Order of Business. - Health (Miscellaneous Provisions) (No. 2) Bill, 2000 [ Seanad ] : Report and Final Stages.
Wednesday, 16 May 2001
Dáil Eireann Debate
Ms McManus: We will not stand in the way of the Minister on this but we are very unhappy that an announcement was made in the budget that this measure was something clearly indicated by  the Government a long time ago. We find it extraordinary that we are now in a situation where at the 11th hour on Report Stage the Minister comes into the House and includes something on Committee Stage and then proceeds to Report Stage on something which is not directly related to this Bill. It is an indication of the disarray and the lack of preparation that both he and his Department have shown in dealing with important issues in the area of health.
When I was made aware that this was to be introduced today I was able to find in my records that I had asked the Minister some time ago whether it would require legislative change. A member of the medical profession had raised that query with me. The Department should have been well aware that legislative change was required to fulfil a commitment made in the budget. Yet this is being included at the very last minute under most unsatisfactory conditions. That is not the way this House should conduct its business of scrutinising legislation proposed by the Government and ensuring that legislation is of the highest standard and has gone through the required processes to ensure our laws are watertight and properly founded.
Mr. Martin: Amendment No. 1 is a technical amendment to amend the long title of the Bill to take account of amendment No. 5. Amendment No. 5 allows for the automatic extension of the medical card scheme to everybody over the age of 70. In the budget 2001 package the Government made it clear that it intended to extend the eligibility for a medical card to all persons aged 70 and over regardless of means, to come into effect on 1 July. The background to this measure rests in the overall Government commitment and decision to significantly improve eligibility for older people in recent years.
The programme for Government from 1997 onwards committed the Government to review medical card eligibility for older people and decided that the income guidelines for entitlement to medical cards for persons aged 70 years or over should be doubled. The improvement which was introduced over a three year period began on 1 March 1999. The income guidelines for those aged 70-79 and 80 years and over which were already higher than the normal guidelines increased by one third in 1999. The second stage of the process was implemented in March of 2000 followed by the implementation of the third stage in March 2001. That basically left about 30,000 over 70 year olds who were not in position to receive a medical card. It is in that context that the Government took the decision to extend it to everyone over 70. More than 1.15 million people  in the country have a medical card so 30,000 is not an enormous figure.
I received legal advice several weeks ago that it would be better if we provided for this in legislation to avoid any potential challenge to the decision to extend medical card eligibility to over 70s. It is opportune and useful that this health amendment Bill provides an opportunity to facilitate such an amendment. It is important that we as a society show our commitment to the elderly and our appreciation for what the older generation has done to build this country. Elderly people have greater medical need than other age groups.
Mr. Martin: Extending the medical card for over seventies is an indication of the Government's commitment to elderly people. We appreciate that they were pivotal in building up the country and the economy. This is a welcome measure which I commend to the House.
Mr. Ring: I hope the learned Members of Fianna Fáil might let us do that. It was poor form that the Government did not have the legal framework in place when this was announced at the budget. It is embarrassing that it must amend the legislation. That should have been done before.
What proposals has the Minister for the cases where wives are younger than their husbands? Will they be allowed medical cards with those over 70? It is wrong that the Minister brought this proposal without it being clarified. It is embarrassing for him to introduce the legislation now. Announcements should not be made like this. Since it came to office, the Government ran out the PR people's press releases and made statements after which it discovered that the legal framework was not in place. This announcement caused confusion that must be dealt with immediately. People to whom medical cards were promised must have them.
I support this measure. Fine Gael proposes that it apply from 65 years up and I hoped that today the Minister would agree to that. We are the only European country that does not provide medical cards for pensioners and children. Every child, from birth to 18 years of age, should have one. I hope the Minister will do this now. In any event, it will happen soon when the new Government takes over.
Mr. N. Ahern: I support the Minister's amendment. It is a tremendous decision by the Government to give medical cards as of right to everyone over 70 years of age. I am surprised the Minister believed he had to introduce legislation lest well paid professional groups challenged this socially just decision. It is appalling and laughable that doctors who are a well paid group pretend to have a social conscience and indicate that they will challenge this in the courts or will not implement it.
Recently, a 92 year old constituent went to her doctor to ask him to accept her medical card. She had been a patient of his and his father's for 45 years. She was treated disgracefully by the doctor, who took the form, muttered something about the IMO, and threw it on his desk. His attitude was that she should come back in a few months time when his association reached an agreement with the Minister. I laugh at doctors pretending to have a social conscience while they treat the elderly like this and act as if they are being asked to do something for nothing. They get well paid for medical card patients and zealously guard their book from younger colleagues to stop them treating these patients. However, they prefer to have the elderly pay the £22 or £25 fee.
It is marvellous that elderly people will have the medical card as of right. They put their shoulders to the wheel over many years. It is disgraceful to see doctors and the IMO mistreating them. The IMO may not tell doctors not to treat these patients but they are typically boorish in treating them. If doctors believe they deserve extra  money, then let them negotiate with the Minister. Dressing it up in the pretence of a social conscience or justice is nonsense. Like any group, doctors have a right to look for higher pay. However, elderly patients seeking to have their forms signed are not strangers but long-term paying private patients. I advised some to go to another doctor but people do not want to do that because they believe they have a relationship of trust with their doctors. The doctors' argument should be sorted out by their association and the Minister. Their way of treating and communicating with their patients is despicable. I hope it is sorted out quickly and that the IMO gets the message to its members to treat their clients, and prospective clients, with dignity and respect.
Ms McManus: I heard a great deal of hogwash from Fianna Fáil on this issue. We must set the record straight. The medical profession would be the first to welcome a scheme that provided free GP care not just for the over 70s, but for the under 70s when we are talking about our elderly population or, indeed, another part of our population.
The reality is that we are not talking about the elderly population but about a specific group within the elderly population who will be provided with medical cards. I for one welcome the provision of medical cards for any group, particularly people who are, generally speaking, more likely to be sick than younger people. I will not, however, go along with this kind of hypocrisy that is being presented here as if somehow the elderly and those most in need are being cared for because clearly what is being put forward here is a proposal which will ensure that those who are over 70 years, of whom there are very few left who do not have medical cards already, will have medical cards. The Minister was right in saying that it is quite a small proportion who do not have the protection of medical cards.
We are not talking about someone who is under 70 years, who is living on low income and who cannot afford to access their GP and we are certainly not talking about providing for families with young children, living in poverty and who cannot access a doctor when they need one. Recently, a cancer patient came to see me who could not afford to see her GP. A mother of two children, both of whom have eye problems, who cannot afford to access their GP came to see me. They are generous in their view and they understand that elderly people are entitled to have free GP care but they are also desperately anxious about themselves and about their children. Another woman with cancer asked me, in reference to the Abbotstown project, where will the  sons be if there are no mothers to look after them.
Fianna Fáil has lost touch with the people. The fiasco at the Ballymascanlon Hotel only underlined the reality that this Government is out of touch if it thinks that there are elderly people who are now protected as a result of this proposed measure. We are talking about people who have made a contribution to this State and have built up the Celtic tiger economy but who have not reached 70 years, and may not reach 70 because they cannot access the care they need.
A person brought to my attention that the medical card income guidelines effective from 1 January 2001 are £162 for a married couple aged between 66 and 69 years. This couple is entitled to an old age contributory pension of £183 which puts them £21 over the medical card limit. The limits set out show there is a more favourable balance towards people who are more elderly, but it is clear that there is still a disjuncture between social welfare payments for married couples of a certain age and access to the medical card.
This area is crying out for reform. We need a new GMS contract. The arguments being put forward by medical professionals who, of course, have a self-interest – everyone understands that so why should anybody be surprised – are simply dismissed. The central issue in the argument being put forward on this is hardly about the self-interest of doctors, because we are not talking about a very big population anyway.
I would like to convey a flavour of this to the Minister now that we are addressing this issue. I thought it would be addressed slightly lower down on the list of amendments, but let us address it now. An article in the medical press headed, “Sense of injustice over medical card scheme permeates local practices”, states that:
The sense of injustice articulated by the IMO in relation to the decision by the Government to give free medical care to people aged 70 years and over on a non-means tested basis, has found echoes in general practice throughout Ireland.
This is particularly true in the North-Eastern Health Board [area] where healthcare is provided for some of the State's most marginalised rural communities in the counties of Monaghan, Cavan, Meath and Louth . . . Between them they span a broad socio-economic canvas. . . . But, regardless of the county, the local community make-up or whether or not the setting was rural or urban, every GP who proffered an opinion on this issue was full-square behind the IMO's assertion that the Government's move was unjust and flew in the face of social equality.
If we are going to seek progress on providing the security and guarantee to people who are sick that money will not undermine their access to a doctor, then we have to get real about it. We do not go along with the political games that are being played in regard to this measure. I suspect  the Department of Health and Children and maybe even the Minister know quite well that this is not dealing with the real issues. There is an issue of social equity and about protecting the health of the public.
One GP made a point about how people lose their medical cards and, increasingly, people are losing their medical cards because they are able to access employment. Dr. Peter Walhrab, a Kells GP, has seen his own GMS list decline by about 25% in just 18 months. In addition to the loss of income this involves, Dr. Walhrab has concerns about what this means for health care through general practice. He said:
The people who lose their medical cards do not become high spending private patients. Their attendance drops off from approximately eight visits each year to zero visits. They simply disappear because they cannot afford the cost of either the visit or the medicines.
This Government is ignoring it and is throwing out a sop to the over 70s and it is trying to paint a picture that somehow it is doing the generous thing and providing care for the elderly. It is providing medical cards for a certain number of elderly people who are excluded at the moment, even though over 70s have a much higher ceiling when it comes to GMS eligibility. That is all. It is not about dealing with the grave injustice that has been done to young people and young families on low incomes and to elderly people on low incomes; people who simply do not feel free, like practically all our European counterparts, to walk into their family doctor and say they are sick and need help and care. This is the party that delivered free secondary education.
Ms McManus: This is the party that in the 1950s was able to face up to very serious economic difficulties but this is the party that has turned its back on the sick and elderly people who so desperately need to have a share of our prosperity. The idea that it is simply sufficient for a public representative to come in here and say the doctors are only interested in more money is not to understand what is happening in terms of sickness—
On Monday the Taoiseach came out of the Ballymascanlon Hotel and tried to convince the nation that there was not a crisis in our health service. Tell that to that mother who is worried about her children and their eye condition. She is married to an alcoholic. They are over the income  limit, but she never gets to see the money. She owes the doctor £25 and she is afraid to go back to him, even though she is desperately worried about her children's eyesight, because of the money outstanding. One could say the doctor is to blame. I told her to go back to the doctor anyway.
If we are serious about health reform, there are certain guarantees we as a nation can give to our people that we now give in this context to the over 70s who are outside the frame, while maintaining the drugs scheme with some contribution from those who can afford to pay. All our people, no matter what their circumstances, no matter how poor or how rich, no matter who they are married to or are dependent upon, should be guaranteed access to their family doctor. That is the concern being expressed, a concern which the Government is simply ignoring. To dismiss this as some kind of private gain is nonsensical. As far as anybody who has looked at this intelligently is concerned, the GMS contract will have to be re-negotiated and a new contract implemented if this matter is ever to be dealt with properly, and that will mean hard bargaining. Let us get started on it. Let us deal with real needs instead of doing a little here and there and trying to look good, which is what the Ballymascanlon event was all about. That backfired in terms of public understanding about where this Government stands on health reform.
I want to make another point in relation to our having to include this in the Bill. This issue was raised with me some time ago in correspondence with the Department. However, according to legal advice I obtained, it is crystal clear that this measure, which was announced in the budget, would require legislation. The categories of people who are entitled to full eligibility under the Health Act are adult persons unable without undue hardship to arrange general practitioner, medical and surgical services for themselves and their dependants, and dependants of such persons. The issue of means arises there. Now, for the first time, the Government is taking a measure which is not related to means or hardship. People will now qualify for medical cards on age grounds. That this measure is being introduced at this very late stage in a Bill dealing with other matters is an indication of something seriously amiss with how this Government is doing its business in the area of health. It is indicative that in its fifth year in office the Government is devising a strategy on health. That is the sort of thing people expect would be devised at the beginning of a term of office.
I put down an amendment which I knew would be disallowed on financial grounds. However, I still believe passionately that it provides a way to go forward. My amendment proposed that we amend the health Act, as stated in the amendment we are now discussing, in terms of providing free general practitioner care for all citizens. That would be real progress, real health care reform. It would meet the needs of people, including our  elderly. It would provide for those elderly people who are not 70 and who are not included in this measure, as well as for all the other categories of people who are currently being denied what is considered among our EU partners to be an essential social service. We are part of the EU and we get the benefits of being in the EU, but somehow we have not come to expect the same standard and level of basic essential services, particularly in the area of health, that our EU partners enjoy. This is about solidarity, and we are not seeing that either from this Government or in the proposals here.
Mr. Daly: I have no problem with Deputy Ring. However, I have a problem with a Deputy who describes us in Fianna Fáil as hypocrites when we have listened to the most hypocritical speech I have heard in a long time, a speech defending the case being made by practitioners against this measure. The Deputy knows there are hundreds of people in every constituency over 70 years of age who are at their wits end trying to meet medical bills. Many of them suffer from cancer or depression. Many of them have to use their savings, limited as they are in some cases, to pay their medical bills. It is hypocrisy of the highest level to make a case for some other sector at the expense of people over 70, many of whom are in a very serious position in medical and in financial terms.
I support the Minister's novel proposal which will alleviate the burden of medical expenses for our elderly citizens, many of whom are in dire circumstances financially and from a health perspective. It may be necessary to take other measures. I concur with the medical profession in its care and anxiety for some sectors of the community who find it difficult to meet their medical expenses. However, there has been a systematic improvement in the guidelines on a yearly basis in each area. The standard may not be what we would all like. I strongly urge the Minister, therefore, in addition to taking the proposed measure, to continue to relax the guidelines in order to alleviate the burden on those who are experiencing difficulty.
This measure is an innovative one which should be fully supported. I call on medical practitioners throughout the country to back and implement the proposal rather than adopting a dog in the manger attitude. The Minister makes these decisions. He is in the best position to do so. It behoves all of us to support him in his efforts in this regard. I am surprised, to say the least, and I am not sure whether what we have heard this afternoon is Labour Party policy.
How is the Minister going to explain to us that the Minister for Finance announced this policy, with which I fully agree and on which Fine Gael  has tabled an amendment to bring it down to retirement age of 65? I have no problem with allowing those who built up the economy to get some benefits from the State even if they are not means tested. At present free travel is all that people over a certain age, irrespective of their means, get from the State. More recently, people over 80—
Mrs. Owen: Everything over 70 but as the Minister mentions that, it came in last October and I have people coming to see me who still have not received their free telephone allowances nearly six months later. The system has not caught up yet.
At the eleventh hour of the introduction of medical cards for those over 70 the Minister suddenly discovers he needs to bring in a legislative basis for it. Is the Minister aware of the anxiety, confusion and distress he has caused for those over 70? They probably clapped and cheered when they heard the Minister for Finance make this announcement. They thought that at least they were getting something and that their medical bills would be covered.
They have tried to find out what is happening from their health boards but when I consulted five colleagues last night I found that not one of them had the same experience with their different health boards when dealing with this matter. Some health boards advise people to fill in the ordinary medical card form and give no other instructions while others are being told to fill in the form but to ignore the section referring to means. The health board in my area says it does not know what to do but advises people not to fill in the form as it is not the right one. There is complete confusion as to how people over 70 are to avail of the mechanism giving them free medical cards. They expect to get them at the beginning of July but it is my impression that with this change in legislation the Minister will not be able to do so by 1 July. I await his response.
What is the number involved? I have been told that approximately 35,000 people are involved, which is more than the number of people who qualified for the extra allowances such as free television licences and so on. If it has taken six months to do this, I do not know how long it will take to process the 35,000 people. I understand that not even the Department knew how many were involved when the announcement was made.
There has been unfair criticism of Deputy McManus for raising the issue of the GPs but what discussions did the Minister have with the representatives of the GPs to inform them they would have to adjust to having higher numbers on their GMS lists? What arrangements were made? Looking at the statements made at the IMO conference it appears they were as surprised when the announcement was made as we were. The Minister has a responsibility to ensure that  when making an announcement like this, which gets him good PR and provides a photo opportunity, what he is announcing is going to work.
I will give the Minister examples of the scenarios that have been painted for me. Someone over 70 may be attending a doctor who does not have a GMS list and when he or she gets a medical card it is damn all use unless he or she changes to a doctor on a list. We should not be advocating that people over 70 should change doctors; they are used to their doctor and they may have a chronic condition on which the doctor has a file. The doctor knows when their form is good or bad and when they need extra care. However, with the medical card the patient may have to try to get onto a list and if another doctor in the area is not as convenient to travel to or does not have room for a new patient, then the person may as well have a used bus ticket. The person will not change doctors if he or she cannot access another doctor. In many areas of my constituency and other large urban constituencies there is a need to reform the GMS structure. Doctors are giving service but they cannot get a list as two or three other doctors may already be in place; the Department has not caught up with the growth of population in many new urban areas. I understand that doctors will have to practise for at least five years in an area before they are considered and even then an assessment is made as to the need for another GMS doctor. A 75 year old who goes to a doctor not on the GMS list may receive a medical card but may still want to go to Doctor A because they are comfortable with that doctor or because they can walk or get the bus to his surgery. What are such people to do? They may as well not have a medical card because they will probably stay with their own doctor.
The Minister has not thought about this. Has he considered a situation where an elderly person is in such a position and gets a medical card but cannot use the card to get drugs unless the card is given by a GMS doctor? A private doctor not on a GMS list who is seeing a patient prepared to pay for the visit cannot give a prescription which allows the patient to get the drugs on a medical card. The Minister will have to consider a category of people who, through lack of choice, will have to stay with the doctor they have, who get no benefit from the medical card and who cannot get their drugs for free because they have a medical card. The Minister will have to see if this can be changed.
That has been highlighted for me also in the case of contract beds in private nursing homes. In these cases a hospital rings a nursing home and asks if there is a bed available, to which a patient is then sent. If it is a GMS patient who does not live in the area where the contract bed is, the nursing home must contact the person's GP, who may be ten or 20 miles away, and have the person's prescription posted to the home. They cannot get a prescription from the doctor serving the nursing home for a medical card patient who is not on their list. An anomaly has been created  here and I was informed of this directly by private nursing homes who have contract beds. They must get drug prescriptions from patients' doctors who may be far away. Many anomalies are arising already and more will occur.
There is a freedom for people and there are those over 70 who still have the financial capacity to pay the £20 or £25 to the doctor but who would like to have the benefit of getting their expensive drugs without having to pay a constant £42 per month. The Minister made an announcement about the £42 and how it would be good for people but then we discovered that many of the products people could claim over the £42 amount are off the list. As well as paying £42 monthly, which many welcomed, there are now additional bills. They will now find that their medical cards are not worth the paper they are written on if they cannot change doctors.
I do not know how the health boards have been told to handle medical cards and who will be eligible for them; in this case everyone over 70 is eligible. I had a case on Saturday like Deputy McManus's case. It involved a man who lost an eye through a random violent attack on the streets 11 years ago. He got a medical card at that time but it has now been taken away because he is a few pounds over the limit. His wife has been diagnosed with lupus but out of the blue his medical card has been withdrawn because he got a little rise; he works for one of the semi-State bodies. He must go to the doctor constantly because the false eye gives trouble and there may be a growth behind it but on paper he is over the limit and his medical card is gone. This has caused him stress and pain and though I have told him to appeal it, he is over the limit and if the health board obeys the rules it cannot give it back.
Mrs. Owen: Discretion does not mean they get it. The man was in to see me and he was practically in tears – his false eye is constantly weeping anyway so there were tears running down his face. That is the reality of life that this Government and Fianna Fáil do not seem to understand. Reading out lists of things the Minister has done is no consolation to the people we meet daily. I hope the Minister meets them also to understand what the health service is doing to people's lives.
I do not understand why the Minister has allowed this situation to arise. I do not understand why the Minister has allowed a picture to be painted that indicates doctors are against this because those I know are not against it. They would like to have known how the scheme would have been administered so they could change their practices to ensure they could take extra  patients who had to move from non-GMS doctors.
The Minister is engaged in seat of the pants public relations and photo opportunities so he can get a good line in the newspapers and tally up everything. Quite frankly, he must be hugely embarrassed as a result of the meeting at Ballymascanlon. It is great that a young man like the Minister can smile and take criticism. God knows I took a lot of flak in that seat. Pressure built up on Sunday when reports began to appear. The Minister built up a storm before the Ballymascanlon meeting so that he could then ride out on his white horse to show the roll of money he received from the Minister for Finance. I would have loved to have seen a roll of money, just as I would like to see real structural reform.
I do not know the internal politics of Fianna Fáil, but perhaps future leadership contentions were apparent in Ballymascanlon. The Minister for Finance dumped on the Minister for Health and Children by saying he would not allow the younger man to get ahead of himself, he should wait his turn to be Leader of Fianna Fáil and that he would not be given anything. Anyone who read the large number of health stories in the Sunday newspapers knows that the Minister, Deputy Martin, was whipping up interest in the Ballymascanlon meeting. The Minister's intention was to build anticipation ahead of the 6 o'clock headlines on Monday which he hoped would portray him as the saviour of everybody and lead him into the next public relations function.
The Minister, Deputy Martin's plan was very clever and it was clear that he had thought deeply about it, but I cannot say it more diplomatically than that the Minister was dumped on by the Minister for Finance. Although it is fun and facetious to make such remarks, it is serious that expectation was built before a Government meeting to discuss the health needs of the country only for people to be told that they would have to wait for the budget. It was not only cynical, but extremely cruel for those whose needs are not being served.
I read about a woman who needs to see a specialist but will not get an appointment for three years, despite chronic back pain. However, she will probably be helped as her case was highlighted. Those who telephone Joe Duffy or Marian Finucane are told that the Minister has asked an official to ask them to get in touch and the problem is then sorted out. Although one is pleased that particular individuals are helped, cases should not be dealt with one by one. Sick people should not have to come to me, to the Minister for Health and Children, to Deputy McManus or to any of our colleagues to seek what they need. They should not have to lie on a trolley in hospital with chronic kidney problems for two and a half days before eventually getting a bed, as I heard about last night. We should not boast about inflicting such pain, indignity, suffering and trauma on patients and their families. One could understand if accident and emergency  departments were over-run occasionally following a major accident, but we should have reached the stage where it is not constantly the case.
The Minister, Deputy Martin, is in charge of the health system and the buck stops with him, but he is not taking that responsibility seriously. The amendments proposed today indicate to me that the Government makes decisions on the seat of its pants, based on what it thinks today's issue is. It decides to give ideas a little run, for example, when the Minister announced that over 70s would get medical cards. Five months later, he wakes up and realises that he made a mistake by not putting the measure into legislation. Only a couple of weeks after another health Bill was passed, the Minister has decided that another Bill is necessary to deal with the fact that we do not know how the new medical card provisions will work.
I hope I will be wiser when this debate is finished so that I can tell those who come to me how they will get medical cards and how they will access the service once they have received cards if their doctor is not a GMS doctor. It would be helpful if those who decide to stay with their non-GMS doctors but also use their medical cards are allowed to get drugs. These questions have still not been answered and I hope the Minister will answer them at the end of this debate.
Mr. Neville: I welcome the fact that the Minister has moved somewhat in this area, but it is not enough. I am disappointed that the Fine Gael amendment to ensure that the situation is improved was not accepted by the Ceann Comhairle. All those over 65, those in continuing education and those under 18 should automatically be entitled to a medical card. As previous speakers said, many families are stressed about health issues, especially if limits are marginally exceeded. Families whose income is £5 over the limit have a chance to be approved at the discretion of a chief executive officer, but those who exceed limits by £10 rarely benefit from discretion, although £10 is very little nowadays. The discretion of the chief executive officer is a matter that needs to be addressed.
I know of an incontinent nursing home resident who has a medical card. He used to receive incontinence wear, such as nappies, to the value of £74 each month. Now that he receives the nursing home subvention of £78 per week he is not entitled to any incontinence wear. I do not understand why somebody with a medical card without a subvention is entitled to support for incontinence wear. I received a letter from the health board outlining the situation, which outraged me so much that I immediately sent it to the Ombudsman as I cannot accept it. Such anomalies are consistently evident in hard cases.
If the Fine Gael amendment had been taken or if the Minister had looked seriously at this problem the means test limits would have been doubled. Much of the stress on families would have been relieved, especially on those who are marginally above income guidelines. Fine Gael's  proposal is only a start as we believe there should be an eventual movement towards full medical cover for everyone, as is the case in many European countries. Until full medical care for all is provided, we must ask if we are being fair and if we are giving the benefit of our economic success to our people.
Our ultimate objective must be to ensure that nobody feels reluctant to visit a general practitioner when they need to do so. Deputy McManus cited the example of somebody who was reluctant to visit a GP with their child as they owed him £25. That highlights the difficulties experienced and I am sure that the Minister encounters such stories in advice centres when people come to him with hard cases. Health board officials are often cold and inconsiderate when they judge such cases as decisions are based on income guidelines. To its credit, my local health board looks sympathetically on cancer patients, but that should be the case for all patients with extreme difficulties.
I know of a young person with an advanced form of rheumatoid arthritis who is quite ill and is trying to provide for a family. He has been refused a medical card as the family's income exceeds means test limits by not much more than £10. Rheumatoid arthritis is a serious and painful illness and brings an awful lot of stress and costs. This area should be fully examined and it is unfortunate that the Fine Gael proposal to double income limits and allow all those under 18 and over 65 to receive medical cards is not in order. We would certainly have liked to have fully debated the measure and had it put to the House.
Mr. Ring: There are two points I want to put to the Minister, even at this late stage. Some fine speeches have been made this morning, including that of my colleague, Deputy Neville. I ask the Minister to review the guidelines on medical cards even at this late stage. The £100 rate for a single person and the £135 rate for a couple, which applied up to a few months ago, are unreasonable. Since the minimum wage was introduced wages have improved, but the guidelines operated by the chief executives of the health boards, who do that job on behalf of the Minister, are not reasonable. An increase of only £1 or £2 again this year is unrealistic. Costs have increased and people are finding it difficult to cope. As Deputy Owen said, some people no longer qualify for medical cards simply because they got an increase in their wages. The Minister should introduce realistic guidelines on medical cards as the current position is unfair.
 I tabled parliamentary questions on this matter last year and again this year. More and more people are losing their medical cards because of the restrictive nature of the guidelines. That is wrong. I could give the Minister examples of people who need medical cards. The Minister is correct that the chief executive of a health board, a community welfare officer or whoever has responsibility for this area, must make a decision on this, but it is wrong that persons should have to beg for medical cards. It is like every job in the world, including that of politics. Some people take a sympathetic view and others will use the green book.
Mr. Ring: There has been a significant increase in the number of people, particularly young people, who has developed asthma. The time has come for the Minister to make another political decision, to address the needs of those who suffer from asthma. Parents of children with chronic asthma have told me they must bring their children to the doctor and then pay for medicine from the chemist. They are virtually being robbed on a daily basis in terms of the expense involved. In recent years a number of my constituents who had suffered from asthma for a long time died from chronic attacks of it. I am not a medical person and I do not know whether the increase in the number of people who have developed asthma is related to environmental issues. Will the Minister examine this matter?
People expected wonderful announcements on the health service yesterday. I want to inform the Minister of two cases of which I am aware. I know a women whose husband died of cancer, her mother died within a month of the husband and now her 13 year old son has been diagnosed with cancer. That woman called to see me on Saturday and on Monday I faxed a letter to the Minister's office on behalf of her son who is waiting for a bed in St. Lukes. That mother is devastated and she came begging to me for help. She cried while asking me when her child could get a bed in St. Lukes. It is wrong that a person should have to do this.
Another women called to see me last week about a matter which is even more upsetting. I  recently heard a colleague of the Minister talk about the health boards. Something must be done to improve the services provided by them. The system has got out of hand and no one is taking responsibility for anything any more. A three year old child has suffered with toothache since February and I was informed by a letter faxed to me yesterday that that child will not be called for a procedure to Mayo General Hospital until 6 June. In the current economic climate, why should a child have to suffer with toothache from February until 6 June because of a 12 month waiting list for treatment? The Minister might ask why the child could not be brought to a dentist. She needs to have an anaesthetic to have her tooth pulled. Four such procedures a week are carried out in Mayo General Hospital and there is a 12 month waiting list. If necessary, those trained to carry out such procedures should be paid overtime, even if they had to be done at 10 p.m. or 12 a.m., or an anaesthetist should be brought in from outside the county. Those two cases highlight what is wrong with the health services and I am sure every Member could give the Minister other such examples.
I raised the matter of the increase in the number of those suffering from asthma and the restrictive nature of the guidelines on medical cards. Medical cards are being given to those over 70, but the Minister should be honest and accept that those who really need medical cards are those with families, as they are being attacked on a regular basis in terms of costs. If one is participating in a FÁS scheme, one will not qualify for a medical card, given the guidelines in place. If the Minister is serious about addressing this matter, he should make a directive or an amendment not to double the rate but to treble it, having regard to the manner in which medical costs have increased.
I deeply resent the comment by Deputy McManus who referred to what I said as hypocrisy. I know who put me here. I speak on behalf of my constituents whom I represent. I deeply resent her use of that word. I have not been lobbied by any professional group outside this House. If a Member on this side of the House spoke the way the Deputy did, and having regard to the slant she put on it, she would nearly be down looking at our declarations of interests to check whether we declared certain interests. If she reads what she said, I am sure she and many of her colleagues would be frightened by the emphasis she put on things.
I do not agree with, and would stand back from, the Labour Party's point of view, which seems to be to do nothing until we can solve all the problems of the world in the one day. That is a ridiculous political position. The measure introduced, to give medical cards to people over the  age of 70, is a good idea. There are, however, other problems. The Minister is solving one problem today and that is good. Deputy McManus is right in that young people cannot afford to go to the doctor as often as they would like. That also applied to elderly people. Elderly people in general would suffer in silence at home rather than bother their doctors. If they feel free in the future to go to their doctors more often because they do not have to pay £22 or £25, that is good. I heard of a woman who recently had a bad fall. She went into her home where she lives alone, cleaned herself up, tidied up the house, went to bed and lay in shock and fear all night rather than ring her doctor.
Ms McManus: I would like Deputy Ahern to explain what he meant by saying there would be some declaration of interests issue in what I said. He made a rather serious statement and I would like to know what he meant by it.
Mr. N. Ahern: There are problems in the health services. The main problem is that the medical profession at GP level or consultant level has too much power. The Minister should take it on and give proper power to the managers rather than allow groups, be they the consultants' association, the IMO or whoever, rule the roost. That is not something that happened just today.
Mr. N. Ahern: I was responding to her charge that I was a hypocrite. I deeply resent that and was responding to that. I suggested to her that her contribution was out of order and if she checked the record of what she said, she and the Labour Party would be embarrassed because the slant I perceived she put on it was not one I would expect from her party.
Ms McManus: The Deputy said that if what had been said by me was said by a Member from that side of the House, we would be raising questions about a declaration of interests. I have no problem with being criticised or abused by the Deputy. That is not at issue. What I have a problem with is a reference which he has made which I cannot leave without it being attended to by you, Chairman, because if I leave it, it does cast a slur which is unclear to me.
Ms McManus: The Deputy may not have been aware that he has done this, but he should withdraw it. I am quite happy for him to have abused the Labour Party or, indeed, to say that I am wrong in using the word hogwash, which I thought I used, although “hypocrite”, I think, is a parliamentary term.
Ms McManus: What I am not willing to accept is any question about some issue of declaration of interests which he has introduced into this debate in relation to me personally, and either he withdraws it or he clarifies it so I can deal with it.
Mr. N. Ahern: I am not saying that Deputy McManus has anything to declare but I am saying that I was surprised at the slant she was putting on things. It sounded like she was more representing or pushing the views of the medical profession than the views which I would be pushing or which I would have thought she, as a member of the Labour Party, would have been presenting. I would have thought she would be dealing with constituents who would be in much the same position as those in my constituency and I was surprised at the way I perceived the slant of her point, that it seemed to be pushing the interests of a professional lobby group rather than the good of her constituents. That is the point I was making.
Mr. N. Ahern: I would agree with some of the points being made by Deputy Owen and Deputy Ring in particular. Certainly in Dublin there is great confusion at health board level. Perhaps that is because since the ERHA was set up there is great confusion anyway.
Mr. N. Ahern: It is not the Minister's fault. There is so much movement of staff that it is difficult. I think many of them do not know what they are doing. Certainly I agree with the point made by Deputy Owen that, depending on the official with whom one is dealing, one is given a different story. I hope once this legislation is enacted matters move along quickly.
Mr. N. Ahern: The Deputies have raised a question and I am raising it also. I am interested in hearing the Minister's clarification but, rightly or wrongly, and I hope I have not been putting too many people on the wrong track, that is what I have been telling them. Although I asked officials in the health board more than once, they could not give me an answer. Therefore I gave my own common sense answer which is, that if one is a full-time dependant, one would qualify. If one is not, if one has a salary as a teacher, for instance, then one is not a dependant and would not qualify. That is my own ruling on it. Certainly there are a great number of questions in this regard and I wish there was somebody who could answer all those questions because, as I say, at health board level there is confusion. However, to blame the Minister for the confusion or the anxiety is nonsense because the people over 70 just want their medical cards. Whether this is set out in legislation is not a matter of concern to them.
I agree with Deputy Neville that many people are losing their entitlement to the medical card  because people who were long-term unemployed are now working. One does not lose it the day one takes up a job or a FÁS scheme. Many such people are entitled to retain the medical card for three years.
Mr. N. Ahern: There are more people working now. If one was unemployed for years and one had a medical card, naturally one deserved the card. However, if one is back at work for two or three years and in a good job, there is no logical reason that one person working for £400 a week would be entitled to a medical card while another person in the same job is not. In fact, that is a cause of resentment because a person who two and a half years ago was long-term unemployed is entitled to a medical card and the other person, who has been working since the age of 18, is not so entitled. Therefore while the scheme which entitles a person to retain their social welfare benefits for a period in itself is a good scheme, it does lead to conflict.
To return to the amendment, of course this does not solve all the problems of the health service. The Minister is taking the opportunity to give medical cards to everybody over 70 and I welcome that marvellous move. I hope this Minister and future Ministers will make other marvellous developments in the health service as opportunities arise.
Mrs. Owen: I want clarification on one issue because I did not have time to check this out. Was an amendment made to the Finance Act to ensure that people, who will now qualify for a medical card under this new scheme, will not continue to pay the 2% health levy? It seems ridiculous that they would be getting a medical card to cover their medical expenses and then at the same time the Minister would be taking the 2% health levy from them. Will that be amended?
Mr. Martin: I congratulate the Deputy for finding out yet another hidden benefit in this particular move which will benefit a large number of public service pensioners. This will be hugely beneficial to a large number of public service pensioners. The Deputy is correct. There will be no need for an amendment but I will clarify that point.
Mr. Martin: I want to reply to a number of issues. Governments are elected to introduce budgets. They have a democratic mandate from the people and they take decisions. We do not negotiate with a range of bodies in advance of budgets on taxation, old age pensions, etc.; we take decisions. We took a decision in the budget to look after the elderly in particular and that was reflected right across the social, community and family affairs programme and in the Social Welfare Bill in terms of the increased eligibility for the free schemes, a very significant increase in the old age pension and a range of other supports for elderly people from Departments such as the Department of the Environment and Local Government in terms of housing aid for the elderly. There was quite a theme and a consistent approach across the board to take measures in that budget which would benefit old people and one of those measures was extending the eligibility for a medical card to those over 70. That is the background to the decision.
The Irish Medical Organisation opposed the decision in principle. It does not disagree with the mechanics but with the issue in principle. The IMO has made clear to me that it would prefer if it were done otherwise. Its preferred option would be an increase in the broad eligibility threshold. Deputy Ring raised the issue of asthma sufferers. In the context of the health strategy which  is being formulated at present, we are looking at eligibility for health services and in particular, eligibility for GP and medical card services. Income eligibility alone could be one option whereby income thresholds are raised. That would not meet the needs of everybody, or the needs of those who are medically more in need of a medical card than others. Medical need must be factored into whatever scheme emerges. I am in favour of extending the broad income eligibility threshold.
The age-specific issue must be a factor. The elderly and the children are two age groups that will always have medical needs. A whole age range of people in between those two groups may not ever visit a GP. There are many people between the ages of 15 and 70 who will not have the same level of recourse to GP services as a person older than 70 or a five year old child or a year old baby would. We must question who would benefit most from that measure. We should discriminate more in favour of families than we do at present.
Mr. Martin: —and which would give a weighting to children. I am also concerned about the issue raised by Deputy Ring. There are varying degrees of asthma. A whole range of other groups, including those suffering from spinal injuries, will have many ongoing medical costs. There are groups of people with minority illnesses and diseases who are not automatically covered either—
Mr. Martin: —but who should ideally be covered by the discretionary framework that is available for use by the health boards' chief executive officers. I met some of those groups recently. Some number less than 100 people. We must look at those statistics in the context of the strategy. I would like to see the emergence of a balanced approach where there would be a commitment to raising the income threshold across the board. Balancing measures would be needed for the disease-specific issues and the age-specific issues in the overall framework. We may have to formalise the discretionary system and create a better discretionary framework.
The legislation we are discussing today is not a factor in delaying the scheme. The IMO raised other issues on which it demanded settlement before it would even begin to negotiate on the issue of the over 70s. We had another series of negotiations with the IMO last year on a range of  issues relating to immunisation and the rates of pay for doctors administering the overall immunisation programme. We settled quite generously with them even though they might not think so. We significantly increased the rates payable in relation to all those immunisation programmes which are essential for good public health.
A whole series of new issues was raised this year. We reached an accommodation last month with the IMO which will cost in the region of £10 million. That includes increased allowances for practice nurses and secretaries which total about £5 million. Grants for GPs towards equipment and refrigeration for vaccines come to approximately £1 million
Increased payments have been made for GPs dealing with extra numbers of discretionary medical card holders and for treating asylum seekers. The number of asylum seekers in the country has increased the work load for GPs and this has cost another £3 million. We have agreed to improve the payments for former district medical officers. We are reviewing the work load in the primary childhood immunisation scheme. My officials have been working with the IMO on all of those issues. Part of the agreement with the IMO is that there will be discussions about the extension of the medical card scheme to include all those over 70 years of age.
I agree with Deputy Noel Ahern's point that if the budgetary decision to include over 70s was not taken, then they would be waiting a long time. Anyone with experience as a Minister with responsibility for health would support that view. Deputy McManus argues that the entire GMS should be re-negotiated. That issue will have to be discussed either in the context of the health strategy or with the social partners. That will be an enormous undertaking and it will have significant cost implications.
We will have to prioritise. If free full eligibility for medical card and GP care is extended to the whole population, it will cost approximately £800 million. To extend the eligibility to those up to 18 years of age would cost roughly £200 million. I do not know if the Labour Party is planning for that to happen over one year, two years or four to five years. We have to invest in more beds in the acute system and that will cost a significant amount of money. We have already provided £2 billion for the modernisation of hospital infrastructure under the national development plan. It was noted at a Committee of Public Accounts meeting recently that inflation alone would add £1 billion over the next six years to that £2 billion. That does not include a whole range of other essential capital projects which are outside the remit of the national development plan. The construction industry is working to the limit to cope with the demand from both the public and private sectors.
A broad, balanced approach must be taken to any budget in any particular year. Everything cannot be achieved at once. Key building blocks must be put in place for the reform of the health  service and that will cost money. These include the manpower forum report and the negotiations about re-negotiation of the contracts with consultants, the employment of additional consultants, new rostering arrangements, bed capacity issue, and the modernisation agenda. The Government has given its approval for a fundamental review of general medical practice. It is long overdue but all are agreed that we need to look to the future of general practice. Young women now make up 70% of trainees in general practice medicine. They must be given the opportunity for family-friendly, flexible working arrangements. The old ways will not suffice for the future.
The operation of the medical card scheme is currently the subject of a review being carried out by the health boards' chief executive officers and this will feed into the group dealing with eligibility under the health strategy. That will deal with the anomalies within the scheme.
Deputy Neville raised the issue of medical card holders retaining their entitlements on entering private nursing homes. They do, and should retain their entitlements. We issued a letter to all health boards clarifying that point again last March that they are entitled to incontinence wear.
Mr. Martin: Yes, we have issued that. Generally speaking I welcome the broad support for the measure from all Deputies in the House. There has been some carping and some criticism and so on but I take it from the comments that everybody is agreed that over 70s should have a medical card. It is an important statement to come from the Oireachtas. I know others want it all done now but it is not possible to do it all now. Last year we received a record increase in funding from the Minister for Finance, Deputy McCreevy, and an extra £1 billion this year which is being used right across the board. People have to realise that health care is not just about the acute hospital system. This Government had a programme for the health and social services which it has delivered in terms of commitments, targets and spending on a variety of reform programmes. To take only intellectual disability and the physical and sensory disability area, any fair minded person in the House would have to acknowledge that my predecessor, Deputy Cowen, and the Minister for Finance, together brought in a major change in terms of the level of funding given to people with intellectual disability. This has resulted in a dramatic increase in respite places for the intellectually disabled, day care places and long-term residential places. More remains to be done but that fundamental  improvement has to be acknowledged. In addition, the physical and sensory disabilities area have also benefited significantly but could benefit more and when the national database is in place we will be in a position to meet those needs properly.
One can compare the budgets of 1996 or 1997 with what happened subsequently. I do not buy the excuse that suddenly from one budget to another the country was awash with money. We were certainly better off. However, there were too many areas that had long been neglected from mental health and access to psychiatric help and so on right across the board. I do not think any party here would make the contribution Deputy McManus made in terms of condemning the Fianna Fáil party or this Government on its record on health. We know there are difficulties out there but we also know that since coming to office and under the stewardship of Deputy Cowen, as Minister, and particularly under the overall stewardship of Deputy McCreevy, we have released significant resources far greater than anything before in a structured and strategic way to improve mental health, services for the disabled, social services, child care, services for homeless people and so on. We inherited a legacy where there was extremely poor infrastructure and we have invested heavily in acute hospital care. There are far more consultants in place in cancer and cardiovascular units than there were in 1997. Far more people are being treated now than in 1997. Between 1997 and today, more than 82,000 extra people have been treated in our hospitals. That has increased volume of activity and increased pressure on the system. Historic issues are converging and are creating pressures on the system. Clearly the historic under investment in health over a 20 year period, prior to 1997, is a key factor as are the demographic changes in terms of the elderly and the population getting older and the basic increase in demand deriving from improvements in medical science and technology. The Government is conscious of its improvement.
Deputy McManus asked why there should be a health strategy now. Surely we have reached a stage of maturity in this House where not every Government feels it must have a new strategy as soon as it is elected, although certainly there can be new programmes. There should be a consistent, agreed strategic framework that governs the evolution of the health care system, that involves not only the political parties but more importantly the partners who deliver the health service on the ground. Over the past 30 years the average length of Government has been three-and-a-half years. Are people saying a new strategy should be invented every time a new composition of Government comes in to office? I do not think that makes any sense. The last strategy was seven years ago, we are now moving—
Acting Chairman: Sorry to cut across the Minister. In fairness I am expected to keep Members on line. The Minister is way off the subject of those over 70 getting a medical card. I do not want to stop the Minister in his tracks but he has gone on a long time.
Mr. Martin: I will respect your observation. Deputy Owen raised the issue of whether non-GMS doctors would be allowed retain existing patients. Precedents have already been set for the doubling of eligibility for over 70s, in which the Government has engaged during the past three years. Non-GMS doctors were allowed retain their patients and we intend to adopt the same approach as we negotiate this issue with the IMO. We are favourably disposed to that suggestion. Dependants will not be entitled to the medical card on the grounds that this is a measure for over 70s. I will not pre-empt next year's budget but these and social welfare issues are issues that will go into the mix in the context of—
Mr. Martin: We are committed. I have no doubt the Minister for Finance, Deputy McCreevy, will deliver his fifth budget. I have dealt with the nursing homes, asthma and most of the issues raised. We shall be working with the office of health gain and with the health boards in terms of the implementation of the provisions of the Bill.
Ms McManus: I assure the Minister I am in favour of strategic frameworks but the timing is wrong. He left it rather late. This is the difficulty with the Minister's reply. It is not clear what his policy is on primary care and GP care.
Ms McManus: The Minister has stated that so far as he can measure, £800 million is the cost of extending the scheme. This is the issue. Is he talking about free GP care and maintaining the drugs scheme or about extending the medical card to everybody?
Ms McManus: If the Minister says £800 million for extending the medical card to everybody then  it is clear, but if the Minister is saying it is simply for free GP care we need further clarification. Can the Minister give an estimate of the cost of simply extending free GP care without interfering with the drugs schemes?
Mr. Martin: I know the Deputy has a view on free GP care but the amendment which was ruled out of order referred to full eligibility. That is the reason I mentioned £800 million. We suggest about £600 million for the GPs.
I indicated my agreement to this amendment during the Committee Stage debate. It provides that the Minister for Health and Children will make a report each year to each House of the Oireachtas on the measures taken by health boards in the preceding year to address the problem of suicide. For technical reasons an amendment to the long title of the Bill is required to enable this amendment to be made. The amendment does not refer specifically to the number of suicides each year as this information is already available to the Oireachtas through the annual report of the Central Statistics Office, which is laid before the House. However, I am advised that this fact would not preclude the Minister from referring to or commenting on the number of suicides in the course of his or her report.
For that reason, I do not accept amendment No. 18 from Deputy Mitchell. However, when he put this amendment on Committee Stage, I said I would come back to him. Today the CSO will announce, or may have already announced that the suicide rate is down again this year to 413. That is down on last year and the figure was 504 in 1998. There is a significant downward trend over the past two years and I hope this improvement will continue given the investment we are  making in the area of suicide prevention. I know Deputy Neville has a particular interest and commitment to that area.
Mr. Neville: I welcome the Minister's response to our amendment. The past ten years have seen a significant change and the Oireachtas can now discuss suicide on an organised basis. It used to be a taboo subject and up to 1991 it was a crime and the responsibility not of the Minister for Health and Children but of the Minister for Justice, Equality and Law Reform. I welcome the changes in the attitude of the State bodies and the Department of Health and Children especially since the report of the national task force in 1998, which was established by a previous Minister, Deputy Noonan, in 1996.
We have been very anxious to see the figures for this year. Last year 439 people – 349 male and 90 female – took their own lives which was a seven fold increase from the first half of the 1960s when on average 60 people per year took their own lives. The figures have dropped from 504 in 1998 to 439 in 1999 and are now down to 413. This is the first time since the 1960s that there has been a drop in consecutive years. There was a drop in the level in 1993, 1987, 1984 and 1976 only for the level of suicide to resume the increase in subsequent years. It is still not below the rate of three or four years ago because of the increase, which averaged around 16% in the last decade.
In spite of this we have to look at the positive aspect of this drop in the suicide level. This is partly due to the attention being paid to it by the various bodies like the Department of Health and Children, the Irish Association of Suicidology and others who have drawn attention to the problem. We have also seen the introduction of some of the recommendations of the national task force on suicide like the appointment of a suicide resource officer in each health board area and the establishment of the national suicide review group. That organisation should be given more teeth and a bigger budget. There is a budget of about £800,000 to promote suicide prevention programmes. The national review group has responsibility for that and a further £100,000 was allocated to the National Suicide Research Foundation in Cork.
While our suicide rate is still very high, some developments have taken place since the national task force set up by a former Minister, Deputy Noonan, completed its report in 1998. Although there were 80 recommendations in that report, only some of them have been introduced. There needs to be a more proactive approach to implementing many of those recommendations.
I recently attended the conference of the American Association of Suicide in Atlanta and many of the states there have a very sophisticated approach to dealing with suicide in schools at the level of dealing with crisis and also intervention where there are troubled pupils. I appreciate that this is not the responsibility of the Minister for  Health and Children, but there is an urgent need to ensure that we have input into the educational system and not just to assist pupils.
When a suicide occurs in a school, there is deep crisis and there is no organised system to intervene and assist the people in that school, particularly the teachers. We are always concerned about the difficulties experienced by the pupils, which are often highlighted, but the teachers may also be in deep trauma and be unable to cope. They may not know how to deal with the traumatised children. There are very good models on how to deal with that and we must look closely at those as was recommended by the national task force.
At a time of unprecedented prosperity, that so many people feel in such despair that they take their own lives highlights the challenge. There will not be simple solutions to this. To tackle the problem in society we must have a systematic approach and programmes to prevent suicide should be put in place. Society must adopt a compassionate and informed response to those who feel suicidal and we must identify the reasons people die by suicide, especially young males. The level of research into that area is totally inadequate. The National Suicide Research Foundation spends a great deal of time looking at the important area of attempted suicide and parasuicide.
Among the factors which in other countries lead to an increase in suicide levels and which we can identify with is an increase in the level of indictable crimes. There has been a very big increase in such crimes since the 1960s. There is an increase in alcoholism and alcohol abuse here and in other countries that correlated to an increase in suicide. Increases in births to single mothers and marriage breakdown have also correlated to higher suicide rates. These factors are representative of the level of integration or cohesiveness in society. The trends, which have shown increases in suicides in other countries, are evident here since the 1960s. That is not to say this problem cannot be tackled. In Finland and Canada, programmes were introduced which reduced the levels of suicide. The national task force looked very closely at the Finnish model where there was a very high level of suicide.
We must also draw attention to the influence of religious values, which has waned, particularly among the young. The growing secularisation of society has changed the values system. Social controls are less strict and people often feel alone and lost. There is no longer a pre-arranged set of relationships, with certainty within those relationships, as was the case in previous generations.
In research entitled “Suicide Rates between the Health Board Areas”, the late Dr. Michael Kelleher demonstrated that the rise in suicide has been a rural rather than an urban phenomenon, a male rather than a female phenomenon, affecting the young and the elderly, and that some counties have exhibited much higher rates of suicide than neighbouring counties which overall  could not be explained by variations in recording practices.
On a regular basis we have heard that suicide rates are way above the levels of the statistics provided by the Minister. I have heard figures which are double the statistics of the Department which I do not accept. Currently there is a debate about coroners' reporting of suicide, and I recently tabled a question in this regard which could not be replied to. Coroners do not bring in a verdict of suicide and there is confusion as to whether they can. They could not do so prior to 1993 when suicide was a crime because a criminal act could not be inferred at an inquest, the result of a finding of the High Court and the Supreme Court in the 1960s. A verdict of suicide inferred the person had committed a crime. However, since the decriminalisation of suicide I believe a coroner can bring in a verdict of suicide, and when the issue was debated in the Seanad the then Minister, Máire Geoghegan-Quinn, agreed with me. There is a dispute in the legal profession as to whether a coroner may do so, and I think the matter should be cleared up.
The statistics are obtained from confidential reports of the Garda, not on the basis of coroners' reports, which are given to the CSO under form 104. Our view is that because the reports are totally confidential and are provided by the Garda, the statistics, which are not fully accurate, are more accurate than those of many other countries. At most there is a 20% variation, and perhaps less, which internationally would be considered very good. The argument that our rates of suicide are not accurate because coroners do not return verdicts of suicide should be put to bed as quickly as possible.
For some time I and my association have been extremely concerned by the effect of the media on suicide. The media have played a large role in bringing about the success we are talking about in terms of a reduction in suicide through responsibly reporting the issue and in highlighting the need to seek help and to deal with suicide. Responsible media reporting is vital in dealing with the issue, but I am concerned by other types of media reporting. Suicide is a complex phenomenon, and the paths to suicide are varied and many. There is no single cause of suicide; many interweaving influences and factors come together to shape the last horrific act. Concern over how individual suicides are reported in the media has arisen from studies which have indicated a risk of copycat suicides, particularly among young adolescents and young adults. There is general agreement that reporting suicide is important and can be beneficial. There is more dissent over the manner and nature of coverage. Suicide by imitation has been recognised. In the US, well publicised clusters of youth suicide appear to have occurred following sensationalised, insensitive and inappropriate coverage of suicide. I am constantly amazed by the number of people from all over the country who  tell me there have been three or four suicides in their areas. One can immediately identify a copycat situation, and we must be concerned about this. There is a fine line between sensitive, intelligent reporting by the media and sensationalising the issue. The focus should be on educating and informing the public rather than on trying to shock or present graphic, or worse titillating, details.
Perhaps the most important guiding principle is to consider the reader, listener or viewer who might be in crisis when they read, hear of see the report. Journalists should ask whether the report will make it more likely that they will attempt suicide or more likely to seek help. Is the report likely to cause extra unnecessary pain for relatives and friends of the deceased person? Last January the President, Mary McAleese, patron of the Irish Association of Suicidology, launched media guidelines on the portrayal of suicide, which we jointly compiled with the Samaritans. This has been widely distributed to the media and I refer them to it.
Suicide clusters represent a dramatic increase in observed over expected suicides in a community. Copycat suicides and cluster suicides may occur following direct exposure to the suicide of a friend or acquaintance and in cases where the victims were known to each other or through indirect exposure where the victims knew of the initial suicide in the cluster through accounts in the media or by word of mouth.
Mr. Ring: I also welcome the Minister's acceptance of the amendment and congratulate Deputy Neville and Dr. Connolly in Castlebar. Both of them have done wonderful work and have been a great consolation to families where members have committed suicide. Recently I spoke to a person who was delighted to meet Dr. Connolly and Deputy Neville in Castlebar. They have done so much to highlight this issue and to get help for people.
Families in which a member commits suicide are devastated and there is no doubt that whatever can be done to make their lives easier and to help them should be done. They ask how, why, what, when and where, and there is nobody to provide answers. I am glad that at least this issue is being talked about openly. Many years ago it was not discussed. I am glad some help is available and I compliment everybody involved. I am glad there has been a decrease in the number of suicides for two years in a row, but many people  still commit suicide and I hope there will be a further reduction in the numbers next year.
Mr. Martin: I thank Deputies for their comments. I assure Deputy Neville of the Government's continued commitment to the implementation of the recommendations of the task force. The PPF has within it a commitment that all the recommendations be in place by 2003, and we are on target to achieve that aim, hopefully before that date. In particular the establishment of the national parasuicide register will be of some significance in terms of ongoing research into the incidence of suicide. The work of the National Suicide Research Foundation, which we will continue to support and to which we will provide additional funding this year, is key to a better understanding of the issue.
I agree with Deputy Neville that we have not yet effectively dealt with addiction as a society, particularly alcoholism, which is significant in terms of the overall suicide figures. To a large extent previous generations brushed this under the carpet and did not put in place the supports required by people with addictions.
 The new social, personal and health programme being introduced in the schools represents the best framework within which issues pertaining to suicide, self-esteem, self-confidence and better motivation among young people can be addressed. The social, personal and health dimension of the new primary school curriculum will be introduced next September, which will be of major significance in terms of the way children are educated.
Acting Chairman: As it is now 1.30 p.m., I am required to put the following question in accordance with an Order of the Dáil of this day: “That the amendments set down by the Minister for Health and Children and not disposed of are hereby made to the Bill, Fourth Stage is hereby completed and the Bill is hereby passed.” Is that agreed?
Ms McManus: While we support the Bill, we cannot support the guillotining of it in this fashion. We have just reached two of the 22 amendments. There is no reason the Bill should be guillotined in this way and we totally oppose it.
Browne, John (Wexford).Byrne, Hugh.
de Valera, Síle.
Kitt, Michael P.
McGuinness, John J.
Ó Cuív, Éamon.
Wright, G. V.
Belton, Louis J. Boylan, Andrew.
Broughan, Thomas P.
Browne, John (Carlow-Kilkenny).Bruton, Richard.
| McGahon, Brendan.
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