Alex White (Dublin South, Labour) | Oireachtas source

I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"notes that:

-- there has been no change to the manner in which discretionary medical cards are awarded;

-- there is no target set in the Health Service Executive (HSE) National Service Plan to reduce the number of discretionary medical cards;

-- of the 24,000 reduction in discretionary medical cards from the start of 2011 to July 2013 almost 23,000 of these persons have been awarded medical cards on the basis of their financial means;

-- the HSE has produced National Assessment Guidelines to provide a clear framework to assist in making reasonable, consistent and equitable decisions when assessing applicants;

-- these guidelines facilitate the application of discretion by decision makers in responding to the needs of the applicant when additional or exceptional circumstances exist;

-- the Health Act 1970 (as amended) provides that persons who 'are unable without undue-hardship to arrange general practitioner' services for themselves and their family qualify for a medical card;

-- in accordance with the Health Act 1970 (as amended), the assessment for a medical card must 'have regard to the overall financial situation' of an applicant and dependants; and

-- the centralisation of the processing of medical cards at a national level, rather than at a local level as was the case before mid-2011, facilitates the assessment of applicants for medical cards in a consistent and equitable manner;

commends the Minister for Health for directing the HSE to set up a clinical panel to assist in the processing of applications for discretionary medical cards, where there are difficult personal circumstances;

further notes that:

-- between mid-March 2011 and end-August 2013, the number of individuals who had eligibility to a medical card increased by 214,244 (13 per cent) to 1,863,062; and

-- the HSE is facing significant challenges in 2013 and in 2014 given the need to set expenditure levels within the parameters of the National Recovery Plan; and

acknowledges:

-- the significant reductions in financial and staffing resources which the health sector has experienced over the last three years; and

-- the range of measures being actively progressed by the HSE to manage its financial resources to ensure that services are provided to persons entitled to receive them; and

commends:

-- the Minister for Health and the Government for providing resources to meet the increase of over 200,000 medical cards since March 2011;

-- the Minister for the passing of legislation to abolish restrictions on general practitioners wishing to become contractors under the medical card scheme;

-- the Minister on the implementation of legislation to achieve savings under the medical card scheme through the use of generic drugs and reference pricing; and

-- the Minister on the savings being made in the cost of drugs for the medical card scheme through negotiations with pharmaceutical drug suppliers."

Deputy Kelleher commenced his contribution by talking about what he described as a policy of withdrawal of discretionary medical cards. He made some reference to it having been announced in the budget last year. I wonder whether either this evening or tomorrow Deputy Kelleher could draw our attention to where it says in the Budget Statement that a policy of withdrawal of discretionary medical cards is being announced or introduced. The motion does not simply imply or suggest but baldly states that the HSE has set a "target" for 2013 to reduce the number of discretionary medical cards. It goes on to say that what it describes as "this deliberate targeting" was approved by the Minister for Health in the 2013 HSE service plan. I would respectfully ask Deputy Kelleher, through the Chair, to draw our attention to where he finds authority in the HSE service plan or budget statement last year for such an alleged targeting. In the absence of Deputy Kelleher doing so, I must put on the record of the House that I must and do reject the contention in the motion that there is a deliberate targeting of holders of discretionary medical cards. I must say that in the absence of any evidence that would bear out this very stark allegation, this contention is false and without foundation. I want to make it clear that there is no "target" to reduce discretionary medical cards in the HSE national service plan for 2013 and neither, I assure the House, is it Government policy.

The Deputies and the motion refer to the reducing number of cards awarded on a discretionary basis. Information from the HSE indicates that there has been a reduction of about 24,000 in the number of discretionary medical cards between the start of 2011 and July 2013. Of these, almost 23,000 have been awarded medical cards on the basis of their means assessment so that they have not, in fact, lost their medical cards. A total of 23,000 out of the 24,000 who no longer have medical cards on the basis of the discretionary approach have medical cards on the basis of their means assessment. Therefore, they retain the medical card. The number of people who hold medical cards on discretionary grounds has fallen in recent years largely because more people who previously were marginally over the normal qualifying limit became eligible for medical cards under the normal scales. I am not saying that this encompasses everybody about whom Deputy Kelleher is talking but it encompasses a huge number.

Contrary to the suggestion that we are targeting people who need our support, this Government has provided funding to ensure an additional 220,000 people are now covered by the General Medical Services scheme since it entered office. The suggestion that there is a tactic to reduce medical cards for budgetary purposes is fatally undermined by the fact that an additional 220,000 people are covered through the GMS scheme. This means that over 43% of the national population currently has access to GP services without any charges under the GMS scheme. That comprises 40.6% with the full medical card and 2.7% with GP visit cards.

I can confirm that there has been no change to the qualifying criteria for discretionary medical cards in the past year and that the scheme continues to operate in such a way that those who suffer genuine financial hardship as a result of a medical condition receive the benefit of a medical card, as they should. I acknowledge that the number of discretionary cards has fallen from the beginning of 2011 to July 2013. This is evident from the publicly available statistics but it has occurred for the reasons I have stated and not as a consequence of some kind of so-called mission on the part of the Government to extract medical cards from those who are entitled to them.

As the Deputies will be aware, under the provisions of the Health Act 1970, as amended, persons who are unable, without undue hardship, to arrange a general practitioner service for themselves or their family qualify for a medical card. In accordance with the legislation, the assessment for a medical card is determined primarily by reference to the means, including the income and expenditure, of the applicant and his or her partner and dependants. Under the legislation, the HSE is responsible for assessing an individual's entitlement to a medical card and a GP visit card. Specifically, section 45(1) provides that adult persons who, in the opinion of the HSE, are unable, without due hardship, to arrange general practitioner medical and surgical services for themselves and their dependents are deemed to be persons with full eligibility. Under Section 45(2), the HSE is obliged in deciding on an individual's eligibility to have regard to the person's overall financial situation, including the means of the spouse, if any, in view of the reasonable expenditure in respect of himself or herself and his or her dependants. The Deputies will also be aware that different criteria apply for assessment for eligibility for a medical card for those persons aged 70 years and over. Assessment is on a gross income basis, as provided for under section 45A of the 1970 Act.

Medical card processing is now carried out centrally with single national governance and a central office location replacing the 100 different locations that existed in the past. Customer service processes, assessment of applications and reviews, correspondence and the consideration of discretion are standardised and operated in a fair and equitable manner. The medical card scheme is now underpinned by a stronger foundation, which enables better governance, more transparency and efficient modern processes.

The PCRS of the HSE oversees the medical card scheme and has a target to process 90% of medical card applications within 15 working days. These turnaround times are now published online on a weekly basis atwww.medicalcard.ie. In practice, almost 95% of applications are processed within the 15 day target. Medical card applications are considered on the basis of an assessment of the applicant's means by reference to the HSE national assessment guidelines and national income guidelines. Where a person's income is within the income guidelines, a medical card or GP visit card will be granted for three years in most cases.

However, and this is the nub of the issue this evening, the HSE has discretion to grant a medical card where a person's income exceeds the income guidelines. The discretion must be exercised by the HSE but the fundamental provision in the 1970 Act is that a person is assessed on the basis of undue hardship in arranging a GP service, as well as his or her means. I will come back to this later on if I have time but a Member opposite referred to one of the cases that were raised by Members, all of which I am sure are absolutely genuine. The Member referred to a case where somebody had a medical card on medical grounds. There is no such thing in our system. Perhaps there should be and perhaps we should have a debate about it. I am quite happy to have a debate about it but the system that has obtained since 1970, over which the Deputy's party opposite presided for most of that period, certainly two thirds of it, does not and never has awarded a medical card to somebody on the basis of a medical condition.

There is no such thing as what one speaker referred to as a medical card on medical grounds. Nobody acting on behalf of The HSE has the authority of this House to grant a medical card other than on the basis of the 1970 Act. We might all have views on whether that Act should be amended but until such time as that occurs it remains the law. Nobody, including Ministers, can act outside the law. In fairness to Deputy Kelleher, he accepts this.

These are all difficult cases and no Member of this House would make light of the human circumstances described by Deputies during this debate. Deputy Seán Fleming referred to circumstances in which individuals with cancer always get medical cards. Is it being proposed that a person with cancer should automatically receive a medical card irrespective of his or her income or circumstances? I do not criticise anybody for making such a proposal but it would entail a fundamental change to our law. If that is what is being proposed, let us debate it.

Social and medical issues are taken into account when determining whether undue hardship exists for the individual concerned in accessing GP or other medical services. Discretion will be applied automatically during the processing of an application where additional information has been provided by the applicant which can be considered by staff or a medical officer, where appropriate. Once a full assessment of an application or a review is completed a letter issues to the applicant advising of the decision. If a review of an application is assessed as ineligible or eligible for a GP visit card only the letter informing the applicant of this decision will include an explanation of how the application was assessed and the details of the means assessment calculated on the application. Applicants will be advised that they can request a review of the HSE decision if they believe their financial or other circumstances have not been correctly assessed. They will also be requested to provide any additional relevant information or details of any change in circumstances since their original application. In addition, the letter will notify the applicant of the option to appeal the decision and the contact details of the appeals office.

Where applicants submit an application without any additional medical documentation and are refused, they will receive a letter giving a calculation of the guideline thresholds and where these have been exceeded. At this stage, they are informed of the option to furnish further medical documentation to support the application. If applicants finish medical evidence at either initial stage or following a refusal, and where discretion has been used, they are informed of the decision of the medical officer. Once again, the letter will notify the applicant of the option to appeal the decision and the contact details of the appeals office. Additional information that can be used for consideration on a discretionary basis, following receipt of a letter indicating an unsuccessful application, includes illness or medical circumstances which results in financial hardship; the cost of providing general medical and surgical services; the cost associated with the provision of medical, nursing and dental treatment; and the cost of medical aids and appliances.

At the direction of the Minister for Health, the HSE set up a panel of specialist medical professionals to assist in the processing of applications for discretionary medical cards where a person exceeds the income guidelines but is facing difficult personal circumstances, such as an illness. These community medical officers, CMOs, apply discretion within the guidelines to determine if the applicant is suffering from hardship, review and interpret medical information provided on a confidential basis and provide reassurance to the medical profession and the public regarding the safeguarding of patient-doctor confidentiality. They liaise with general practitioners, hospital consultants and other health professionals as appropriate so as to determine the health needs of the applicant and his or her family. They advise on the granting of discretionary medical cards to an applicant and his or her family on the basis of the guidelines. They also work closely with staff in the PCRS and contribute to the ongoing development and delivery of an equitable, efficient and streamlined medical card application process nationally.

Medical card eligibility provided either on the basis of means or where discretion is involved is identical and provides access to exactly the same set of health services. More people than ever before have medical card eligibility. It now stands at almost 41% of the population. Furthermore, over 43% of the national population currently has access to GP services without any fees under the general medical scheme.

Deputy Seán Fleming quoted the Taoiseach on the emergency medical card system. The HSE has a system in place for the provision of emergency medical cards awarded on a discretionary basis. The Taoiseach must have been referring to this system. These cards are provided to patients who are seriously ill and in urgent need of medical care that they cannot afford. Emergency medical cards are issued by the HSE within 24 hours of receipt of the required patient details and the letter of confirmation of the condition from a doctor or a medical consultant. Deputy Browne referred to an end of life situation in which an individual was waiting for an emergency medical card to be issued. That sort of situation should not arise. I can provide my colleagues with further details on emergency medical cards and the circumstances in which they should be issued.

The processes I have outlined for consideration for a medical card on a discretionary basis clearly demonstrate that every effort is made to assist, support and facilitate both new applicants and those under review. The opportunity to provide additional information in support of an application is afforded to an individual following refusal on means assessment basis and the avenue for appeal is also advised. I am aware suggestions have been made in the public domain in recent months that the criteria for awarding discretionary medical cards had changed. I emphasise that there has been no change to the qualifying criteria for discretionary medical cards in the last year.

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