Liam Twomey (Wexford, Fine Gael)

I welcome the Minister of State to the House to speak on the Bill. We would have preferred to see the Tánaiste here but it is good to see a Fianna Fáil Minister in the House talking about the health services because the Minister's colleague who held his position before the reshuffle has been as silent as a Trappist monk on this issue. He has still not made a statement — he was a great man for issuing statements — on his role in this issue. That is disappointing considering that Fianna Fáil is the largest party in this House and should show more concern not only for the health services in general but also two issues we are talking about, namely, legalising nursing home charges and doctor only medical cards. However, a huge number of problems remain outstanding about which the Minister of State, the Tánaiste, Deputy Harney, or any member of Government do not appear to show much concern. Those problems are just as important to people as the two issues we are debating today.

Of concern to me and some of the people I have been talking to is the reduction in the number of public only nursing home type beds in the health care system. Some people are of the view that what the Minister is trying to do in this legislation is force people into using private nursing homes, not because of eligibility criteria but because there are no public nursing home beds in certain areas, and the numbers available are constantly decreasing.

That was brought home to me in my constituency where a new hospital to replace what was basically a workhouse, St. John's Hospital, Enniscorthy, is proceeding at an extremely slow pace. Phase one, currently being built, will not replace the current full complement of the hospital. St. John's is one of the few hospitals remaining in the country which is basically a former workhouse, a throw-back from two centuries ago. It is used now to look after the elderly in County Wexford.

Yesterday, I spent most of the day in County Kerry where two issues were brought to my attention. A promise was made to the people of Kenmare that €2 million would be provided to put an extension on to the district hospital in the town. That money has not been provided and there is no commitment to make it available. The people have not got a straight answer from anybody regarding that money.

I visited Dingle also where a local landowner made a very generous gesture in giving approximately five acres of land to the health board on which it could build a new district hospital for the people of that peninsula. Again, no commitment was forthcoming and there has been no indication of when the funding will be made available to build a hospital.

The district hospital in Dingle is also a former workhouse. One can go up to the third floor of that hospital — thank God it is no longer used for patients — and see the original lay-out of the workhouse as it was in 1840. One can see where the straw would be brushed out of the wards when the bedding was changed once every six weeks when it was used as a working house. Now, over 150 years later, we are talking about imposing nursing home charges on people who are being treated almost like the way animals were treated. It is disgraceful that we are talking about imposing nursing home charges when we should examine how we can look after the elderly in our society.

I do not want the Minister to implement a policy which will force patients into private nursing homes, not because the care in private nursing homes is substandard, although that issue has been raised a few times in this House regarding certain institutions, but in terms of the cost to patients. That is something of which the Minister has not taken much notice. These nursing home charges have now been made legal but the Minister should examine the overall level of cost to patients.

That is an issue we have raised in the House since the legislation was passed before Christmas. It was raised at Question Time and again two weeks ago. Subvention payments, which patients are entitled to if they have to go into private nursing homes, average €150 per week. There has been no increase in that payment since 2001. For all the fine words we have heard in the House, a basic entitlement for elderly patients has not improved since 2001. Where does that leave patients if they need to obtain additional funding to enable them to enter nursing homes?

As the Minister of State is aware, one will not come across too many private nursing home beds that cost €150 per week. The people to whom I refer must seek enhanced subvention payments. Such payments are described by some as being at the discretion of the CEOs of the respective health boards. Patients are beginning to feel, however, that they are at the mercy of health board officials rather than their payments being at the discretion of those individuals. This is as a result of the difficulties they encounter in obtaining enhanced payments that are realistic in nature. I will provide an example of this later. The vast majority of patients in private nursing homes are paying in excess of €500 per week to retain their places there. That is a huge burden on the individuals involved and on their families.

We discussed this issue on Question Time two weeks ago. I referred to a patient in County Wexford with whom I am familiar who sold her house a number of years ago and used the proceeds to fund her stay in a nursing home. Her money was beginning to run out when she raised the issue with me last November. I tried to make contact with the local health board and with officials throughout the region on her behalf. The best response we received was the woman in question would receive an enhanced payment of €80 per week. This was despite the fact that she paid approximately €600 per week for her nursing home place. When I raised the matter on Question Time, the health board miraculously arrived at a solution last week and the woman will be given a bed in a public nursing home.

What happened in the case to which I refer is disgraceful for a number of reasons. I would hate to think that the woman in question's continued long-term nursing home care had anything to do with political intervention. One of the major problems with our health service is that too many of the services it offers are at the discretion of people who should not possess that type of power in the first instance. The position as regards people's entitlements should be much clearer. I refer here not only to medical cards but to long-term care in institutions. Some of the provisions in the legislation will exacerbate the problems that exist or will, at least, return us to the bad old days when politicians had more to say about people's health care than did their doctors.

Concerns about the care of patients with dementia and Alzheimer's disease have been raised on numerous occasions. The Government is implementing a policy relating to the care of those with dementia. This was supposed to be put in place within seven years, commencing in 2002. I have not seen any major progress being made in respect of that policy, despite the fact that concerns about the two issues to which I refer are becoming more widespread. There is a major cost involved for families that try to pay for services on a private basis. Dementia and Alzheimer's patients are categorised as high dependency and require additional nursing care. This means, therefore, that there is an extra cost involved.

The Government is making extremely slow progress in respect of this matter. Most of the patients have seen nothing in terms of points four, five and six of the Tánaiste's magic ten-point plan to resolve the accident and emergency crisis. A great deal was made about the provision of 100 long-term residential beds, step-down facilities and respite facilities. Most of the patients to whom we are referring will see little benefit from the provisions in the plan. The Government needs to wake up to reality and deliver a much better service to elderly patients. All it is doing in this legislation is legalising a cock-up it made three to four years ago. The Government knew much more about this matter than has emerged to date and I am anxious to see what the Travers report will have to say in that regard.

The Minister of State referred earlier to the health strategy, which was the bible for Fianna Fáil during the most recent general election. National goal No. 2 of the strategy states "New legislation to provide for clear statutory provisions on entitlement will be introduced." The target date for this was 2002. No action has been taken on this goal in the past three years. It is easy to see why that is the case. When someone decided to examine the legislation, did they recognise that there was a problem vis-À-vis nursing home charges and a huge number of other issues on which the Government has not delivered?

While what is happening in terms of the provision of health services might be seen as the continuation of a form of political patronage into the 21st century, in some respects it might also be seen as evidence of the Government's incompetence. Perhaps the Government behaves as it does because it is afraid to make any difficult decisions for fear that this will cost it votes. Services are being denied to patients and there is, therefore, clear guidelines and legislation. I refer here to the legislation promised since 2002, which must to be delivered. The Minister of State referred to a nine-point plan and the fact that a number of sub-groups are considering this matter at present. How long will those sub-groups continue to meet before we see real action in terms of people's entitlements?

It is sad that the Tánaiste is not present because I would like to ask her where she stands in terms of a policy to fund the care of the elderly in the future. There is major uncertainty and insecurity in respect of this matter at present. We have broached this subject on a number of occasions in the Dáil in recent months but, again, no clear answers have been offered in respect of it. The Minister of State made an important point on a recent Question Time when he stated that if a person's house is worth in excess of €75,000, this would be taken into consideration as means when he or she is seeking subvention payments in respect of private nursing home care. He stated earlier that he does not understand why a person who owns a house worth more than €1 million should receive support from the State. Where does the Minister of State stand as regards the grey area in terms of houses worth between €75,000 and €1 million? At what point does the Government believe someone's private house should be considered as part of his or her means?

The Tánaiste got into a hell of an amount of hot water when, at a conference in 2003, she stated that a person's private home should be considered as means when he or she is seeking a nursing home subvention. The Government has completely fudged this issue since 2002. Another of its objectives in the health strategy was that, by the end of 2002, it would publish a policy on funding of the care of the elderly into the future. I understand that a number of submissions on that matter were made to the Department of Health and Children and that a policy was drawn up but that, for some reason, the Government has not seen fit to publish it. Even though the position is being regularised and we are making it legal to take money from elderly patients in nursing homes, the Government has done nothing to inform those who are 55 years or older who may wish to avail of these services in the future exactly what will be their entitlements.

It is the responsibility of Government to make decisions and I am surprised this Administration is sitting on the issue and making no progress on it. I am of the opinion that a large number of members of the Cabinet — both Fianna Fáil and Progressive Democrats Ministers — want to take family homes from elderly people to pay for their long-term care but that for some reason they are hedging their bets and refusing to make a decision on the matter. That failure to make a decision is probably holding back a number of other initiatives and this should be made clear to the people. Funding for care of the elderly into the future will become a massive issue within the next decade. It is time for action and not hedging one's bets. The Government must come clean on this matter in the near future.

I wish now to deal with the issue of doctor-only medical cards. I am disappointed with the Government's handling of this issue. I promoted the granting of such cards before the Tánaiste announced their creation in the Estimates. I stated that we should immediately introduce a system involving such medical cards because I have seen the difficulties that arise in general practice. A number of patients do not receive the services to which they are entitled because of the cost involved in delivering them. Some mothers will not bring their children to see a doctor because of that cost. The solution to it was that people could get a professional opinion that would help to relieve the anxiety as to whether they were genuinely sick or it was just a viral illness that did not require further treatment. We are now approaching the month of March and not one doctor-only medical card has been issued. Not only that, 10,000 standard medical cards have been withdrawn since the announcement was made in the Estimates that 30,000 more were promised. That is not a proper reflection on the Minister's commitment to the health services and especially to the people concerned.

The Minister of State pointed out in his speech that the Department was going to deliver medical cards to patients on grounds of need rather than on the basis of percentage of the population. That is the Fine Gael position, as the Minister of State knows. We feel it they should be extended to 40% of the population. It is going to be done on the basis of what people should receive. However, nothing has been delivered and instead medical cards have been taken away since the announcement was made. It should never have been introduced as the permanent solution to this problem, merely as a temporary solution.

The Minister has now introduced a third tier to the health care services. This will work out badly in the long term for the patients involved. My concern is how the medical card scheme is administered in tandem with the provision of health care to people who are dependent on the State. For instance, full eligibility is based on financial hardship but allows a certain discretion on medical grounds by a health board chief executive officer. A percentage of medical cards are supposed to be issued on a discretionary basis by the CEO based on the medical needs of patients rather than financial criteria. I welcome those initiatives and support them, but they still have the potential for abuse. However, there has not been much abuse of this kind within general practice, although doctors know that some people with medical cards are not entitled to them. It may be that such people did not fill in the forms honestly, but one cannot be 100% certain whether such cards are issued on the basis of who they know rather than what they need.

However, the doctor-only medical card uses the term "unduly burdensome", which is a lesser test than financial hardship. Going back to the health strategy, the Minister promised to reduce the ambiguity over entitlement to services. This term, "unduly burdensome", may be interpreted in a number of different ways by health board officials in different regions. That means the problems we had with the old health boards, where services were different throughout the country, will continue. Some people in a given area were able to get enhanced subventions of up to €500 a week while in other places they could only get up to €300. It is a distortion of what people throughout the country may get. There is no level playing field when terms such as that are introduced. More problems are being introduced with this legislation than are being dealt with.

It is vital that entitlement to any public service is clear-cut. That is where the legislation from 2002 is coming from. We must get rid of any semblance of grace and favour from the public service system, whether it is health care or public authority housing. Grace and favour means that people are more dependent on the politician or public officials than on the laws of the land and what they are legally entitled to. This legislation makes no great improvement on that. I detect a discretionary element creeping in which is more or less going back to putting people at the mercy of officials.

It might be worthwhile to offer a short history lesson on this issue. The Tánaiste likes to go back to 1970 when she talks about the issue of nursing home charges. Prior to 1970, the dispensary system was in operation where a doctor was hired in a local parish and patients considered too poor to pay were allowed to go to the dispensary medical practitioner. Patients got access to the dispensary doctor by getting either a green or a red ticket from the local politician. The green ticket entitled them to go to the doctor in the surgery whereas the red ticket entitled them to house calls. The reason the system was got rid of was that it was wide open to abuse and political cronyism, where people who were connected got the red ticket for house calls but those who were not only got the green and were told to go the surgery. So much of what is now being done goes back to that old system of basic abuse. I wish the Minister, in going to the trouble of doing all this, had cleared up that system to a greater degree.

Some of the points scoring against the Opposition indicated in the Minister of State's speech suggests that children with illnesses will not have to renew their medical cards. I have recently encountered a constituent with an adult family member who has intellectual disabilities and is entitled to a medical card. That medical card used to last for about two years at a time and the family is now getting renewal forms every six months for it, even though the person concerned is an adult with intellectual disabilities and there will be no change in personal circumstances in the next six or 12 months or even two years. Doctors see this system creeping into general practice as well where cards are being given for shorter periods. Perhaps the health boards hope that in some cases patients will not renew their cards, will not have the ability to do so or will be too intimidated.

Such issues regarding primary and elderly care are constantly being raised in this House. The Minister of State's speech appears to indicate that much is being done in this regard but in fact it is very little.

This legislation seems to have been thoroughly vetted from a legal viewpoint so that a referral to the Supreme Court will not be warranted and we will not be debating it again in the House in two months' time. Perhaps the reason the Minister of State is present is because the Tánaiste does not want to have to face into this again. Section 1(b) of the Bill, which amends section 45 of the Health Act 1970, states in respect of a spouse: "including the means of the spouse, if any, of that person, in addition to the person's own means". Perhaps the Minister of State should ask a constitutional lawyer to have a look at that because it might be considered to be an unconstitutional attack on marriage. Perhaps the Minister of State could clarify this in case he has to return to the House in two months and start all over again with a third version of this Bill.

See this speech in context