Seán Ryan (Dublin North, Labour)

I propose to share time with Deputy Upton.

This Bill is typical of the careless and possibly even negligent approach the Department of Health and Children takes in respect of people's rights and entitlements to health care. It deals with two issues, namely, entitlement to a "mini" or "yellow pack" medical card and the way in which long-stay charges will operate in future. As we know from the shocking saga that unfolded in recent months, these two issues are closely linked.

I wish to deal first with the matter of long-stay charges. The Tánaiste is basically proposing to reintroduce those aspects of the ill-fated Health (Amendment) (No. 2) Bill 2004 which the Supreme Court found were not unconstitutional. That Bill was put through the House in a disgracefully short time. There is no reason for a similar approach to be taken in respect of the legislation before us. There is also no reason to simply reintroduce the same provisions. We have an opportunity, of which we should avail, to improve on them. The main proposal is that people entering long-stay care should be charged a maximum of 80% of their old age pension. We cannot decide if this is fair and equitable until we know who is entitled to such care.

The proposed arrangements for charging will mean an old person whose only income is a social welfare pension will pay the same as someone who has another source of income or possesses private means. The majority of people who enter public long-stay care only have their basic pension. However, the right to avail of public long-stay care is, in theory at least, available to everyone. There are not nearly enough places to cater for this need. There is no legal provision for a means test to obtain access to such care. The assessment is supposed to be on the basis of need of care. As is usual in the health service, the conditions regarding entitlement are not at all clear and the health boards, even though they are obliged to do so under the Freedom of Information Acts, have failed to publish information about the conditions attached.

Before we can decide what is a fair and equitable regime for charging people for care, we should know who is entitled to avail of that care. The Bill should deal with that entitlement and then proceed to deal with charging. The Government is refusing to deal with the basic entitlement because to do so would mean it would be obliged to acknowledge what we all know, namely, that the only people entitled to public long-stay care are those on very low incomes. Not even all of those to whom I refer are in a position to access this care. The failure to clarify entitlements led to the current difficulties arising. The continuing failure to do so can only lead to further problems in the future.

On the specific issue of how charges are to be assessed, it is not acceptable to grant an older person access to only 20% of their old age pension. An older person in care should be able to buy items such as clothing, a few drinks, cigarettes, sweets or presents for their grandchildren. Is this too much for them to expect? They should be able to access at least 25% of their pensions for this purpose.

There are older people in need of long-term care in public facilities in areas of Dublin who are facing a waiting period of up to 12.5 years. That is a ridiculous situation and it should not be allowed to continue. Many elderly people are being forced to remain at home and rely on family support at a time when community care and home help services are being cut back. In addition, hundreds of acute hospital beds are being occupied by elderly people who do not require that level of care and this means that those who need a hospital bed are forced to wait even longer. This is happening at a time when beds are available in private nursing homes. The Tánaiste has made some progress on this matter. However, the level of that progress has not been sufficient. I accept that older people would prefer to live in their home environments. In circumstances, however, where they must enter care, it is totally unacceptable that they should be obliged to wait up to 12.5 years to do so. The waiting period to which I refer is a fact; not a figment of my imagination.

The charging arrangements will not only apply to older people, they will also apply to those with intellectual disabilities in long-stay care and to those with mental illnesses who are voluntary patients in such care. Many of these will be receiving disability allowance which is considerably less than the old age pension. Recipients of disability allowance could be left with about €18 if the maximum charge is applied. This is totally unacceptable. Some disability allowance recipients are only in care for five days a week. How are they expected to survive for the other two days?

The Tánaiste will probably say this is the maximum, but the legislation should ensure that everyone affected can retain at least 25% of his or her payment. The Tánaiste will probably say she intends to do that by regulation, but these guidelines should be included in the primary legislation. We have had enough trouble over regulations in this area in the past. Unless the entitlement to retain a minimum income is in the primary legislation, the people concerned will be dependent on the discretion of the Health Service Executive not to apply the maximum charge. That is totally unacceptable. Certain matters ought not to be subject to the discretion of the Government or its agencies and one of these is the right to a basic level of income. While the exercise of discretion may be appropriate in some cases, the record of the health boards in applying discretionary provisions was abysmal, to say the least. They effectively avoided exercising their statutory discretion in the awarding of medical cards and allowed the Department of Health and Children to decide who should get them. Perhaps the HSE will take a different view, but somehow I doubt it.

There are other problems which this legislation does not address. The practice of taking pension books from long-stay residents should stop immediately. The residents should have control over their money and pay the charges which are levied in the same way as every other service user does. The legislation does not deal with the difficult issues which arise in the case of people who are unable to manage their own money. The arrangements by the Department of Social and Family Affairs for agents to deal with pensions are just not good enough. They do not respect the dignity and autonomy of individual older people and the agents are not subject to any form of supervision as regards how they use that money. This is a major concern.

The Bill proposes some minor changes to entitlements to a medical card — the "real" medical card. The legislation does not address the problems which have been identified in several reports on this matter. It was interesting to hear the Tánaiste in her contribution make reference to the fact that nobody in this House was expounding the right of medical cards for all. She was trying to wash her hands as regards the commitment given by this Fianna Fáil-PD Government prior to the last general election when it promised to extend medical card eligibility to an additional 200,000 on low incomes. The reality is that medical card cover has fallen by 100,000 since the general election.

See this speech in context