Cecilia Keaveney (Donegal North East, Fianna Fail)

I am delighted to be able make a brief contribution on the Bill, the purpose of which is twofold. It seeks to provide a framework to charge patients for the maintenance element of inpatient services and publicly funded long-term care residential units and to facilitate the introduction of general practitioner medical cards. Since I entered the House, I have pursued the introduction of something which is more than a medical card. Rightly or wrongly, medical cards have become more than a way for a person to see a doctor and obtain medicine. They are associated with everything in the system, including free examinations in schools. People often direct at public representatives comments to the effect that they cannot take up work because they will lose their medical cards if they do. The medical card has so many implications beyond health that there is a need to create more tiers in the provision of available services.

If I were Minister, I would consider creating cards for services at stages between doctor visits and the entitlements of a full medical card. For example, a person with an income exceeding the threshold by a certain amount should receive ten free doctor visits and ten free prescriptions per year. At another income level, a person should receive five free visits and five free prescriptions. While there will always be people who fall outside whatever categories are established, an approach like the one outlined would greatly advantage those who are not regular visitors to their doctor but would find some provision valuable. I would like to think that the proposed general practitioner cards represent an initial point on a journey to a different form of provision. I noted in the Minister's speech a reference to a review of the system after a certain period to ascertain its operation for the 200,000 card holders. As no Member would describe the medical card income limits as generous, the 25% increase represents a necessary starting point. Many people have great needs which relate not only to health but to associated factors.

Visiting a doctor should be as much about prevention as treating illness. I was astonished to discover at a recent briefing in Buswells Hotel at which the Irish Cancer Society informed Members about cervical smears that medical cards do not cover prevention. It is an issue which needs to be examined. It is much cheaper to intervene early to stop something from happening than it is to treat it afterwards. At the Joint Committee on Arts, Sport, Tourism, Community, Rural and Gaeltacht Affairs, of which I am Chairman, we discuss the issue of obesity. If one addresses such matters early, one will not have to spend significant sums later. The concept that a medical card can be used to provide only treatment in an age in which so much knowledge of prevention exists is outdated. Prevention should be top of the list.

As I was a student in Belfast, I am called for smear testing every two years. Despite my Donegal address and attempts to encourage the practice in question to accept that I am no longer a patient, I continue to receive the communication. I imagine there is a legal requirement to continue to inform me that the practice is available to perform a smear test. It is very comforting to think that someone is watching out for people and calling them for testing rather than leaving matters in their hands. It was recently said that if one did not have to take one's car to the car testing centre, one would not do it. It is because one gets a letter that one attends, despite that the test is provided ultimately for one's safety.

It is important to find out if something is wrong before it becomes a problem that can kill. The faster we create screening programmes which call people for tests, the better. Such programmes should include cervical smears, breast examinations and tests for male cancers, including prostate cancer, which kill just as many people per year as their female counterparts. While I acknowledge that there are cost implications in extending the medical card system, I implore the Tánaiste and her officials to consider the long-term gains rather than the short-term pains. As with the smoking ban, any short-term pain such as expenditure on medical cards is bound to yield a preventative result.

Previously, the Minister discussed the efforts of successive Governments to keep older people at home or within their communities in residential care. There have been tremendous advances in primary care provision in my area. I attended another briefing recently at which a group sought to promote a holistic approach to primary care. When I asked them what could be done to improve services in the north west, they had to apologise and say that if they had realised I was from the region, they would have told me how proactive the former North Western Health Board had been in improving services.

Many people want to help people to stay at home, but there are simple problems. A few months ago, a constituent of mine was assessed for a home subvention which was approved. The family has not received any support to this day. None of them is particularly wealthy and every one of them is involved in activity. Some of them are students and some of them work. However, they are doing their best to keep the show on the road. They could easily have told their father they were going to leave him in a home or in one of the hospitals, but they chose not to because they wanted to deal with the matter themselves. However, they need a break and a bit of support. Spending months trying to get home subvention is not in keeping with what is said about the policy of trying to help keep older people in their own location.

I wish Ms Gertie Monagle, the former matron of Carndonagh Community Hospital, well in her retirement and wish her replacement, Ms Maura Gillen, every success. She said her goal is to ensure that people coming to the hospital live until they die. One hopes this is the goal in many district hospitals. In Ms Gillen's case, Carndonagh's gain will be Buncrana's loss. However, she is in the area and will make sweeping changes.

There is a question whether money should have been taken in the past, but this Bill will ensure that money is taken in future. It is important that money will be applied exclusively to the health services and will not go back into the general Exchequer. The Minister said earlier that it is part of health funding and should be maintained in that area because it is needed there.

The new doctor visitor medical card will attempt to target 200,000 people. There are adjustments in the income guidelines in respect of standard medical cards, and changes will help 30,000 people qualify for the standard medical card. Perhaps there could be a certain number of free prescriptions or doctor visits for people who fall just outside the general guidelines.

I welcome the new provisions for parents of children with illnesses which persist from year to year. This is a new concept and I hope it will help the vast number of people who need it. The provisions mean that they will not need to reapply for the medical card every year. I know many people affected by this and, unfortunately, the children will never get better. Until medical science advances significantly, the types of conditions they have will not improve, yet they are subjected to medical card income reviews. These are not even based on income but on medical evidence. I am glad the system is being changed.

The Bill refers to a small number of children with serious illnesses who will be involved. The number will not be very small, but neither will it be very large. I have come across people who, at a very young age, have degenerative rheumatoid arthritis. At the age of 20 they have to get two hips or possibly an elbow replaced, yet they must prove every year that they have a problem with their health. I do not understand this situation. They have a serious medical condition and a doctor can reasonably state they will not get better. It is similar to disability benefit in that somebody whose case is solid and whose situation will never substantially change should not have to go on to a scheme to prove him or herself for a year. Perhaps we are being optimistic in thinking that something might change.

I have a problem with the drugs payment scheme increasing considerably because for many of the people to whom I refer, the prescription might be the bother. Some people try to be clever or prudent by going at the start of the month to get their medication and then again on the very last day of the month to get the next month's supply. The pharmacist tells them they cannot do that and must come back tomorrow and pay another €85. I am unsure of the standard procedure in this regard. Is the pharmacist right or is the individual right in trying to maximise what he or she gets in the month? I would like the matter clarified at a later date.

A figure for gross income might suggest that a household earns a great deal of money. What if the spouse does not get a fraction of that money? Often a spouse can have a medical problem but may not be in a position to go to the doctor because he or she does not get a fair share of the money coming into the household. I know of cases where people are living on very meagre weekly allowances and must save to get the money to go to the doctor. We should be aware of genuine cases, flexibility should be maintained with regard to welfare officers and people must realise that sometimes such shocking situations exist.

I was trying to attain a broader modernisation agenda with regard to medical cards. Section 4 of the Bill deals with those who are exempt, a person's reasonable expenses needs are taken into account in the application of section 45, and the issue of undue hardship is reflected in that.

We have potentially one of the best health systems in the north west. The hospital in Letterkenny constantly strives to have more facilities and is achieving more specialties. It is also achieving great birth rates because the population in Letterkenny has increased by 42%. Hospital facilities, however, have not expanded to meet population needs or the ageing profile of the demography or the new specialties which need space. However, we have one of the most committed staff in the country, if not Europe.

I raised this issue on the Adjournment debate last week. This is not bed blocking or a case that one hears of in another part of the country where people are crying wolf. These are genuine facts backed up by statistics. Thirty thousand people cannot go through an accident and emergency department with only six bays. People referred by general practitioners and in need of inpatient terms of stay cannot be dealt with without support for the accident and emergency unit — which is being progressed — and providing a significant number of new beds. There is no viable reason for a delay. We can talk about the need for money, but if the statistics and facts are irrefutable, the matter must be progressed.

A nursing unit in Buncrana needs simple stuff such as tarmac in the car park, PVC windows, fascia board and work on the main entrance. Given that an application has been made to the minor capital works scheme, that will happen. With regard to the hospital in Carndonagh, I hope the extension to the dining area, the day hospital, the required painting and decorating and the tarring will proceed.

The Tánaiste should speak to the Minister of State, Deputy Noel Ahern, with regard to voluntary housing schemes where volunteers develop a number of sheltered housing locations. In some cases, particularly at district hospitals, people are fit to leave hospital but their families are not in a position to deal with them. However, with a little support, these people would be able to live on their own. There should be a move between the Departments of Health and Children and Environment, Heritage and Local Government to ensure sheltered accommodation for people who are fit to leave hospital. It would be worthwhile if they could move into sheltered accommodation with either a nurse or a caretaker to oversee them and ensure they are in safe hands.

The BreastCheck service and a breast surgeon are needed for Letterkenny.

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