Ciarán Lynch (Cork South Central, Labour)
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I thank the Ceann Comhairle's office for allowing me to raise this matter today. I also thank the Minister of State, Deputy White, for coming to the Chamber to respond to it. I wish to propose a minor alteration to the medical card review process. This modification would have no cost, would improve the notification system and would make life much easier for a substantial group of vulnerable people.

When medical card holders are selected for review they are written to and requested to complete forms in order to establish their continued entitlement to the medical card. If they cannot establish that entitlement they are cut off and the system is as simple as that. However, a problem arises with a substantial cohort of people, who are clearly entitled to hold a medical card under the present arrangements, but who for one reason or other fail to return the review forms to the satisfaction of the PCRS.

As the onus is on the cardholder to update the Health Service Executive, HSE, about a change of address or other circumstances this frequently causes difficulty. I will cite some instances with which I have dealt in my office. In all of these cases the people were solely dependent on social welfare income. There was no bar to the renewal of their medical cards. The first instance was an 80-year old man and his 73-year old wife who were cut off because they did not return the forms. They had moved house eight years ago and their new address had never been conveyed to the processing system even though they had visited a doctor and pharmacies regularly during that eight year period. This couple lost their medical card cover abruptly and were refused their monthly prescription. Once the review forms were conveyed to the primary care reimbursement service, PCRS, they were reinstated.

The second case concerns a gentleman who suffers a rare condition, Buergers disease, as a result of which he has had multiple amputations on his hands and feet. He is wholly dependent on the kindness of others and failed to return the forms in the allocated time. This gentleman lost his card cover, was refused prescriptions but has since been reinstated. The third case was cited by Dr. Brendan Crowley in a recent letter to TheIrish Times. It concerns an 84-year old woman with Alzheimer’s disease who was unable to arrange to have the forms completed and returned in time. This lady lost her medical card cover for a period but it has been reinstated.

The final case concerns a couple with two adult, intellectually challenged, dependent children. In this instance the forms were completed and returned in the prepaid envelope supplied but the PCRS did not receive the forms. The gentleman rang to check that they had arrived and fresh forms were sent out. These were completed and inserted in the prepaid enveloped but again the PCRS did not receive them. The application was eventually e-mailed from my office and receipt was subsequently acknowledged. This couple had been without medical card cover for some months but thankfully as of last Monday the card was restored because they qualify on medical and income grounds. I am sure that every Member has encountered situations such as this whereby people who do qualify have lost cover through some disruption in the application process but the cover has been restored.

I have a very simple proposal. At present a general practitioner, GP, is notified that the card is due for review and may be cut off. I propose that the pharmacist who filled the most recent prescription should also be notified of the pending review and its possible consequences. Every patient in need of medication must make contact with the pharmacist at least monthly in person or through a representative and the pharmacist is directly concerned with ensuring that the patient has the correct medication and is ideally placed to assist the patient in completing a review.

All that is required is that electronic notification be given to the pharmacist who last dealt with the patient stating that the patient’s medical card is up for review. It could even be a docket that would be inserted into the prescription bag. The patient or the person caring for the patient-----

Seán Kenny (Dublin North East, Labour)
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The Deputy is over his time now.

Ciarán Lynch (Cork South Central, Labour)
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I will wrap up. I will make a very short response if the Acting Chairman gives me a bit of leeway.

The patient or the person caring for the patient can be made aware of the requirements of the review and if necessary can be assisted in completing the forms by hand or on-line. The Minister of State will say that many pharmacists can deal with the prescriptions. I propose that the notification would go through the last pharmacist. When I dealt with these cases I asked the people to provide a print-out of their pharmacy costs. In all cases they came from one pharmacy. Most people deal with one pharmacist. I am sure that the Minister of State’s research will show this. I await the Minister of State’s reply and will then make additional comments.

Alex White (Dublin South, Labour)
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I thank the Deputy for raising this issue.

I am somewhat unclear as to the specific procedure the Deputy refers to and I certainly was not aware of the proposal that he was going to make before I approached my response to his contribution to which I have listened very carefully. For the benefit of the House I will outline the procedure that is in place. The HSE, has a very structured protocol in place for the review process and every effort is made for ongoing engagement with persons during this process.

Under the Health Act 1970, eligibility for a medical card is founded primarily on the undue financial hardship test and every application must be assessed on that basis. Under the legislation, determination of an individual's eligibility for a medical card is the responsibility of the HSE. The Health Act 1970 obliges the HSE to assess whether a person is unable, without undue hardship, to arrange GP services for themselves and their family, having regard to their overall financial situation and reasonable expenditure. Under the legislation, having a particular illness or medical condition in itself does not establish eligibility for a medical card. That is the law.

All medical card and GP visit card holders are subject to a periodic review of eligibility to determine continuing eligibility. The HSE makes every effort to provide a person with sufficient time to renew their eligibility. Each month, the HSE analyses the Medical Card Register to identify those medical or GP visit cards that are scheduled for review within three months. A review notification will indicate the card holder should complete a self-assessment or request the card holder to return evidence of household income, assessable outgoings and medical circumstances to enable a full review assessment to be conducted by the HSE. The Deputy has referred to that.

The HSE has increased this notification time to four months in respect of those persons who were granted eligibility on the basis of discretion. This is to allow an additional month to ensure that all pertinent medical and other data is provided for inclusion in the assessment process. A reminder letter is issued a month later if the requested review form details have not been returned at that point. If a person does not return the review form within the time specified, continuing eligibility cannot be confirmed and the medical card cannot be reissued. In these circumstances, or where the review process establishes that a person no longer holds eligibility, the eligibility ceases.

Persons are requested to return their completed review forms at least one month in advance of the due expiry date of their existing eligibility. This is to allow the HSE sufficient time to carry out the review and-or to get back to the individuals, if the application is incomplete or requires any further details to be furnished. Where a review form is returned, but not fully completed by the expiry date, it is HSE policy to extend the eligibility of the client for a reasonable period of time until the review is carried out and a final decision made on the person's continuing eligibility, once there is appropriate communication from the person concerned. Medical card holders who genuinely engage with the review of their medical card eligibility will not have their eligibility withdrawn before that review is complete.

In addition - this comes closer to the specific issue raised by Deputy Ciarán Lynch - a person's GP is kept informed of any review notifications of their patients. GPs are advised three months in advance of the review dates of their patients' GP visit cards or medical cards and, subsequently, the following month and the month after that, if the patient has not returned the review form by that time. GPs have full electronic visibility of the medical card panel of patients available to them and have the facility electronically to allow temporary extension of eligibility for expiring cards where a sensitive renewal is appropriate. The temporary extension may also be allowed where they are aware that a person is still availing of services but there may be something that prevents them from carrying out a standard review, for example, a blind person with little family support.

Given that over 40% of the population, or approximately 2 million people, qualify for a medical card or GP visit card, the scale of the administration of the general medical services, GMS, scheme is significant. Over 700,000 individuals were assessed by the HSE in 2013. Well in excess of 95% of applications were processed within the target of 15 working days. In view of the processes I have outlined, and the experience over 2013 that I mentioned I am satisfied that every effort is made to assist, support and facilitate persons undergoing review. I will consider carefully what the Deputy said with respect to pharmacists, and the involvement of GPs, who can extend the eligibility in certain circumstances. There is a different relationship between the GPs and their patient groups because in the GMS a GP has a list of his or her group which has its own integrity as a list associated with that GP. The same would not be the case in respect of pharmacists for the reason the Deputy has outlined. I will consider what he has raised. I did not have an opportunity to do so before he stood up but I will certainly consider it and come back to the Deputy.

Ciarán Lynch (Cork South Central, Labour)
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I thank the Minister of State for his response and for being open to my proposal. The proposal is not a question of changing the qualifying criteria. The criteria remain exactly the same for those who qualify and those who do not. I am proposing a change in the system and its operation that provides a better quality service to the customer who holds the medical card. A difficulty arises for people who fall out of the system and are subsequently entitled. They are penalised for this because they are not reimbursed for any medications they paid for during that period if they do not have medical card cover. The Minister of State is dead right to say that the GP monitors the overall situation but I propose bringing the pharmacists into the equation. Research in my office will show, and I am sure that it would show if the HSE were to carry out detailed research, that most people on medical cards deal with one sole pharmacist. It might be the case that when people are occasionally sick they get medication from the nearest pharmacy on the way home but most people who have an illness deal with one sole pharmacist.

What I am proposing is that they go into the notification system. In the cases I have dealt with, particularly the cases where people had changed address, they had no notification that the card would expire and so were not engaging with the system. The pharmacists might even have had the wrong address. When the person goes to pick up the prescription bag, perhaps there should be a note inside in the bag or some acknowledgement stating that the card is about to expire, outlining the details the pharmacist has and explaining that if the person does not respond, he or she will be out of the system.

What I am proposing is a very small adaptation to the system, one which improves the quality of service which the HSE is providing and which ensures that people who qualify for medical cards do not find themselves temporarily outside of cover, with costs accruing during that period for which they cannot be compensated at a later time. If a person does not have card cover and subsequently re-qualifies for the card, those costs cannot be reimbursed.

Alex White (Dublin South, Labour)
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As I indicated to the Deputy earlier, I will certainly discuss the issues he raised with the PCRS. One of the drawbacks I foresee, and to which the Deputy alluded, to be fair to him, is the question of which pharmacist to use. The Deputy helpfully suggests it would perhaps be the most recent pharmacist, but it is not necessarily always the case that the most recent pharmacist a person has seen is their usual pharmacist. While I am being slightly speculative, it might very quickly draw the system into having to then notify a multiplicity of pharmacists in respect of one individual, which would obviously be problematic.

The differences I outlined earlier between the pharmacists and the GP are that the GP has a set list and tends to know his or her patients over a period of time. I had a very interesting meeting yesterday with the Irish Pharmacy Union. It makes the point that community pharmacy is very important in our system, and I agree with that. The pharmacists are close to many of the people they see and they very often know their needs. We want to integrate and make sure that the pharmacy profession and pharmacists do that kind of work and have that relationship with their patients, as I know they already do and are anxious to have.

For all of those reasons, I will certainly take seriously what the Deputy has proposed. It is not without complication administratively, I would have thought, but we will have a look at what he is saying.