Mary Harney (Dublin Mid West, Progressive Democrats)

The contributions reminded me of the Second Stage debate. Although the Deputies opposite had some of their amendments ruled out of order, they managed to talk to the subject of those amendments. Perhaps I can address some of the issues raised.

In regard to Deputy Twomey's amendment, I agree it is important to have clear policy directions on long-term care and issues around the elderly. We have the Mercer and the O'Shea reports on nursing home subvention. We have an aging population and each year 12,000 more people reach the age of 65 and 1,500 more people reach the age of 80. Over the next 20 years, with expected trends, the demographic profile of our population will change quite dramatically. Clearly, immigration will play a part in perhaps addressing some of the imbalance but there will be a lot more older people.

I am a strong fan of care in the home and the community. It is the wish of the majority of older people to remain in their own homes, or certainly in their own communities, for as long as they can. Many of the long-term care issues must deal with housing related issues as well. The traditional family home in urban environments is not conducive to somebody who has become partially disabled. The two storey home with the conventional bathroom is not suitable for people who might be wheelchair bound or who suffer from certain mobility issues. In other countries, there is much thinking on this particular subject. I recently met some people from the United Kingdom who are involved in the planning of new housing developments not specifically for elderly people but which will incorporate adaptation more easily than the traditional home.

The Government is anxious to bring some certainty to the issues involved. Many of the strategies have dealt with these but I suppose because of other pressures, we have not been able to resolve some of the outstanding problems in this area — mainly the financing ones. How do we finance long-term care into the future in the context of demographic changes? The Minister for Social and Family Affairs, the Minister for Finance, the Minister of State, Deputy Sean Power, and I held a meeting in January with senior officials on this issue. We have put together a group of officials to report back to us by the summer so we can bring finality and certainty to this issue from a policy perspective. It is certain that unless we know the road map, we will not make the right decisions.

The creation of the Health Service Executive — a unified system nationally — will bring uniformity to some of the issues raised by the Deputies opposite. In a country of four million people, it should be clear what citizens are entitled to as far as support is concerned, yet it varies a lot while market conditions change from one place to another. It is more expensive in some places to access nursing home accommodation than in others. Even if that is discounted, there are huge discrepancies. Although it is not easy from a financing perspective — we spend approximately €1.2 billion annually in this area — to find the resources required, we must at least have uniformity countrywide.

The same applies to another issue I want to address, that is, the medical card issue and the concept of hardship enshrined in legislation. A medical card is given at the discretion of the CEO of the health board but when discretion is given to a large number of people, there are differences in interpretation. Again, we need greater uniformity in this area. I have already spoken to the HSE and it is intended to have further discussions. Already approximately 70,000 people have medical cards on this basis.

Deputy Ó Caoláin suggested that medical rather than financial need should be the criterion on which a medical card was granted. There is some merit in that perspective. Some have medical cards on the basis of medical need. We recently made a decision that chronically ill children who have a medical card by virtue of their illness should not have to reapply each year to have the card renewed because their illness is such that they are not going to recover. The idea of placing the burden and sometimes trauma on their families of applying for the renewal of the medical card is unnecessary and not desirable. Measures are being implemented in this regard.

I have a problem with somebody who is very rich and has an illness, perhaps a minor one but one nonetheless that requires ongoing medication, having a medical card while somebody who is less well off has not, unless one accepts the principle of universal application. I do not support it.

I am a strong fan of making choices and having priorities. If we were to give everyone a conventional medical card, it would cost approximately €4 billion a year. The full medical card, if I may use that term, costs approximately €1,000 a year. It is in order to extend at least the doctor part to the widest number within the resources available that we decided to introduce this new concept of the doctor only card. I am conscious that many people, particularly families with young children, may often need only a doctor's reassurance. It may not be necessary subsequently to get medication. Deputies Twomey and Cowley would know more about this than I. Perhaps one third of those who visit the doctor do not require a prescription or medication. The idea that parents in less well off circumstances should have access to a doctor without worrying about the cost, particularly where children are concerned, is one I support. That is why we have introduced this new concept.

I agree that it is always better to have graduated benefit than to have a severe cut-off point whereby if all the criteria are met, one gets full benefit but if one is just above the threshold, one gets nothing. There is a band in the middle and that is what this provides for. Obviously, it is decided on income grounds. It is difficult to get accurate income data in Ireland because incomes are rising very fast. In the past it was easy to predict what it would cost if the threshold were increased by 7.5%, which has been done in respect of the conventional card, and by 25% in respect of the new card. One could estimate accurately the number who would benefit. Because incomes are changing quite rapidly and the method of calculating who is entitled to the medical card, rent or mortgage allowance, the cost of travel to work, the number of children and so on, it is a complicated task to have a fairer system. I would love to be able to have a global figure but that might militate against those in particular circumstances, particularly if a mortgage, high rent or a big travel to work bill is concerned in the case of those who must travel long distances.

We estimate, based on the data available from Revenue and Indecon, that 200,000 people will qualify on the basis of the new threshold to which we have agreed. If there are not 200,000, we will further adjust the threshold. Perhaps we are sometimes conservative regarding where we set the threshold but we are setting it based on income, not numbers. It is not a case of deciding we must have a certain number of medical cards. We are trying to move along an income route in which those who earn a certain income and are in certain circumstances should qualify for the doctor only or conventional card. If our income data are wrong, I will be more than happy to adjust the threshold later this year because we have €60 million assigned for the additional cards.

It is intended that the cards will be issued during the month of April. Originally we thought that legislation would not be necessary. Subsequently it proved it was necessary. In the light of what has happened recently, we must be cautious and conservative and at least have the law right rather than take a chance with all of the consequences of doing so.

Deputy Neville referred to the various grants to assist people to stay in their own homes. I had some discussion with the Minister for the Environment, Heritage and Local Government recently. He informed me that if one were entitled to a disabled person's grant of €8,000 to adapt one's home, it would cost approximately the same in bureaucracy to provide the grant. That seems crazy and the Minister intends examining the whole area of grants to make it much easier. We have a very complicated system under which one must get at least three quotations and ensure the applicants are tax compliant. In addition, in our society when people see that a grant is involved, an additional premium is demanded. In the meantime one must wait a long time for anything to happen. For the relatively small amount it costs to take out a bath and put in a shower that is wheelchair friendly, people should not have to go through this plethora of bureaucracy. The Minister for the Environment, Heritage and Local Government is examining this whole issue. The grant could play a very important part in helping people to stay in their own homes and be given subject perhaps to certification by a geriatrician that the adaptations are needed.

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