Gerald Nash (Louth, Labour)
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I am glad to have this opportunity to raise an issue which will be familiar to all Members. All of us have at some stage been asked for advice or help with regard to medical card applications. Of course, we are usually only ever asked to help in cases where a card has been refused on grounds of income and a review or appeal is sought on grounds of hardship, in most cases caused by the expense of dealing with an ongoing illness or disability.

It is important when dealing with such cases that the system is fair and is seen to be fair. In cases where a refusal to grant a medical card is being reviewed or appealed, the Health Service Executive, HSE, issues a simple “Yes” or “No” decision at the end of its deliberations. This is fine where a review or appeal has been successful but it is deeply frustrating in the unsuccessful cases where people are left in the dark as to the reasons behind the decision.

It is not unreasonable for the HSE to provide a basic summary of the reasons behind such decisions. Such reasons may include insufficient medical evidence, a relatively low level of cost or a myriad of other explanations. This information could prove crucial in deciding whether or not to proceed to a further appeal.

The HSE, however, does not seem to share the belief this is a reasonable proposition. Incredibly, it actively blocks any attempts to disclose the reasons behind its decisions and will only provide them on foot of a freedom of information request. Surely, such a stance cannot be justified. One promise we made when we got into government was to bring more transparency to our decision-making process across all State bodies. Much progress has been made and more will come. In light of such changes, the attitude taken by the HSE is looking increasing archaic and obstructive.

I believe there is a culture in the HSE that has to be changed. There are elements of management within the organisation that do not understand the principle that they are there to serve the public, not to make life difficult for them. Such a culture was referred to recently by the outgoing Ombudsman who pointed out the contrasting difference in policy between the Department of Social Protection and the HSE whose default position seems to be closed and defensive, often to the great cost of the State and the distress of our citizens.

On this particular issue, I see no reason for the HSE to continue with its policy of requiring freedom of information requests before releasing information regarding medical card decisions. If anything, it would streamline the process and help reduce the small number of spurious appeals. More importantly, it would of course remove much of the frustration and distress for medical applicants. Also there is the additional difficulty for some families that they may be handling the application for a person who is unable to do so themselves, either through illness, age or disability. Freedom of information requests in such cases can be difficult if those assisting are not legally the guardians or wards of the person requesting the card.

Will the Minister give strong consideration to changing these procedures? I cannot see how any cost would be incurred by such a change. If anything there could well be savings. More importantly, we would make our system a little bit more human and easier to navigate.

Alex White (Dublin South, Labour)
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I thank Deputy Nash for raising this matter.

Medical cards are provided to persons who, under the provisions of the Health Act 1970, are in the opinion of the HSE unable, without undue hardship, to arrange general practitioner, GP, services for themselves and their dependants. The assessment for a medical card is determined primarily by reference to the means including the income and reasonable expenditure of the applicant, his or her partner and dependants.

Medical card and GP visit card eligibility is subject to periodic assessment review by the HSE to determine a person's continuing eligibility to be approved for a medical card or GP visit card under the general medical services scheme. This can either be on the basis of a self-assessment completed by the card holder or a full review assessment conducted by the HSE.

In the former case, the card holder is simply asked to declare whether his or her circumstances have changed to an extent likely to affect their continuing eligibility to be approved for a medical card. A person who answers "No" to this question on the returned review form will have eligibility renewed for a further period. A person who answers "Yes" is required to provide the details of current circumstances relevant to conduct a full assessment of eligibility.

In cases where a full review of eligibility is undertaken, the review proceeds with an assessment of household means to determine if the applicant is within the income limits to qualify for a medical card or GP visit card. If a review application is assessed to be ineligible on the basis of means for both a medical card and GP visit card or means assessed eligible for a GP visit card only, and the application also includes other medical, social or financial details that do not form part of the means assessment, the application will then be considered on discretionary grounds for a grant of a card under the undue hardship-undue burden provisions of the medical card scheme of assessment.

Having completed a full assessment of a review application, a letter issues to the applicant advising of the decision on the application. If a review application is assessed ineligible or eligible for a GP visit card only, the letter issuing informing the applicant of this decision will include an explanation of how the application was assessed and the details of the means assessment calculated on the application. In addition, the letter will notify the applicant of the details should he or she wish to appeal the decision or provide additional relevant information for a further review assessment.

Notwithstanding the above practices adopted by the HSE in informing an applicant on the outcome of the assessment of the review application and how this decision was concluded, an applicant can appeal this decision or exercise the right under section 18 of the Freedom of Information Act to be provided with a statement as to the reasons for decisions or actions that causes the withholding of a medical card or GP visit card eligibility to the individual concerned.

Gerald Nash (Louth, Labour)
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I appreciate the time the Minister has taken to address this issue in the Chamber. I am familiar, as every Member and public representative is, with the processes involved in appealing a medical card decision. A situation I encountered recently with a constituent has shone a light on some of the inadequacies of this process. The Department of Social Protection deals efficiently with providing details of why a welfare payment has been refused. The HSE and the Department of Health need to be informed by this approach. It is beyond me as to why, in this day and age, a citizen would need to institute a freedom of information request as to why he or she was refused a medical card. I do not believe it is fair or humane. It is not a practice over which we can continue to stand. It is important that this issue is addressed in terms of transparency, openness and fairness.

It is bizarre the HSE has not learned lessons from the past. While I accept it is improving in many respects, along with interacting with the public, it still needs to be understanding of personal circumstances and provide basic information to applicants who have been refused a medical card. The HSE has been less clear on refusals due to illnesses or disabilities. I hope the Minister of State, with his progressive reform agenda, will deal with some of these bureaucratic inadequacies in the HSE, which will go a long way to inspire more confidence in the organisation.

Alex White (Dublin South, Labour)
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I will take very seriously what the Deputy has said on this issue. Towards the end of his second contribution he distinguished between a decision on the basis of income, where the income categories are relatively straightforward and ascertainable and the person either satisfies the requirements or does not, and a discretionary decision. Where the discretionary aspect comes in, a decision is made on the basis of the HSE's additional jurisdiction to extend a medical card even in circumstances in which the person does not satisfy the income limits. When the HSE responds, it also indicates how the decision was concluded. That does not satisfy the Deputy in terms of what information should be given to the applicant on why he or she was refused. The applicant is told that he or she was refused but not why. I will undertake to examine that question. Could the Deputy indicate that his issue is that subset of persons who are relying on an application for a discretionary medical card? I will certainly consider that.