Alex White (Dublin South, Labour) | Oireachtas source

He made a very good speech and I will deal with it if I get a chance.

Under Section 45(2) of the Act 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 on him or herself and his or her dependants. Different criteria apply for assessment of eligibility for a medical card for those persons aged 70 years and over. That assessment is on a gross income basis. A person over 70 does have the option of choosing the net income assessment, should he or she wish not to be assessed on the gross income basis.

The HSE has discretion to grant a medical card where a person's income exceeds the income guidelines. This discretion must be exercised by the HSE in accordance with the legislation. The fundamental provision in the 1970 Act, however, is that a person is assessed on the basis of undue hardship in arranging a GP service having regard to his or her means. In that context, the HSE takes into consideration social and medical issues when determining whether undue hardship exists for the individual 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. Several Deputies have asked about the extent to which a person is told when he or she applies that he or she can or should submit further information in respect of medical expenses. While an applicant may be denied eligibility for a medical or GP visit card, if the person has referred to a medical condition which is causing undue hardship a medical officer may review his or her eligibility, if the person's GP completes a medical report which is furnished together with a prepaid envelope.

Having completed a full assessment of an application or review, a letter issues to the applicant advising of the decision thereon. If a review is assessed as ineligible or eligible for a GP visit card only, the letter issued 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. If this is not happening I want to know about it. Some people have interpreted what I have said as meaning that the Minister has a role in deciding on the merits of individual applications. The Minister has no role in this regard. If I am wrong when I state in this House what happens or should happen in the mechanics of an application, and solemnly say that I am advised by the HSE this or that process is applied, and if somebody can give examples of my being wrong I want it drawn to my attention. I will then immediately draw it to the attention of the HSE that something we say happens in the mechanics of applications is, in fact, not happening. I have taken these points up when Deputies have raised them.

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 also informed of the option to furnish further medical documentation to support their application.

Additional information can be used for consideration on a discretionary basis, following receipt of a letter indicating an unsuccessful application. Additional information that may be relevant to the exercise of discretion includes illness or medical circumstances which result in financial hardship; the cost of providing general medical and surgical services; the cost associated with the provision of medical, nursing and dental treatment; or the cost of medical aids and appliances. Where discretion is exercised with regard to an applicant with an illness or disease, it is the effect of reasonable expenditure related to that condition on a person's financial situation that is relevant.

The processing of medical cards at a national level, rather than at a local level as was the case before mid-2011, ensures that all people are assessed in a similar and fair manner when applying for a medical card, irrespective of where an applicant lives. Concerns have been raised in this House that an individual may or may not, or would be more likely to, get a medical card depending on where he or she lived. I listened to what Deputy Colreavy said about this and must respectfully disagree with the impression he gave that it was in some way acceptable. I do not think it is at all acceptable. We all would share the view that everyone should be treated in the same fair and consistent manner. I have seen figures relating to early 2013 showing that some counties, such as Cork, Limerick and Tipperary, at one stage had three or four times the proportion of discretionary medical cards per head of population compared to other counties, such as Louth or Meath. In previous years, there was a local assessment process, which, although it might be seen as desirable from one point of view, actually led to there being real inequities throughout the country. Bluntly, it meant that a person may have been awarded a discretionary medical card in one part of the country that he or she would not have obtained in another because of the lack of a centralised standardised approach.

That said, I acknowledge that the transition to a nationally consistent standard system of assessment has caused difficulty at renewal stage for households with incomes above the HSE threshold, even where an illness or disability is involved. Shortly after the introduction of the new system the Minister for Health, Deputy Reilly, requested the HSE to set up a clinical panel to assist in the processing of applications for discretionary medical cards, where income guidelines have been exceeded, but where difficult personal circumstances exist, such as an illness that would affect a person's financial circumstances.

In addition, at the behest of the Minister, the HSE is examining how individuals, who are not entitled to a medical card, could still receive services that meet their needs. This issue is being addressed in a manner that includes all of the services and supports provided by the HSE, with as much flexibility as possible, and at a local level. Notwithstanding what Deputy Colreavy said, it is a very real and important opportunity for people to be able to access services in circumstances where they perhaps no longer have the medical card but although in some cases they are above the income limits, even substantially so, they still need access to services for themselves or their child. We must move the system forward to ensure we provide that and put in place protocols for quick access to services that people need in their communities where they have a medical condition or illness.

It is intended that improvements will be made, and it has been brought to my attention that they are needed, to the level and extent of information published by the HSE and local information points will be established at major health centres around the country, where members of the public can obtain comprehensive information and support in accessing their full range of supports and entitlements from the health services. I have seen examples of cases where people with a medical card who lost their eligibility were entitled to the long-term illness, LTI, scheme but were not aware of that. It is not acceptable that a person would be coldly refused continued eligibility to a medical card where it is not drawn to their attention, or there is not some way of their knowing, that they could have access to the LTI scheme, which could cover their medications, equipment, medical devices and other services that they need. Appropriate notice is also being considered as part of this review for existing medical card holders who may no longer be eligible on renewal but where serious medical conditions or disability continues to exist. In that way people would have a decent level of notice where eligibility has been found not to exist. The Government is fully aware of the difficulties that arise for persons who are deemed ineligible, particularly after a period where they have held a medical card.

As the House will be aware, one of the key goals of the reform of our health system is to ensure that people receive health care according to their particular needs, rather than based on their income. It is an anachronistic and inappropriate basis for a 21st century health system and it is far from any comparable modern health system in any other European country where we continue to assess people on the basis of their means to determine their eligibility to access health services. It seems essential that we move towards a health system that is based on universality of access. The concept of eligibility has been amended by legislation passed by the Oireachtas in 1991 and 2005 and the House did not depart from the principle of means testing in terms of access to health services. One result has been that the means based legislative framework has produced a very complicated eligibility system, with all of the difficulties, anomalies and contradictions that exist throughout our system.

Some members have criticised the bureaucracy involved in the system and Deputy Colreavy referred to the forms required to be completed. Others have said to forget about the forms, that the humanity of the situation should always win through. However, as legislators, we must also have regard to the fact that we should have clear entitlements. People should be clear on what their entitlements are and they should be either entitled or not entitled to a particular service. It should not be the case that people have to come begging or go to politicians to make a personalised case to be treated as an exemption. Their entitlements should be clear and they should be consistent across the country. We do not have that type of system. The only way we will achieve that is by working together in order to create the kind of reformed health system that we need where we have proper equality of access for all our citizens based on need and not based on their income.

It has been suggested - though perhaps not in this House - that in the meantime we should consider moving from eligibility based on means to a system where people are eligible on the basis of their having a particular medical condition. I have thought long and hard about this, as I am aware other Members have. On the face of it, it is clearly right that if one has an illness one should be able to access the health service. That is what we want and what I passionately believe - as I think we all do - we need to achieve in terms of the reform of the heath system, but we cannot simply shoehorn the new system into the old one. We have to continue to manage the existing system fairly and transparently while moving as quickly as we can to introduce a new system. We are trying to do two things at the one time. If we were to try to replace in the interim our current inadequate system with an illness based system, that would have very significant unintended consequences that we would need to address. The first question that comes to mind is which illnesses or conditions should enable a person to access health services and which should not? Our immediate reaction to that question would be "any and all illnesses". Which of us will be the first to stand up and say "we would exclude a particular illness or condition"? Would eligibility extend for the duration of an illness or condition or once a person had that illness or condition would they retain their medical card permanently? How would we choose one illness over another? Would we be acting in an arbitrary manner or excessively impairing the right to equal treatment? How would we even define an illness? It has become more difficult in the modern age sometimes to define a disease or an illness. Would we set clinical criteria in the legislation or leave it open to medical practitioners or the HSE to interpret? Similarly, who would determine if those criteria or conditions w;ere met? Would we rely on the opinion of a GP, who would be placed in the invidious position of determining if his or her patient can use the health system while at the same time potentially benefiting financially from that decision? There are many examples of anomalies that would arise in that situation which I do not believe would bring about the fair and transparent system that we want to have.

On the issue of constitutional rights covered in the motion, I strongly believe we should have robust constitutional rights but the allocation of resources, particularly to the health area, is a political question and there are political differences as to how best to allocate resources. We could place rights in the Constitution but we as politicians would still have to argue and resolve in this House how best to allocate resources. Even the argument between universality and another system is a political issue that requires to be resolved, as does the issue of resources and how much we allocate to health versus other areas of public expenditure.

I agree that our system is not fit for purpose, as Deputy Ellis said. We need to work together to reform and change it. There is much that we could discuss on this issue but I want to hand over to Deputy Barry.

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