Éamon Ó Cuív (Galway West, Fianna Fail)
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Tá áthas orm deis a bheith agam an t-ábhar seo a thógáil anseo sa Dáil.

There are 3,000 people living on our offshore islands. It is a very small, but valuable population. There are basic GP services on most of the islands with reasonably large populations, but for all other medical services, islanders must go to the mainland. This imposes all sorts of challenges. For example, if an islander has to be at an early appointment in the likes of Galway or Letterkenny, it often means leaving the night before and staying in a guesthouse overnight. If the patient has to be accompanied by someone, it means two people must do that. If it is a child going to Dublin, it can mean two overnights – one to get there and the other to get back. I am not even talking about the time spent in the hospital. It might only be a day appointment, but that would still require the parents and the child to overnight. That is a lot of extra cost.

It is estimated that the average cost of living on an island is 33% higher than it is on the mainland. Over the years, schemes were introduced to recognise this well-recognised reality. For example, islanders pay cheaper car tax because their cars cannot go on the mainland. In most cases, they have to keep second cars. Islanders get an extra allowance under certain long-term welfare payments, for instance, the State pension, the invalidity pension and so on.

What we are seeking is that, when the assessment is carried out, a considerable allowance be built into the calculation to account for the extra costs associated with living on an island. This would be easily ascertained, as the health services know the addresses of everyone living on the islands.

An island GP wrote to me, and maybe she is right. She believes that every single person who is actually resident on an offshore island should be automatically entitled to a medical card. As she states, life on an offshore island has a multitude of difficulties and hardships and anyone needing medical attention off the island has to endure a long journey and often an overnight stay or two even if it is only for a day appointment, and is not guaranteed to get home as planned if the weather changes.

For these myriad reasons, if we could get the Government to take the big jump and do the obvious and simple thing of giving everyone on an offshore island a medical card, it would save on a great deal of administration and calculation, as many of the 3,000 already have medical cards. If that is too big a jump to take in one go, then the alternative is to build into the calculation a considerable allowance so that what is reflected is not people’s nominal incomes – it is 33% dearer to live on an offshore island – but their disposable incomes, which are much lower than is the case on the mainland.

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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Ba mhaith liom buíochas a ghabháil leis an Teachta as ucht an cheist seo a cur. Eligibility for a medical card is primarily based on a financial assessment, which is conducted by the HSE in accordance with the Health Act 1970. The HSE assesses each medical card application on a qualifying financial threshold. This is the amount of money that an individual can earn per week and still qualify for a card. It is specific to the individual’s financial circumstances. As of 1 April, almost 1.6 million people hold eligibility for a medical card and 660,487 hold eligibility for a GP visit card.

Persons aged 69 years and under are assessed under the general means-tested medical card thresholds, which are based on an applicant’s household income after tax, PRSI and the universal social charge. Certain expenses are also taken into account. Examples of allowable expenses include rent, mortgage, certain insurance costs, childcare, maintenance and net nursing home costs, which help to increase the amount a person can earn and still qualify for a medical card. Some social welfare payments, for example, child benefit, fuel allowance, etc., are also exempt from medical card income assessment.

In this context, there is an existing increase for living on a specified island, which is sometimes called the island allowance or island increase. The Deputy will be familiar with it. This is intended to compensate for those extra costs of living on an island off the coast of Ireland. The Deputy may wish to note that the island allowance is also exempt from assessment when applying for a medical card.

Every effort is made by the HSE, within the framework of the legislation, to support applicants in applying for a medical card and, in particular, to take full account of the difficult circumstances in the case of applicants who may be in excess of the income guidelines. The HSE may exercise discretion and grant a medical card even though an applicant exceeds the income threshold where he or she faces difficult financial circumstances, such as extra costs arising from an illness. Social and medical issues are also considered when determining whether undue hardship exists for an individual accessing general practitioner or other medical services.

The Minister for Health assures the Deputy that, in order to ensure the medical card system is responsive and sensitive to people's needs, his Department keeps medical card issues under review and any proposals are considered in the context of potential broader implications for Government policy, the annual budgetary Estimates process and legislative requirements arising.

I note the pertinent points the Deputy made about the additional costs that islanders face. Living on islands is something that the Government wants to encourage and support in order to keep as many families on the islands as possible and to keep our islands alive and vibrant into the future.

Éamon Ó Cuív (Galway West, Fianna Fail)
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I thank the Minister of State for reading out the reply. It is the exact same as I received to a parliamentary question on 6 March 2024. If the Department of Health thinks I am going away, I am not. The reality is the Minister of State addressed the issue at the very end. The script did not address the realities of the issue.

I was amused that the officials mentioned the fact that social welfare recipients of a certain type receive an islander allowance. I persuaded the Minister for social welfare of the day, when I was Minister of the islands, to introduce that. It was progressive. They recognised, in the social welfare code, that there are extra costs living on an island but the reality is most of the people referred to in that part of the reply already have medical cards. Mainly, they are pensioners and, as the Minister of State will be aware, for those over 70 years, there is a much higher threshold. They are not the target group.

Many people on the islands are young and are working and we want many more young and working people on them. We want to create a viability to rear families on the islands.

Children up to a certain age get GP cards, but we need full medical cards, and we need it for the parents, for two reasons. The first is it is dearer to live on an island, irrespective of one's health condition. The second is it is way more expensive to access medical services, as the Minister of State can appreciate, if people have to travel from an island, get to the mainland and, as we have pointed out in many cases, and as the doctor pointed out, stay overnight or a second overnight to get to their appointment and back even though it might be only a day appointment.

There is probably another script - the Minister of State need not bother - but maybe we would deal with the issue rather than scripts. What I would hope he would say is that he will print out the transcript of this debate and make sure it gets into the right hands. This would be a cost-neutral exercise because by the time they take all these criteria and they do all this means-testing, the cost of giving the medical care would be well covered by the saving on very expensive bureaucracy.

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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I will not be disingenuous and read the script in closing because the Deputy is well aware of the response.

The issue he is raising is a much broader issue in terms of the reality of living on the islands in this day and age. It is a broader issue for Government and future governments to consider in respect of the economic, financial and other supports that can be put in place to ensure - it is something we all want to achieve - that we keep families living on the islands but also increase the number of people living on the islands, and particularly attract young people who want to choose living out on our beautiful islands as a lifestyle and a wonderful way of living.

As I outlined in the opening response, that is the scheme that is in place, but what the Deputy is raising here is a much broader issue about affordability and the harsh reality at times of services being available on the mainland and people being able to access those services and being able to afford to access those services. I will take this back to the Minister and for wider discussion within government around that as well.

Catherine Connolly (Galway West, Independent)
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This is particularly relevant, given the topic that is coming after this.