Catherine Murphy (Kildare North, Independent)
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The issue I raise relates to reviews of medical cards which have been granted on medical hardship grounds. Reviews are frequently carried out soon after the medical card has been granted. I am aware of a number of cases where reviews are being done of medical cards that were allocated until April 2015. A problem arises because the evidence provided by medical card holders is not retained and is, therefore, not available to the officials carrying out the review. This means the medical card holder must gather this evidence again as part of the review, which can be costly, especially if they need to visit a general practitioner or consultant. While data protection issues may well arise in these circumstances, these could be overcome if medical card holders were asked to sign a data protection waiver.

I will illustrate the problem I describe by citing a number of cases with which I am dealing. One case involves a young father aged in his 30s who has experienced kidney failure and is being maintained on medication. He is not yet on dialysis. The young man has a mortgage to pay and was awarded a medical card on medical hardship grounds. As part of the review, he must again gather all the evidence he provided for the initial application. His medical card has been withdrawn and he has lodged an appeal. It will not be in anyone's interests if this man cannot afford his medication as the cost to the health service will be higher.

Another case involves an eight year old child with profound disabilities who is in a wheelchair and is fed through a tube. She has the mental age of an eight month old baby and while her parents would love her medical diagnosis to change, that will not happen. The child was awarded a medical card until April 2015 but an early review was initiated, with the result that the parents must go through the whole process of gathering the evidence again because it is not retained by the relevant officials. The same problem arises in respect of another child with a heart problem, which is not likely to change.

In another case, a man in his early 60s who is receiving chemotherapy treatment is unable to work because his condition has worsened. The family do not want to get a letter stating his condition is terminal because they want to hold out some hope. He, too, is being put through a rigorous review.

While I understand that people's financial circumstances change, the medical conditions of many of the individuals in question are unlikely to change. I ask that the rules governing medical card reviews be relaxed to assist people who genuinely need a medical card for reasons of medical hardship. They should not have to endure the torture of having to repeatedly gather certain information given that their health condition will not change.

James Reilly (Dublin North, Fine Gael)
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I thank the Deputy for raising this issue.

Under the Health Act 1970, eligibility for a medical card is founded primarily on the undue financial hardship test. Under the legislation, determination of an individual's eligibility for a medical card is the responsibility of the Health Service Executive. The 1970 Health Act obliges the HSE to assess whether a person is unable, without undue hardship, to arrange general practitioner services for himself or herself and his or her family, having regard to his or her overall financial position and reasonable expenditure. If an applicant's means are above the financial thresholds for eligibility for a medical card or a GP visit card, as set out in the national guidelines, the HSE examines for any indication of medical or social circumstances, which could result in undue financial hardship. However, even where a person exceeds these financial thresholds, eligibility may be granted on a discretionary basis if these circumstances are such that a person cannot access general practitioner or other medical services without undue financial hardship. In these cases, social and medical issues are taken into consideration by the HSE when making a decision on eligibility.

It is important to note that discretion is not a stand-alone exercise. Exercising discretion remains an integral part of the assessment process for a medical card.

Eligibility for a medical card continues for as long as a person meets the criteria set out in the Health Act. The legislation requires a person to notify the HSE of any change in their circumstances, including income, expenditure, medical or social issues, which renders them no longer entitled to a medical card. In practice, few people do so. As a result, the HSE has an obligation to ensure that the medical card register is as accurate as possible and that its voted budget is being spent appropriately in the medical card scheme. One recognised auditing practice now carried out by the HSE is random reviews.

All card holders, irrespective of the basis on which the card was awarded, may be subject to a periodic review of eligibility to determine continuing eligibility. As Deputies will be aware, each person eligible to a medical or GP visit card receives a plastic card on which a "valid to" date is printed. This is the latest date that a review may be conducted in respect of that person. Notwithstanding the "valid to" date printed on the card, the HSE reserves the right to review eligibility at any time and to take appropriate action in circumstances where the cardholder no longer fulfils the criteria for eligibility under the medical card-GP visit card national assessment guidelines.

Persons who have been granted a medical card under the financial hardship provisions of the medical card scheme are required, when the subject of a review assessment, to submit all relevant and up-to-date details. This is necessary so that the HSE can make a correct determination of continuing eligibility. Where an applicant indicates on a review application that medical evidence has been previously submitted relating to a life-long medical condition, and this has been confirmed by the HSE, the HSE will not request further medical evidence in this regard. The applicant will, however, be required to submit all other information material to a review assessment.

A critical element of probity in the medical card scheme is the ongoing review of client eligibility by the HSE. Overall, the HSE assessed the eligibility of more than 700,000 individuals in 2013. More than 95% of complete applications were processed within the 15 working days target. I am satisfied that all reviews undertaken are appropriate and carried out in an appropriate and a facilitative manner.

Catherine Murphy (Kildare North, Independent)
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The Minister stated in his reply that additional information will not be sought in respect of a life-long condition. However, that is not the true in two of the cases which I have brought to the Minister's attention. I will bring that information to the attention of the HSE, using the reply given to me today by the Minister.

I understand that economic situations can change and I am not disputing that reviews should be carried out. However, requiring a person who, for example, is suffering kidney failure and is in receipt of chemotherapy and cannot work to provide information which it is costly to obtain in order to prove that he or she has a medical condition is unfair. The Minister said that the expiry date on the card is the latest date for a review. In the cases of the two children I mentioned the cards were valid to end April 2015 and they had been issued on a three-year basis. There appears to be a systematic review that occurs way short of the expiry date of the card.

The Minister will be aware that for a child with a major disability, such as one of the children to whom I referred, a medical card is of critical importance in the context of access to other services within the HSE, including a public health nurse and so on. As such the medical card becomes critically important in keeping a child like that in reasonable health. I hope the Minister will consider requesting that further changes be made. I do not think it is unreasonable to ask that people whose condition is not going to change not be asked to provide the same information in a fairly short timeframe, when doing so puts them under huge pressure.

James Reilly (Dublin North, Fine Gael)
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On the Deputy's final point, the HSE has guaranteed me that people will be approached three months before a review to advise that one is due and that further details may be required.

On the individuals to whom the Deputy refers, I would like to have their details privately so that I can examine their cases. I do not believe there is anybody in this House who wishes to see families who already are bearing the burden of ill-health or life-long disability subjected to unnecessary distress. That is certainly not what I, as a doctor or a Minister, want to see. I would like to see a situation whereby if medical cards are selected for random review and a desk-top study reveals that the person's situation is unlikely to have changed because he or she has a life-long condition, terminal illness, renal failure or other such problems which are unlikely to have improved, they will be set aside until the regular review is due. I will raise that matter with the PCRS and the Minister of State, Deputy White.

We do have to audit our system. If we did not, the Deputies across might not be the first but they would certainly be among those who at the Committee of Public Accounts would hold me to account for not guarding scarce public resources and ensuring they go to those who need them most. We know that we have a lot of need in our society, that we need to bring fairness and equity to the system and that in the past people in some parts of the country could get medical cards based on very loose criteria while those desperately in need in other parts of the country could not. As stated by the Chairman of the Joint Committee on Health and Children, Deputy Buttimer, in the old days in certain parts all it took was a telephone call and a representation and a person got a medical card. That is not fair.

We want equity in the system in so far as we can. We want consistency of approach. I believe in discretion. Not long after I became Minister I asked the PCRS to set up a team of doctors to ensure that there was a medical input in terms of discretion. They do their best to ensure that people who have life-long conditions, disabilities and other serious conditions that are unlikely to improve are given medical cards. Even those who may now have a poor outlook but may improve in six months or a year's time with new treatment, etc., get the benefit of the doubt in all cases. That is what we try to achieve. In any system of the size of the PCRS, with almost 2 million people on medical or GP visit cards, people will fall through the cracks. A good system should try to catch them. This Chamber is another avenue in which to highlight those cases. I welcome when cases are highlighted so that I can look into them and ensure that all matters have been carried out in a way that allows those who are most vulnerable in our society to get the most help and support that we can give them. That is the purpose and function of the health service.