Cecilia Keaveney (Donegal North East, Fianna Fail)
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I acknowledge the importance of the doctor-only medical card but in the context of the broader modernisation agenda which the Minister spoke of yesterday we might consider the concept of, for example, ten free doctor visits and ten free prescriptions, or five of each, for those at different levels of income so that there is a broader modernisation agenda than just having the medical card or having nothing.

I am glad the Tánaiste is here this morning as I wish to raise the issue of the medical card being used for prevention rather than just for treatment. It is important that screening programmes, for example, cervical smear tests, and BreastCheck are extended to the north west and nationally. The point made by the Irish Cancer Society that the medical card is not available for prevention and for screening needs to be addressed.

While the Tánaiste is here, I again ask her to consider the need for beds in Letterkenny General Hospital. The situation there should not be one of "bed-blocking". There has been a substantial population increase of 42% in the area, accompanied by a demography of aging people, so that these beds are a necessity and in no sense a luxury for the people of the north west. Since the Executive is unlikely to be up and running and the North-South Ministerial Council will not meet in the near future, I ask the Tánaiste what we can do in the meantime to ensure that North-South co-operation will continue between Letterkenny and Derry. Without the North-South Ministerial Council and the Executive, many of the health issues which can be dealt with at a cross-Border level are not being given sufficient priority.

There is a critical mass between Derry and Donegal which means that services missing in Derry can be provided in Donegal and vice versa. For example, there is a very good breast screening programme up and running in Derry and cervical smears undertaken on people in Donegal are being examined in Derry. Is there anything the Tánaiste can do to ensure that, in the absence of the Executive and the North-South Ministerial Council, the health issues in the north west which are dealt with in Northern Ireland will be addressed. There is a very good track record of Altnagelvin Hospital and Letterkenny General Hospital working together. We need BreastCheck and all the other services, as well as beds for Letterkenny General Hospital. I welcome the concept of the doctor-only medical cards.

Dan Neville (Limerick West, Fine Gael)
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I am glad of the opportunity to discuss the Bill. I welcome the Tánaiste to the House and I look forward to her contribution.

The Bill deals with the Supreme Court decision on charges made to the elderly and doctor-only medical cards. Had it not been for the work of the Fine Gael leader, Deputy Kenny, and Deputy Perry, the issue of the illegality of charging elderly people in nursing homes would never have been raised. The Government has argued that the illegality goes back to 1976. The Supreme Court decision suggests that the illegality became much clearer after the passage of the 2001 Act, which was brought in as part of the Government's pre-election spree and the implications of which were not fully thought out. The Comptroller and Auditor General's report of 2001 revealed that the decision on the over-70s medical card was taken by the Department of Finance in the days before the 2001 budget with little or no consultation with the Department of Health and Children.

There is evidence that following enactment of the 2001 Act, the Southern Health Board provided the Department of Health and Children with legal advice it had received on long-stay care. The then Minister, Deputy Martin, referred to this legal document in an interview, claiming he did not read it, while the Tánaiste referred to it in the Dáil.

The issue of the over-70s medical card and charges in public nursing homes was raised at a high level meeting attended in December 2003 by the then Minister, Deputy Martin, the Minister of State, Deputy Callely, who at the time had responsibility for the elderly, and the Minister of State, Deputy Tim O'Malley. The minutes of that meeting show that long-stay charges for the over-70s were discussed. This is clear evidence that the Health Act 2001 which introduced the over-70s medical card was considered a problem in terms of long-stay charges. The then Minister, Deputy Martin, claimed to have left the meeting when the issue was being discussed, but the two Ministers of State at the Department remained. We are aware of what has been discussed in the Dáil on several occasions regarding the information received by the Ministers of State, if the Minister was not there. That information and the minutes of the meeting, which were only two pages long, were put on the record of the House by the Tánaiste.

People on non-contributory pensions will receive repayment and their means will be assessed against those pensions. In other words, old age non-contributory pensioners in public nursing homes will be penalised because Health Service Executive will refund the moneys perhaps to their bank accounts and if the income of pensioners goes over the threshold of €20,000 as a result, their pensions will be reduced. The Department of Social and Family Affairs will claw back the moneys which the State has refunded to those pensioners.

In a response to Deputy Stanton, the Department pointed out that it has collected €5.4 million from pensioners' wills in 2004 and the same amount in 2003. That is an aside, but the point is that pensioners with no other income or assets above the means threshold who choose to save their pensions and the moneys they will now receive will be penalised when they go above the threshold. The Department of Social and Family Affairs will interpret the refund as means, treating it similar to assets from property and inheritance when assessing means. Elderly people are legally obliged to inform the Department of Social and Family if their means change so that their pensions can be reviewed. They sign up to this when they apply for non-contributory pensions. The upcoming refunds should not be included as assets in the assessment of the means of those in receipt of the non-contributory pension or other payments such as the disability allowance. What is the position of people with intellectual disabilities or those in similar categories? Will they be means tested if they receive a refund? I ask the Minister to take that issue on board

A number of years ago, I dealt with the case of a medical card holder who needed incontinence wear. The person was admitted to a private nursing home and the refund for incontinence wear was withdrawn. The issue was taken up with the health board at the time, which refused to make a refund or to recognise that there was an anomaly. The anomaly was that incontinence pads were not covered where medical card holders were admitted to private nursing homes. However, prior to admission, they were covered. Following numerous representations to, and pressure on, the Department and the Mid-Western Health Board, the position changed in April 2003.

Medical card holders charged for incontinence wear in private nursing homes prior to April 2003 should be refunded. It is discriminatory to refund medical card holders availing of public beds. One of the criteria for not refunding the cost of incontinence wear in private nursing homes is entitlement to nursing home subvention. If an elderly person is in receipt of nursing home subvention, he or she is entitled to a refund. The position is contradictory and unfair. If this issue was examined as thoroughly as the issue of illegal charging, it would also be found to be illegal. Will the Minister comment on this in her reply?

Earlier the Irish Wheelchair Association made a submission to the Oireachtas Joint Committee on Health and Children. Its representatives raised an important issue relating to medical cards for people with disabilities. They pointed out that wheelchair users, in particular, and others with limited mobility face additional costs associated with specialist products such as mobility and communications aid and additional expenditure on specialist transport, heating and so on. Despite the additional costs, their medical card threshold is the same as that for non-disabled people. This leads to people with disabilities not attending doctors when ill, resulting in late diagnosis of their conditions. Will the new medical card address this issue, given the new guidelines regarding what can be considered in individual cases other than means?

The association's representatives also referred to the benefit trap faced by people with disabilities. They are dissuaded from taking up employment but they made a number of recommendations. The income limit for medical card eligibility should be increased significantly for people with physical disabilities while, under the back to work initiative, medical card entitlement should be extended to five years for people with disabilities. The transfer of entitlement to aids and appliances to a cost of disability payment should not be affected by employment.

I have raised other issues relating to the elderly on a number of occasions. I refer to the Minister's examination of the housing aid for the elderly scheme and her discussions with the Department of the Environment, Heritage and Local Government. This issue raises its head regularly in our constituency clinics. Elderly people wait for years for simple work to be done to their houses to enable them to live in comfort when they have needs due to their age. The disabled person's grant scheme is operated by local authorises but that has been brought into disrepute recently, although my experiences with Limerick County Council have been positive.

However, the same cannot be said of the housing aid for the elderly scheme and its objectives. When the Bill was introduced to abolish the health boards, the Minister was emphatic that the issue of representations by public representatives would be recognised as part of the change from health boards to the Health Service Executive. I made a representation on behalf of an elderly person living alone on 4 March 2003 and I outlined the reasons he needed work done to his house. This need was recognised by the health board and the community welfare officer who examined the case. However, following two years of frustration I tabled a parliamentary question to the Minister to find out when the work would be done. The question was passed on to the Health Service Executive and I received a reply, which stated, "I wish to confirm that an application for housing aid is at present with the housing aid department in Limerick and they are awaiting final input into the process from the relevant services". For the past two years the case has been with the Limerick health services but I want to know what action is planned. Having not obtained the information locally, the Minister directed the question to the Health Service Executive. I am now told it is with the housing aid department in Limerick, something that I have known for two years. Surely the Tánaiste and Minister for Health and Children must accept that it flies in the face of her commitment to the House, especially on Committee Stage of the previous health Bill regarding the abolition of the health boards.

Regarding the elderly and nursing homes, there is obviously growing pressure because of the needs of our aging population. There are inadequate resources in the public sector to deal with the demand for nursing home services from people with limited means. The area needs considerable examination to ensure people who are elderly and need inpatient or nursing home care are treated with dignity and respect in examining their situation.

There are a few matters that I wish to raise, the first being the subvention, which has not been examined for the best part of four years. It is an obvious statement, but it is worth saying that the cost of nursing homes has increased dramatically, having more than doubled in the past four years. The nursing home subvention element has not increased to match it, and that is putting enormous pressure on families and especially the residents themselves. We now have people in need of nursing homes whose families are considering social housing for them because of the pressures. There must be a review of the nursing home subvention payment which, as we were informed this week, averages €150 per week. In the context of nursing homes costing more than €600 per week, that is inadequate.

I also wish to raise the issue of the enhanced, top-up nursing home subvention. The disparity between areas in that regard is totally unacceptable. It is approximately €50 in the mid-west, while in the former Eastern Health Board area it is €650. How can one justify such a disparity in the enhanced nursing home subvention payment? It is paid after all aspects of a person's circumstances have been examined and it becomes quite obvious that there is a serious financial issue involved which determines that an enhanced nursing home subvention should be paid by the regional health executive.

We must introduce clarity and equality to the area. If the Tánaiste and Minister for Health and Children says to me that in certain areas of the country nursing homes are much more expensive than in others, that is a fair argument. We need transparent information to show why the rates should be different, but there is no such information or analysis. It is done on an ad hoc basis in each health board area. If, as it now transpires, the disparity between nursing home costs is not as pronounced as some years ago, with prices for many nursing homes across the country reaching the levels found in the former Eastern Health Board area, there is a need for a full and comprehensive examination of subventions and payments for the different categories, including the basic and enhanced payments.

I would like to raise the repayments of moneys to those illegally charged in nursing homes. I will deal with one area for the purpose of illustration and leave those who are psychiatrically ill and perhaps long-term in-patients. I understand — I hope the Minister will correct me if I am wrong — that a person must claim for the repayment that he or she is owed by filling in and signing forms. Some might not be aware of that or competent to do so. The State has an onus and legal responsibility to repay the moneys owed to everyone. If I have moneys and owe someone, I have a restitutive responsibility to repay him or her.

I would appreciate the Tánaiste explaining the procedure for making the payments. If it is a form-filling exercise, those more informed and able will be in a position to avail themselves of their rights, but those whom I have mentioned, who have a disability, including an intellectual one, or are in long-term psychiatric care, will be less likely to claim and receive their entitlements.

I would also like to quote from Age and Opportunity regarding how we approach age, ageism and the elderly:

Focusing on aging as representing a constellation of problems that require interventions ignores older people's own resilience in the face of difficulties and their own capacity with proper resources for organising themselves and devising their own solutions at the individual and collective level.

We miss out on that where the dignity of elderly people is interfered with. Someone is ill in a hospital and there is a decision to make because he or she can no longer live in the community and must go to a public or private nursing or welfare home. There is a debate between the consultants, the family and the hospital ward, but the elderly person is not often consulted. The quotation concerns the need to ensure the elderly are consulted and recognised rather than disregarded as an adjunct to a problem; that should not happen.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I am pleased to commend this short Bill to the House. It has two purposes, to put reasonable charges for long-stay care on a legal basis and to provide hundreds of thousands of people on low incomes with the opportunity to visit their GPs without worrying about the cost.

Both purposes are guided by the single key principle that there should be legal clarity regarding public services and charges. Members of the public, patients and their families deserve no less. It is not tolerable that people, particularly vulnerable people and those suffering from ill health, should be uncertain of whether they qualify for a service, or whether and how much they should have to contribute towards the cost. People working in our health services can do a professional public service job if they operate in an environment of legal clarity.

In an increasingly litigious society, legal uncertainty is tested and exploited in many ways that are, to say the least, not always in the public interest. The cost to the public and taxpayer of achieving legal clarity is highest when it comes from protracted and repeated litigation. The cost is lowest when it comes from coherent policy, meticulous law-making and professional public administration.

That is why the Government welcomed the clarity provided by the recent decision of the Supreme Court about past charges for public long-stay places. I do not intend to dwell on the points I made when the House debated that decision two weeks ago. I will just say that this Bill stems from the Government's determination to provide legal clarity in the interests of patients, their families, taxpayers and better public administration.

On the repayment of past charges, the Government is working on a scheme of repayments that will be efficient, user-friendly and as automatic as possible. There are many practical and legal issues to be worked out in handling the repayments. It is important that people keep firmly in mind that the Supreme Court has found that repayments should be made and that the Government fully accepts that. The Supreme Court has decided there is no need now for people to go to another court. I assure Deputies that persons who were being charged need not employ a solicitor to get what they are owed. I look forward to bringing details of the repayment scheme to the House as soon as possible.

We could all agree that the full context for the repayments issue will only be known when the report by Mr. John Travers is available. It makes little sense to debate that report in advance of it being completed, let alone published. I expect to receive the report tomorrow and I will bring it quickly to the Government next Tuesday and to the House, as I have already indicated.

On some of the points made by Deputy Neville, the intention is that where we can identify people we will pay them their moneys. It will not be a question of making applications and so on. In the case of deceased persons, somebody will have to prove that they were the representative of that person. For those who are alive but of unsound mind, and as I have already indicated publicly, the Statute of Limitations cannot be applied to people of unsound mind. My view would be that we would identify those persons and repay their moneys.

This is a mammoth task for the State. We have never engaged in an exercise of this kind before in terms of the scale. We will need some outside expertise, perhaps even from outside the country, to help us with the task because in other jurisdictions people have handled mass claims in the past and they would have a good deal of experience. That could be of invaluable assistance to the Government. When the Travers report is to hand, hopefully tomorrow, we will be in a better position to indicate the nature of any scheme we will introduce, the timeframes and so on.

My colleague, the Minister of State, Deputy Seán Power, opened the debate with a detailed description of the main provisions of the Bill. I would like to concentrate on the policies behind it. There is close to all-party consensus in the House that it is reasonable that people in public long-term stay places should make some contribution, where possible, to living costs or shelter and maintenance. That policy has been in place here for almost 50 years. That consensus is clear, given that the policy was implemented by successive Governments and Ministers for Health, albeit on a legally flawed basis, for the past 29 years. It is also clear from public debate and debates in this House in the past three months that most people accept it is fair to require a reasonable amount to be contributed, considering especially that older people living at home must meet their living expenses from their pensions.

I was pleased that the constitutionality of legislating for these charges going forward was fully tested in the Supreme Court and was found by the court to be constitutional. For example, the court stated: "In authorising the Minister to impose charges on the specified category of person, the Oireachtas clearly intended that the resources of the Health Boards would benefit so as to better enable them to provide the services in question while at the same time seeking to avoid doing so in a manner which would cause undue hardship."

The court further stated:

The level at which charges can be fixed by the Minister is narrow in scope ranging from a nominal charge to 80% of the pension ... It was clearly the intention of the Oireachtas that any charges would not cause undue hardship generally or in individual cases and no doubt that is why it fixed the maximum charge at 80% of the pension.

It was useful that the court recognised the importance of this source of funding for health services, which is in the order of €2 million to €2.5 million per week. I have heard suggestions from the Opposition, however, that section 1 of the Bill may be unconstitutional. I am obliged to accept the advice of the Attorney General's office on this legislation, and we believe the Bill is constitutional. Ultimately, Bills are tested in the Supreme Court, perhaps under an Article 26 reference, which is what happened with the Bill we passed before Christmas, or in particular circumstances.

Section 1 refers to the Health Service Executive taking into account a person's overall financial situation, including the means of a spouse, in making a decision on eligibility for a medical card. Yesterday, the Minister of State, Deputy Seán Power, set out the reasons for this provision in the Bill. It reflects existing law, policy and practice and is based on long-standing constitutional principles that recognise the obligation of one spouse to support another. It is not unconstitutional.

Again, for the purposes of clarity I inform the House that I intend to bring forward an amendment in the Bill on Committee Stage to repeal section 140 of the Social Welfare (Consolidation) Act 1993. This is to prevent anomalous charges being raised through other legislation which are not in line with the exemptions provided for in the Bill now before the House. This will secure the exemption from charges of those persons involuntarily detained in mental hospitals and it is necessary to ensure consistency in this regard in future.

The provisions of the Bill on long-term stay charges are clear and unambiguous. The Bill is being brought forward in the light of the positive decision of the Supreme Court on exactly similar provisions in the 2004 Bill.

I am pleased also to use this Bill to propose to the House section 4 providing for new medical cards to make general practitioner services free for many thousands of people. This is an innovation for social justice and for the effective use of public resources. For many years, we all shared a concern that people on very low income should not be deterred from visiting their GP on cost grounds. In particular, we have agreed that parents should not be deterred on cost grounds from bringing their children to their GP. The Government is now acting to address those concerns.

The traditional medial card will continue to be held by 85% of medical card holders but with this policy, the same budget allows us to provide four times as many people with free access to their GP than with the traditional medical card. There are no industrial relations, administrative or legal barriers to doing that once we have passed this legislation. All we need is this short legislation amending primary legislation to establish a legal basis for doing so. If, as I hope, the legislation is approved by the Oireachtas this month, the Health Service Executive will be in a position to issue the new medical cards in April.

The policy of the Government is clear. We are providing the resources to fund these new cards. We are bringing forward the legislation to underpin the new cards. We want to see people taking up the new cards. We want people to visit their doctor and bring their children to the doctor as often as needed.

I intend to monitor closely the uptake of the new cards to ensure that the many thousands of people to whom we wish to give cards apply for and receive them. As Deputies will be aware, income guidelines are set for the Health Service Executive for eligibility for medical cards of both categories. These income guidelines are set on the basis of the best and latest information available on incomes and expenditure in the population. The income guidelines for new medical cards are 25% higher than for the traditional medical card.

It remains difficult, however, to set any income guidelines based on historic data to achieve an exact number of people to be covered prospectively. If we find significantly fewer people than expected take up the new cards because incomes are growing faster than we anticipate, we will revise the guidelines.

We are providing the budget, the administration and now the legislation so there is no barrier to the policy being implemented. The Government wants to make it easy for people to apply for these cards and to use them. I know the HSE will do all it can to ensure that happens, including constructive discussions with the Irish Medical Organisation on implementation.

Providing GP cover to many thousands more people in this way is effective social justice. We are providing graduated benefits according to income. It is much better that State benefits are not "all or nothing". We know from our experience of reducing unemployment how important it is, for social justice reasons as much as anything else, to avoid poverty traps. Graduated benefits are a fair and effective way to help people at different levels of income.

We are using scarce public resources to help those who need help, not those who can ably provide for themselves. The alternative to channelling resources to people most in need is "one for everyone in the audience". I do not agree with that. To give everybody a medical card, at an average of approximately €1,000 a year, would cost an extra €3 billion over and above the current position. I have not heard any party openly propose tax increases of €3 billion to pay for medical cards for all, and I doubt I will ever hear it from parties who are serious about being in Government.

The policy of the Government is based on a coherent and integrated view of economic and social progress. The new medical card is one innovation within the strategy and I hope it will stand the test of time for many thousands of people in the years ahead.

Deputy Neville raised a number of matters in connection with the Health Service Executive. The executive has only been in existence for two months and does not yet have its full cohort of staff. It is intended that it will have a fully resourced public affairs division to deal with public representatives. I have spoken to the acting CEO and the chairman and they are anxious to establish the division as soon as possible. It is hoped it will be up and running, if not before the summer then shortly thereafter. As regards a role for public representatives at regional level, we will progress that matter as soon as possible.

I intend to pursue many of the issues — incontinence pads etc. — to which Deputy Neville referred. I will reflect on what were people's entitlements and communicate further with the Deputy. We cannot have a situation where, in respect of people who require institutional care, particularly in the private sector, families will not be given support to allow them to care for elderly relatives at home. If a mistake was made in the past it was that too many of the resources went towards the institutional side and too few towards home or community support.

I hope the Government will be able to finalise its views and policy perspectives in respect of long-term care later in the year. Currently, 12,000 people reach the age of 65 and 1,500 reach the age of 80 every year. There will be major demographic issues for society going forward in terms of how it funds care of the elderly. Greater emphasis must be placed on community and family support because we could not afford, as a society, to fund institutional care for everyone. We must, therefore, have institutional care where it is necessary and unavoidable which will be supported but we must also give serious consideration to how we might support further activity in the community. Currently, the home care and home help systems are in place. The new home care package, which forms part of the overall A&E package, is a start in terms of trying to help people to remain at home with their families. That is when people do best in medical terms and are happiest. If they wish to remain at home, people deserve to be able to do so.

Seán Ryan (Dublin North, Labour)
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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.

John Browne (Wexford, Fianna Fail)
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Unlike the Deputy's Government.

Seán Ryan (Dublin North, Labour)
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I am not pulling the figures out of the air. This is according to figures given through parliamentary questions.

John Browne (Wexford, Fianna Fail)
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It is because so many people are working.

Seán Ryan (Dublin North, Labour)
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The Minister will say, of course, that people are becoming wealthier and that their incomes are increasing, putting them above the qualification threshold. This is utter balderdash.

David Stanton (Cork East, Fine Gael)
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It is balderdash.

Seán Ryan (Dublin North, Labour)
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Average industrial earnings are up 50% since 1997, while the income threshold for medical cards is up by 27%.

John Browne (Wexford, Fianna Fail)
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Balderdash.

Seán Ryan (Dublin North, Labour)
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The medical card qualifying threshold is not even keeping pace with earnings, which is part of the problem. These so-called "yellow packs" or doctor-only cards are a cop-out. They will only entitle people on low incomes to have free access to a general practitioner. They have little to offer the person who will be left with the cost of prescription drugs, a public hospital bed, out-patient services and other charges. The Government has promised 30,000 of these "yellow pack" cards, but not one has materialised so far. The legislation providing for them was only introduced in the Dáil this week.

The Minister of State at the Department of Health and Children, Deputy Seán Power, in his introduction said the "yellow pack" card quota would be increased for people who were 25% over the medical card income guideline. For a couple under the age of 66 the medical card income guideline is €222. Another 25% on that does not even reach the minimum wage level and there is no commitment to try to keep that in line with any of the guidelines being referred to, whether it is the increase in health costs, in the average industrial wage or basic social welfare payments. As matters stand, more and more people will be taken out of the medical card system. There is a perception that this is the first step towards doing away with what we would call the free medical card system. In this context, it is interesting to note the drop in medical card cover between 1997 and 2005 in all counties — Dublin, Wicklow, Laois, Longford, Offaly, Westmeath, Clare, Limerick, Tipperary North——

John Browne (Wexford, Fianna Fail)
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What about Wexford?

Seán Ryan (Dublin North, Labour)
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——Cavan, Louth, Meath——

John Browne (Wexford, Fianna Fail)
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The Deputy is on a tour of the country.

Seán Ryan (Dublin North, Labour)
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Indeed, the constituents of Meath will be made very well aware of the neglect and broken promises by this Government as regards medical cards. Monaghan, Donegal, Leitrim, Sligo, Carlow, Kilkenny, Waterford, Wexford, Cork, Kerry, Galway, Mayo and Roscommon all have seen a massive reduction in the number of medical card recipients in the period between 1997 and 2005. This is a cop-out and the Minister of State knows it. This legislation does not go far enough. I would like more time to deal with this matter.

Mary Upton (Dublin South Central, Labour)
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I thank Deputy Ryan for sharing time.

I want to concentrate on one issue that arises from the consequence of the lack of suitable and affordable care for elderly people, either at home or in nursing homes. The Minister will be aware of the Pollack report on cystic fibrosis, which was published recently. It was quite damning of the services and facilities that are provided for such patients. In particular, I would like to refer to a letter sent to me by a young man named Simon. He is 23 years old and he refers in his letter to Saint Vincent's hospital:

The ward which has been allocated to us is now being used for older men and women who are awaiting beds in old folks' homes and hospitals. Because of this, cystic fibrosis patients are suffering as we cannot get beds. At the moment, there are three six bed rooms for women and one six bed and one three bed room for men. Of these 27 beds, the majority are taken up by older men and women who do not suffer with cystic fibrosis, which is a life threatening illness. Some of these older patients can be on this ward for up to one year. Complaints have been made to our specialist team and we are told it is down to bed management and overcrowding at the hospitals, yet no one seems to be doing anything to alleviate this hardship being placed on cystic fibrosis patients. This problem has been going on for years at this hospital.

He goes on to refer to another ward, which he names:

I could not open a window due to the fact that I was put in with five elderly male patients and the heat was suffocating. This does not help me as a sufferer with an illness which is life threatening.

I quoted specifically from this letter because it refers to the fact that acute beds are being allocated, of necessity, to older people who should be in another environment, either at home, in the community or in a suitable nursing home. It is not fair either to those older people, who should be in a different environment. It is certainly not fair to the medical and nursing staff in that ward who are stretched to the absolute limit to deliver a quality service to all of the patients with very different needs. Most definitely, it is wrong that young patients suffering with cystic fibrosis are compromised and are susceptible to cross infections. Their lives are literally being put at risk due in part to being placed in inappropriate wards. This is because beds are taken up by older people who should be in a completely different environment.

In that hospital, a new wing has been built. I do not know the purpose of that new wing but it has been vacant for months and probably longer than that. Why is that part of the hospital unoccupied? If it were made available, there could be some rearrangement, relocation and alternative management that would allow a structure to be put in place to alleviate the situation. Older people could be moved to a different environment and beds freed up for acute patients which are urgently needed. It is not the fault of the elderly patients that they are taking up beds in these acute wards. The facilities available are so inappropriate and so undersubscribed for keeping people in the community and in their own homes that it is impossible for families to manage that. It is impossible for many elderly people to deal with the bureaucracy that surrounds accessing those facilities. While it is good that this issue is raised in the Bill, the Tánaiste should look very carefully at those facilities provided in the community, or the lack of them. There is a lack of home help and a shortage of grants for disabled persons and elderly people to allow them live in comfort in their own homes. This could free up facilities that should be available for acute patients.

Joe Callanan (Galway East, Fianna Fail)
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I support the Bill which provides for the introduction of doctor-only medical cards and the making of small deductions from the old age pensions of people in welfare homes.

I congratulate the Tánaiste on the introduction of doctor-only medical cards for people on incomes above the full medical card thresholds. The cards will facilitate free doctor visits for a significant number of families on low to medium incomes. The families will also be able to obtain free drugs above the €85 per month, or approximately €21 per week, threshold of the drugs refund scheme. Doctor-only medical cards are an aspect of a great scheme which is demonstrative of the way the Government looks after the less well-off who find it difficult to meet the cost of doctor visits.

I welcome the increase in the income thresholds for ordinary medical cards which will extend eligibility to a greater number of people. I ask the Tánaiste to examine the possibility of providing medical cards to all students. As she knows, students do not have much money in their pockets and doctor visits may prove costly for them. The former provision of medical cards to all students was discontinued by a Labour Party Minister.

I compliment the welfare homes in my area of east Galway on the excellent care they provide to patients. The Tánaiste visited St. Brendan's Home in Loughrea where she saw at first hand the quality of care provided. She witnessed the home's problematic upstairs accommodation and promised to give a high priority to the provision at the home of the very necessary 60-bed unit to relieve the dangerous conditions for parents who must stay at the building. The 60-bed unit and the community welfare home at Ballinasloe formed part of the national development plan and the plan for the former Western Health Board area. Ballinasloe has been promised a community welfare home for 20 years. Will the Tánaiste approve the projects to proceed? There is strong demand in Tuam for the provision of a community hospital. I recognise that the Tánaiste is considering various ways to provide it as a step-down facility to relieve the great pressure on Galway's two city hospitals.

A few night's ago, I attended a meeting of nursing home owners concerned at the level of subvention paid in the HSE's western area as against the level paid in the east coast area. A subvention of only €228 is paid in the west as opposed to €520 on the east coast. It is unfair as there is little difference between costs in each area. Will the Tánaiste consider the matter as some of the smaller nursing homes in the west find it very difficult to survive? I am strongly of the opinion that home-based subventions should be introduced to give elderly people the choice to remain in their homes for as long as possible. Given the choice, most elderly people would prefer to be cared for at home.

While I accept that changes in income disregards for carer's allowance have been of great help and I thank the Minister for Social and Family Affairs, Deputy Brennan, for them, many elderly people are not connected to a person eligible for the allowance to care for them. If such elderly persons were provided with home-based subvention, they could pay for the care to allow them to remain at home for as long as possible.

Social services do great work in caring for the elderly which is not properly recognised. In most cases, it is the work of social services which allows elderly people to remain at home through the provision of meals on wheels to remote areas and transport to centres for the elderly at which people can enjoy a hot meal and the company of friends in a social setting. Much of the work is carried out voluntarily. I acknowledge the work that is done for the elderly and call on the Tánaiste to provide as much funding as possible to social services. Last year, the then Minister, Deputy Martin, provided a new minibus for Portumna social services to transport older people from remote areas to centres for the elderly. It was a great addition to system. Under the direction of Sr. Alacoque, Ballinasloe social services make a significant contribution in my local area. I acknowledge also the great work being carried out by public health nurses who must provide services of all sorts when they visit patients. They are well able to do their jobs.

I ask the Tánaiste to clarify the position on refunds of charges for nursing home care for pensioners with medical cards who are or were in private nursing homes. Are they entitled to a refund? I take the opportunity to acknowledge the work of the previous Minister, Deputy Martin, for the health service. I voice my support for the Tánaiste in her efforts to provide quality health services for young and old. While it is a difficult task, a good woman, born in Ballinasloe, is well able for the challenge.

Seán Crowe (Dublin South West, Sinn Fein)
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I wish to share time with Deputies Finian McGrath, McHugh and Gormley.

Through this Bill, the Government is acting swiftly to ensure that long-stay patients in residential care who can be charged in the wake of the Supreme Court judgment will now be charged without further delay. The Government states it has lost €2 million per week in payments since the charges were found to be illegal and it has been very quick to clear up this part of the equation, but we are still in the dark regarding many other matters. What about the money lost to people who were wrongly charged? How will they be reimbursed?

My office has been inundated with queries from families with elderly relatives in nursing homes. The common denominators are words such as "hardship", "difficulty" and "small income". It might be a small amount but it represents a huge difference in quality of life for people in nursing homes. These families want to know what their position is now and what they must do to receive their entitlements. The helpline established by the Health Service Executive seems constantly engaged. The Government must do much more to inform people and must make hard decisions as soon as possible about how people will be repaid the money that was taken from them illegally.

The Dáil has not been given the information by the Government. The Minister for Health and Children said the Government got legal advice as far back as 1978 stating that the legal basis of the charges was not sound. This is an amazing admission and a damning indictment of successive Governments. The Minister should publish the advice from 1978 given to her predecessors, as well as the 80-page legal opinion sent by the South Eastern Health Board to the Department in 2002. Why did her predecessors, since 1978, including the Minister, Deputy Martin, not act? The Oireachtas and, more importantly, the public and relatives of the elderly have a right to know.

The second part of the Bill implements the Government decision to introduce the GP-only medical card. This was announced in November and, with the Estimates and budget, flagged as one of the great initiatives of the new caring, sharing coalition. I welcome the extension of the entitlement to free GP services to more people. Sinn Féin has called and campaigned for this, a fact about which my constituency colleague, Deputy O'Connor, should have no doubt. However, I question the attempt to present this as a fulfilment of the promise made by Fianna Fáil and the Progressive Democrats before the 2002 general election.

It does not fulfil that promise for two reasons. First, these are second-class medical cards which have been described as "yellow pack" and not the real thing and certainly not of the same quality. They only cover GP visits and represent a quarter of the value of the real medical card. Second, the Government is once again playing a numbers game in an effort to con the public. More than 100,000 people have lost their medical card since this coalition first took office in 1997. Almost 65,000 people have lost their medical cards since 2002. If the Government is claiming to stick by its word, the figures do not add up.

More important than figures are the real people who need access to health services. They are all our constituents. Their income is above the very low level of the medical card income guidelines and they cannot afford private health insurance. Many of them may now qualify for the GP-only card, but they must still pay the cost of medicines up to the value of €85 per month after yet another increase imposed by the Government. They must still pay hospital charges.

Yesterday a Deputy pointed out that the number of medical card holders with full entitlements will possibly decrease and will be gradually replaced by those entitled to GP-only cards. This would represent a significant cutting back in public health services, a situation which must be fought tooth and nail.

There is no consistency in the Government's health policy. A few years ago it granted the medical card to all those over the age of 70 regardless of their circumstances. That is fine because in doing so it recognised the principle of equal access to health services for all. However, this only applied to those over the age of 70. A very wealthy retired person on a large pension is entitled to free medical care, whereas a family with young children, struggling to survive week to week, must be almost destitute before qualifying for free medicine and medical care. It does not make sense.

A 2003 survey showed that 33% of men and 45% of women identified financial problems as the greatest factor preventing them from improving their health. This sums up the inequality at the heart of the health service and this Bill will do nothing to challenge that.

Finian McGrath (Dublin North Central, Independent)
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I am grateful for the opportunity to speak on this extremely important legislation. It is about the charging of residents of public nursing homes up to 80% of their pensions for long-term care and provides for the introduction of doctor-only medical cards for 200,000 on low incomes. This issue was a fiasco from the start, and all major political parties must take responsibility as it happened on their watch. It is a disgrace and now we have rushed legislation to dock 80% of the old age pension. Most people do not mind making a contribution, but 80% is a scandal and a rip-off of the elderly who have served this nation well over the years. It is cheapskate politics and lacks compassion and care for the elderly.

I challenge the role of the Minister of State, Deputy Callely, regarding the issue. He was present at the crucial meeting in December 2003 when the issue of illegal health charges was discussed. He was Minister of State at the Department of Health and Children with responsibility for the elderly at that time. Why did he stay silent? What did he know? What did he do about it? What illegal advice was he given? It happened under his watch as Minister of State. If he has a few minutes, after being down in the Port tunnel, which has caused damage to 185 homes under his new watch, perhaps he will explain why he turned his back on the elderly over the past 12 months.

Let us look at the Minister of State's record on the elderly while he was in office. During his reign, approximately 440,000, or 11% of the State's population, were over 65 years of age. Of these, approximately 266,000 were over the age of 70 and one third of these lived on their own. Some 25,000 elderly people were in long-stay beds or nursing homes and a further 13,000 needed high to maximum dependency care and continued to live at home.

It is the wish of the majority of elderly people to receive care at home or in the community, a concept which I support. Many families of the elderly make sacrifices to provide the best possible care. The inadequacy of the nursing home subvention causes great hardship for many families, as do the cuts in home help carried out under the Minister of State's term in office. The failure to abolish the means test for the carer's allowance is a further attack on the most vulnerable in our society. Day care centres serving the elderly and disadvantaged communities were grossly under-resourced under the Minister of State's watch.

The Government must immediately put in place adequate resources and a comprehensive infrastructure for care of the elderly. This is the Minister of State's record, and he is at it again. This is not a personal attack, it is a political attack. He should get the boot for his record and he should bring the Minister for Transport, Deputy Cullen, with him.

I support Deputy Connolly's position on a moratorium on the withdrawal of the medical card for existing card holders. We must also look at marginal cases who will get the doctor-only card and clarify the legal position regarding medical card holders in private nursing homes. In terms of money owed, £1 in 1976 is now worth €9.36. That is the reality and the Government must not to be stingy to our elderly. It is pay-back time, and time to give our elderly maximum care and support.

Paddy McHugh (Galway East, Independent)
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I welcome the opportunity to speak on this Bill, which is relatively small but very relevant following the recent Supreme Court decision. We owe a debt of gratitude to President McAleese for initiating the referral to the Supreme Court of the most recent legislation dealing with nursing home charges. That action undoubtedly saved many people much angst if they felt a compulsion to have the legislation tested in the courts. At least we now know that when this legislation is passed, as I presume it will be, the future basis for nursing home charges will be put on a firm foundation. One of the peculiarities of this House is the irrelevance of the contributions made at times when discussing legislation. This occasion is no exception. The Bill is specific and deals with only two issues: long-term stay charges and doctor-only medical cards. As regards charges, the issue is whether people who can afford to should pay a contribution. If that principle is accepted, and it is one that I support, then we should go ahead and implement it. The blame game for the fiasco that was first discovered 11 Governments ago will have another airing when the Travers report is published. Recriminations should be left to another day because while we squabble here, the taxpayer must foot the bill to the tune of approximately €2.5 million per week.

There has been an attempt to lay the blame for this fiasco at the Tánaiste's door merely because she is the current Minister for Health and Children. That is disingenuous to say the least; dishonest would be a more accurate description. We should not lose sight of the fact that Deputy Harney was the only Minister who acted when the matter was brought to her attention. This, however, is a discussion for another time, after the publication of the Travers report. So also is the issue of repayments of what we now know were illegal charges.

There is a question concerning those who had to go to private nursing homes because they could not be accommodated in public nursing homes. The position of such people needs to be clarified in the interest of fairness.

The legislation also deals with doctor-only medical cards. While any action that helps people on low incomes deal with their daily bills is welcome, it is regrettable that the cards will not cover the cost of prescriptions. Doctor-only medical cards will certainly not fulfil the commitment made to provide an additional 200,000 medical cards. That commitment related to full medical cards, not half ones.

While attempting to focus my comments specifically on the legislation, I cannot allow the occasion to pass without agreeing with my constituency colleague, Deputy Callanan, about the need for progress to made on the issues of the Loughrea nursing home and promised hospital for Tuam.

John Gormley (Dublin South East, Green Party)
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When the previous legislation on this matter was introduced, it ended in a debacle. At the time, we warned the Tánaiste that the legislation was unconstitutional and infringed people's property rights but she took no heed and ploughed on regardless. The previous legislation simply legalised theft. We were stealing from the most vulnerable in society. Following the recent Supreme Court decision, the Tánaiste sought to spread the blame to others. She talked about maladministration, which not just implicates former Ministers in the 11 previous Governments but also senior civil servants.

I hope the Travers report will focus on the warning given to the Government in 2001, which it failed to heed, and the 80-page legal document submitted by the health board in 2003, which the Government also ignored. We need to know what the former Minister for Health and Children, Deputy Martin, knew at the time and what other Ministers knew. It is not simply a case of pointing a finger at the Tánaiste; we are clearly pointing a finger at this Administration.

The previous speaker referred to home-based subvention, which is an important issue because the solution should not be based on nursing homes. We must examine this matter. Constituents have told me that they are prepared to look after their elderly parents who have been in hospital for up to six weeks, taking up valuable beds. We may wonder why we have an accident and emergency crisis but here is a solution. I am glad to see the Minister of State, Deputy Tim O'Malley, nodding in agreement. We need to examine this matter thoroughly and give that subvention to those prepared to avail of it. We would save a great deal of money, free up many beds and have a much better health service if that were done.

I agree with the Government backbencher, Deputy Nolan, who quite rightly said we need to increase the income limits. We all know of many deserving cases. I am glad such people are no longer afraid to visit their doctors but I am sure they are afraid that when the doctor makes a diagnosis, be it an ulcer or other complaint, they will have to fork out a great deal of money. A patient with an ulcer, for example, may have to pay €100 per month for medication. How can someone on a low income afford to pay that? That they must pay out such amounts will cause even more stress, which will exacerbate their illness.

The doctor-only medical card represents a miserly half-measure. It does not fulfil the promise made by the Government at the last general election. Many people will still be afraid to visit their doctors because, depending on the diagnosis, they may have to pay a great deal for prescribed medication.

We are told that to lead a healthy life, one should choose one's parents carefully and be wealthy. All the indicators show that the less well-off have the worst health problems. The State should examine ways of evening up the situation so that we will have a truly equal society, but it has not happened yet. Under Britain's much maligned national health service, one can get an appointment with a doctor and obtain medication free of charge but it does not happen here. Such facilities should form a fundamental part of primary health care, yet our primary health care strategy is in tatters.

The publication of the Government document is welcome but its recommendations are not being implemented. The Government document states that over 90% of illnesses can be dealt with at primary care level and I agree with that. The idea of primary care is to examine prevention, thus nipping illnesses in the bud. However, given the introduction of the "yellow pack" medical card, we can see that the Minister does not fully adopt that approach. We need to examine the root causes of illness. We know, for example, that 80% of cancers are environmentally linked. Therefore, prevention comes down to the basic ingredients of our lives, such as clean air and water.

There have been many scares recently concerning radon gas. We need to look at air pollution and what we are putting into our water supply. Do people have a genetic predisposition to some of the ingredients in drinking water and will they affect them adversely? I raised the question of microwave radiation with the Minister of State two days ago on the Adjournment debate. I do not understand the Government's schizophrenic approach to health care. On the one hand, it states that it wants to invest more money in health care, and is doing so, but on the other hand it is making society more unhealthy by investing more in roads instead of public transport and by locating mobile phone masts close to schools.

Next Sunday, in my own constituency, such a mast will be put in place at Ardee House, Rathmines, which is close to St. Mary's School. It is the first public building so affected under the new licensing rules. I regret very much that my constituency colleague, the Minister for Justice, Equality and Law Reform, Deputy McDowell, did not act to prevent this from happening. It is going ahead on Sunday. Meanwhile, the UK's independent expert group has referred to the precautionary principle and how such masts should not be located close to schools because it would raise radiation levels thus adversely affecting children. How can the Minister of State justify putting a mast of that sort near a school? He will wonder later on why it is that people have cancer. I just do not understand the logic.

In his reply, the Minister of State suggested that normal planning regulations will apply. We know the 2001 planning and development regulations exempt such developments from the normal planning process. Therefore, neither the public nor the city council have an input. There are no rules so we do not have a proper examination of the pros and cons of this development. That is most regrettable. The reply that is trotted out all the time is that this is normal planning, but it is not normal planning. This matter, which I have raised a number of times today, is causing me much grief. It should have gone through normal planning. I appeal to the Minister of State, Deputy Tim O'Malley, who is a member of the Progressive Democrats and whose colleague is putting through this measure, to please ensure the installation of the phone mast on Ardee House in Rathmines is reconsidered.

Michael Ring (Mayo, Fine Gael)
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I wish to share time with Deputy Crawford.

Seán Ardagh (Dublin South Central, Fianna Fail)
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Is that agreed? Agreed.

Michael Ring (Mayo, Fine Gael)
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I agree with what Deputy Gormley said about cancer. The recent food scare will be the next big issue to hit the country. I did not realise people put colouring into food. I always knew people put colouring into their hair but thanks be to God I never did that myself to the bit I have. With respect, that is not relevant to the Minister of State, Deputy Tim O'Malley.

Tim O'Malley (Limerick East, Progressive Democrats)
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Deputy Ring is fairly sharp.

Michael Ring (Mayo, Fine Gael)
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On a more serious note, this matter will become a big issue. It is already a big issue in Great Britain and it will also develop here. I have been saying for years that the additives being put into food are poisoning us. It is unnatural to see how long bread, milk and other foodstuffs last. It is not right. It is no wonder so many people are sick and dying from cancer.

In terms of the Bill, I wish to speak about medical cards and nursing homes. I will not repeat what I already said in the House in regard to nursing homes. What happened was a disgrace and should not have happened. I was junior spokesman on health in 2001 with Deputy Gay Mitchell when the Ombudsman clarified the rules and regulations on nursing home care. I raised the matter on many occasions. According to the Ombudsman, people were entitled to a State bed as long as they were aged over 70 and had a medical card. I used his ruling on every occasion when constituents came to me seeking a full-time bed in a nursing home in County Mayo. When doctors or health boards tried to put people out of hospitals I told them they had no right and I would take legal action against them if they did so. They never once removed anyone from a hospital because they knew the law and that they would not win in court. They knew they were obliged to find a bed for such people. That is a fact and it is on the record of the joint committee.

We had a great health board system but the only people it was good for were the people who worked for it. Another scandal is coming down the line in regard to people on pensions. The Minister of State may not be able to reply on the matter today but I intend to raise on the Adjournment shortly the new ruling by officials in the ambulance service. A woman from Ballycroy recently came to my clinic. She is over 70 years of age and is in very bad health. She needed a hospital appointment in Galway. She lives on about €165 a week. She could not get the health board to provide a service to bring her from Ballycroy to Galway, a 150 mile round trip. She could not afford a taxi and there was no family to help out. That is an abuse of the elderly. If the State wants her to stay in her own home to save it money, it should provide the few necessary services she needs, including home help and transport for her hospital appointments.

Why does the State have to make a big thing about nothing? I often wonder from where the people who make these decisions come. Perhaps they come from Russia in the bad old days. They have no conscience or understanding of the lives of elderly people. The Department should investigate why elderly people in Mayo whom I represent cannot be brought to badly needed hospital appointments. These people are prepared to stay in their own homes.

Reference has been made to home care and home help. Another issue, which I intend to raise first in a private capacity, is in respect of a family where an 18 year old is left looking after four children. I thought the State was there to provide services. I do not understand how the State or social workers could allow a young girl of 18 years of age to look after four children following the recent sudden death of her mother. I am investigating the case and intend to bring it to the attention of the health board and the media. It is not right and should not happen. The family gets one hour of home help every day. We would be better off providing home help and back-up for the family instead of having a social worker making a report once a week and then going home, which does not deal with the problems.

The courts recently made a decision that a young man would be sentenced to 18 months imprisonment. That person was advised by a professional that the best thing he could do at 16 years of age would be to pack his bags and go to England. It is sad if that is the kind of society in which we live. We have gone down the American road which is not a very good road to go down.

I intend asking the party spokesman to table two amendments in regard to medical cards. Health board chief executives always had discretion on this matter, and to be fair they used their discretion well. They must be allowed to have discretion to award a full medical card. If somebody has a medical card on medical grounds they should not be told from April on that they are not entitled to a full medical card, that they will be entitled to a GP-only medical card.

Yesterday, the Minister of State referred to the fact that local HSE areas will have an appeal mechanism. In my local health board area we had an independent appeal mechanism up to about two years ago. A barrister was employed by the health board as an independent assessor. I had many a row with him but in all fairness to him, 50% of appeals were successful. When he went into private practice and up to the Four Courts his replacement was a health board official who had worked with every single one of the community welfare officers. It would be impossible for such a person to make an independent judgment against his colleagues. I appeal to the Minister to change that aspect of the Bill. An independent person should fill that role, not somebody who worked for the health board for 25 years. Such a person would ring his or her colleagues to ask about the case and then say it is fine. I do not exaggerate when I say that 80% of appeals were unsuccessful as opposed to 50% when an independent appeals officer was in place.

I will ask the Fine Gael spokesman to table two amendments and ensure they are discussed and accepted. It makes sense that there would be an independent appeals officer and that people awarded medical cards on medical grounds or due to other circumstances would not just get the yellow pack type of medical card, but a full medical card. I ask the officials to take note of this to ensure it is brought to the attention of the Minister. It would be wrong if that happened.

The Minister referred to expanding the guidelines for medical cards. As they stand, the guidelines are ridiculous. A single person living alone in receipt of €153 does not qualify for a medical card according to the guidelines dated 1 January 2005. The threshold for a married couple is €222. If the couple have two dependent children under 16 years of age they get an allowance of €31 each for them. A family living on €280 or €290 is not entitled to a medical card. Even if one adds25%, it is still not enough.

I welcome any expansion of the entitlement criteria for medical cards, even GP-only medical cards. I have met parents who cannot bring their children to the doctor because it costs them €50. A consequent visit to the chemist could cost them €75. If there is a number of children in a house, nine times out of ten, sickness such as flu or another virus will spread to them all. I have seen many parents without medical cards who could not bring their children to the doctor because they could not afford to do so. Every person in this House knows the guidelines are wrong. The people who adjudicated on the guidelines for the past 20 years were the chief executives of health boards. How would they know, no more than some politicians, because they do not understand how this affects people? They were on big salaries and did not understand how the system worked.

I can table a parliamentary question to get information but I am sure the officials will have it. If one looks back over the past ten years at how the guidelines on income were increased, one will see that they did not even keep pace with inflation, which was low in recent years. It was wrong but it happened. They targeted the most vulnerable in society and took away their medical cards. This time next year when we return to the House, we will find that fewer people have medical cards than at present. With the minimum wage continually increasing, more people will fall outside the guidelines.

It is important to ensure community welfare officers or superintendents have the right of appeal and the right to grant full medical cards. I appeal to the Tánaiste and her Department to examine the proposal for an independent person to hear appeals rather than someone who worked for a health board for 20 years.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I thank Deputy Ring for sharing time. Like other Deputies, I question why no explanatory memorandum was included with this important Bill. The previous Bill was rushed through the House without proper consultation and we are all aware of what happened. I pay tribute to the President because she saw sense in the issues we raised. I was one of those who raised questions about the Bill's legality at the time and we were proved correct, for which I am thankful. I also thank my colleague, Deputy Perry, and our party leader, Deputy Kenny, for raising the issue of the illegal charging of nursing home residents.

The Minister of State at the Department of Health and Children, Deputy Tim O'Malley, who is in the House, along with his colleagues, Deputy Callely and the former Minister for Health and Children, Deputy Martin, were all present at the meeting in 2003 when this issue was discussed and yet nothing was done about it. This issue is extremely serious and it seems to have been ignored. If it had not been for the tenacity of our party leader, Deputy Kenny, in continuing to raise the matter in this House on a weekly basis, I am not sure it would have ever seen the light of day.

The Minister of State at the Department of Health and Children, Deputy Seán Power, stated yesterday that this Bill is intended to establish a sound legal basis for the policy to charge residents a contribution towards their shelter and maintenance in long-term institutions. That may be possible. I hope for everyone's sake that the legal position is correct. However, I am worried about the lack of information available regarding how the means test will be applied to those requiring subvention in private nursing homes because of the shortage of places in State run nursing homes.

For example, at the time of the last election, 254 people in Cavan-Monaghan were in receipt of subvention but when the election was over, an effort was made to reduce this number to 150 or 170. Eventually, we achieved agreement on 214 and, thankfully, we have now achieved a level of 234 people in receipt of subvention. The trauma which many families have to endure in order to get this subvention is unreal. On Tuesday I sat with an aged man who is in respite care in St. Mary's nursing home but is being turfed out because there is no room for him. Although he owns his own house, he has had great difficulty finding ways and means of support. This man had paid his way all his life and this is a traumatic situation for a man without a single family member closer than second or third cousin, with whom to discuss the issue. We must have a more caring and realistic approach.

The trauma endured by a patient from Monaghan in a west of Ireland nursing home in order to receive subvention was nothing ordinary. Furthermore, the subvention was not even paid from the time of the patient's arrival. The personnel in charge of the nursing home stated they had never come across the like of it before. There is a major difference in how the elderly are treated in different areas and I hope that under the new health structure this issue will be sorted out once and for all. Every patient, no matter where he or she lives, should have similar access to accommodation and receive similar treatment.

Before the laws changed in Northern Ireland in the early 1990s, many people from Cavan and Monaghan were sent across the Border because they could receive full care there for free. Moreover, the health boards encouraged this practice. This leaves the constituency with a seemingly low base from which to judge the situation. However, we must remember that the former North Eastern Health Board area has experienced the single biggest increase in population anywhere in the nation and the numbers of people over 85 years are also increasing. Therefore, we have a bigger problem than anywhere else, which cannot be ignored.

I am dealing with the case of an elderly man who received legal advice from a solicitor that he should retain 20 acres of his small farm holding. However, the man's son needs every inch of the farm in order to make a living without having to pay his father. This is accepted and acknowledged but the father is in a nursing home and the family must pay €350 per week along with the man's pension in order to keep him there. The family has only in recent weeks received a small subvention but the situation is crazy because the man's wife is still alive. Does she have no rights? It is impossible to understand.

In another case, a mother in a nursing home had owned her own house and when she married her husband bought all the land around it. Their son is now the only person living in the house and he farms the land. The house is being used as collateral as far as the health board is concerned. This must be examined. I am pleased with the Tánaiste's comment this morning that the repayments of money to those who are entitled to it will be simplified and dealt with without legal complications. It is a serious problem because it will be a complicated process but I accept the Tánaiste's commitment and hope it works.

This Bill provides that 80% of patient's pensions must be paid for maintenance and so on, which will leave €30 or €35 depending on the pension. However, there must be some flexibility in this regard. I would not like to see the situation in which a relatively fit person who enjoys taking a drink or a cigarette or having his or her hair done would be tied to such an amount. If the person wants to buy birthday presents for grandchildren, €35 will not go very far. I want to see that situation made reasonable and respectable.

More than 100,000 medical cards have been removed from the system because of the failure to increase the limit for the means test. This issue has already been addressed by many Deputies on both sides of the House. However, I have a major question to ask about how eligibility is evaluated in different areas. From January 1997 to September 2004, County Cavan lost 3,630 out of 22,000 medical cards, County Monaghan lost 6,000 out of 22,000 and the four former North Eastern Health Board counties together lost 28,000 out of 113,000 medical cards. However, in County Cork, the home of the former Minister for Health and Children, Deputy Martin, out of 139,000 cards available in January 1997, only 8,097 were removed by September 2004. One must ask how this came about and why there was such a difference. This difference is more than 20,000 when one takes everything into account. There is talk about 300,000 new medical cards being issued, but we have already lost 100,000. Where are we going? Reference has also been made to 200,000 new doctor-only cards. My colleague, Deputy Twomey, proposed such cards as a means of dealing with the problem. As a member of the British-Irish Interparliamentary Body, I had the privilege of touring a number of hospitals in Wick in the north of Scotland, Wales and other places. It was clear that where proper, free primary care was available it removed enormous pressure from the accident and emergency services. That area of services must be improved dramatically but the Minister's proposal does not go far enough.

The Tánaiste said that the traditional medical card would continue to be held by 85% of medical card holders. Does that mean that some of the 200,000 doctor-only cards will replace the medical cards or will there be 200,000 doctor-only cards as well as 30,000 extra medical cards? That must be clarified. The 200,000 doctor-only cards, the 30,000 extra medical cards and the existing 100,000 medical cards must remain in place to ensure people have proper access to primary care. It will remove many of them from the accident and emergency departments and alleviate much of the pressure.

I am grateful that Monaghan General Hospital is back on call for medical purposes. However, the Minister should ensure that something is done about the surgical service.

Tim O'Malley (Limerick East, Progressive Democrats)
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I thank Deputies for their contributions to this debate. The Government brought forward this Bill to establish a sound legal basis for the policy of requiring some contribution towards shelter and maintenance of people with full eligibility in long-term stay institutions. The Supreme Court has confirmed that it is constitutionally sound for the Oireachtas to legislate for this policy. The issue is being put beyond legal doubt after nearly 29 years.

The other matter addressed in the Bill, the introduction of a doctor visit medical card, is a major step forward in ensuring that people on low incomes have access to general practitioner services and advice. The Health Service Executive, as the body established to administer the health services on a national basis, will be in a position to commence the introduction of these cards as soon as the Bill has been enacted.

It is a long-standing feature of our system, and one which has been policy under Governments of all the major parties over the past 30 years, that most people in publicly funded long-term care should make some contribution to the cost of this care. Quality care is expensive and, even with a contribution from those receiving this care, the bulk of the cost of providing a high standard of quality care must be borne by the Exchequer. The charges to be imposed on those in public nursing homes under the provisions of this Bill represent approximately 10% of the overall cost of care.

The income foregone by the Health Service Executive for as long as these charges cannot be raised is estimated in the region of €2 million per week. A statutory framework that puts the long-standing policy on a sound legal footing and safeguards the income generated from this source is vital. The provisions of the Health (Amendment) Bill 2005 will secure this source of income, which has been an essential element of the funding of our health services in the past and must remain so in the future.

The introduction of a doctor visit medical card is the most efficient way to help a significant additional number of people to access primary care. It is in line with the commitment contained in the health strategy to ensure that the allocation of medical cards is on the basis of prioritising groups most in need of those services and is intended to benefit approximately 200,000 people.

I will take this opportunity to respond to some of the points made by speakers during the debate. With regard to the provision in the Bill referring to 80% of the maximum old age non-contributory pension, it must be remembered that this is the maximum weekly charge that can be levied. If this is taken together with the provision in the Bill to allow the Health Service Executive to reduce or waive the charge imposed on a person to avoid undue financial hardship, 80% of the maximum non-contributory old age pension is a reasonable upper limit to set for the charge.

A number of Deputies expressed concern that the percentage of the population covered by a medical card has declined over recent years. However, they neglected to mention that this is attributable in large measure to the economic success we have enjoyed, which has reduced many people's need for State support to meet health care and other living costs.

Furthermore, the Government's objective is to ensure that people most in need can have a medical card rather than simply to achieve coverage of a certain percentage of the population or to issue a specific number of medical cards. It is to give effect to this targeted approach, and many Deputies in the past have sought such a targeted approach, that, at the request of the Tánaiste, changes to the income guidelines have recently been introduced by the Health Service Executive and are intended to ensure that an additional 30,000 medical cards can be issued in the current year. This is in addition to the doctor visit cards which will be introduced subsequent to the passage of this Bill.

There is no question of the Government seeking over time to reduce the number of standard medical cards in favour of issuing increased numbers of doctor visit cards. Several Deputies were worried about this. This initiative is intended to complement the existing medical card arrangements which have been in force for many years.

The Department of Health and Children has recently written to the interim chief officer of the Health Service Executive to indicate formally that the Government's objective in bringing forward this initiative was to enable approximately 200,000 medical cards to be issued in respect of general practitioner services and that the Tánaiste wishes to have the necessary administrative arrangements in place to enable the new cards to be issued from April. Deputy Twomey and other speakers welcomed the introduction of the doctor visit cards. It has also been welcomed by many groups in the community. It is recognised that for many people, particularly mothers of small children, visits to the doctor were a problem. This applied to people whose incomes are just above the medical card threshold. They were afraid to visit the doctor because of the cost involved. That will no longer arise because with the doctor visit cards they will be able to visit the doctor free of charge.

The Health Service Executive has been requested to have the necessary preparatory steps taken and operational guidelines developed such as will enable applications for doctor visit medical cards to be accepted as soon as possible after the enactment of the relevant legislation and the cards subsequently issued to persons who meet the relevant criteria. With the establishment of the Health Service Executive, the administrative arrangements for this card will be operated on a standardised basis throughout the country.

While the Health Service Executive intends initially to set the income threshold for the doctor visit cards at 25% higher than applies for the standard medical card, this threshold will, if necessary, be reviewed in light of experience to ensure the desired number of cards are issued to those intended to benefit under the scheme. Therefore, if there are not sufficient applications for the cards, the thresholds will be raised until the level of 200,000 cards is reached.

The Bill will bring clarity to the issue of charges for long-stay care where it is clear there has not been a sound basis for the practice going back nearly 30 years. The legislation will also ensure the income flow from charges imposed to date is secured and that it will continue to support the provision of quality services for those in long-term care. I am pleased to note that none of the major parties has registered any difficulty with the principle involved here. The introduction of a doctor visit medical card is a supplementary initiative which will enable 200,000 people from lower income households to attend a doctor free of charge. This will help to overcome barriers to assessing GP services for many individuals and families who are above the standard medical card income guidelines.

Many Opposition Members referred to the imminent Travers report. I do not wish to comment on the report because it will not be released for a few days and I have not seen it. Obviously, there will be further debate in the House on the report. As one of the Ministers who attended a certain meeting, I presumed legal advice would be obtained and this is what I told anyone who asked me about the matter.

Dan Neville (Limerick West, Fine Gael)
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Did the Minister of State inform the senior Minister of what happened?

Seán Ardagh (Dublin South Central, Fianna Fail)
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Deputy, this is not a question and answer session.

Tim O'Malley (Limerick East, Progressive Democrats)
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As I stated, there will be a debate in the House.

Dan Neville (Limerick West, Fine Gael)
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It is a simple question. Did the Minister of State inform the senior Minister of what happened when the Minister of State was outside the door?

Tim O'Malley (Limerick East, Progressive Democrats)
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I am not aware who was inside or outside the door.

Dan Neville (Limerick West, Fine Gael)
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The Minister of State, Deputy Tim O'Malley, and the Minister of State, Deputy Callely, as the Tánaiste stated-——

Tim O'Malley (Limerick East, Progressive Democrats)
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The Deputy may not have heard what I said. I am sure there will be a debate on the Travers report in this House.

Dan Neville (Limerick West, Fine Gael)
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The Minister of State should answer "yes" or "no".

Tim O'Malley (Limerick East, Progressive Democrats)
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I was never asked to inform anybody.

Dan Neville (Limerick West, Fine Gael)
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Surely, with such an important——

Tim O'Malley (Limerick East, Progressive Democrats)
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The Deputy asked me a question. Will he wait for the reply? If he read the minutes of the meeting, he would know that the recommendation of the meeting was that legal advice would be sought in regard to the question. It was my presumption that this would be done. That is all I wish to state on the matter.

Dan Neville (Limerick West, Fine Gael)
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The Minister of State did not inform the Minister.