Paschal Mooney (Fianna Fail)
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Before taking the motion, I would like to extend a hearty céad míle fáilte on behalf of the House to the newly promoted Minister of State, Deputy Seán Power. It is a great privilege and pleasure to have him here for the first time in his capacity as a Minister of State. I wish him well.

Mary O'Rourke (Fianna Fail)
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As Leader of the House, I also bid the Minister of State welcome. I am sorry that it is not more rousing.

Brendan Ryan (Labour)
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Both as a Member of the Oireachtas and as a Kildare man, I would like to associate myself with the welcoming remarks. I have known Deputy Seán Power for many years. Our fathers were acquaintances, to put it mildly, in Fianna Fáil circles in County Kildare, so he is particularly welcome. With all the nuances of politics, I wish him well in his ministerial office. He is more than capable of doing a good job, and I hope that he is allowed to do so.

I move:

That Seanad Éireann, noting that the number of persons holding medical cards is more than 100,000 less than it was in 1997, and recalling the promise before the 2002 election to provide 200,000 extra medical cards, condemns the decision by the Government to abandon that election commitment and calls for:

(1) an immediate commitment to restore the number of medical cards to that extant in 1997,

(2) to provide the promised additional 200,000 and

(3) to outline a timetable for the introduction of a comprehensive system of primary health care which is free at point of use.

I was entertained by a little piece on the RTE web news today in which the Tánaiste appealed to Opposition parties not to play politics with problems regarding delayed heart surgery in Our Lady's Hospital in Crumlin. I can only say that when Ministers stop claiming credit for anything good that happens in the health services, those of us in Opposition will stop raising everything wrong with them.

The motion deals with the number of people who have ceased to have medical cards and the failure to implement a very explicit promise to extend the number of such cards. I intend to deal with the entire issue. I remember something that used to cause great hilarity in my house when my children were small. When they were having their fun and wanted to run around a little, Daddy used to cover his eyes with a blindfold and pretend to chase them around. Of course, being blindfolded, he could not see where he was going. Were it not for the human suffering involved, watching the Government's performance on medical cards would provide the rest of us with some similar entertainment. Once it had put its ideological blindfold on, it could never really manage to do anything properly regarding the health services, and that is what has happened; it has let ideology get in its way. The Tánaiste is now reaching the stage where she is defensive about the whole suggestion. She is not an ideologue but a pragmatist, and I may return to that theme later.

Let us deal with the indisputable facts. The percentage of the population that holds medical cards has dropped dramatically in the seven years that the Government has been in power, from perhaps 39% of the population to perhaps 27%. What is beyond doubt is that approximately 100,000 medical cards have effectively been withdrawn, since people have ceased to be eligible. It is worth putting on the record the income levels under which one is eligible for a medical card — it is a matter of opinion whether one is entitled. The threshold is €206.50 per week for a married couple and €26 for each additional child. The position for a single person is not even clear-cut, but it is approximately €142 per week.

The legislation under which medical cards were introduced makes it clear that such a card is meant to be available to someone where it would cause undue hardship for him or her to have to pay for GP services and drugs bills. The spin-off from the medical card system has been an enormous improvement in the dignity of those holding one over the previous dispensary doctor system in which people were stereotyped. It is perhaps the most effective and visible area where everyone has access to what is essentially the same service, subject to the one major caveat of money. Most people going into a doctor's surgery to see a GP have no way of knowing whether the person in front or behind in the queue is paying the doctor or has a medical card. That is a very progressive position.

However, the number of couples in this State who have an income below €206.50 has, thankfully, dropped. It is a very good thing that the proportion of our population on that sort of income has fallen. The proportion of the population with an individual income of less than €142 a week has also, thankfully, dropped. Let us all celebrate that happy situation as the achievement of sensible economic policies pursued by a succession of Governments going back to the late 1980s. However, as we have all become prosperous, doctors have sought to share in the prosperity, so that the price one pays for going to see a GP has gone up not at the rate of inflation but at the rate at which incomes have risen. It is probably a little unreasonable to suggest that GPs should have done other than increase their fees in line with the aspirations of society at large. Now a couple with two children, one of whom is working full time and another part time on the minimum wage, and with an income of €380 a week, are in our legislation and culture, and behind our ideological blindfold, presumed to be able to pay for medical care for themselves and their children without undue hardship.

This means that if they go to a GP they should be able to pay a sum between €35 and €50. Later on that week, if one of the children gets an infection along with a bad headache — the warnings about meningitis appear on television — the parents may bring the child back to the GP and pay perhaps another €40. The child then turns out to be suffering not from meningitis but from an ordinary infection which necessitates a prescription. Prescriptions are expensive and the parents may have to pay €50 or €60. In a one-week period, it is therefore not unreasonable to say that a couple earning less than €400 would have to fork out €50 for a doctor, perhaps twice in a bad week in the winter, when children get sick.

We all know how quickly children get sick and how one worries about them. The couple, one of whom might be earning the average industrial wage and the other working on a part-time basis, must pay €150 out of their week's income. Our dominant political culture, as exhibited by the Government which has been in power for seven years of unprecedented prosperity, has resulted in that being seen as acceptable.

One Member from the other side of the House said to me that I should be celebrating people's escape from dependence on the State because they no longer had medical cards. The ESRI report published yesterday made it clear what this escape from dependence meant, namely, that when people moved marginally above the income eligibility limit for a medical card, the average number of visits to a GP dropped from 6.6 per annum to 3.6 per annum. Neither figure is excessive. An average rate of six or seven visits per annum to a GP for someone on a medical card is not excessive. What we have is a deliberate decision to leave eligibility alone. That is why the amendment is so intellectually offensive. It gives the impression that something very positive happened accidentally, namely, that incomes went up.

The income levels for eligibility for medical cards are not written in stone. The Government could have doubled the income allowance for children and for couples, for whom it could have increased the allowance by 50%. There was no reason not to except that getting people off the medical cards saved money and created the illusion that more money was available for other elements of the health service. Ultimately, it was a matter not of resources, of which there is no shortage in this State, but of an ideologically driven view of how a health service should run, namely, that as many people as possible should be driven out of public health care into private health care, since it is for this that the Government stands.

Having the resources and the money, the Government could have afforded to do something about medical cards. It chose different priorities, leaving a significant gap and great hardship for young working families with young children for whom every hint of illness in the family is a threat of imminent hardship because of the scale of the costs involved and the absence of proper public support.

Kathleen O'Meara (Labour)
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It is with great pleasure that I second the motion. I understand that the new Minister for Health and Children, Deputy Harney, will attend the House later to speak on the motion and I welcome that. When she took over the Department, one of her first remarks was to note how the income threshold for the medical card had fallen and that it should be addressed. While I welcome that, the question has occurred to me as to where she has been for the past seven years. She has been sitting in the Cabinet which made the decision not to increase the income thresholds for the medical card. She has been sitting in the Cabinet responsible for the fact that fewer people now have medical cards and that people are in some cases facing serious hardship because they are over the income limit for a medical card.

Although there are many public representatives in both Houses aware of the hardship caused by the stinginess of the Government regarding this issue, and its failure in this as in other matters to live up to its promises, I will confine my remarks to Members in this House. We sit in our offices and clinics, meeting people who are struggling and cannot afford to go to the doctor. Senator Ryan has pointed that out graphically.

Children in poor families are one of the groups suffering. This morning I attended a budget briefing in the Mansion House by the End Poverty Coalition. That is an umbrella group for a large number of voluntary organisations working with children, including Barnardos, the largest charity, the Society of St. Vincent de Paul, the Children's Rights Alliance, etc. They have already made their budget submission and they consider it an absolute priority that the medical card income limits be extended. They feel the medical card should be widely available to children and they state that we can afford to make them available.

Poor families suffer from ill-health and that has been so in this country for a considerable period. In the past ten years in particular, and specifically in more recent years, we have had the resources to ensure that we can tackle disadvantage and poverty and deal with the fact that poor people suffer ill-health. This Government has chosen not to do so.

I have previously listened carefully to the comments of the Tánaiste, now also the Minister for Health and Children, and will listen carefully to her this evening because there seems to be a realisation that there is a problem. Whether that realisation is linked to results in the local elections of last June remains to be seen, but the budget will be a benchmark of the commitment of the Government to tackle the very serious issues facing us, particularly those related to poverty.

Another group comprises old age pensioners who are not yet 70 and have thus not reached the age of automatic entitlement to a medical card. They are aged between 66 and 70 and their pensions put them over the threshold for the medical card. I have met a number of these people, who live in fear of being ill because of what it can cost to visit a doctor.

Another group is single people on low incomes. They might be in their 20s and perhaps not supporting a family and children. They are over the income limit for a medical card but because they are on low incomes, they cannot afford to go to GPs.

I apologise for neglecting to welcome the Minister of State, Deputy Seán Power, to the House. I congratulate him on his appointment and we are pleased to have him attend the House. I put it to him, however, that we are paying an economic cost for the fear of single people on low incomes to visit a GP because of a simple lack of funds. These people must instead resort to an accident and emergency unit and we are approaching the winter when such units will come under even more pressure. It was noted in previous years that people used hospital outpatient departments because they could not afford to go to a GP. They are part of the significant number of people queuing in hospital outpatient departments, sometimes for days, for treatment which could possibility be administered at primary care level.

The second economic cost relates to those who do not attend a GP because of their lack of income and who leave an illness until such time as it may require hospital care, leading to absence from work and decreased productivity. We are short-sighted in our approach to this issue, given that the Government is so clearly committed to economic productivity, which is not bad in itself but should not come at the cost of people's health.

I look forward to hearing what the Minister has to say. There is no doubt policy on medical cards is not only leading to hardship but contributes to an increasingly two-tiered society in which, if one is on a low-income, one is effectively consigned to a life of hardship and one's ability to get out of the poverty trap is impaired.

On Monday last The Guardian commented on the British Government's stated policy of getting people back to work, which is a good policy. However, the newspaper noted that simply being back at work does not deal with the issue of poverty because of the problem of low income. Those in low income jobs need supports similar to supports received by those in other employment. We must also consider the position of low income families at work, in particular the implications for children. While there is a serious housing problem, I will confine my remarks to the subject of debate, which is related to health.

The medical card is an important instrument in assisting those in poverty and is particularly important for the children of poor families. In that regard, it is a serious public policy issue. I hope the Government is rethinking its policy and that the days of stinginess are over. In particular, I hope the days of assuming that somebody on a medical card visits a GP for the sake of it are also over. The figures show that people visit doctors when they are ill. Unfortunately, due to Government policy, many people are ill who cannot afford to see their doctors.

Camillus Glynn (Fianna Fail)
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Cuirim fáilte roimh an Aire agus gabhaim chomhghairdeas leis. I welcome the Minister of State and congratulate him on his appointment to office. I am sure he will be a great success in his new role.

I move amendment No. 1:

To delete all words after "Seanad Éireann" and substitute the following:

"notes with approval the unprecedented levels of growth that have been and are being experienced in the Irish economy and the consequential rise in employment levels. Seanad Éireann also notes, that a consequence of these higher employment levels is that fewer people qualify for medical cards and commends the Government for its measures which enable persons returning to the work force after long-term unemployment to retain the medical card for three years and for its commitment in the programme for Government to extend medical card eligibility further.

I welcome the debate and look forward to the contribution of the new Minister for Health and Children, Deputy Harney. She excelled in her previous portfolio and I am sure she will have the same level of success in her new position.

I agree with the Minister's recent statement that we must reconsider the question of medical card eligibility. It is far too low and has undoubtedly slipped back significantly in recent years. Senator Ryan stated that GP consultancy fees have increased substantially, which is the case. However, it is important to note that the Government introduced the minimum wage for the first time although I do not claim that this is wonderful as it should have happened long ago.

It is also important to note that medical cards are an income-related facility. In tandem with the provisions of section 45 of the Health Act 1970, the chief executive officer of a health board has certain discretionary powers in regard to those who exceed the guidelines, which were reviewed in January last. The question of medical evidence plays an important part in the case of those who are ineligible for a medical card due to a medical condition. Even where the medical evidence precludes the applicant from qualifying for a medical card, the chief executive officer can, if he or she considers there is financial hardship, grant a medical card.

For those who do not qualify for a medical card, there are schemes such as the long-term illness scheme and the drug payments scheme. Many allowances such as carer's allowance, child benefit, domiciliary care allowance, family income supplement and foster care allowance are all disregarded when determining a person's eligibility. Given these factors and the discretionary powers of the chief executive officers, having an income that exceeds the guidelines does not mean that a person not eligible for a medical card will definitely not be awarded that card. In over 25 years in public life, I have dealt with many cases in which a claimant was outside the guidelines but, because of financial difficulties, was allowed a medical card.

Students who are financially independent of their parents are also entitled to apply for a medical card in their own right. There was a time when students were entitled to a medical card but a Labour Party Minister for Health discontinued this.

Brendan Ryan (Labour)
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That was so long ago, Joe Duffy was in jail.

Camillus Glynn (Fianna Fail)
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History is an important subject because if we learn from mistakes we will not repeat them. Senator Ryan is a member of a party with a moving policy — it makes it up as it goes along. However, those of us who live in the real world must deal with the facts as they are.

It is open to all persons to apply through the chief executive of a health board for a medical card if they are unable to provide these services for themselves or their dependants without hardship. In line with the health strategy, Quality and Fairness — A Health System for You, the possibility of extending the medical card by statute to various groups is undergoing ongoing review in the Department in the context of the strategy's second goal. This should be viewed in the broader context of the strategy's emphasis on fairness and its stated objective of reducing health inequalities in our society. It is a fact that there are and have been inequalities and while much work has been done in this regard, more needs to be done.

I agree with Senator Ryan that the time is past when people trailed into the surgeries despite everybody knowing the situation. The medical card scheme, the GMS and the choice of doctor scheme were innovative policies which should be welcomed by all right-thinking people. Health board chief executive officers have discretion in regard to the issuing of medical cards and a range of income sources are excluded by the health boards when assessing medical card eligibility.

Reference was made to the number of medical cards which have been discontinued. As it is an income-related facility, it is to the credit of this Government and the incoming Minister for Health and Children, who brought many more people into the workforce, that people are now in the workforce playing their part in society and are therefore falling outside the eligibility terms for medical cards.

Although a person's income exceeds the guidelines, a medical card may still be awarded by a health board chief executive officer. The health strategy includes a series of initiatives to clarify and expand the existing arrangements for eligibility for health services, including recommendations arising from a review of the medical card scheme carried out by the health board CEOs under the PPF which include streamlining applications and improving the standardisation of the medical card application process to ensure more fairness and transparency. There were many difficulties in dealing with applications that I as a public representative dealt with over many years by providing clearer information to people about how and where to apply for medical cards.

As somebody with a background in the area of health I am aware that there are people who can afford to go to a doctor, or people who have medical cards, who will not go to a doctor for reasons best known to themselves. One reason that has been put forward is that they might not like what the doctor might have to say. I do not know whether that is true.

The Department of Health and Children is committed to the preparation of new legislation to update and codify the whole legal framework for eligibility and entitlement in regard to health services. There are 768,895 medical cards at the moment, covering 1,151,106 people. That is just under 30% of the population. However, it must be recognised that many of the people who had medical cards have entered the workforce and are now ineligible for a medical card.

Brendan Ryan (Labour)
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The eligibility terms should be changed.

Camillus Glynn (Fianna Fail)
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That point has been conceded and I agree with the Minister on that. However, the terms have been adjusted every year. That must also be conceded.

In 2003 payments under the GMS to general practitioners in respect of capitation fees and allowances amounted to €286.8 million. Many cards were withdrawn because of duplication. In addition, many people are now outside the terms of eligibility for a medical card because they have been inducted into the workforce as a result of the policies of the incoming Minister. That must be appreciated and welcomed because nothing compares to the dignity of work.

Fergal Browne (Fine Gael)
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I welcome the Minister to the House and congratulate him on his appointment as Minister of State at the Department of Health and Children. His appointment was welcomed in Kildare although it is a point of contention that we in Carlow-Kilkenny got no Minister. However, it is the new Minister's moment of glory and I wish him well in his new job. I hope he will not forget about Carlow.

This motion is very appropriate. I am glad the Government parties are not querying the need to do something in this area. It should be borne in mind that people on the minimum wage will not qualify for a medical card. That is the bottom line. I accept the point Senator Glynn makes regarding people being back at work. However, we all see people in our clinics who are barely outside the eligibility criteria for medical cards and we also fight cases for them. Most are subsequently granted a medical card. Unfortunately, some are not. Many people are put off and do not bother applying because they do not realise they can apply for one based on medical condition if their income is in excess of the strict financial limit.

A married couple with an income of €206.50 a week who are under the age of 66 cannot qualify for a medical card. If someone on an income of €206.50 a week needs to go to a doctor — the going rate in Carlow is at least €45 — then to a pharmacy where the cost of drugs will be at least €40, and make a return visit to the doctor at €45, the total expenditure is at least €120, more than half their income. That is the real issue.

As a public representative it annoys me when people who have had a medical card for years are cut off for some reason and must go through the whole process of applying for a new medical card, arguing their case, invariably on medical grounds. They are then granted a card, but months will have elapsed and in the meantime they will have amassed huge medical bills and have wasted the health board's time because the staff in the health board must deal with an issue they should not have to deal with. I ask the Minister to ensure that if somebody with an ongoing medical condition has a medical card it is renewed automatically. It would save everyone time and effort and ensure people do not run up expensive bills.

I had a case in Carlow recently of a constituent who has severe medical problems, whose daughter has only one kidney and also suffers major medical problems, failing to qualify for a medical card. I was successful in arguing a case for them, but they endured months during which they did not have a medical card and ran up huge bills in the meantime. That should not be allowed to happen. One message I hope the Minister will take away from this debate is that people with an ongoing medical condition which has been proven and who have a medical card should not be forced to apply for a medical card every year. It is unnecessary.

The Government's record on health is atrocious. I welcome the appointment of Deputy Harney as Minister for Health and Children. The previous Minister, Deputy Martin, did not do his job. He fudged every issue he could. He commissioned report after report but did not enact many of their provisions. All he did was write further reports on the reports. I hope that when the new Minister gets up to speed in the Department she will take decisions and implement them. Her predecessor did not do so and we are suffering as a result. I hope the Minister will not commission any more reports. We have plenty of reports. I am sure the Minister of State must have shelves of reports in his office which he will never read. I hope that all the reports that have been written will be implemented.

In 1997 and in 2002, a clear promise was given by the Government to increase the number of medical card holders by 200,000. It is appalling there are now almost 100,000 fewer card holders. That is even more remarkable when one considers that in the meantime all people over 70 years automatically qualified. There is no doubt that many of those people deserve to have a medical card. However, there are many people over the age of 70 years who could afford private medical care and do not need a medical card. That is a big difficulty.

I urge the Government to give careful consideration to giving medical cards in respect of children under four years of age. Based on my experience with my nephews and niece the difficult period for children seems to be between birth and four years of age. After the age of four years, children tend not to get sick as much. When they are older they might fall out of a tree and break a leg but that is an occasional mishap. Invariably if there are three or four children in a family and one gets sick there is almost a guarantee that the other two or three will also get sick. It puts a huge strain on families if they have to go to the doctor with three or four children, to the pharmacy for drugs and then to the doctor for a repeat visit. The Government should, therefore, consider giving those under four years of age a medical card and prioritising medical cards for the elderly who have an ongoing medical condition. Those who need medical cards most should be targeted. I am terrified of a free-for-all system. With respect to Dr. Michael Smurfit, as he is over 70 years of age, he would be entitled to a medical card. All Members will agree that he does not need it as much as a woman with a family on the minimum wage. Anomalies in the system need to be addressed.

The national health strategy, published in 2001, promised an investment of over €1 billion in primary care yet three years after its publication only €16 million has been spent. The Department only refers to ten pilot projects when 600 primary care centres were promised by 2012. Badly needed funding for primary care is being withheld until 2007. This morning my local radio station held a discussion on medical cards where the point was made that last year income levels were not increased. Another disastrous decision that the Minister must take into account is that of former Minister for Finance, Deputy McCreevy, who raised the threshold level for the drug refund scheme. While the medical card threshold has remained the same, accident and emergency charges and the drug refund scheme threshold have increased, a double slap in the face.

Yesterday's ESRI report on health provides food for thought. It claimed medical card holders only attend their GPs 6.6 times a year, validating Senator Ryan's point about the misconception that they go to the doctor every day of the week. People in private care attend 3.5 times a year. This indicates that the cut-off level is wrong. People are harming themselves by not going to the doctor because they cannot afford to do so. This has a knock-on effect on absenteeism from work which IBEC recently highlighted. I urge the Minister to increase the threshold level for medical cards and consider giving cards to all under four year olds. Those on the minimum wage must qualify for medical cards. Those who already hold medical cards, and whose medical circumstances have not changed, should not be forced to renew their applications. It is unnecessary and time consuming for everyone involved.

John Minihan (Progressive Democrats)
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I am delighted to speak on this motion and I welcome the Tánaiste's appointment to the health portfolio. While the health service is one of the major issues of debate, we should remember that our health service, when compared internationally, is a very good one. I admit there are problems but since 1997 the coalition Government has endeavoured to address these in many ways. Various reports on health reform have been compiled and are now in their implementation phases. The Progressive Democrats, along with our Government partners, are confident that when we face the electorate, it will be seen that we have delivered on the commitments made to health service reform. Members have argued that if the reform of the health service were purely a question of money, we would have a health service second to none. Members should recall that €10 billion is now spent on health care compared to €3 billion in 1997. If we had known then that €10 billion would be spent by 2004, our health service would now be second to none. However, this is not just about money.

The medical card system can be looked at as a glass half full or half empty. It must be acknowledged that many people's standard of living has increased to such a point that they can forfeit their entitlement to a medical card. That is not to say there will not be people on the threshold who find themselves ineligible. The introduction of the minimum wage should be used as a benchmark for society. If one is below the minimum wage, one should be ineligible for taxation and entitled to those services provided by the State such as medical cards. Hopefully, this will be achieved some day.

Any examination of the medical card system must be done in the wider context of the operation of the GMS scheme. Between 1997 and 2003, the scheme's budget increased from €303 million to €938 million. Much of this additional investment was required due to increases in drug costs, the demands from a growing population and an increase in the number of general practitioners operating in the scheme from 1,600 to approximately 2,200.

The Government introduced medical card eligibility for those over 70 years as an assurance that they can, without fear of financial restraint, approach doctors for medical care. Approximately 1.15 million people are covered by medical cards. While I admit this is a lower figure than previous years, it can be explained by our changed economic circumstances. Many people are no longer eligible on means grounds. The management of the medical card scheme and the introduction of databases have removed duplicate and deceased card holders. These improved internal management structures within the health boards in identifying those eligible for medical cards have changed the figures. The introduction of the co-op scheme with general practitioners providing 24 hour direct access to a doctor has also made a difference. Further work is needed to alleviate the difficulty of people going directly to accident and emergency departments rather than their GP for minor medical issues. This has created a bottleneck at one end while at the other, sufficient step-down facilities are not available to free up acute beds. With the implementation of the reform programmes adopted by the Government, more people opting for co-op GPs and step-down facilities, the freeing up of acute beds will increase. The Government has responded to the need for reform with increased staffing for general practitioners — for example, nurses, whether asthma specialists or general GP nurses, can now work in GP surgeries. Given our multicultural society, GPs are being offered training to deal with non-EU nationals and language difficulties. Funding has been put in place by this Government in that regard.

I have no doubt the Government is committed to extending medical card coverage, as set out in the health strategy, to increase the number of persons on low incomes eligible for medical cards and to give priority to families with children, in particular children with a disability. While this commitment may not have been met to date, this Government will be judged on what it delivers over a five year timeframe. History has proven that if we continue to pump money into the health service without addressing the management deficiencies in that service, we are throwing money at a system which will not deliver the standard of health care we want.

The health boards and their chief executive officers have addressed the new guidelines laid down for the extension of medical card facilities for those returning to full employment. That was a welcome development in that people were not dissuaded from entering the workforce on the grounds that they would lose their right to a medical card. These are welcome measures which are necessary in order to move people away from becoming dependent on a social welfare system and to encourage them to go back into the workforce.

I support the Government's amendment. We have a health service that is moving in the right direction and we now have a Minister who will continue the reform programmes this Government has set out. When the Government completes its term of office, it will be seen to have made a major difference to the health service delivered to all citizens.

Mary Henry (Independent)
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I welcome the Minister of State, Deputy Seán Power, and look forward to seeing a lot of him in the House because I have found him a good person to work with.

I find the amendment to this motion very depressing because while we all know there has been terrific economic growth in this country over the past ten years and that there has been a huge investment in the health service, the paper published by the Economic and Social Research Institute yesterday entitled Ireland's Health Care System: Some Issues and Challenges, by Anne Nolan and Brian Nolan, made the most profoundly depressing reading. Having spent €20 of my own good money on it, I will give Senators some of the benefit of what they said in their conclusions. They looked at Ireland and the basic outcome of our health service, including the life expectancy of men and women, infant mortality rates, low birth weights and so on. The only country worse than Ireland is the United States and I hope the Government takes this into account when considering the fact that investment in financial terms is not the only thing that matters with the health service. The paper states:

Some of the difficulties in such a benchmarking exercise were seen when we [looked] at a key indicator, namely the level of health spending. This has risen very rapidly indeed in nominal terms in recent years, outpacing even the exceptional scale of economic growth. However, in purchasing power terms and as a percentage of GNP it was only at the UK level — which the British government considers too low compared with other EU countries — by 2002. Re-classification of some spending by the Department of Health by the OECD in 2003 also significantly reduced their estimate of Ireland's health spending, a process which may not be applied uniformly across countries.

In other words, some expenditure which we put under the health heading was included by other countries under social services.

The report further states:

With primary care a central focus of official strategies we then investigated the use of general practitioner services by people at different income levels, in particular those with and without entitlement to free GP care. Having controlled for other characteristics, including health status, those with medical card cover were found to have on average about 1.6 more visits each year than those with similar characteristics but without a medical card. Even if the health status indicators available to us understate the difference in needs between those with and without medical cards, it seems likely that the different financial incentives they face also play a role in producing this very substantial gap. The current substantial charges facing Irish patients without medical cards in all probability discourage some "necessary" as well as "unnecessary" GP visits, and this would also apply to introducing charges for medical card patients, essentially because of the uncertainty about drawing this distinction — particularly for the layman in deciding whether to visit.

I can tell Senators that is the way it is. As several Senators have said, we have a situation where those who are just above the limit are put off going to see their doctor, which can be most counterproductive at a later stage when they end up in accident and emergency or are admitted to hospital.

The difference in visiting rates have been alluded to. Table 6 on page 79 of the above mentioned paper is very useful because it compares visiting rates per percentile income of people in the various OECD countries from the lowest ten percentile to the top ten percentile. We differ in one dreadful aspect, that is, in the third percentile — I am sure most people would probably reckon it is a pretty low income — we drop off from 6.6 visits to the doctor per adult to 3.6. That does not occur in respect of any other country. There is a serious problem for patients at that income level which must be addressed. I do not care what we have put into the health service — it is a huge amount of money — but there is a target group of people who are probably at the butt of the discrimination in the health service.

One finding which cheered me up, from the point of view of general practitioners, was that there was no difference in visiting rates to doctors, whether they were paid a fee per item or capitation. That was cheering. At least the medical profession is not encouraging people to go to their GPs.

We are also running into trouble where people manage to get the money together to go to their GPs but do not have the money to buy the drugs they need. There is price-fixing in every country in Europe, and Ireland is one of the highest. The prices for drugs are fixed between the pharmaceutical industry and the Government. Is the price being fixed particularly high in this country because of the extent of employment the pharmaceutical provides? We really need to look at that issue and I have no doubt the Minister, Deputy Harney, and the Minister of State, Deputy Seán Power, will do that. A doctor telephoned me today to say that a patient of his with respiratory disease could not buy her inhaler, that she had lost her medical card and that she ended up in Beaumont Hospital. That is counterproductive.

Even in areas such as chiropody — I declare an interest because I am the president of the Diabetes Federation of Ireland — chiropodists' payments have been index linked since 1979. They now get €18.87 per visit but the cost of dressings and so forth have gone up enormously in the interim. They reckon they need €35 per visit, so those who will take medical card patients are asking them to pay €10 towards their treatment. Many of these people cannot afford the €10, so they do not visit the chiropodist and present in the diabetic clinic when they have ulcers on their feet and are admitted on average for a month. Can anyone tell me the rationale behind that?

I read in the newspapers the other day that in Ballymun, there is considered to be an excessive use of anti-depressants and that people there are on them for far too long. Ballymun was one of the primary care pilot centres.

This is a very good idea. Members must have seen in newspapers the antiquated Ballymun health centre that has been closed on occasion because of a danger from electrical faults. It also had to be closed last winter because there was no heating. That is bad but what is infuriating is that there is a state-of-the-art medical centre across the road which has been idle for two years because of some kind of dispute between the Department of Health and Children and the Eastern Regional Health Authority. Nobody can identify the problem. Can anyone explain the point of that?

In addition, the centre was told it could recruit more staff, yet when it tried to do so it was told there was a ceiling on recruitment. Is that any way to run a health service with such fragmented decisions being made? We have to look at how things are on the ground, taking into account the improved economic situation and the fact that so much money is going into the health service.

I cannot understand why some people cannot get medical cards immediately. The Post Polio Support Group made a presentation to the Joint Committee on Health and Children, of which I am a member. Thank God we have not had an epidemic or any cases of polio since the early 1960s. A group of some 200 people suffer with post-polio syndrome. They have serious medical problems. Many of them have not been able to work for years and others who struggle to keep working are above the income threshold for entitlement to a medical card. They are dying off. Each year there is a decreased number of them, yet this small group of people cannot get medical cards. The over-70s got medical cards, which I welcomed but I said there were more deserving groups.

The level of investment in the health service needs to be examined. I recognise what is being invested. I read the Brennan and Hanly reports. I have read about 100 reports commissioned in the time the previous Minister was in Hawkin's House which, incidentally, is a dreadful building. Unless we take a more targeted approach to dealing with problems in the health service we will still keep coming up with dreadful reports about the basic statistics. When I saw that our infant mortality rate was so bad I could have wept. I keep looking at infant mortality rates in reports like that of the UNFPA so I can boast about ours and I was very surprised we figured so badly in this one.

I warmly welcome the Minister to the House and to her new position. I hope she will have great success in her job. I assure her that any criticism I may make of departmental policies is only done in an attempt to be constructive.

Geraldine Feeney (Fianna Fail)
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I support the amendment proposed by my colleague, Senator Glynn. I warmly welcome the Minister to the House and wish her well with her new portfolio.

There are significant demands on the health budget which exceeds €9 billion. Particular areas need attention and, as other speakers have pointed out, we are all aware of the problems. We are not saying problems do not exist, they do. The widening of eligibility for medical cards is only one of the problems which needs to be addressed.

The Government has spent more on health than any of its predecessors. Senator Minihan pointed out that ten years ago the health budget was in the region of €3 billion while today it is almost €10 billion. As he said, ten years ago one would have thought that if €10 billion were spent on the health service it would be a first class one.

A significant and growing percentage of national wealth is spent on health. Many of the measures currently in train to improve the health service will come to fruition in the years to come. Opposition Members are meant to be bright people and they will appreciate that there is no quick fix——

Brendan Ryan (Labour)
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This was a civilised debate up to now.

Ulick Burke (Fine Gael)
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Allow Senator Feeney to continue without interruption.

John Dardis (Progressive Democrats)
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We will make an exception for Senator Ryan.

Geraldine Feeney (Fianna Fail)
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I liked Senator Ryan's story about blind man's buff but we will leave that for another day.

John Dardis (Progressive Democrats)
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He has taken the blindfold off.

Geraldine Feeney (Fianna Fail)
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There is no quick fix solution to the problems of the health service and one has to be fair about that.

Brendan Ryan (Labour)
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Seven years is a long time.

Geraldine Feeney (Fianna Fail)
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The Government is engaged in essential long-term planning and investment.

I wish to digress for a brief moment without being hounded for it. Two ground-breaking developments introduced by the Government in recent times are the ban on smoking and the treatment purchase scheme, the latter being one of the most innovative initiatives ever implemented. I smile as I say that in the presence of the Minister, Deputy Harney, because we know from where it came. We are very proud of it and it has taken, and continues to take, many people off waiting lists.

I would welcome a review of medical cards, including costs, to try to establish whether patients are getting the best value for the expenditure involved. We need to examine areas such as access, care, treatment and drugs. On taking up office recently, the Minister, Deputy Harney, pointed out that it is not merely a question of doctors' fees, the high cost of drugs is also a factor. Senator Henry alluded to this matter and I agree with her. Drugs are very expensive. If a review of medical cards is instigated, one could look at expanding the system. The Minister is courageous but she is also kind hearted in seeking its expansion.

I will not dwell for too long on the ESRI report to which previous speakers referred. Of course we are all concerned when we read about the growing body of evidence that suggests people do not go to their GPs because they do not have a medical card. They are putting their health at risk. A new class of people are no longer going to the doctor. When my children were quite young, which was not today or yesterday, if one of them was sneezing and sniffling on a Monday I would try to push him in with his brother so both of them would be sniffling and sneezing on Tuesday or Wednesday and I could take two for the price of one to the doctor. At that time I had four children under four years of age. I am sure young mothers today are no different than I was 15 to 20 years ago. If a review were to take place, I believe savings would be possible on the whole scheme and those savings could be used to expand it.

I would welcome the introduction of new ideas. What about the GMS operating in partnership with the VHI? The VHI could pick up part of the bill, or people could have a medical card for GP purposes only and would then pay their own drugs bills. Senator Browne claimed children under four should have medical cards. I would not broaden it that much. However, I would like to see large families with, for example, six children under six or four children under four where parents are strapped for cash——

Fergal Browne (Fine Gael)
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The Senator should be realistic. How many families fall into those categories?

Geraldine Feeney (Fianna Fail)
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Perhaps an allowance could be made in such cases. There are still growing families. One need only look around here to see that.

Senator Henry made a case for the post-polio group. I am sure such people do not like to be called victims. I am a member of the Joint Committee on Health and Children to which the Post Polio Support Group made a presentation in recent months. The members of the group are to be admired. They pointed out to us the growing cost of visits to a GP and the cost of drugs. Some 200 people are affected. These people are not young, they are all getting on and I would like to see them looked after.

As Senator Minihan already said, the Government is committed to the health service and will continue to be committed. I have no doubt that with the Minister as head of the Department, she will drive this and will give us value for money. On other occasions when she has been in the House the impression she has given was that of a caring Minister, especially where people's lives were being affected. I wish her well in her new portfolio. As spokesperson on health she can always rest assured of my support in this Chamber.

Derek McDowell (Labour)
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I welcome the Tánaiste to the House and congratulate her on the courageous decision to enter the Department of Health and Children. I am sure her arrival will be of considerable relief to the Minister of State, Deputy Power. I could see he was having difficulty balancing being thrilled with the perks of power with the notion of having to go out to Lansdowne Road on this dark autumnal evening and witness-——

John Dardis (Progressive Democrats)
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The Senator has no evidence for that. That is outrageous.

Geraldine Feeney (Fianna Fail)
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That is uncalled for.

Derek McDowell (Labour)
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I think the Minister of State has more of a sense of humour than the Senator. However, I wish the Minister well.

The specific purpose of the motion this evening was to deal with the issue of medical cards. I want to make a political point first which needs to be said. There is a notion abroad that the two parties in Government made a large number of promises before the last general election and have systematically broken them all since. That is not actually fair to the Government. The Government parties did not make many promises before the general election. They made relatively few that would catch the eye. This was one of perhaps two or three that was important and caught the eye, deceived people and persuaded them to vote for the Government. It was an important undertaking and promise on behalf of the Government parties. That in a sense emphasises the level of betrayal people feel and the hypocrisy in which the Government has engaged. It is regrettable.

Speakers on the Government side such as Senator Minihan said they could not rush into this, being only seven years in Government. They could not be expected to deliver on such a promise which was given only two or three years ago. Others said so much money had been spent without any immediate results being expected. They need to look for value for money, reform of the system and so on. All of this is fair in itself, but does not address the net issue the House is discussing this evening, namely, medical cards.

I want to talk about GP services in particular, and to some extent pharmaceuticals, and everything that follows from that. This is a net issue which can be disposed of with relative ease provided there is the political will to do it and to engage with the medical profession, GPs and their representative bodies to ensure we have a system that is capable of delivering.

The former Minister for Health and Children, Deputy Martin, told the Dáil only a few months ago that it would cost about €685 million to introduce a comprehensive GP system. The figure for extending medical cards to all those under 18 would be just €151 million. I do not mean this personally but when I listen to Members on the other side of the House such as Senator Feeney suggesting that the medical card might, perhaps, be extended to tiny cohorts such as children under four, I wonder at our lack of ambition in this country. It would cost €151 million to extend the medical card system to all those under 18. We are spending multiples of that on far more frivolous purposes. The wonderful SSIA scheme is costing €600 million a year. For a quarter of that cost the medical card could be extended to all those under 18.

I am sure the Minister is well aware that there is a particular difficulty with children. These are the people, unfortunately, who are most likely to suffer owing to the lack of a comprehensive system. All of us have met mothers who have to make difficult choices between keeping the household moving in a particular week and bringing a child or children to the GP. It is an unfortunate fact that those who are least likely to be able to afford the €35 to €50 for a visit to a GP are the people most likely to need the service. They are young children and people in poorer households with lower incomes. These are the people most likely to need GP intervention because of malnourishment, poverty and its effects and, perhaps, unemployment. Unfortunately, these are the people who can least afford it.

My party believes and argues passionately for a comprehensive GP system and free access to family doctors. Such a system is taken for granted in most western European countries. What is crucially important is that we can afford it. All that is required is agreement from the general practitioners in order to introduce the system. I do not underestimate this. I imagine the Government will extend eligibility over the next few months. It will be looking at a number of different ways to do it. It could be extended on an income basis by, for example, widening the threshold for means tests. It could be done on the basis of infirmity involving people with particular illnesses who must see a doctor on a regular basis. It could also be achieved by targeting a particular age cohort.

If the aim is to end up with a system in five or ten years where everybody has access, then I do not suppose it matters which particular half-way house is used. I would favour doing away with the means test in favour of an age cohort of those under 18. However, that should be done only if the intention is to end up with a comprehensive system that facilitates everybody. If it is not, then a more complex mix is needed. We need to ensure in the first instance that people who visit the doctor on a regular basis are not prevented from doing so. We must also ensure that people on low incomes are not prevented from going to the doctor by virtue of that fact. A more complex reaction is needed, therefore, if the Government intends to do it on a bit by bit basis.

I know, however, that the Minister is one for big ideas and likes to take large strides. I would urge her to look at the possibility of a comprehensive arrangement and deal with the doctors on the basis of a per capita system, a per item mechanism or some combination of the two. Frankly, I do not care but whatever system we put in place should facilitate people through its ease of access.

I want to mention the primary care strategy. All of us are persuaded that this is the way forward and that investment in primary care is essential not just for itself, but because it takes the emphasis off secondary care, which is far too common in this country. We depend far too much on secondary care intervention at far too early a stage. All of us are persuaded of this fact.

The previous Minister for Health and Children, Deputy Martin, was quite persuasive in his convictions and the manner in which he put forward the case. I have heard the current Minister refer to this briefly over the past couple of weeks. It is essential we do not lose track of this. Much of this is not sexy, but it is of major importance. There are only ten primary care teams in the country, despite all the trumpeting three years ago. They are acknowledged to be generally successful where they have been introduced, but ten teams after three years is a pitiful result. We need to be moving forward. I believe general practitioners are more open to these radical moves than they might have been ten or 15 years ago. We know that members of the medical profession, GPs included, wanted for many years to ensure that their private patient base was effectively protected and resisted so-called socialised medicine because of that concern. The profession is changing, not least because there are now far more women doctors who want a life and who are quite happy to work eight or ten hours a day.

I am also conscious of the fact that there are many women, and indeed men, in the medical profession who are anxious to change the way GPs work and do not want to be on call 24 hours a day, seven days a week. They want to have a life and to do a decent job. They are more than anxious to get into serious negotiations with the Minister and her Department. I hope she is also anxious to do so. If so, she will have support from this side of the House.

Rory Kiely (Fianna Fail)
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I congratulate the Tánaiste on her appointment as Minister for Health and Children. She has 15 minutes in which to address the House.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I would like to thank those Members of the House who have spoken for their good wishes. I want to assure them I am no messiah. If Senator Henry was in the House I would pass on a letter to her I received last week from somebody wishing me well, and acknowledging that I was a consultant and expert in health care. The person was sure I had all the answers and clearly believed Senator Henry was the new Minister for Health and Children. The writer of the letter thought Senator Henry and I were one and the same person.

In An Agreed Programme for Government which covers the five-year term, 2002-07, the two coalition parties agreed to extend eligibility for medical cards. I assure the House this commitment will be met. We intend to give priority to persons on low incomes, families with children and particularly to children with a disability.

Extension of medical card eligibility, allied with reforms to achieve better value for money, is one of the priorities I have set since being appointed Minister for Health and Children. We recognise and acknowledge that income eligibility limits are low — too low in too many cases. The issue, therefore, is not one of principle but of how and in what manner to best achieve extension of the medical card entitlement in a way that devotes scarce public resources to those who need them most.

Fergal Browne (Fine Gael)
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A Chathaoirligh, may we have copies of the Minister's script?

Rory Kiely (Fianna Fail)
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I can make them available.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I will make sure the Senator gets a copy.

Fergal Browne (Fine Gael)
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We normally get copies of it.

Rory Kiely (Fianna Fail)
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There is no obligation on the Minister to provide copies.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I do not have copies with me but I will make sure the Senator gets one.

Rory Kiely (Fianna Fail)
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The Minister to continue without interruption.

Mary Harney (Dublin Mid West, Progressive Democrats)
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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.

Michael McCarthy (Labour)
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I too welcome the Tánaiste and Minister for Health and Children and congratulate her on her appointment to that Department. She is a brave person to take on a troublesome area, a Department famously described by the Minister, Deputy Cowen, as "the Angola" of Departments. There is a great deal of work to be done in this area. In 2002 the coalition parties gave a clear commitment, at a time of unprecedented economic growth, to extend the medical card scheme to 200,000 people. Many people were lured to the polling stations and voted for the Government parties on that basis. In the two years since, we have not seen delivery of that commitment. Many commitments were made in various areas but none was more critical than this area which deals with a vulnerable section of society that is less well off than most. It is an undeniable fact that many people are forgoing the cost of visiting a doctor because they do not have the means to pay. That leads to the situation in which more and more people are presenting themselves at accident and emergency and are more distressed and in a worse medical condition than they would normally be.

When the Tánaiste took up this position she said that figures revealed the cost of extending the GMS to 100,000 people is approximately €150 million. Our spokesperson, Deputy McManus, has done a great deal of work in this area and following her research maintains that the same amount of money would cover approximately 200,000 medical cards. I call on the Tánaiste and the Government to end the litany of promises made in this area and to extend the income eligibility for people to qualify for medical cards.

One Minister described the extension of the scheme to 200,000 people as "extraordinarily expensive". I presume many of these policy areas were costed at the time of the election. If it was not "extraordinarily expensive" in 2002 how can it be so in 2004? To make the commitment in the first instance someone, somewhere must have costed that proposal. I do not accept the proposal from the Tánaiste or anybody else that it would be "extraordinarily expensive". It is a good investment and it would be money very well spent. No one in Government could deny that. Surely there is enough money in the budget surplus of €2.3 billion to cover the cost of extending the income eligibility to those to whom it was promised.

We must impress upon the Tánaiste that it is money well-spent and if we do not spend the required amount of money in this area there will be an unnecessarily high demand on the resources at accident and emergency as people will present themselves there if they decide not to attend GPs because of the prices some charge. To someone on a social welfare payment of €140 a week, €40 or €50 is a lot of money. Few Members of this House could live on those rates of payment. It is also an indisputable fact that there are 100,000 fewer people in receipt of medical cards now than there were in January 1997 when the rainbow Government was in power. There is something seriously wrong if more people received medical cards when the country was less well off. We have had the Celtic tiger and unprecedented economic growth yet fewer people are receiving medical cards. The medical card qualification is the lowest since the GMS was introduced 32 years ago. That alone should be a wake-up call to the Government.

The figures prove that the promise to extend the scheme was a sham. The Tánaiste said on her appointment as Minister for Health and Children that she does not have a political ideology but she does have political practicality. The practical experience of any Member of either House should be that there is a section of society which is less well off than most, which is vulnerable and is being directly affected by the Government's decision not to extend the GMS. That is shameful. I hope that while the Tánaiste occupies the Department of Health and Children there will be a change in this policy, that we will see real action in this area and an end to the litany of false promises, and that the Government will stop taking advantage of the most vulnerable people in society.

Maurice Hayes (Independent)
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I too welcome the Minister to the House and add my congratulations to her on taking over this portfolio. I have great confidence that she will bring the same energy and success to that as she has brought to other jobs in Government. I was cheered by her response to, and concern for, the very real problem of people caught in the poverty trap on the threshold of the medical card eligibility.

Senator Henry quoted from the ESRI report on health status. I take that with a grain of salt because health status is influenced by more elements than health care. The dominant factors are genetics, environment and lifestyle. Health care accounts for approximately 20% of that. These are matters over which the Minister and the Government have only indirect influence and it is unfair to pillory the Minister for this. One figure however, did bring me up short, namely, that at a certain point of moving out of eligibility, utilisation of the GP service has dropped by half. This suggests that those who most need the service and are most dependent on it are forced to give it up or forced to make enormously difficult choices about depriving their children of health care or finding some other means to balance the family budget. This aspect needs to be addressed.

Part of the problem is that the rate of health care inflation is higher than the rate of inflation in the general economy. To increase health budgets in line with general inflation is normally not enough. People are caught in the trap whereby because they are earning a few more euro per week they are suddenly faced with enormous health bills. We need to find a way to cushion that.

Apart from that I agree with a great deal of what Senator McDowell said. The concentration needs to be on how we run primary care. People often jump up and down about bricks and mortar in hospitals. However, a well-developed primary health care system would help us to deal with many of the problems now presenting in hospitals. I would prefer to have a free system and recover the money through taxation or some other means.

Derek McDowell (Labour)
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Hear, hear.

Maurice Hayes (Independent)
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That might be like asking the Minister to climb the north face of the Eiger in the current political climate. Primary health care contains the core of the answer to the problems. Without going the whole hog of a totally free system, Senator McDowell made some other suggestions. I believe the new generation of doctors, particularly female doctors, would welcome a different form of contract or organisation. Strong arguments exist for extending the co-operative system, particularly the after-hours system, which is very successful where I live in Northern Ireland and is staffed by young doctors. Equally much is to be said for ensuring that children have care in the same way and a great deal of weight could be taken off accident and emergency departments by having minor injuries units staffed by nurse practitioners as well as by such doctors. Changes are taking place in the boundaries between professions and roles and we should be prepared to take advantage of these changes.

Since the cost of drugs is so penal, not only on the health service but also on those who have to buy their drugs when they lose eligibility, a case may be made for more insistence on generic prescribing. It is worth looking at the organisation of the health service to determine why it costs so much in terms of input to produce a relatively small output. The machine has an enormous capacity for consuming resources and just keeping itself going. We used to argue that for every £5 of input, we were lucky to get £1 of improved output.

I refer to a matter to which Senators Henry and Feeney adverted, namely, the case of a small number of survivors of the polio epidemic in the 1950s. They are now aged and some are frail. They have very heavy medical costs and generally do not have medical card eligibility. I was present at the Oireachtas joint committee on the day they appeared before it. The Secretary General of the Department was questioned and was to come back to explain why they could not get these cards. I would like the Tánaiste to make that a matter of personal interest, as it could do an enormous amount of good for a very small expenditure.

Frank Feighan (Fine Gael)
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I welcome the Minister of State to the House. I wish the Tánaiste well in her new role as Minister for Health and Children. She faces a very difficult task. In light of what has gone on in recent years, the confidence of the general public and the health boards in the health system, while not at an all-time low, is very low. Without playing politics, the Opposition hopes that something can be done to instil a new confidence and that health will not be such a serious issue when we meet people on the doorsteps or in clinics.

Politicians should not have to involve themselves in such cases. Health care professionals and managers are paid enormous amounts of money and it is sad when people find the health system has let them down despite the billions that have been invested. They have to come to my constituency office to ask me to make representations regarding medical cards or waiting lists, which is wrong. As politicians, the sooner we can divorce ourselves from this system the better. Unfortunately, the health system is the way it is.

I have always found the Tánaiste very honest in her approach. While I have not always agreed with her, I have always found her to be very honest and pragmatic. She tells it as it is and I respect that in a Minister. However, she will find it very difficult to measure up to the promises made in 2002. As politicians we should not make rash promises. A rash promise was made to increase the number of medical card holders by 200,000. I know people have mentioned this again. It is quite obvious that the number of medical card holders has reduced by 46,000. This is driving constituents crazy because they simply do not have medical cover.

The income ceiling for eligibility for medical cards has increased by a mere 8% since May 2002. While we welcome the 46% increase in the drugs refund scheme, unfortunately, charges for accident and emergency treatment have increased by 42% and the nightly cost for a public bed has increased by 36%. I am single, I get a nice salary as a Senator and would not consider myself to be on the breadline. While I regard myself as being quite measured and am not a devil may care person, I would put off a visit to a doctor if I had a cold as it costs €30 to €45. There is also the increased costs for prescription drugs. Sometimes it can cost up to €80. If I were a father with two or three children earning just over the ceiling for medical card eligibility, I would end up putting my children at risk as some people do because they cannot afford doctors' fees. This situation is seriously wrong.

The percentage of the population covered by the scheme has fallen from 31.24% in January 2002 to 29.43% in January 2004. It has been mentioned that the CEOs of the health boards have discretion in allocating medical cards in cases of hardship and medical need. Their discretion is limited by the budget of the health board for which they work. The CEOs of health boards often act as if they own the health boards. Although I have never served on a health board, I do not doubt that officials in the health system are sometimes almost as powerful as those who are elected to represent the various constituencies. When politicians make representations to CEOs — those who make the decisions — they may be told that funding is or is not available. If one has served on a health board and one's relationship with the CEO is okay — if one knows him well — one will get a much more favourable audience than that given to others, such as Senators and Deputies from Opposition parties and county councillors.

Allowing the relevant Minister to have a say is also part of the system. Politicians should be divorced from the health system but — this is where the contradiction comes in — the system is run by politicians, unfortunately. It is operated by people who have not delivered and are primarily interested in covering their own jobs. I wonder if the changes in the health board structures will help to change the current jobs for the boys system. That is another day's work, however.

Children under the age of four should receive medical cards automatically. I do not think there should be a limit on funds in such cases. Similarly, cancer patients should receive medical cards as a matter of course. Some cancer patients who have called to my office have told me about their fight to get a medical card. A person who is going to hospital for cancer treatment, such as radiation, should receive a medical card automatically. Given that most cancer patients go through a traumatic time, the Government and the health boards should ensure they are given medical cards.

We are all in it together. This is a serious situation. I wish the Minister for Health and Children, Deputy Harney, well in trying to get through the morass she faces. Any success she will have in her new Department, which has been referred to as Angola, will be a fair achievement.

Rory Kiely (Fianna Fail)
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Senator O'Rourke has eight minutes.

Mary O'Rourke (Fianna Fail)
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Senators welcomed the Minister of State, Deputy Seán Power, and the Tánaiste to the House earlier. Similarly, we are glad that the Minister of State, Deputy Tim O'Malley, is back in the House. We have welcomed the Minister of State and enjoyed his company on the many occasions on which he has been in attendance. The motion proposed by the Labour Party Senators is extremely focused and all the better for it. The Tánaiste said earlier that she is preparing to speak in the Dáil this evening on a motion which has 80 separate elements. I do not doubt that the motion before the House at present is quite focused on the provision of medical cards.

Brendan Ryan (Labour)
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We are very helpful.

Mary O'Rourke (Fianna Fail)
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In her speech, the Tánaiste reiterated the comments she has made on radio and in various interviews with media commentators. She spoke clearly about the provision of medical cards, particularly for those on the margins. I refer to those who are deemed to be ineligible for medical cards because they exceed the limits by €5 or €10, rather than those on the margins of society, who are clearly eligible for medical cards.

Senator Feighan said earlier that he does not think politicians should be involved in making the case for people in need of health care. He is hoping for a kind of never-never land if he thinks it will ever happen that politicians will not have such a role. I am sure the Cathaoirleach, the Minister for Health and Children and the two Ministers of State at her Department who have been to the House this evening will agree that health is the area of care about which politicians are most often asked during constituency clinics. I encounter three or four such cases each weekend.

We all know it costs between €35 and €45 to visit a doctor, before one has to find the money for the cost of a prescription. Many parents, especially mothers, who try to balance their domestic budgets for the week find that they cannot afford to pay for the visit to the doctor or the prescription costs for one of their children. Children have many needs during the first few years of their lives. Parents may have to call a doctor for ailments which may seem insignificant in retrospect, but which are highly important to them at the time. One cannot remove the element of care or urgency in the minds of parents when they are addressing such issues.

I have great faith in the Tánaiste's ability to fulfil the commitment she gave this evening to extending medical card eligibility. I strongly urge her to fulfil it, although I appreciate that she cannot do so overnight. She was quite right to refer to improvements in the number of people in employment and the increases in salaries and wages. I continue to have concerns about parents of young families and people who are deemed ineligible for medical cards for the sake of a small amount of money. Such cases are very difficult. Other Senators have said that politicians' constituency duties should not be related to the health sphere of activity. I do not agree that public representatives should be removed from all such spheres of activity, however. What is the point of politics if one cannot take up particular cases?

I wish to discuss the so-called discretion of the CEOs of the health boards. When I first became involved in this area, the CEOs used to have great discretion. If a particular person's application for a medical card was rejected, one could submit an appeal on his or her behalf to the relevant CEO. The CEOs I encountered, most of whom were men, supposedly reviewed the case. In years gone by, there seemed to be a much greater level of acceptance of the need for such exceptions. The appeals one made were normally accepted if a fair case was made. In recent times, however, the parameters of the eligibility criteria seem to be rigidly adhered to in the cases I encounter. The guidelines are not as flexible as I think they should be and, indeed, as the original scheme envisaged they should be. I am certain that the room for flexibility and discretion has lessened extraordinarily.

The CEO of a health board is only as good as the money available to the board for disbursement. I would like the appeals system in health boards to be restored to its former vigour and weight. I am sure the Minister of State understands these matters well because he has come across many cases in his professional role. Politicians do not live in isolation — they have to stay in touch with the real world. Is the Cathaoirleach anxious to say something to me?

Rory Kiely (Fianna Fail)
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I was being generous to the Senator, possibly because she is the Leader of the House, when I told her she had eight minutes.

Mary O'Rourke (Fianna Fail)
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Does the Chair want me to stop?

Rory Kiely (Fianna Fail)
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The Senator can speak for another minute.

Michael McCarthy (Labour)
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The Chair and Senator O'Rourke have almost used up the minute.

Mary O'Rourke (Fianna Fail)
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I have used up the minute. I knew by his face that the Cathaoirleach was getting anxious.

The new team in the Department of Health and Children, led by the Tánaiste, will ensure that the pleas from the Dáil and the Seanad will find a resonance within the Department as the Tánaiste is engaging in deliberations. I strongly urge the Tánaiste to ensure that the commitment given in 2002 in the programme for Government is adhered to.

Brendan Ryan (Labour)
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I welcome many aspects of the debate. It appears that everybody agrees there is something wrong with our primary health care system. I do not think I heard a single instance of dissent from that view. The trouble is that we knew, because it is well documented, that a good primary health care system is the essential prerequisite for a good hospital care system and a good health care system for elderly people and children. Everyone knew that seven years ago and yet we have been in the extraordinary position that the Government decided to spend a vast sum on the health services. After having done so, it produced a health strategy. It had been in office for almost five years before it did so. What it was really saying was that it had spent a great deal without knowing what it was doing; it worked out the strategy afterwards.

It would not have taken much serious reflection to see that two things would happen, the first being that eligibility for medical cards would drop proportionately as prosperity increased. This country was prosperous before the coalition came to power. It inherited a prosperous country and its job should have been to manage it. Instead, it has spent more time pretending that it created something that it inherited and that others are the cause of the problems it did not solve. In both cases, its energy could have been better devoted to confronting the fundamental fact that primary health care is the bedrock of a good health care system.

It was inevitable in a period of spectacular and welcome increases in prosperity that eligibility issues would arise. It is the most extraordinarily belated conversion to hear everyone on that side of the House tell us that there is a problem with eligibility and affordability. It is not often that I defend them, but we have at least begun to move away from blaming the GPs for this problem. In a piece that I wrote recently, I pointed out that if I go to see my GP, it costs me €45. I wanted to get my electric cooker fixed and the company said that it would cost me €100 to get the person inside the house.

Mary O'Rourke (Fianna Fail)
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That is just a cooker.

Brendan Ryan (Labour)
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That is a cooker. That is about 60% more than the GP would have cost. I have had the great benefit of not having to have a GP visit the house in many years, since the children were small. I presume that it is now about €60 for a house visit. That is still 40% less than they were going to charge me to have someone stand inside the door to look at my cooker. Let us not blame the GPs for everything. We made a political decision. The Government decided the resource allocation for the health services and that medical card eligibility was down at the bottom of its priorities. In terms of humanity, it was a profoundly wrong decision, but, more importantly, on the level of efficient delivery of cost effective health care for our people, it was a profoundly bad one.

Senator McDowell spoke about a universal system of primary care free at point of use. Far from being cloud cuckoo land, it is the reality of life for people in most of the civilised countries of Europe. In Sweden, Norway, Finland and such countries, people have access to a primary health care system which is effectively free. Let us not hear that nonsense about how it would distort or overburden our economy. This year's world growth competitiveness index shows us slipping down the list for every factor. Going up the list are the civilised countries of Europe that have recognised something the Government has consistently failed to see, that economic prosperity is a means to an end — to provide a good society. The failure of the Government on this issue, as on many others, has been the failure to use prosperity to do what people wanted it to do.

Rory Kiely (Fianna Fail)
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When is it proposed to sit again?

Pat Moylan (Fianna Fail)
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Tomorrow at 10.30 a.m.