Mary Harney (Dublin Mid West, Progressive Democrats)

The Government is currently working on Estimates for all Departments in preparation for approval and publication of the Book of Estimates later this autumn. The goal of extending medical card eligibility is a very high priority for me in the context of those Estimates.

The motion before the House offers an opportunity to set out certain aspects of how the GMS scheme currently works. There has been much concern about social welfare recipients losing out on medical cards because of the increases in social welfare rates in recent years. The Department of Health and Children has advised all health board chief executives that medical card holders should not lose their medical cards because they have received increases in social welfare rates announced in recent budgets. In addition, the CEOs have been asked to ensure that both medical card holders and applicants are made fully aware that the increases in social welfare payments would not disadvantage them in any way when applying to retain their medical cards.

As a matter of course, the medical card income guidelines are revised annually in line with the consumer price index. The last such increase was notified in January 2004. Health board chief executive officers have discretion in respect of the issuing of medical cards and also the discretion to take into account a range of income sources that are currently excluded by health boards when assessing medical card eligibility. Despite someone having an income that exceeds the guidelines, a medical card may still be awarded if the chief executive officer considers that a person's medical needs or other special circumstances would justify it.

Non-medical card holders and people with conditions not covered under the long-term illness scheme can avail of the drug payments scheme. Under this scheme, no individual or family pays more than €78 per calendar month towards the cost of approved prescribed medicines.

Since July 2001, all persons over the age of 70 have a statutory entitlement to a medical card. Some people have criticised that decision and I acknowledge the points made by the Brennan commission and others on value for money and its implementation. However, I do not hear many people or party spokespersons committing themselves to reversing the decision.

The health strategy includes a series of initiatives to clarify and simplify the existing arrangements for eligibility for health services, including recommendations arising from the review of the medical card scheme carried out by the health board CEOs under the Programme for Prosperity and Fairness which include, among other things, streamlining applications and improving the standardisation of the medical card application process to ensure greater fairness and transparency; providing clear information on how and where to apply for medical cards; and proactively seeking out those who should have medical cards to ensure they have access to the services available.

I am committed to the preparation of new legislation which will update and codify the legal framework for eligibility and entitlements to health services. Between 1997 and 2003, overall payments made under the GMS scheme have increased from €303 million to €938 million in that six year period. Much of that additional investment was required to address the increasing drugs cost and demand. Also during that time, the number of general practitioners with GMS scheme contracts increased from 1,641 to 2,181.

In this period of office the Government introduced measures to provide medical card coverage for citizens over 70 years of age. Initially, this was on a phased basis in 1999 and 2000 and in 2001 eligibility for medical cards was provided to all people aged 70 or over. The people in this age group are among those in greatest need of health care services. By providing medical cards it allows our older citizens to attend their general practitioner when needed without concern.

Currently, 1.15 million people have medical cards. That figure is lower when compared to figures for other years. It can largely be expected, however, as a result of a number of factors including more people having jobs and more people earning higher incomes. These are positive results for the individuals concerned and for our society.

These factors, however, may also mean that some people are no longer eligible for a medical card on purely income grounds. I point out that this effect is offset to some degree by the policy of the retention of medical cards for people moving into employment. I am happy to acknowledge that this measure was introduced by the rainbow Government in 1996 and has been maintained by this and the previous Government.

The purpose is to remove disincentives for long-term unemployed persons taking up jobs. It means, in effect, that persons on the live register for at least one year, otherwise known as long-term unemployed, who take up insurable employment are deemed to meet the criteria for retaining their medical cards for three years. This provision also covers participants on approved schemes such as the back to work allowance, community employment, Jobstart, jobs initiative, partnership and group initiatives and development courses such as workplace and vocational training opportunities schemes.

The ongoing management and review of the medical card databases has been a factor also in the reduced numbers who hold medical cards. This verification exercise by health boards, which took place in 2003, resulted in the removal of approximately 104,000 cards. Most of these cards would have been considered by health boards to be normal deletions due to death, change in eligibility status or persons moving from one board area to another. A certain proportion were removed due to being duplicates or expired records for people aged 70.

I underline again that our commitment to extend medical card eligibility is one that will be met. By contrast, it has not been part of the strategy for the general medical service under this or previous Governments to achieve medical card coverage for a set proportion of the population as a whole. It is to allocate resources to people based on need — in other words, we will not pick a fixed number to extend them but rather deal with income thresholds and real hardship cases as much as possible.

In this regard, I need hardly add that a policy to implement 100% coverage of the population with medical cards, that is, free GP care for all, is neither socially nor economically equitable. There are not many people who believe that a reform priority for our health services should be that people who are well off, in good jobs, own businesses and have massive wealth should have access to their GP, drugs and dental care met by the rest of society. That is not the route to social equity or the efficient use of public resources.

Primary care in general practice is and will continue to be a key part of our health services. For that reason the Government has increased funding for GP co-operatives. From 1999 to 2003, a total of €46.5 million was invested by the Government in the development of general practitioner led out of hours co-operatives. In 2004, a further €26 million has been provided. Out of hours co-operatives allow general practitioners to put in place arrangements to provide services to their patients while their surgeries are closed in the evenings, weekends or bank holidays. There are out of hours co-operatives in all health board areas — unfortunately, too few of them.

The reform of primary health care has a major role to play in alleviating many of the difficulties that end up in the accident and emergency service or the hospital system. Senator McDowell acknowledged that and I agree with him. We do not solve one problem in the health services without creating others; it is part of a jigsaw. Primary health care and its reform to a modern set of circumstances, as the Senator said in respect of people's working conditions, is a central part of the reform of the health strategy that has been embraced by the Government.

This debate centred on medical cards. The debate in the other House was somewhat broader; I understand it dealt with 80 different items. This is the first opportunity I have had since taking over the Department of Health and Children to say that health care and its reform is a major priority for the Government. Nobody wants to live in a society which does not have a health service that is responsive to people on the basis of medical need and no other basis. Notwithstanding the great injection of public funds into health services, a threefold increase since 1997, we have major challenges ahead if we are to create a system that is fair and responsive to the needs of patients. Above all else, patients must be put first. There are 120,000 people working in the delivery of health care, of whom 97,000 work directly for the Department or the health boards; the balance work for voluntary organisations and other bodies delivering health care. It is a considerable number of people and they do not come cheap. Next year, to meet the salary bill of those who work in the health services will cost €500 million, over and above the almost €10 billion that we spend this year. We must make sure that we operate the health services to the best possible standards, that we have modern work practices in every respect. The manner in which we operated in the past is no longer relevant to an area that is changing very rapidly. We must ensure that our practices are flexible enough to deal with real situations as they arise.

This afternoon I had the opportunity to meet with the chief executive officers of the six Dublin hospitals and the chief executive officer of the Eastern Regional Health Authority, and his deputy. We want to work together and be focused on solving in the immediate future the accident and emergency difficulties that confront the acute hospitals in Dublin. Solving one problem, however, creates others, and in particular there are many people in acute hospitals who should be in different facilities. They do not require to be in the acute hospital services. In the Dublin area alone there are over 300 people in beds who would be more appropriately placed in step-down or other facilities. We must work on different levels to provide solutions if we are to have a health service that can respond within a reasonable timeframe to the expectations of our citizens not just in accident and emergency, but for other services too.

I thank the Cathaoirleach for the opportunity to speak in this debate. I look forward to returning to the House on the health care professionals Bill which will shortly be initiated here, at the request of the Leader of the House. I look forward to returning to the House over the next two and a half years to deal with many aspects of the health services.