treatment straightaway applies for a card, there might be a delay for a number of months. In the meantime, the individual incurs significant expenses. Reimbursement occurs only when the card is granted. Is there any way of backdating? I am told it is not possible. I ask the officials to consider backdating to the time of application, especially if significant expenses have been incurred in the interim by somebody with cancer or some other such condition.
At a meeting of this committee last Thursday, witnesses took issue with the Gardasil vaccination and referred to the need for ongoing support for their daughters' ongoing care. We also met people on the subject of Huntington's disease. Subsequent to our meeting in January, we wrote to Mr. O'Brien about the issues identified by the group lobbying on behalf of those with that disease. Fibromyalgia and asthma have also been raised. It was said to us that kidney transplant patients had their treatment stopped because they were over the income threshold.
The medical card review group reported in September of last year that there was no internationally accepted list of diseases, prioritised according to severity, and referred to the need to move away from purely financial assessments and consider the quality of life of an individual rather than just the disease or condition. I apologise for being a little long-winded. With regard to eligibility for ongoing supports, is there any movement that might benefit the people I have just mentioned? This committee meets their lobby groups and advocates on an ongoing basis.
Mr. John Hennessy:
I will call on colleagues to address some of the points that were raised. First, I acknowledge the gratifying complimentary remarks on the medical card system. It was an area that was in a controversial place for quite some time. Hopefully, we are coming out of that.
On the over-70s medical card and the issue of discretion, I might ask colleagues to comment. My understanding is that there is no discretionary provision in the over-70s medical card scheme. One either meets the gross eligibility criteria, or one does not. There is no question of discretion being applied.
Mr. John Hennessy:
That is probably where the dilemma applies. The test for the over-70s card is a very straightforward one. If one is pursuing an application for an ordinary medical card with discretionary provision, one needs to supply far more material and information. That is the reason people are being invited to apply for the full card as opposed to the over-70s. If one qualifies for the over-70s card, it is much simplier and one avoids the necessity for that complication. If one happens to be over the gross income threshold, there is no option to apply discretion and to do the test.
Is that made clear to people? Many of us find that the over-70s persons who apply are not necessary looking for the GP card but for the ancillary supports and services, appliances and medication that come with it.
Mr. John Hennessy:
It was raised by a number of members today and is clearly arising as a particular issue. We may need to look at our communication material, information and supports around that to make it easier and more understandable for applicants. We will certainly take that one away and Mr. Kieran Healy can have a look at it.
Mr. Healy might wish to speak about the help and assistance available locally for applicants. Deputy Healy mentioned face-to-face contact and the importance of having a human being to deal with rather than someone at the end of a phone. That was always intended to be part of the reform programme in the GMS. It was intended to re-establish that local dimension and to keep the best of what can be done from a central point and on a national basis while restoring what can be of assistance and help to applicants at local level. Mr. Healy might be able to speak to that for a moment in terms of some initiatives happening at local level.
The issue of the figures on refusals and appeals was mentioned by a number of members. We will provide the figures. We have published figures on the number of applicants refused and on the number and success rate of appeals. We will be able to help members with those figures. I thought we had a dedicated line for Oireachtas Members, but that might be confirmed.
We will take away the issue of the grant date for applications and have a look at it. To be fair, if someone can make a reasonable case that expense was incurred between the date of application and the date of grant, we would need to take a look at it.
The issue of support for groups where harm has been the consequence of medical treatment was raised. We have been taking a very sympathetic approach to those in any case and a number of very obvious groups come to mind. I am not as familiar with the particular groups mentioned, but I would be happy to take up those issues and to take the details from the Deputy later.
Ms Anne Marie Hoey:
A question was raised on the number of applications that are successful and those that are not. Overall, approximately 80% of all applications we receive are successful. Approximately 20% are not. That is just an overall figure in the year to date. The number of appeals we receive has reduced greatly compared even with early this year and certainly to last year. We receive approximately 20 to 25 appeals per week on average and approximately 25% to 30% are upheld. We were asked about the number who apply for a discretionary cards. People to not apply for discretionary cards as such. It is as they go through the process that discretion becomes an issue where the person does not qualify on foot of means but there is evidence of a medical condition. We take that condition into consideration and decide whether a card should be awarded based on discretion. Deputy Peter Fitzpatrick asked how many staff we have based on the volume of work we process. Currently, we have 150 staff at the national unit in Finglas.
Deputy Sandra McLellan asked about the number for the dedicated line which is (01) 864 7180.
Ms Hoey might have picked me up slightly wrongly. I was speaking about the decision-maker at the end of the dedicated line. That is where the problem is. We have a dedicated line, but we do not get to speak to a decision-maker. That is the problem. I have highlighted that before on numerous occasions as have other members.
Ms Siobhan McArdle:
Deputy Stanton raised the issue of the category of clients who fall within the 16 to 25 year old age group. There are two categories within the group, one being dependent or financially dependent upon their parents or guardians. Within that category are three further categories. Defined dependants live with a parent or guardian while in full-time education, live with a parent or guardian while earning less than €164 or live with a parent or guardian while in receipt of a social welfare allowance less than €188. However, people within the 16 to 25 year old age bracket can be deemed to be financially independent where they live with parents or guardians but earn more than €164, live with a parent or guardian while on a full rate of social welfare of an amount greater than €186 or more, or live with parents but also spouse, partner and, or, children. There are two categories. It is a complicated number but clients fall into one of those categories and their eligibility is assessed on that category.
Mr. Kieran Healy:
The expert report and the Prospectus-Deloitte review of the process have recommended greater connectivity between the centre, PCRS, the national medical card unit, and the local offices. We recognise that the good part of processing in terms of centralisation must be matched with a wide footprint nationally so that people can access advice and information on how to apply and the eligibility criteria at local level. We recognise this. In terms of the recommendations from both reports, we have already begun an engagement with the staff at a local health office level and staff in the acute hospitals sector, mainly medical social workers who are a first point of contact for people in the hospital setting. Medical social workers provide advice that a person in particular circumstances should apply for a medical card. We are endeavouring to do this in particular with local health office staff, but it is not just with them. We are also inviting local public representatives to come to those information exchange sessions.
We are also inviting GPs and their staff in order that we can explain the complexity of the assessment process and provide clarity, as we are trying to do today, on some of the complications in establishing eligibility and the documentation required to provide us with a seamless way of assessing the application form. As we communicate better with local offices and push out the information, we hope it will be more freely available to a wide range of stakeholders, including public representatives who we know have direct contact with the public and those who come to their constituency offices on a daily basis. The more we can provide clarity on the assessment guidelines and the legislation underpinning what we do, the more we hope the communication approach will improve the information available.
Mr. John Hennessy:
There are one or two items we may have missed earlier. The volume of correspondence is an issue about which colleagues may be able to speak as there are electronic solutions coming on-stream that should dramatically reduce the level of physical or paper correspondence that ties up so much time and effort. Deputy Regina Doherty mentioned the decision taken on cancer patients under 18 years of age. The director general exercised his discretion on that issue, probably at the absolute limit of what the legislation permitted under section 45(7) and very much on the basis of a recommendation from the clinical advisory group. That may be an avenue to which we might take some of the groups mentioned by the Chairman.
I am delighted that the form 11 issue has been sorted out, but it must have happened very recently as I dealt with a relevant matter last Friday. At some stage the committee might be notified of the outcome. There is a dedicated line for public representatives, but there seems to be a glitch between that section and the main section. For example, if an applicant sends additional information and he or she comes to the office of a public representative a day or two afterwards, the person on the dedicated line for public representatives may know that something has come in but may not be able to identify what. That is a problem. If the individual was able to say everything was fine or that X, Y or Z had been left out and something else was required, it would help to streamline the process.
Ms Anne Marie Hoey:
The volume is significant, but we are working on a couple of major projects for 2016 to develop an online system to which people will be able to upload all of the supporting documentation required and as part of which they will also be able to make the application online. Our vision after this is that all interaction will be online and that we will not have to send out letters.
Ms Anne Marie Hoey:
There are a couple of systems for those aged over 70 years. There is the gross income application form, with which if people are not successful, they can make a net income application. Failing that, everybody in the group is eligible for the GP care.
We have started a project with the Department of Social Protection to enhance links. During the course of next year we will reduce our reliance on people having to submit information on Department of Social Protection benefits as we will be able to obtain it directly from the Department.
Deputy Seamus Healy has mentioned that call takers may not be able to see the additional information required. In the past few weeks we have enhanced the system and all additional information coming to us is scanned such that call takers can see exactly what information has been submitted. If somebody sends evidence of a payslip or of whatever was missing in the first instance, it will be available to the call taker if somebody calls to ask if the information has been received. They can then say "Yes" and give an indication as to when the application will be processed and a decision made for communication to the individual concerned.
I thank Ms Hoey for being here and making a very comprehensive and thorough presentation. I thank Ms McArdle, Mr. Healy and Mr. Hennessy. I also thank the staff of the primary care reimbursement service, PCRS. As Deputy Peter Fitzpatrick correctly noted, we have been out there twice and the level of engagement and discourse has been particularly strong. The process has been a two-way street. I ask the delegates to convey to their colleagues and staff our sincere thanks, not just for their diligence and commitment but also for their courtesy and the way in which they carry out their business. People are wrongly often critical of public servants behind a veil of anonymity, but the staff of the PCRS do a tremendous job. I convey my thanks and those of the committee to them. I am sure everybody knows that medical card issues are some of the most common about which we hear in our constituency offices. I wish everybody a prosperous and happy Christmas and thank the delegates for being here. Committee members can have a lie-in tomorrow as we will not be meeting until 11.15 a.m.