Éamon Ó Cuív (Galway West, Fianna Fail)
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I regret that we are meeting at this hour of the evening and under time pressure, but I hope we can come back to this issue.

If the population of rural Ireland continues to decline, it will have a vortex effect in that as the services are withdrawn, the population will decline. What we are doing here must be about revitalising and regrowing rural Ireland. As somebody who comes from Dublin 4 and who has lived in rural Ireland for years, I know it is a great place to live. If one has a job there, there is a great quality of life and it has fantastic potential that is not being realised.

I wish to address the HSE first on an issue that has not been touched on. There is the vexed issue of the means test for medical cards but I am not referring to the means test. I have no problem with it and there must be a means test for qualification for it. However, the service we get from the HSE has gone beyond ridiculous with respect to the information sought, the delays, the obfuscation and the nonsense.

I will give one or two examples. I dealt with a farmer who is in receipt of jobseeker's allowance, which is a means-tested payment. Anyone who understands the system knows there is a difference between the thoroughness of the Department of Social Protection in checking that one is not earning money elsewhere and that of the tax man. The Department of Social Protection carries out way more checks than those carried out in respect of a self-assessed taxpayer. This farmer started farming fewer ten acres of land in Carraroe in south Connemara in the area of Leitir Mealláin, and people will know how good the land is there. The Department asked for his accounts for three months. The farmer lost money because he had to buy the stock and he had not sold anything. He prepared accounts and submitted them and the Department but was told that they were not good enough and that he would need to get an accountant to prepare his accounts.

I deal with other cases perennially involving farmers who are in receipt of the farm assist payment, which is means tested. Farmers awarded this payment by the Department are given a document, the IN 93. It contains every detail of their income and expenditure and the Department of Social Protection is able to verify what they got from the Department of Agriculture, Food and the Marine, which is the big part of their income, because the State pays it. There is a little certificate that goes with it and farmers are normally asked to produce it. We have had cases where the HSE has asked a farmer to produce a tax return certificate, a P21, or an assessment of income. The farm assist payment is not taxable. It is very unlikely that a farmer in receipt of farm assist will have enough income to have a taxable income and, therefore, make a tax return to prove that they would have no tax to pay. The tax people, in most of those cases, do not insist on a tax return. When a farmer has a detailed document from the Department of Social Protection setting out the farmer's income down to the last dime, the HSE should accept it. I have tabled parliamentary questions in these cases and sometimes the HSE has backed off.

I find it extraordinary that people who are vulnerable in terms of bureaucracy have to jump through 50 hoops to prove the obvious. I am not against reasonable checks but anybody who understands the system knows that if one is in receipt of the farm assist payment or other such payments, they are thoroughly examined. I have dealt with cases where, after 28 days, if an applicant does not get a response, the process is cancelled and the applicant has to start all over again. I am sure Dr. Daly can tell me that this is happening all the time. These are vulnerable people and there might be one document they did not submit or whatever. The applicant must then complete the form again, and that is fine if he or she kept a photocopy of the original form submitted, and he or she also has to get another copy of all the documentation originally submitted. This is quite a challenging form to complete.

The first thing we need in this State is some balanced common sense and recognition of data matching. The HSE has access to a fair bit of data matching. I do not see the point in persecuting 99% of the people to catch perhaps 1%. I am not against reasonable checks but I have found that common sense has gone out of the system. I utterly support what my colleague said about the home help service and home care packages. Many people can be kept at home with support.

Access to health services is another issue that arises for my constituents who may live a distance of 60 miles from a hospital. There is no assistance, regardless of the circumstances, to get transport to and from appointments other than in a very limited number of cases where people are on dialysis. I very much welcome what my colleague said about the review of island services and I look forward to its publication in January 2017. I presume the islanders have been involved in the process and I hope its recommendations will be implemented.

We got many figures about primary care teams but the witnesses from the HSE have not told me how many comprehensive primary care teams with all these support workers are located in real rural Ireland as against peri-urban Ireland. In other words, there is urban Ireland, peri-urban Ireland and rural Ireland. As Dr. Daly would know, the population is growing rapidly in 30-mile commuter belt outside Galway city. New houses are springing up all over the place. If the authorities did not try to stop all the rural housing, we would have no problem with the population in those areas. When one travels 40 minutes from Galway city to Glenamaddy, Glinsk and south Galway, the population goes off the cliff, as it were, in that it has gone the other way and declined. That can be seen on the map before us. The same can be found in the west and, depending on the size of the town, the population in the area around it would be bigger or smaller. I would be curious to know how many comprehensive primary care teams we have in real rural Ireland. I do not want to get local about this and perhaps Galway is unique but every week we are seeing support services such as physiotherapy services and dental services being withdrawn from the real rural areas.

I would be interested to hear from both groups about the provision of minor treatment services such as routine X-rays, ultrasound and so on - it is not rocket science - in places like Clifden or Belmullet, which we have been considering. In the extended rural areas of the country in west and south-west Donegal, west Connemara and the further end of south Connemara, and the further end of east Connacht, should there be a clustering of services for carrying out minor surgeries and minor diagnostics? Technology is getting cheaper. In many cases we are centralising services but many services can be decentralised because technology has made it possible to deliver services locally. That computer in front of me is bigger than the mainframe computer of the 1960s. Rather than having one for everybody in the audience, should a cluster of services be provided in Clifden, An Cheathrú Rua, Belmullet or Mulranny which would enable many people, who would have travelled to accident and emergency departments, to be treated locally? That would ease the number of cases presenting at accident and emergency departments, reduce the travelling involved and allow those procedures to be done swiftly.

The issue with the rural practice allowance is symptomatic of the chaos in the system. I spent two years trying to elicit information from the HSE on how it decides who gets the rural practice allowance and who does not. I am sure my two colleagues, the Deputies here, will be fascinated by this. A doctor in Renvyle was refused a rural practice allowance and I submitted a freedom of information request and did everything to find out about it but all I got was obfuscation, but they should have known I would keep coming. I am surprised that people in the system did not know that Ó Cuív does not take obfuscation. I got a list of all the doctors in the country who have the allowance and I do not know how HSE could justify that it could not be given to a doctor in Renvyle which would be the equivalent of not giving it to a doctor in Waterville or in Ballyferriter in County Kerry.

It would be the equivalent in your case, Vice Chairman, of not giving the allowance to a doctor in Goleen. I will never understand how Renvyle did not qualify and a town suddenly sprang up, although the census said it did not have a town with the stipulated population. I would be very interested to know, first, whether there are now clear criteria by which the rural practice allowed is allocated and whether it is being applied equally to all doctors across the country. I understand the doctor in question had to take the HSE to court. I would have thought an error of that proportion would have been immediately rectified.

I will skip FEMPI because that is a very wide issue and I will focus on two things. The first is distance coding. Could the HSE indicate whether it is intended to restore distance coding? We had it in our policy for the election and the cost is not significant in terms of what is spent by the HSE. The second is whether the HSE will set the rural practice allowance, in particular for very rural areas where one would expect it to be especially important, at a level that would attract doctors to live, work and earn their living in such areas? We proposed an increase to €25,000. I understand that the saving made in reducing it from €20,000 to €16,000 was minimal. I also understand the saving in respect of distance coding is approximately €5 million a year. I am sorry for taking so much time but I have been working on such issues for a long time. The health service spends €14 billion a year and as it is very hard to get one’s head around €14 billion, let us forget about that figure and say €14,000. Let us presume there was €14,000 in front of me here and that €5 million is equivalent to €5 out of the €14,000. It is much easier for people to get their head around and it is the exact same computation as €5 million out of €14 billion but it is the exact same proportion. If I said, here is the budget for the year of €14,000 and asked for €5, the first response would be that it is insignificant and that I should get it. What is the policy on distance coding and is there an intention to restore it, or to increase the rural practice allowance to €25,000, or to introduce some of the other proposals Dr. Martin Daly made? I would be interested to hear Dr. Daly’s view on the matter. The generation that is there is there; they will be there until they die and they will be carried out in boxes. The real question one has to ask is whether mothers in particular will be willing to settle in communities if there are no services, namely, good schools and good medical services available locally, on-call if needed. I do not wish to be sexist about this but I have watched the pattern for a long time.