Jerry Buttimer (Cork South Central, Fine Gael) | Oireachtas source

I live in the real world where I deal with people every day of the week. I welcome the fact that 93% of those aged over 70 will have a medical card or a GP-only card. I agree it is difficult to have probity with regard to medical cards. However, Members of this House are legislators and as such we must make difficult decisions in the interests of our nation, of our citizens and of our country. It is a case of responsible people framing policy and these decisions are not made in isolation but rather the basis for these decisions must be considered.

I refer to the Health Act 1970 which established the criteria for eligibility to access medical services. Section 45 provides:

A person in either of the following categories shall have full eligibility for the services under this Part---

(a) adult persons unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their dependants,

The section also ensures that a person's overall financial situation is taken into account.

This is the current system and it is based upon income and hardship, that is, based on a means test and on discretion. We are all politicians and we meet people regularly. I remind Deputy Collins that we do not live in bubbles, we live in the real world. We realise that people need a system to be flexible and to exercise discretion rather than being rigid and inflexible. However, neither should eligibility be based solely on income because the health needs of individuals must be recognised at all times. As a society we should ask whether it is appropriate that outside of income assessment, the only other way to get full eligibility for health services is through the exercise of discretion. From what I can determine, there are very few clear guidelines as to how discretion is exercised. At times there is no clear rationale for decisions and no way to scrutinise decisions.

Why has the system been allowed to develop and continue? It can be traced back to fundamental characteristics of our political system, such as clientilism and patronage. One could go further and say that the system of discretion facilitated the wink and nod approach in political life. At one time, discretion created a situation where direct political influence could affect a decision and could put the deciding officers in the invidious position of exercising discretion over applications from people known to them. Discretion must always play a part in the awarding of medical cards, taking into account the totality of the situation in a household and the medical and social circumstances.

Administration of the medical card system has been centralised and the political element of the decision-making process has been removed while still allowing for that discretion which is now exercised in a central office by a medical officer but it is difficult to assess the exercise of that discretion. This uncertainty is also causing concern. I welcome the HSE's commitment given to Members at a briefing today and at the health committee that it will communicate clearly its decisions with regard to medical cards. The staff in the PCRS are working within the legislative guidelines and they are wonderful people, as are all our public servants working in the health sector. However, the centralised processing means there is one method and application of the rules for assessing eligibility which applies equally in Cork as in Donegal, in Wexford as in Tallaght. That is the way it should be. There is one uniform approach but it must be done humanely and with a degree of flexibility rather than being applied rigidly. When the system has moved away from the practice of political clientilism I ask whether the discretionary basis should be so wide. We should be considering a reform of the legislative basis of the system which is the Health Act 1970. Is it time to revise the criteria for making decisions? Should the Health Act be amended to allow for a clinical diagnosis to be a reason for accessing services? These changes pose difficulties and they cannot be implemented overnight but they would result in a fundamental change in how decisions are made and how access and entitlement are determined.

Members opposite who criticise the Minister for Health should take note that he is a reforming Minister who is prepared to take on the slow artic that is the Department of Health and the HSE in order to change the health services for the better. I describe it as being akin to turning a tanker which cannot be turned full circle in one manoeuvre. This Minister has been in office for two and a half years. He is turning the ship and he is getting there.

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