Simon Harris (Wicklow, Fine Gael)
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I thank the Minister of State, Deputy Jan O'Sullivan, for responding to this matter. I congratulate her on her promotion. I am pleased to have the opportunity to raise in the House the need to re-examine the current system of issuing prescriptions in light of what I believe are inefficiencies and inequities created by requiring GPs to reissue all prescriptions from hospital consultants, in particular in the area of mental health services for medical card holders.

As the Minister of State will no doubt be aware, the roll out of primary care centres was discussed at the Committee of Public Accounts in great detail this morning. I believe wholeheartedly, as does the Government, in the rationale behind the move to primary care centres and the need to ensure we can treat as many patients as possible within their own communities, in an effective and streamlined manner.

The programme for Government commits to an ambitious programme of reform in this area, one which is essential to the delivery of the best possible standard of health care in this country. The progress made last year by the special delivery unit shows that advances can be made even at a time when the health service has to face severe financial cutbacks. To do this, it is essential that all resources are utilised in the most effective manner possible. It is in this wider context that I wish to raise the need to re-examine the way in which prescriptions are issued to medical card holders.

I have been contacted by many constituents frustrated by the system currently in place, where families attending hospital or psychiatric services have to revisit their GP in order to get their prescription re-written as a GMS order to access their entitlement to receive it for free. This is most pressingly a problem in the case of prescriptions. Mental health prescriptions are obviously prescribed for very good reason, and often require individuals to take them consistently over a prolonged period. Depending on the circumstances, prescriptions for these long-term medications are sometimes issued on a weekly basis, requiring the patient to visit the GP for a GMS order every time a prescription is required.

Some modern health medications for treating conditions such as autism can cost up to €300 per month. If parents are not in a position to see their GP, as I understand was a concern for some families over the Christmas period, they may not be able to afford the cost of the prescription. That has real consequences for the children and families concerned, and pharmacists have little or no discretion in issuing such prescriptions without a separate GMS order. The system appears to be extremely bureaucratic. I would appreciate if the Minister could outline the rationale behind having GMS orders issued in this way, given that it appears to result in a duplication of resources. Patients see a specialist in a particular field, who prescribes the medication they feel is most suitable. They then have to revisit their GP in order to obtain a GMS order for the prescription. This same process takes place when a prescription is issued by a hospital. That is causing widespread waste of time and inefficiencies and is wasting the time of doctors at a time when the health service is clogged up. I am informed that while hospitals can use a special form to issue a prescription for up to seven days, in practice this is often not used. It is not the most practical measure. The current system can result in additional, unnecessary visits to GPs. I look forward to engaging with the Minister on the matter.

Jan O'Sullivan (Limerick City, Labour)
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The Medical Council's guide to professional conduct and ethics states that "it is in the best interests of the patient that a general practitioner, GP, supervises and guides the overall management of their health". There are approximately 2,600 GPs in active practice, of which approximately 2,300 hold a contract with the Health Service Executive, HSE, for the provision of services under the general medical services, GMS, scheme to medical card and GP visit card patients. Approximately 40% of the population is covered by the GMS scheme. GMS contracted GPs undertake to provide their patients with all proper and necessary treatment of a kind generally undertaken by a GP. That includes the issuing of a prescription for medicines or drugs as is determined to be necessary by the GP for his or her patient.

Since 1996 there has been an arrangement under the GMS scheme for the emergency supply of medicines for medical card holders on discharge from hospital. Community pharmacists participating in the GMS scheme are authorised to dispense a maximum of seven days' supply of medicines prescribed for persons who have been inpatients in a hospital or who have attended an accident and emergency department and because of the circumstances of their discharge and-or the urgency of the prescribed medication it would not be possible to attend their general practitioners to have the hospital prescription transcribed to a GMS prescription form. This arrangement relieves any difficulties that patients might encounter who are due to be discharged from hospital late in the evening or at weekends.

I believe that the Deputy is raising this matter, as he indicated, in the context of recent changes to the supply of medicines to some mental health patients in the area of the former Eastern Regional Health Authority. In line with the Health Service Executive's stated policy to standardise and streamline arrangements under the State drug schemes, to improve equity for service users and increase efficiency, local services have been advised to direct medical card holders requiring psychiatric medicines to attend their local general practitioner. This approach aligns the arrangements for the dispensing of drugs and medicines to persons on medication for a mental health condition, who reside in the greater Dublin area, with the arrangements that pertain in the case of persons living in all other parts of the country. This is also consistent with the arrangements for dispensing drugs and medicines across the full spectrum of medical conditions and is consistent with the policy of normalising and de-stigmatising this aspect of our health care service. It is also consistent with the key recommendations in A Vision For Change, the report of the expert group on mental health policy, pertaining to the treatment and care of mental health conditions in the primary care setting where it is acknowledged that treatment in this setting "enables the largest number of people to get easier and faster access to services".

This initiative ensures that general practitioners have a full involvement in their client's medications, including their psychiatric drugs. The process also ensures that pharmacists, who continue to provide this medication to eligible persons under the various scheme arrangements, can claim reimbursement in respect of these drugs with their other monthly submissions. These claims will be reimbursed by the HSE at the tariffs set by the Minister for Health under the applicable regulations. This change will not disadvantage medical card holders and it will reduce the administration associated with these arrangements and free up resources for other patient services.

In summary, I assure the Deputy that it is best clinical practice that a person in need of treatment should regularly attend their GP and that the GP is fully aware of the medications that any patient may be being prescribed. This is entirely consistent with the gatekeeper role played by the GP in the delivery of primary care. Furthermore, due to the reimbursement arrangements under the GMS scheme whereby a GP is paid a capitation fee per eligible patient on their list, there are no additional costs associated with an eligible patient attending. Rather, the rationalisation of previous local arrangements to fit with the national arrangements provides obvious administrative savings and increased efficiencies.

Simon Harris (Wicklow, Fine Gael)
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I thank the Minister of State for her comprehensive reply. I am sure she will not mind me respectfully disagreeing with much of it. I cannot accept that this is best practice when it is a practice that only applies to medical card holders. If a private patient seeks psychiatric medical attention in the morning, he or she will get a prescription, go to the pharmacy, pay for the prescription and go home. If patients with medical cards seek prescriptions, they attend their mental health specialists, for wont of a better phrase, and get their prescriptions, which are useless to them for accessing medication. They must then attend their GP and endure the difficulty associated with getting appointments and waiting times in some areas. It is only then they can go to their pharmacies. All of this adds an additional layer of bureaucracy and inconvenience for medical card patients. Were the process standardised across the board, the response would have some credibility but that does not seem to be the case.

I welcome the fact that there is no extra cost but there is an extra inconvenience to patients. I value the role of the GP and the answer made a great deal of sense in that respect. We are all on the same page, in that we want to move to a situation in which mental health care is received in the community. Ideally, the GP should be situated in the same building.

This situation needs to be examined in light of the great technology that exists. We saw how Revenue could have used it to good effect in respect of pensioners recently. Computers should be able to talk to one another. The areas in question, for example, autism, are often specialties and specialists would be the best people to monitor the situation.

It risks stigmatising those on the General Medical Services scheme with mental health difficulties. There is an issue and I would appreciate it if the Minister of State relayed my comments to the Minister for Health.

Jan O'Sullivan (Limerick City, Labour)
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I will. The Deputy has made a good argument on the other side. I am not the Minister directly responsible but the notes I have been given state that the arrangements will be kept under review. That the Deputy's voice might be listened to might give him some comfort. There are reasons for taking these measures. I understand the Deputy's points and I will convey them to the Minister.

Simon Harris (Wicklow, Fine Gael)
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I thank the Minister of State.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I assume the Minister of State is taking this matter on behalf of the Minister for Health.

Jan O'Sullivan (Limerick City, Labour)
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Yes.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I thank the Ceann Comhairle for selecting this Topical Issue for debate. I do not want to waste too much time, but I am disappointed that the Minister or the relevant Minister of State at the Department of Health is not present. One reason for turning Adjournment debates into Topical Issue debates under the heading of Dáil reform was to ensure the relevant Minister would take the debates.

When the Minister, Deputy Reilly, came to power, he arrived with great fanfare. One of his first actions was to step down the old HSE board. He is yet to appoint a new one. As he stated himself, he has taken control of the reins and the buck stops with him. Were he present, I would ask him whether he was satisfied with the fiasco that is the medical card situation. I am not the only Deputy to raise this issue, as I am sure that Members on all sides of the House have experienced a high level of engagement with constituents in this regard. Those constituents have been frustrated with the situation since the centralisation of the application process last July. I could give example after example. On Joe Duffy's phone-in radio show today, there was an hour and a half of examples of people experiencing extreme levels of frustration and anxiety. They are sick and are only looking for their entitlements, yet they have been given excuse after excuse.

I have been contacted by a lady who applied for a medical card last August. She needed a serious operation and her card was due to expire at the end of August. We telephoned at the end of the month and were told to telephone again in September. When we did so we were told to telephone again at the end of the month. The situation went on and on until, in December, the card was extended by one month to cover her operation.

I have with me a letter to the HSE's Primary Care Reimbursement Services, PCRS, in Finglas dated 15 June 2011 regarding a medical card in the name of Mr. X. The letter referred to the appeal received on behalf of Mr. X and, as he was within the limits for a medical card for a married couple, asked the PCRS to arrange to process the medical card at its earliest convenience. Today is 26 January 2012 and the man is still awaiting his medical card. He is lucky, as his doctor facilitates him when he has his weekly check-ups, but his pharmacist has understandably refused to accept him. In another example, a single man with two children applied last September, submitted further information in October and is still awaiting a decision.

The buck stops with the Minister for Health. How does he intend to resolve this matter? It is generating unnecessary anxiety among a large number of people. On Joe Duffy's radio show today, the manager of a GP surgery spoke about the unbelievable number of forms that she must re-fill because she has been told the originals have been lost. Deputies are told that we can only make two inquiries per call. People are not allowed to submit more than one medical card application per envelope. This is lunacy. What will be done about it? Deputies from all parties will submit parliamentary questions to beat the band to get answers on the position regarding people's medical cards. This will cost more money than an efficient and effective service would. Under the Croke Park agreement, if there are not enough people working in the service, additional staff could be redeployed to it to process medical cards within 15 days. At present it is taking 15 weeks at a minimum.

Jan O'Sullivan (Limerick City, Labour)
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I thank the Deputy for raising this issue. The Minister of State, Deputy Shortall, is on official business in Northern Ireland and telephoned me to ask if I could take this debate for her. I apologise on her behalf but she could not be present.

This debate provides me with an opportunity to set out the steps being taken to address problems that have arisen in the processing of medical cards. The final part of the centralisation project took place on 1 July with the centralisation of medical card processing and associated tasks for the entire country in the PCRS's office in Finglas, Dublin. For the first time in the State's history, a single uniform system of application processing has been put in place. It replaces the different systems previously operated through more than 100 offices across the country. Some of the changes that have been introduced include the www.medicalcard.ie website and the standardisation of medical card assessments.

The new arrangements should ultimately provide for a far more accountable and better managed medical card processing system. However, there have been difficulties. These issues are a matter of concern and the Minister of State has held several meetings with the HSE to raise them. She has been hands-on in addressing the matter. As a result of those discussions, a number of changes are being introduced to the medical card application system to assist in accelerating the turnaround for applications by easing the level of pressure on the medical card system, particularly with respect to the review process, which has placed a large demand on the resources of the centralised office due to the timing of the re-issuing and, hence, review of a large cohort of medical cards.

In 2010, the central office introduced a self-assessment review process for people aged 70 years and over, as that cohort was managed entirely by the central office. Following on from this development, from January on the HSE will ease the review process for all pensioners. This change will mean that reviews for medical cardholders who are 66 years of age or older will operate on a self-assessment basis, as currently happens with those aged over 70 years. The self-assessment review model will also be extended to medical cardholders under 66 years of age who were granted their medical cards on the basis of a means assessment and who the HSE is satisfied is living in this jurisdiction. The HSE is also standardising eligibility periods from two years to three years for people aged under 66 years, with a new four-year eligibility period for medical cardholders aged 66 years or over.

Notwithstanding this, there continues to be an obligation on all cardholders to notify the HSE of any change in their circumstances that would no longer entitle them to hold a medical card. The HSE is in the process of arranging access to data in the possession of the Revenue Commissioners and the Department of Social Protection to allow them to conduct reviews without troubling medical cardholders for further documentation. It is also intended to increase the fine applying to false claims in a forthcoming Bill.

Discretionary cards, emergency cards and cards held by people in a small number of other categories will continue to be reviewed in the normal way but the HSE is confident that the extension of the self-assessment model to the great majority of medical cardholders will simplify the process substantially, improve the service to the client and continue to improve turnaround times for reviews. It is hoped that ultimately 80% of renewals will be dealt with in this way.

The new process also focuses attention on active users of the medical card in order to ensure those most in need are captured within the streamlined process. In addition, from 1 February, the HSE will implement a new system which gives GPs the additional ability to identify and assist the most vulnerable medical card holders. GPs will be able to maintain the eligibility of these patients where they are going through the renewal system. They will also be able to add newborns to the medical card system online.

The Minister of State, Deputy Róisín Shortall, wishes to emphasise that in no circumstances should a medical card holder who genuinely engages with a review have his or her entitlement withdrawn before that review is complete. This is unacceptable. Some such cases were brought to her attention in recent weeks. The HSE is taking steps to ensure the rule is properly implemented.

In addition, the primary care reimbursement services's central office is working to deal with some of the processing issues that have arisen. This has included reviewing and refining the systems for the receipt and logging of applications and documents sent in following requests for additional information. In addition, the PCRS has received further staff resources this month as a result of a transfer from the Central Statistics Office. This should make an impact on processing times. My colleague, the Minister of State, Deputy Róisín Shortall, will continue to monitor the situation and has arranged to meet the HSE on a regular basis to discuss any issues that may arise with respect to medical cards.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I thank the Minister of State for her reply which included some positive elements, particularly the four year eligibility period for medical card holders aged 66 years and over and the extension of the self-assessment process to include those above that age. However, not everybody over 66 years should have to undertake an assessment. Instead, assessments should be made at random, as is the case with the Revenue Commissioners in respect of tax returns.

The Minister of State painted the new centralised processing facility in Finglas in a very positive light. Unfortunately, that does not tally with the experience of service users. If there is a need to redeploy more staff to the unit, it should be done. As it is, it is neither efficient nor effective.

I welcome the Minister of State's undertaking that there will be no more cases of people losing their medical card before the review period is complete. What concrete steps will be taken to ensure the 15-day turnaround time is achieved in all cases? I know from my constituency office that most medical card applications are 100% complete when submitted, yet additional items of information are being requested before they are processed. There is a certain view, not entirely unjustified, that these delays are part of a stalling strategy the purpose of which is to secure cost savings. Will the Minister confirm that there is no cynical tactic on the part of the Government in this regard? To employ such a tactic would be despicable.

This is an issue affecting the most vulnerable in society, including seriously ill persons who cannot afford to wait for their medical card to be granted or renewed. I acknowledge that there are occasions when applications are submitted without all of the necessary information, in which cases one cannot expect an answer within 15 days. However, in the case of fully completed application forms, the 15-day turnaround target should always be met.

Jan O'Sullivan (Limerick City, Labour)
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We all acknowledge that the centralisation process which began some years ago has resulted in some problems in the processing of medical card applications. The Minister of State, Deputy Róisín Shortall, regularly meets the HSE in an effort to iron out any the difficulties that arise. As the Deputy acknowledged, there are proposals which will make it easier for people, including self-assessment and so on. These are being implemented on a gradual basis.

As I said, the reviewing and refining of the systems for the receipt and logging of applications and documents is ongoing. As public representatives, we have all seen cases in which a person is adamant that he or she has submitted all the required documentation only to receive a request for more information. That issue is being addressed, but I accept it is frustrating. I will convey the Deputy's concerns to the Minister of State who is taking a hands-on approach to this issue. I agree that as we are talking about very vulnerable people, we should ensure the information is available. As I said, a person whose case is under review will continue to hold his or her card until the review is completed. I recognise this is a cause of great worry.

Robert Troy (Longford-Westmeath, Fianna Fail)
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Will the Minister of State clarify that the delays which have occurred are not the result of a stalling tactic the purpose of which is to achieve cost savings?

Jan O'Sullivan (Limerick City, Labour)
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I am assured they are not.