Fergal Browne (Fine Gael)
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I move amendment No. 1:

In page 3, before section 1, to insert the following new section:

"1.—The Health Act 1970 is amended by inserting the following new section after section 44, but in Part IV—

'44A.—Within three months of the passing of this Act, the Minister shall lay before each House of the Oireachtas, a statement of strategy detailing its plans for the funding of the care of the elderly in both public and private nursing homes.'.".

The amendment is self-explanatory. The Opposition feels that the Government's track record on care of the elderly is not sufficient. There have been many recent cases where private nursing homes in particular have come under scrutiny and, unfortunately, have not fared well in regard to conditions for residents.

The Government's strategy for the elderly is purely a strategy without practical effect. Yesterday, I drew the Minister's attention to the issue of home help being cut to a maximum of ten hours per week, which contradicts the image the Government tries to portray of its views on the elderly. It would be useful if in the next three months the Oireachtas had an opportunity to hear the Government's strategy for the care of the elderly and have an input into it. How we treat the elderly reflects on society at large and, therefore, it is important the strategy is inserted in legislation. If it is not so inserted, it will never be achieved.

Mary Henry (Independent)
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Planning ahead is always a good idea and the amendment suggests this should happen. I have one concern which I am sure the Minister will address. There is a dichotomy in this situation. The Department of Health and Children is in charge of policy and this matter is a policy issue regarding the care of the elderly in public and private nursing homes. However, the accounting and auditing of the health service will be in the hands of the Health Service Executive. No matter what policy the Department may make, the Health Service Executive will have a significant hold over whether the policy will happen because it will be in charge of funding. The Minister might elaborate on whether I am correct in this assessment.

We have had grim examples of the lack of proper accounting within the Department of Health and Children in regard to medical cards, to which I will refer later in the debate. While I recognise that much diverse work is being done within the Department, there will be great difficulty with the division of its funding. No matter what policy it puts forward, I do not know how it will progress that policy because the executive arm will be a totally different body. What the executive arm will do with excellent policy, I have no idea. Will the Minister elaborate in the context of the amendment?

Seán Power (Kildare South, Fianna Fail)
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Without doubt the future financing of the long-term care of older people is a serious issue and one that will need much attention in the near future. The Mercer report on the future financing of long-term care in Ireland, commissioned by the Department of Social and Family Affairs, has been published and, following on from this, Professor Eamon O'Shea drew up a report on the nursing home subvention scheme. From a Government perspective, we consider these two reports very important as we plan ahead and decide how we should finance long-term care. Earlier this year, the Tánaiste, the Minister for Social and Family Affairs, myself and officials from various Departments, including the Department of the Taoiseach, established a committee which will report back by the middle of this year. The Tánaiste indicated in the Dáil in recent days she would make recommendations on this matter later this year.

There will be no easy decisions. It will be a necessary but costly exercise. In the past we did not give this area the attention it deserves. This has been acknowledged and within Government circles there is a realisation of the importance of the issue and a willingness to deal with it speedily. We will come forward with suggestions before the year is out.

Senator Henry referred to the Health Service Executive taking over auditing functions. While it is a time of reform in the health services, this will not present us with any difficulty in regard to implementing Government policy. It is for the Government to decide on policy and then to ensure its implementation.

Senator Browne was critical of the Government, yet in excess of €287 million of additional funding was provided for health services for older people between 1997 and 2004. We have placed great importance on this sector and increased the funding for it each year. While the issue is important I do not see any merit in accepting the amendment and for that reason we will oppose it.

Fergal Browne (Fine Gael)
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I expected that reply from the Minister of State. What is the position regarding elderly people who have been taken out of institutions and are now living in houses provided by health boards or the Health Service Executive? Will they have to pay rent? That is another issue arising on the doorsteps. If the Minister of State cannot answer now, he might do so later.

Seán Power (Kildare South, Fianna Fail)
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If the Senator provides the details of the issue, I will have the matter clarified and report back to him.

Fergal Browne (Fine Gael)
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I have been let down.

Paddy Burke (Fine Gael)
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Amendment No. 2 has been ruled out of order as it involves a potential charge on the Revenue.

Mary Henry (Independent)
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Section 1 allows a great deal of discretion regarding what might happen to people because of the clause "including the means of the spouse, if any, of that person in addition to the person's own means". If a couple had been separated for decades, would the legislation take account of that? I presume there are clauses in the legislation to ensure that huge sums of money cannot be transferred by a person requiring care to another person. However, what if the couple have been separated for years and perhaps even have a judicial separation, though they are not divorced? They may have made financial arrangements on separation. One person might have been profligate and the other might have tried his or her best to live in a normal and modest manner. The latter person might now be asked to subscribe towards the care of the former in a nursing home. That is not just.

Seán Power (Kildare South, Fianna Fail)
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These are operational issues on which the health boards would have previously made decisions. I believe most Members accept that we must have some flexibility in the system if it is going to work. We are all aware of situations where in terms of income, a couple might be a little over the guidelines but there would be certain other factors we would like to see taken on board. For that reason it is important to include some flexibility.

It is important that the income of a spouse be considered. If not, one could have a situation where a person has limited means but the spouse has perhaps in excess of €250,000 annually, and yet the person would qualify.

Mary Henry (Independent)
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That is what I said could happen but it could also happen the other way round.

Seán Power (Kildare South, Fianna Fail)
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That is why we have a certain flexibility in the system.

Mary Henry (Independent)
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Flexibility has got us into the mess we are in.

Seán Power (Kildare South, Fianna Fail)
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In fairness, while there have been different interpretations around the country in terms of medical card qualification, the system has worked quite well within the health board regions. The flexibility has helped in that regard. Though Senator Henry might not agree, the fact that we have had flexibility and that the CEOs could on occasion consider special cases of particular hardship and grant medical cards has proved helpful.

Fergal Browne (Fine Gael)
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The measure in section 1 regarding the spouse's income could fly in the face of equality legislation. Senator Henry's point regarding separated couples is relevant. What drives us all mad on both sides of the House is when a Member advises someone about getting a medical card, the person is either accepted or turned down, and then a similar case arises which attracts a different decision. I realise the system must have flexibility but the Minister of State should bear in mind that taking a spouse's income into consideration could create problems down the line. Senator Henry's point is valid.

Mary Henry (Independent)
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The other case mentioned by the Minister of State brings up exactly what I meant when I said that one could have a situation where all funds were transferred to the name of the other spouse so that the person would seem incredibly poor. It is also necessary to consider the other side of the coin, where one could have people who have been separated for a very long time. One such person could still be the spouse and could be asked to pay money. That person might not be very well off but his or her income will be taken into account.

I repeat that flexibility has got us into the mess we are in because some health boards, realising that they were doing something illegal, as informed by their legal advisers, stopped making deductions. I admit that some of them stopped making deductions only when they were told by some of the people in nursing homes that they should not be deducting money.

This could turn out to be a serious issue because the various people administering the scheme, who we can be sure will be short of money, will have flexibility which may give rise to another inequity in the scheme. I am not proposing this as a hypothetical situation but as one I see coming around the corner.

It worries me greatly that frequently we see legislation being rushed through the Houses even though Members bring up problematic cases that could arise. What happens? A couple of weeks later, or at a very good guess, two years, such a case arises. I see the issue before us as giving rise to disgruntled people making complaints very soon. I believe such people will nevertheless be legally liable because they will still be the spouses of the people involved.

When divorce legislation was introduced in this country, everyone said that we would all get divorced whether we wanted to or not. That did not happen. Substantial numbers of people have not changed from being separated to being divorced. They are the older people to whom this legislation will apply. As couples they made amicable financial agreements years ago but people will now be able to come chasing after them in their old age if they think there is a spouse who may have lived very frugally over the years and is better off than the one now in need of care. I am not putting this forward as a hypothetical case because I foresee such cases arising.

Seán Power (Kildare South, Fianna Fail)
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It is difficult to put in place a perfect system which will meet all circumstances but if we do not deal with the matter in the way we propose we will end up attempting to treat all applicants as individuals. That would not be to their advantage and would not be fair. The method we propose is the fairest way to proceed. Up to now, health board CEOs would have different interpretations but the HSE intends to operate standardised guidelines throughout the country. Before this, someone in a particular situation in Kildare might have qualified for a medical card while a person in similar circumstances in Galway might not have qualified. We will now have standardised guidelines countrywide. That is the best way to proceed.

Camillus Glynn (Fianna Fail)
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I agree with the Minister that it is very difficult. As the old saying goes, exceptions make bad laws. The central point is that whatever resources are available for the elderly should be devolved to that care area and utilised to the optimum effect and that those who benefit from the resources should be the right people to do so. I have worked in this area and I stand over that.

There are many care models for the elderly. If they have not already been examined it would be useful if the Department of Health and Children or indeed the Oireachtas Joint Committee on Health and Children, of which Senators Henry, Browne and I are members, took an in-depth look at what is available. Several models of care, not just the geriatric hospital or the welfare home can provide for the elderly. We also have community care and retirement villages available. Senator Browne made a valid point when he referred to old people who were devolved from institutions into the community and are now living in old persons' dwellings. Undoubtedly, care in the community is a better service. When one thinks of planning for the future in the psychiatric services, community care is a better service, although it is far more expensive.

We should pursue the best model. I support the Minister's views.

Mary Henry (Independent)
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One hears constant complaints that we are supposed to be legislators but just come in here to act as messenger boys or girls. If I see an aspect of a law that I believe may cause injustice, I must point it out.

Camillus Glynn (Fianna Fail)
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The Senator is right to do so.

Mary Henry (Independent)
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I will consider putting down an amendment on Report Stage.

Seán Power (Kildare South, Fianna Fail)
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We are discussing the scenario whereby one person in a couple is a high earner while the other is in a lower income bracket. It is only fair that the combined income should be taken into consideration and that the authorities shall have regard to a person's overall financial situation. Senator Henry has expressed some criticism of the administration of medical cards. In my experience, I have not seen any situations where the income of an estranged spouse caused difficulty for a person applying for a medical card after people had been separated for a number of years. The rules have been interpreted quite fairly in that regard. There is only so much money available and a euro can only be spent once. We provided €60 million for the doctor-only card this year. It is important that we try to relieve the hardship that exists by ensuring the money is spent where it is most needed and provides the best value.

Mary Henry (Independent)
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I do not wish to prolong the point but I am only too aware that a euro can only be spent once. However, I feel that some people who in the past may have been very unjustly treated by a partner may now be unjustly treated by the State by being obliged to pay up for this person. I intend to put down an amendment on Report Stage and we will consider it then.

Fergal Browne (Fine Gael)
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I move amendment No. 3:

In page 6, between lines 3 and 4, to insert the following:

"(d) paragraph (b) shall stand repealed on 1 March 2010.".

Fine Gael is in favour of the GP-only medical cards but only as an interim measure. On this side of the House, we propose the insertion of a time limit of 2010 because we fear the Government plans to make this a longer-term option. The only benefit conferred by the new GP-only medical cards is the facility of going to a GP without charge. The cardholders lose out on all the other benefits of a full medical card. Hence, a GP-only cardholder will not have free inpatient or outpatient consultation or have dental or optical work performed without charge, not to mention the cost of medicine. Moreover, a cardholder's children sitting the leaving or junior certificates will be liable for examination fees. Although people have described it as half a medical card, in fact it is only about an eighth of a medical card.

The primary purpose behind the new card was the protection of younger children. We could not countenance the death of a child from meningitis because its parents could not afford a doctor. Under the new scheme, a parent may bring a child with a rash to a GP straight away to get a professional opinion. Fianna Fáil gave a very firm commitment in the last general election to provide 200,000 extra medical cards. However, the Government has not even maintained the number of medical cards, which have actually fallen.

While I accept that people tend to be wealthier now, the Government's policy on giving full medical cards to the over 70s, irrespective of means is daft. Individuals like Dr. Tony O'Reilly and Dr. Michael Smurfit will receive medical cards. Hopefully, my father will reach the age of 70 in a year and a half. Although he has both a Dáil pension and a teacher's pension, he will be entitled to a medical card, which is totally wrong. Mothers with children with ongoing medical conditions come into my constituency office having being turned down for medical cards. We are putting this amendment forward to emphasise that the GP-only medical card needs to be reviewed in 2010. It should only be a temporary measure to allow the Government to rectify the broken promise it made in the last general election to allocate full medical cards to an additional 200,000 people. Recent figures confirm it failed miserably to do so.

Joanna Tuffy (Labour)
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I support the amendment's intentions but the operation of the new cards should be reviewed much earlier. We need to introduce a more comprehensive measure. Many people will not qualify for the new card type and many who will qualify should be getting a full medical card in any event. If the Government had kept its promises, they would have done so.

Senator Browne mentioned the issue of the over 70s receiving full medical cards. I actually agree with the idea that the over 70s should have full medical cards irrespective of income, but when set against the fact that most children do not have the same right, it seems unjust. We should at least introduce a measure whereby all children have access to free GP care. One meets people from middle income backgrounds who must think twice before bringing their children to a GP because of the associated costs. It should not be that way. Recently, I looked after a child who, it transpired, had measles. I was worried initially that it might be meningitis. I did not think twice about going to the local GP. If a person has a cough, he or she would think twice about going to the doctor as a visit costs €40, even if he or she was on what we would consider an average income.

Camillus Glynn (Fianna Fail)
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The proposal to introduce doctor-only medical cards is a very welcome measure. I am glad the Labour Party is supporting Fianna Fáil policy relating to people over 70. Middle income earners are pretty much liable for everything and entitled to nothing. Too often in our clinics we meet people with young families and big mortgages who are in excess of the guidelines. These people will be helped by this worthy proposal. I am pleased Fine Gael has given it some qualified support because it is worthy of support. It will be of tremendous benefit to middle-income earners for the reasons I have stated.

Seán Power (Kildare South, Fianna Fail)
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I am delighted to learn of Fine Gael's new policy where it wants to withdraw medical cards from people over 70.

Fergal Browne (Fine Gael)
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I did not say that.

Paddy Burke (Fine Gael)
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The Minister, without interruption.

Fergal Browne (Fine Gael)
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Let us be fair. I never said that. I said it is unfair that children do not have medical cards.

Seán Power (Kildare South, Fianna Fail)
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The introduction of the doctor-only cards has been received very well throughout the country. We will issue 200,000 of these cards to people who may have been reluctant to visit their doctor in the past because of the cost. We all realise the expense involved in visiting a doctor. While the new card will not cover the purchase of medication, in many cases, particularly when a parent takes a young child to the doctor, he or she often receives advice or reassurance and leaves happy without requiring any medication. At least people will have the comfort of having the card. Parents will be able to take their child to the doctor, take whatever advice is offered and if they need to be referred to somewhere else, they can do that. We are providing €60 million in 2005 for these medical cards. The qualifying criteria for the cards will be 25% above the normal income guidelines for the full medical card. We are expecting 200,000 people to take up the cards. We will review the matter in the event that the final number falls short of it and increase the guidelines to help 200,000 people qualify.

It would be unwise to legislate for the automatic cessation of these arrangements in five or six years as Senator Browne is proposing. We do not have a crystal ball and it is difficult for any of us to see how things will develop in the future. This is a very innovative initiative that deserves support and I the general public very much welcomes it. We have previously experienced a situation that Senator Glynn referred to where it was a case of "winner takes all", where people got nothing if they failed to qualify. Now 200,000 people who would not qualify for the full medical card will qualify for the doctor-visit card and I am sure it will make a big difference to their lives.

Fergal Browne (Fine Gael)
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I would like to clarify a point. It is disingenuous of the Minister and Senator Glynn to twist what I was saying.

Camillus Glynn (Fianna Fail)
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I quoted what the Senator said.

Fergal Browne (Fine Gael)
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If they listen for a change, they might hear what I am saying. I do not think anyone in the House could justify giving a medical card to a multimillionaire in his 70s while a woman with four or five children, two or three of whom could be regularly sick or have a recurring condition, does not get a medical card. That was the point I was making. We now know that when the medical card was given to the over 70s, the Department of Health and Children underestimated the number of people over 70 and had carried out no research on the matter.

Most people would agree that medical cards should be given to younger children in particular, especially children under the age of five or six. Any of us who know families with young children know that if one child gets sick, invariably the rest of the children get sick. It is worth pointing out that the public was promised full medical cards and are now getting only one eighth of the benefit of the medical card. The public has been completely short-changed by this Government. The Minister of State's reply indicates this is a more long-term plan by the Government and that it has no intention of changing it.

Will the Minister of State give a commitment to extend the doctor-only card to include, for example, people with children who are exempt from junior and leaving certificate examination fees? Will this scheme be extended over time or is it rigidly fixed as a GP-only scheme? When people receive their cards, their initial satisfaction will fade over time and they will realise they have got a very bad deal.

Mary Henry (Independent)
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I welcome the introduction of medical cards of any description. I think my colleagues in general practice are glad to see that those who are genuinely deserving will receive these cards. The Minister of State is correct in saying that advice and reassurance is frequently all that is needed. It is not a case of there being a pill for every ill. However, advice and reassurance take far longer to give than a prescription and I am not quite sure what time has been factored into GPs' very busy lives to deal with these people who almost certainly are denying themselves medical treatment because of the cost. I know from reports from some of my colleagues in general practice that they frequently see people who have to come back for a second or third visit and are not charged for those visits. Therefore, there is a kind of "free doctor" system at the moment, despite the fact that many people do not have medical cards.

The Minister of State might be able to fill me in on a few details about the scheme. Will the 200,000 medical cards be issued on the same day? Will the primary care sector have to deal with the situation without any forward planning? There has been very little progress in the ten primary health schemes that are running as pilot projects. I heard that permission had been given directly by the Minister, and I think she was correct in doing so, for the Ballymun health centre to go ahead. I then discovered that everything has to go out to tender. It will be at least nine months before the centre is up and running, despite the fact that the old centre frequently has to close due to problems with wiring and heating.

These new medical cards will be of very little use to people in areas where there are no GPs. I am sure there could GPs in these areas if we had more Irish graduates qualifying, as was stated in the Hanly report. It would be a good idea if the Minister for Health and Children encouraged the Minister for Education and Science to double the number of people going into medicine; this could happen if the Government allows it. Perhaps then, those with the doctor-visit medical card could actually visit a doctor. There are many problems with implementing this scheme on the ground and I would be very grateful if someone would give me some answers because despite all the avenues I have gone up to date, I have not been able to get much information about it.

Seán Power (Kildare South, Fianna Fail)
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The Government has no plans to reduce the number of standard medical cards in favour of increasing the number of doctor-visit cards. This doctor-visit initiative is intended to complement the existing medical card arrangements. The doctor-only card will provide much assistance to families who would not qualify for a full medical card. The Minister explained the scheme when it was announced on the day the Estimates were published in November 2004. We will be inviting applications as soon as the legislation is passed. It will follow on in time that the cards will come on stream. We do not expect to see them all being issued on the same day or in the same week. However, the money is being provided and we hope that up to 200,000 people will avail of the cards.

On the issue of setting means guidelines for the over 70s and whether we should give medical cards to millionaires, how can we have a fair system that discriminates against a certain group of people? Child benefit does not discriminate on the basis of income and is paid on behalf of every child in the State. We have adopted the same policy for the medical cards of the over 70s.

Fergal Browne (Fine Gael)
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Is the Minister aware of any plans to review the GP-only cards or could negotiations be held with the Department of Education and Science on the proposal that a medical cardholder would be exempt from paying exam fees, for example? Is this policy rigidly stuck to GP-only cards or is it open to review, for instance a possible extension over time to include optical, dental or other costs?

Mary Henry (Independent)
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I do not expect the Minister to answer me immediately as the information may not be available to him, but our constituents are concerned about whether these cards will be phased in or all arrive on the same day.

Seán Power (Kildare South, Fianna Fail)
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To answer Senator Browne, this is a new system and will be under constant review. The Government is anxious that the uptake rate of 200,000 people uses up the €60 million provided this year, as it is intended to spend every cent of that money solely on the doctor-only card. The Government is certain this new scheme will work well and it will be kept under review. This side of the House does not hold a monopoly on wisdom and will listen to any proposals that people wish to make. Such proposals could be of assistance to families, particularly those with two or more children doing exams in a single year.

To address the question of phasing in, once the legislation has been passed the Government will make every attempt to try to have the cards issued as quickly as possible. However, some people may make an immediate application while others may be awaiting the results of an application for a full medical card. As such, we do not expect all the cards to be issued on the first Monday of the month in question but over a period of time.

Paddy Burke (Fine Gael)
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Amendment No. 4 is out of order as it involves a potential charge on the Exchequer.

Fergal Browne (Fine Gael)
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I move amendment No. 5:

In page 6, between lines 16 and 17, to insert the following:

"(4) The Minister shall issue guidelines detailing the criteria which shall be used when an assessment of 'unduly burdensome' under this section is being made under this section.".

We must have clarity on this issue. The term "unduly burdensome" is open to interpretation and it is in everyone's interest to issue guidelines to make lives easier if possible. This would ensure fair play, otherwise the decision could be a subjective view on whether someone has an entitlement when the opposite might be the case. It is in the interests of the Department and the Health Service Executive to have clarity on this point.

Mary Henry (Independent)
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I think the House has heard enough from me for the moment.

Seán Power (Kildare South, Fianna Fail)
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The House will never have heard enough from Senator Henry. It is always nice to have the contribution of someone involved at the coalface of the issue.

Senator Browne's amendment seeks to require the Minister to issue guidelines to specify the criteria to be used in deciding whether a person meets the test set in section 58(1)(b) of the Health Act 1970. Upon the passage of the Bill, that section would establish the principle that the term "unduly burdensome" represents a lesser degree of difficulty than the term "undue hardship", which is the basic test for the standard medical card. As indicated previously, the Department has conveyed to the Health Service Executive the Tánaiste's wish that it should base its initial guideline on a 25% increase of the income limits in force for the standard medical card. This guideline can be revised if the anticipated number of people does not qualify or take up the new cards.

The medical card scheme has operated under the Health Act 1970 on the basis that decisions on undue hardship are taken at the individual health board level. The income guidelines governing these decisions were agreed by the CEOs of the health boards while the operational agreements of the doctor-visit medical card scheme are currently being drawn up between the HSE and the IMO. To introduce a system of ministerial guidelines would represent a fundamental alteration of the basis on which the medical card scheme operates. I am not, therefore, in a position to accept the amendment.

Mary Henry (Independent)
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I am anxious that a spouse who may not have been seen for years may be used as a measure of assessment but I will not repeat my previous comments. Section 5(3) provides that "a choice of medical practitioner shall be offered under the general practitioner medical and surgical service made available under this section" wherever it is considered practicable by the Health Service Executive. I hope we do not end up with something akin to the old dispensary scheme because the choice of doctor has made a great difference for medical cardholders and medical practice at primary level. While people cannot be guaranteed a choice, as there may not be even one doctor in an area or so on, we must not return to the situation of a division between those with the medical card and those without it. Senator Glynn and others will agree that the dispensary scheme was not a good one. I do not know which Minister for Health deserves praise for moving Ireland beyond this scheme so that general medical services could be provided by all listed general practitioners to both public and private patients but it improved general practice enormously for patients and doctors alike.

Camillus Glynn (Fianna Fail)
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I agree with Senator Henry that the dispensary scheme system often did nothing to compliment human dignity. Both she and the Minister will agree there is a growing difficulty for people to get on a general practitioner panel in certain urban and rural areas because of a shortage of GPs. We should let the message go out to the many good young men and women who may go into the medical field that there are GP openings, such as in Mullingar. For the first time in my 26 years of political life, I have been approached on this issue to examine what can be done. The former health boards stood in the breach and appointed persons to a panel but that did not address the core issue. There is a need for additional GPs in certain locations.

Mary Henry (Independent)
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It is nice to have support from the Government side of the House and I am sure the Minister knows this is an urgent problem that must be addressed.

Seán Power (Kildare South, Fianna Fail)
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I thank the Senators for their comments. This is about trying to progress and develop the health services and providing a standardised service throughout the country. Senator Henry spoke about the old dispensaries but despite our difficulties we have seen wonderful progress made. We hope this legislation will play a part in developing a better health service for everyone.

Paddy Burke (Fine Gael)
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When is it proposed to take Report Stage?

Camillus Glynn (Fianna Fail)
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Now.