Wednesday, 2 March 2005
Dáil Eireann Debate
Mr. Connolly: I referred earlier to it being a case of “a stitch in time”, in medical terms, in respect of people visiting their GPs. Those with medical cards can receive treatment at the appropriate time rather than being obliged to do without it. The fear of losing their medical cards is a major disincentive for these people to take up even low paid employment and their relationship with poverty is thus maintained.
The number of full medical cardholders has dropped dramatically from 38.3% of the population in 1983 to 25.7%. This decrease occurred despite the target in the programme for Government to have 200,000 new medical cards. The GP-only medical card will merely be a substitute for the real thing and I do not know whether the same service will be provided to those who possess such cards. These medical cards should, however, at least cover prescription costs or a significant proportion thereof. The payment of €85 per month for medicine represents a major outlay for those on low or even reasonably high incomes.
The timescale relating to the introduction-implementation of GP-only medical cards is a matter which requires urgent attention. A number of community welfare officers do not know what is happening in respect of these cards. The fact that no monetary guidelines have been issued in respect of the cards is making life difficult for everyone involved, particularly people living on the fringes. Not everyone in receipt of social welfare payments qualifies for a medical card. Income guidelines have not kept pace with social welfare increases and this has given rise to certain problems. The guidelines should at least have been index linked. There should be no question that people in receipt of social welfare payments should not be entitled to a medical card. Many people who previously qualified for full medical cards will no longer qualify. No one can claim that people living on social welfare payments are living in luxury. As stated earlier, there should be a moratorium on the withdrawal of medical cards until the doctor-only cards are introduced.
Arising from the Supreme Court judgment on the controversial Health (Amendment) (No. 2) Bill 2004, this legislation makes provision for the imposition of charges on elderly people in nursing homes and in full-time care. A great deal of money was taken illegally from people in the past and one presumes this will have to be repaid to them. It must be recognised that money taken in 1976 has lost its purchasing power and there is no point returning it to people now. In that context and if we use the formula used by health boards, namely, the addition of compound interest at a rate of 7% per annum, we will discover that a pound taken in 1976 is now worth in excess of €9.
Mr. Healy: I am surprised by the fact that a Minister of State has been charged with taking the Bill. It is inappropriate that this should be the case. The Tánaiste should be present for the debate on a Bill of this magnitude and importance.
Mr. Healy: I intend no disrespect to the Minister of State at the Department of Agriculture and Food, but the senior Minister at the Department of Health and Children should be present for the debate. It is a reflection on the House and on the public in general that neither the Tánaiste nor any of her Ministers of State is present.
The Health (Amendment) (No. 2) Bill 2004, which was introduced before Christmas, was rushed legislation. Such legislation is almost always bad. The Bill before us is also being rushed through the House and will be the subject of a guillotine at 1.30 p.m. tomorrow. Members will not have had an opportunity to discuss it in the time available.
I wish to put a direct question to the Tánaiste in respect of private nursing homes. Has she obtained legal advice on the position of private patients in private nursing homes? Did she request such advice and has she received it? If she has not requested it, will she please do so and communicate the details of it to Members when she receives it? A serious legal issue has arisen in respect of private patients in private nursing homes in terms of whether they are covered in the same way as medical card holders in public hospitals and nursing homes are covered. I meet people on a daily basis who have been forced to enter private nursing homes — they are paid a subvention to facilitate this — because when they applied, through their relevant health board or through the Health Service Executive for places in public hospitals or nursing homes no such places were available. These patients are entitled to full coverage in the homes to which I refer. The Tánaiste should either outline the advice she has received in respect of that matter or seek such advice and pass it on to Members.
As regards medical cards, this is another issue on which the Government has reneged. In the most recent general election we were promised that 200,000 full medical cards would be provided. That promise has not been kept. I predict that in a short number of years there will be more “yellow pack” or doctor-only medical cards than full medical cards. These cards represent a way to undermine the entire medical card system. The promise relating to medical cards that was made during the general election campaign should be kept. People who suffer from conditions such as asthma should be entitled to full medical cards.
Caoimhghín Ó Caoláin: This is a dual purpose Bill. First, it gives effect to those parts of the Health (Amendment) (No. 2) Bill 2004 that were found to be constitutional by the Supreme Court and, second, it introduces the GP-only medical card announced by the Government last November. These are two distinct and separate matters and I must question their inclusion in one Bill. I also question the rush to enact the first part of the legislation in the absence of clarification on how those people wrongly charged by the State for long-term residential care are to be reimbursed.
The Government is moving swiftly to ensure that those inpatients receiving long-stay care who can be charged following the Supreme Court judgment will be charged as soon as possible. There is no similar rush to repay those unlawfully charged over a period of many years. In the memorandum to the Bill, the estimated cost of the loss of income to the State since 9 December 2004, when charging was stopped, is €2 million per week. Where is the estimate for what those mostly elderly and infirm people are owed by the State?
We have been informed that a Cabinet sub-committee has been formed to decide on the scheme of reimbursement. However, I detected a distinct lack of urgency on the part of the Government. It is certainly in contrast to the swift production of this Bill. This is all the more unacceptable, given that we now know about the extent of the knowledge within the Department of Health and Children and successive Governments about illegal charging of long-stay patients over many years. The system knew people were being wrongly charged but did nothing to stop it. Since this issue came to light there has been widespread concern and confusion among the families of people in long-stay residential care. Following the Supreme Court judgment, they are still none the wiser about the next steps to be taken and the implications for their personal circumstances. We learned this week that the Health Service Executive had allocated only six staff members to the dedicated helpline. An additional four staff has made no appreciable difference as long delays in answering calls are still experienced. I tried that line before coming into the House for the recommencement of this debate and I had to hang up in total frustration after waiting for a long period.
My fellow Sinn Féin Deputies and I have had many inquiries to our offices on this matter. I presume other Deputies have been contacted by many people seeking information, and there is none. There is a dearth of information. The State’s response to date has been disgraceful. The Government must start to make decisions and get the information out to the general public. Above all, it must repay all those entitled to repayment.
I now turn to the second part of the Bill, the doctor-only medical card. What has become known as the “yellow pack” medical card appeared out of the blue last year. Whether it was inspired by the blue sky over Inchydoney is anybody’s guess. There was no indication previously that the Government would take this route. During the 2002 general election campaign, the Fianna Fáil Party promised to provide a further 200,000 people with medical cards. It is often forgotten that the PDs made a similar promise when its manifesto in 2002 ensured eligibility criteria would at least keep pace with movement in income. Not only have the promises of both coalition partners not been fulfilled, but the situation has gone into reverse. There are now 64,478 fewer people with medical cards than when those promises were made in 2002. There are 109,767 fewer people with medical cards than in 1997 when the current coalition came into Government. It gets worse, however. In January this year 6,296 people lost their qualification for medical cards. The figure for the month before was 2,068, so since Deputy Harney took over as Minister for Health and Children well over 8,000 further people have lost their medical cards. Where does this leave the Minister’s estimate that in the region of 200,000 should qualify for the doctor-only medical card?
It is a convenient figure for the Government, which has been haunted since 2002 by its own extravagant promises. Does the figure have any meaning? The reality is that many of these cards will go to people who were previously entitled to full medical cards but who lost them because their incomes rose above the disgracefully low level of the income guidelines.
On budget day, I tabled a parliamentary question to the Minister for Health and Children, asking the approximate cost of the doctor-only card compared to full medical card. She stated that the doctor-only card would cost approximately €250 per year while the annual cost of the full medical card is €1,000. Both in terms of the numbers qualifying and the value of the new card, it is clear that Government’s claim of generosity is by no means all that it would like the public to believe. We also have to take into consideration the Government’s hiking of hospital charges and medicine costs to see that it is giving with one hand and taking away with the other. While the extension of free GP services is welcome, as far as it goes — how far remains to be seen — the Government cannot fool people into thinking they are getting the full value of the medical card. They will still bear the heavy cost of medicines, which together with hospital charges, represent three-quarters of the value of the real medical card.
This Government has been responsible for a succession of steep rises in the costs of medicine. Those who fare worst are people whose incomes are just above the medical card income guidelines and who must take regular medication. A year ago they had to pay €70 a month before they were entitled to a refund under the drugs payments scheme. After two rises in the threshold over the past 12 months, they must now pay €85 per month. For people on low incomes, especially those dependent on ongoing medication for their very lives, this is a disgraceful rise.
This Bill maintains the myth that entitlement to a medical card is based on undue hardship. The reality is that the entitlement is based on income guidelines drawn up by the Minister and her Department within the constraints set by the Minister for Finance in the annual Estimates. Only in the most exceptional circumstances will people above those income guidelines be considered for a medical card, no matter how much undue hardship they and their dependents experience. All Deputies, without exception, will have had experience of representing people in such circumstances who have been denied medical cards. This Bill introduces a further euphemism. It states doctor-only cards will go to people for whom payment of GP fees would be “unduly burdensome”. Again the reality is dictated by the income guidelines and not by the individual circumstances of each applicant, no matter how heavy the burden they may carry.
This Bill in both its parts, adds another rickety extension to a ramshackle, ill-planned, inequitable and inefficient health service. It comes at a time when the Minister, Deputy Harney, is accelerating the development of private medicine and giving favoured treatment to the private health business. The accident and emergency crisis continues in all our hospitals. Local hospitals are being denuded of services, including those in my own constituency. The development of primary care, supposedly the cornerstone of the Government’s health strategy, has been put on the long finger.
The Government may be rushing this Bill through in time for the by-elections. The Minister denied there was any connection when I asked her this question about a week ago. However, I do not believe the good people of Meath or Kildare will be fooled.
Mr. O’Connor: I am tempted to say to Deputy Ó Caoláin that it might do his party the world of good to visit that place of pilgrimage in Cork. They might take their scriptwriters too, and it might change their attitude.
To be serious, I have been listening carefully to the debate. I listened in particular to the Minister of State this morning. There has been some talk as to what Minister should have been here and I will not get involved in that. However, I have great admiration for the work of the Minister of State at the Department of Health and Children, Deputy Seán Power, and what he does in the Department. He blazes a trail struck for him by Deputy Callely, who certainly impressed greatly as regards services for the elderly, in the short time he was at the Department. Deputy Seán Power’s speech this morning was measured, particularly as regards services for all the people. He also made the point, in fairness, about the doctor-only medical cards. The term “yellow pack” has a good soundbite, and perhaps that is all right, but we should be careful about upsetting people who wish to qualify for such medical cards. Perhaps we should find a different phrase. The occasional soundbite is all right, but let us remember the Government is trying to create a situation whereby people on lower incomes qualify.
As a Government backbencher I support the view that we should help those who are in need of medical cards. Since I have picked on Deputy Ó Caoláin I will give some credit to Deputy Crowe who has made the point, as I often have, that the best way to get people out of the poverty trap is through employment. Many people in my constituency often make the point that where they are unemployed, receiving different assistance benefits and want to go to work or into full-time education, it is often difficult to make such a decision because they must do it in the knowledge that they will lose benefits. There is often an issue with medical cards, although the situation has improved a little in recent years.
I am pleased to have an opportunity to speak on issues related to the provision of services for older people and to support what the Government is doing in that regard. I speak as a representative of the constituency of Dublin South-West where there is a young population, particularly in Tallaght, but also in Firhouse, Templeogue, Greenhills and Brittas. There are also many elderly people in those communities and I am always happy to support the groups that look after them. The significant progress which has been made in the growth of funding available for this sector is indicative of the Government’s commitment to the ongoing development of health funded services for older people.
One of the great achievements of western societies in the 20th century has been the increase in life expectancy. As the standard of living for the young and middle aged in this country has risen, so the quality of life of successive generations is improving. Modern medicine, social policies, political will and community enterprise mean that more people live longer and more fulfilling lives. The majority of older people are healthy and fit and hold good positive attitudes. I recently spoke to a gentleman in my clinic who let slip that he was aged 81. I was astonished and it is great to see that kind of attitude in our elderly.
It is interesting to note that there are more than 60 million people in the European Union who are aged 60 and over. Figures from the Central Statistics Office collated from the results of the census suggest that the average age of the population is increasing. Projections based on the 1996 census indicate that in 1996, 11.5% of the Irish population was over 65. Forecasts suggest that 18% to 21 % of the population will be aged over 65 by 2031. The Government is aware of this trend and addressed some of these issues in the health strategy, Quality and Fairness — A Health System for You, published in 2001. The Government is committed to developing services for older people, both residential and community based, to meet the needs of our growing older population. We know there are economic and financial consequences of people living longer. Each generation of people in their active years must accept responsibility towards the support of the elderly.
The Government’s commitment to the development of a comprehensive range of services for older people can clearly be demonstrated by outlining the resources made available in recent years for service developments. In excess of €287 million in additional funding was provided for health services for older people between 1997 and 2004. This demonstrates the Government’s ongoing commitment to improving services for our older population. In 2005, a further €15.228 million in additional funding was allocated to services for older people. This funding is being used for a variety of services, including the nursing home subvention scheme, the home care grant scheme, home help service, elder abuse programmes and support for voluntary organisations. Since 1993 there has been an unprecedented level of investment in the nursing home subvention scheme. A total of €5 million was allocated for the scheme when it was introduced in 1993. The total expenditure on the scheme in 2005 will be €120 million.
In line with a Government decision, an expenditure review of the nursing home subvention scheme was undertaken by the Department of Health and Children in association with the Department of Finance. The review was carried out by Professor Eamon O’Shea and the objectives of the review were to examine the objectives of the 1993 nursing home subvention scheme and the extent to which they remained valid, to assess the service delivered and to establish what scope, if any, existed for achieving the programme objectives by other more efficient and effective means. Professor O’Shea’s report, Review of the Nursing Home Subvention Scheme, was launched in June 2003 simultaneously with the Mercer report, Study on the Future Financing of Long-Term Care in Ireland, which was commissioned by the Department of Social and Family Affairs.
Community supports are vital to maintain older people in their homes for as long as possible. Long-stay nursing care should only be a last option in care planning for older people, with the community supports acting as a real support for older people who wish to live in dignity and independence in their community. Numerous studies have highlighted that older people would prefer to remain living at home rather than going into long-stay care. The Government is committed to developing the various community and home support schemes. The total expenditure on the home help service in 2005 will be €118.75 million. I would like to be unusually parochial and mention my support——
Mr. O’Connor: I want to mention my support for the Tallaght home help services which provide great service. If I do not tell the House where I am from, the Deputies will not know so I have to remind them.
The Health Service Executive areas have piloted home care grant schemes as an alternative to long-term residential care to assist older people living at home in the community. Older people who are discharged from the acute hospital system, as well as those living in the community, are targeted under these schemes. In the HSE eastern regional area, people have been discharged from acute hospitals under the Slán Abhaile and Home First pilot projects. In the HSE southern area, a similar project, Cúram, has been piloted. The Department of Health and Children has been working with the HSE to develop a national home care grant scheme. A draft of the scheme is being finalised by the HSE for presentation to the Department. Funding of €2 million has been allocated to the HSE in 2005 to introduce the scheme.
It is acknowledged that there is insufficient provision of public long-term care beds to cater for the growing elderly population with a resultant over-reliance on the private nursing home sector. I served on the Eastern Regional Health Authority along with Deputy Mitchell and other colleagues and am brave enough to lament its passing. I know it might get me into trouble in some quarters but I am not that happy about its passing. The Eastern Regional Health Authority and the Southern Area Health Board are particularly affected because of a lack of public long-term care beds. This was acknowledged when the Department of Health and Children was preparing the health strategy and there is a commitment in the strategy to provide 1,370 additional assessment and rehabilitation beds, 600 additional day hospital beds and facilities encompassing specialist areas such as treatment for falls and osteoporosis, fracture prevention, Parkinson’s disease, stroke prevention, heart failure and other problems. In addition, the strategy proposed the provision of an extra 800 extended care community nursing unit places over a seven-year period that would include the provision of long-term care beds for people with dementia.
Under the national development plan, capital funding of over €253 million is being made available for the provision of services for older people in the period 2000 to 2006. On a national basis, this will enable a comprehensive infrastructure of community nursing units and day care facilities to be put in place as well as the refurbishment of existing extended care facilities and the replacement of older unsuitable accommodation. The House will recall that I mentioned the elder abuse programme. The publication of the report, Protecting Our Future, in late 2002 was a momentous occasion for the elderly in this country. They were given a blueprint to deal with the scourge of elder abuse and a pledge that this blueprint would be implemented. Up to recently, there was a feeling that elder abuse did not exist in this country, but the report confirms that there is a problem, the extent and nature of which remains to be identified.
By defining elder abuse and recommending implementation of structures to deal with suspected cases, the report will, I hope, give older people who feel they are the victims of it the confidence to report their anxieties, as appropriate, to social workers, public health nurses, gardaí, professionals or care workers. While the report is the first attempt to deal with elder abuse, it is still an important one. As abuse can come in many shapes and forms, there is need to make the general public more aware of the problem. It is even more important to target relevant service providers to make them aware of the steps taken to respond to elder abuse and the procedures that will be available to deal with it. I hope greater awareness of the problem will lead to lessening of its incidence.
As recommended in the report, a national implementation group has been established. A number of the report’s recommendations are based on experience gained from two pilot projects. Despite the absence of major publicity, sufficiently serious and numerous cases have come to light to justify the process. The Department of Health and Children is determined to press ahead with gradual implementation of the report. Funding of €800,000 was provided in 2003 to commence implementation of the elder abuse programme. Last year, an additional €750,000 was allocated to each health board area to ensure the continued implementation of the programme, including the appointment of case workers. An additional €900,000 has been allocated for 2005.
I concur with the broad thrust of the report, which recommends placing the response to elder abuse in the wider context of health and social care services for older people. As the number of older people rises, we should not forget that they have been instrumental in building the healthy State we enjoy today. Their contribution to the economy is widely acknowledged and the Government is fully committed to improving all aspects of their lives by focusing on issues that affect their well-being. The cornerstone of the Government’s health policy is to keep older people living in their own homes for as long as possible. To remain at home has been shown in research as the preferred choice of older people. All Members will have seen this finding corroborated through their constituency work.
Implementation of the recommendations outlined in the report will help to ensure the observation of the fundamental right of older people to be treated with respect in their twilight years. The starting point for making the changes called for in the report may well involve each of us reflecting on our attitudes to older people. We must begin to question our attitude to older people to satisfy ourselves that we do not harbour the in-built negative feelings towards them, which can often be the source of unintentional abuse. We must proceed on a journey during which we absorb much and learn to cope with what may be considerable fallout.
In November 2004, the Tánaiste announced additional funding of €70 million to implement a ten-point action plan to improve delivery of emergency services. The Tánaiste met senior management of the Health Service Executive with which the Department of Health and Children is working closely to ensure early implementation of the plan. The measures outlined in the plan include transfer of 100 high-dependency patients to suitable private nursing home care, negotiation with the private sector to meet the needs of 500 people annually for intermediate care of up to six weeks and the expansion of home-care packages to support an additional 500 older people at home. Funding of €16.8 million to the former Eastern Regional Health Authority will result in more than 600 patients being discharged to more appropriate settings. A total of €5 million was provided to the former Southern Area Health Board under the delayed-discharges initiative 2003-04 to facilitate the discharge of patients from the acute hospital system.
It will be clear to the House from my contribution that the Progressive Democrats Party and Fianna Fáil have an undeniable commitment to older people. While we acknowledge the need to avoid complacency about the continuing development of services to meet growing demand, the Government and its immediate predecessor can be proud of their record to date. We are aware that we must continue with our efforts.
Mr. O’Connor: No one has ever said that being in Government was easy. One continues to do the job to the best of one’s ability and waits for the results. While I do not believe polls any more than anybody else, I believe the public is of the opinion that the Government is on the right track.
Mr. O’Connor: Thank you, a Cheann Comhairle, for protecting me. The Deputies should read the newspapers I read. I walk the streets of Tallaght, Greenhills, Templeogue, Firhouse and Brittas where people tell me what I presume they tell the Members opposite. I listen to what they say. When they are unhappy, I try to respond, but when they express satisfaction, I do not go overboard about it. I am spending a little time outside Tallaght knocking on doors in Kildare where I do not get the sense that people are very unhappy either.
Mr. O’Connor: I would have mentioned the following earlier, but I was trying to avoid being too parochial. I have been particularly pleased by significant recent developments in the care of the elderly in the Tallaght area. There was no nursing home in the area for a long time, but one has been operating at Kiltipper Woods for several months. It is a tremendous facility, the work of which I support strongly.
While the Ceann Comhairle would not encourage me to tell a story, I often think of my late uncle who died at 93 a few years ago in the context of discussions of care for the elderly. As I listened to the Minister of State, Deputy Seán Power, discuss the way the Government has developed services, I remembered my uncle Mick calling me to come close for him to tell me that while the home he was in was great and he was well fed, the only problem was that it was full of old people. Perhaps that sums up the way we should treat and care for the elderly.
I appreciate fully the measure of the contribution older people continue to make to society. Older people have a wealth of experience that can be harnessed and embraced for the good of the country and our communities.
Ms O. Mitchell: I mean no disrespect to the Minister of State, Deputy de Valera, but it is absolutely outrageous that the Minister for Health and Children is not present. There is nothing more important on the Tánaiste’s agenda than this Bill. Despite having got it wrong once, she does not appear to care that she might get it wrong again. There is nothing more important for her to do than to attend to listen to this debate. When the Bill was before the Supreme Court, her senior counsel argued on her behalf that it would be catastrophic for the State if the charges were found retrospectively to be illegal. While it was found that the charges were illegal and that the money must be repaid, the Tánaiste has not bothered to come to the House to deal with the catastrophe. We should ask what signal her failure to attend sends to taxpayers and the people affected by the court’s decision.
Despite the fact that the Tánaiste is not present, I welcome the opportunity to speak on the legislation as I did not have a chance to discuss the failed Bill which passed through the House before Christmas. It is small wonder that the Bill was struck down by the Supreme Court as we all know rushed legislation is never sound. Even if it does not constitute an outrageous attempt to legalise a practice retrospectively, rushed legislation is of no use. I do not know if the Tánaiste was motivated by naivety, poor advice or absolute desperation in attempting to legalise charges retrospectively, but her approach was doomed to failure. The Supreme Court has clarified the position and restitution must be paid.
While the matter was before the court, a rush of blood to the head prompted another poor and ill-considered decision to pay everyone affected €2,000. At this stage she must be learning, albeit, the hard way, to be very wary of advice from the Department, because good advice is based on good information. Despite worthy people in the Department and the best of intentions, the reality is that they do not have good information. They only have a very tenuous grasp of what is really happening on the ground, which is why, year after year, budgets over-run in hospitals and health boards and time bombs continue to go off in the health service yet nobody ever seems to see them coming.
I asked several parliamentary questions last week to try to elicit the exact extent of the State’s liability following the Supreme Court decision. The answers were much as I expected in that they basically have not got a clue. That is the reality. No matter what they say about it being €500 million or €2 billion depending on how far back one goes, the reality is that they do not know. How could they possibly know? The information may be there somewhere, but it seems utterly irretrievable. One cannot retrieve any kind of information regarding the health service. When the Department introduced medical cards for the over-70s, it could not tell how many people over the age of 70 were alive. How could it possibly know the number who have died over the past 30 years, as well as those alive today?
The Tánaiste has promised a Supplementary Estimate later in the year to pay for this mess. The Minister of State can pass the message on to her that it may be the first Estimate to pay for this, but it will not be the last. It will be years before we know how much this will cost. Not only do we not know the numbers involved or how far back we will have to go in repaying people, we also do not know whether repayments will reflect the value of the charges at the time they were levied or the current value.
The situation is also not clear with regard to people who had medical cards or partial eligibility and could not get into public beds. Several people have raised this appalling matter. Ignoring the problem will not solve it because it will keep coming up and the Government will have to face up to it. Legally the State must repay charges paid for those in public beds. If there is one group with a genuine grievance, it is those forced into private nursing homes despite, in many cases, having medical cards and circumstances which entitled them to some form of help in terms of getting into a State-run home or a public bed in a private nursing home. These people were on low incomes, and many were pauperised and spent their entire savings paying for a nursing home. They sold their homes and once that was gone their children had to take over payments at the very time they were trying to raise their own families and had big demands on their resources. The Minister must deal with these people in a fair and open manner and reimburse them.
Reimbursement must not be made dependent on whether people can produce a written application form for a public bed, as has been suggested. The Minister, and any public representative who has had any dealings with the elderly, will be aware that the allocation of nursing beds was, at best, ad hoc, and probably in most cases absolutely chaotic. There was no formal system of application and no consistency of application, either geographically or over time. Clients in precisely the same financial circumstances in different health board areas were dealt with in a completely different manner simply because some areas had larger numbers of public beds than others. For example, I read that Donegal had a huge number of public nursing home beds relative to the population compared to a built-up area such as Dublin.
In some cases, people were moved into a public bed in order to vacate a bed in an acute hospital, where demand for beds was greater than in other hospitals and a higher turnover was needed. This was done whether people could afford it or not, and in many cases they could well afford a nursing home bed. Sometimes the situation depended on the time of the budgetary year, in that one had a better chance of getting a contract bed in January than in December when health board budgets were exhausted. There was no consistency, application forms or clarity surrounding the matter. Over the years, many people parted with far greater sums of money than the 80% of old age pensions about which we are now speaking. If they are not included in at least the same level of compensation the Tánaiste can look forward to spending much more time in the courts dealing with that problem.
There are estimates regarding the amount that is owed, but it is only the tip of the iceberg. The actual exposure of the taxpayer is completely unknown, which is why the Tánaiste should be here listening to this. Deputy O’Connor gave us a stream of consciousness which did not deal with this problem in any way. This is the biggest catastrophe for the taxpayer and the elderly in many years, and it is being made to appear as a slight little hiccup in the overall process of Government.
So far we have had no accountability. Nobody wants to sit up and say, “This is my fault.” No heads have rolled and no one has acknowledged any sense of responsibility. The taxpayer will just have to pay up and shut up and that is the end of it. If a private sector company overcharged the public, we would be here jumping up and down saying the company must repay moneys. If the shareholders realised the kind of liability that had been built up, they would have given the board of management their walking papers long ago. Unfortunately, taxpayers are not in the happy position to do that but they will vent their anger eventually.
We do not yet have the Travers report regarding how this situation happened and how it was allowed to drift for so long. I was a member of the health board and, whatever happened before 2001, following the report of the Ombudsman and the introduction of the medical card for the over-70s, everybody with anything to do with the health service knew there was a problem with regard to charging. Since 2001 public representatives have been receiving queries about the legality of charges. Health board members knew this was a potential problem and it was discussed in and between health boards and the Department. It is unbelievable that the Minister did not know about it. If she did not know, then the previous Minister, Deputy Martin, was even more removed from reality than I thought at time. It was the topic of conversation. Even the previous Minister’s much-vaunted reform programme was very much informed by the recognition of the growing cost of care of the elderly. The legality of charges, their lack of consistency and clarity, the subventions and their inadequacy, the failure to increase the subventions, the implications for the public purse of the medical card for the over-70s and the entitlement to nursing homes were all constant topics of discussion among everybody involved in the health services.
On top of all that came the Ombudsman’s report and the subsequent debate about the distinction between entitlement and eligibility, behind which the Government is still hiding. There was then a promise in the health strategy of legislation to clarify the distinction between eligibility and entitlement which we still do not have. It was not faced up to because this problem would have come to light. It is inconceivable that the then Minister for Health and Children, in a period of intense debate surrounding the issue of the cost of care for the elderly, somehow never heard a hint that the charges for nursing homes had a questionable legal basis. Without a doubt, he had more than a hint, as had his Department. He and the Department undoubtedly reached a very comfortable accommodation with each other which was a mutually beneficial arrangement. He agreed not to rock their boat and they agreed not to rock his. I am not suggesting there was explicit collusion, but there was definitely implicit collusion. A decision was made to allow the position to drift and to go on indefinitely. It was not faced up to in 2001, 2002 and 2003, so the bill for the taxpayer increased. It suited the then Minister to have a soft landing out of the Department and perhaps the whole matter could be swept under the carpet until after a general election. If it was not for the efforts of Deputies Kenny and Perry the matter would never have come to light. In short, the Tánaiste was dropped in it because clearly she did not have her finger on the pulse of what was happening in the Department of Health and Children. The previous Minister for Health and Children, Deputy Martin, is off to Australia but I would say it is not far enough as far as the Tánaiste is concerned.
I support the notion of charges for health services, including nursing homes. It is perfectly reasonable that people should make a contribution towards nursing home accommodation costs from their pensions. It is becoming clear that everybody is now eligible for a nursing home bed and the maximum they will have to pay is 80% of their pension. I would love to think that is what will be facing me and everyone else, but that was never envisaged when medical cards were introduced for the over-70s. It was never budgeted for and it is certainly not affordable without a major change in our tax system. We are not talking about small Supplementary Estimates; it is a major change in the fiscal system, if that can be afforded. That provision is not being faced up to in this Bill.
I can tell the Minister of State — I wish the Tánaiste was here to listen — that this matter will eventually end up in the Supreme Court. Whether it intended to do so or not, the Government has created a legitimate expectation among the public that they are entitled to a nursing home bed and that all they will have to pay is 80% of their old age pension. Sooner or later that fact will have to be recognised but it has not been faced up to in the Bill. Unfortunately, that means the taxpayer will once again end up with a big bill when the matter is referred to the courts and ends up in the Supreme Court. It is a difficult nettle to grasp but it must be dealt with, otherwise it will be allowed to drift.
People can reasonably say they do not need to make provision for the future through savings as they are all entitled to a nursing home bed. The queuing system for acute hospital beds that operated in the past will not work in this case. One can only go so far in arguing about the distinction between eligibility and entitlement. The previous Minister for Health and Children promised to clarify that legislative aspect, but the clarification has not been made. It must be clarified, however, otherwise we will end up forever in the courts with a taxpayers’ bill exceeding the appalling vista we already face with retrospective payments of God knows how much. At the same time, services will have to be reduced across all health programmes.
This position is truly catastrophic, as was argued in the Supreme Court, for the elderly and the taxpayer. We are still burying our heads in the sand as regards what future provision is required to accommodate the elderly in nursing homes. There is a retrospective difficulty but we are building up an even bigger one for the future.
Mr. Dennehy: I welcome the opportunity to contribute to the debate on this Bill. We are all well aware of the reason this legislation is before the House; it is to create a legal framework to apply a reasonable level of charge for the maintenance element of long-term, public residential care units and to create the legal process whereby 200,000 extra people can be granted medical cards which will permit a doctor’s visit without charge.
I welcome the decision to extend the provision of medical cards. The number of additional cards is estimated at 200,000. We have had an assurance that if the figure employed for eligibility — that is, 25% above the current level — does not lead to an extra 200,000 people obtaining cards, it will be modified to do so. A sum of €60 million has been allocated to that end.
Over the years, many representatives of all parties on health boards and elsewhere have requested such facilities. Various descriptions were used, including limited liability, but it basically concerned the introduction of a second type of medical card. That concept was strongly supported over the years. I have heard the request being made by members of all political parties at public meetings, on health boards and on the Committee on Health and Children. Many interest groups, including GPs, have sought a similar facility. The rationale behind the request for GP-only medical cards was that in many instances no treatment, other than a doctor’s examination and reassurance, is required for patients. The cost of visiting a GP was an inhibiting factor for some people. In some instances, parents became sick from stress and anxiety over their concerns for their children’s health. GPs have made the case that often a simple examination can reassure a patient and if further treatment is necessary they can point them in the right direction.
The worst possible form of politics is for party spokespersons to try to denigrate this positive and constructive move by labelling these cards as “yellow pack”, thus suggesting that they are of little or no benefit. The latest attempt in this regard was made by our friend in Sinn Féin, Deputy Ó Caoláin. He said that others referred to the cards as “yellow packs”, but that was just adding the same tag to them. Not only is this the worst possible type of politics but it is also patently untrue to say the GP-only cards are of no benefit to anyone. Some €60 million will be invested in the scheme this year to the benefit of 200,000 people. Apart from any other aspect, that is proof of the benefits involved.
The scheme will apply to those who are marginally above the current eligibility limits for medical cards. We have been seeking a re-examination of the situation to target that group and this is now being done. It would be almost impossible to draw up a scheme to provide 200,000 extra medical cards for full eligibility because, as we all know, the cost of drugs is open-ended. Unfortunately, in the past, we found that in many cases there was not much control in this area, even though we had concerns about it. We can quantify the cost of medical cards directly, while we could not do so for the supply of drugs, although there is a separate scheme in place for that. The bottom line is that at least €60 million is being diverted from other areas to a targeted group of people who are less well off.
Political honesty is required from those who oppose this scheme. There is a clearly identifiable group who require preferential treatment, including targeted services. The GP-only card scheme goes some way towards meeting their needs. This kind of targeting includes the medical cards for the over-70s scheme, which has been opposed by several speakers today. I campaigned to extend that scheme to include the over-65s so they would automatically become eligible for a medical card. Many of my colleagues, from all parties, who served on the Southern Health Board were anxious to implement such a scheme.
I am intensely annoyed by the mischievous comments that have been made about the proposed scheme, particularly when the commentators were among those who campaigned for such a scheme over the years. Last night we heard a further outburst in that regard when one Deputy from the west, who shall remain nameless, told us that we were giving medical cards to billionaires. I am sure they are running down to the doctor every day, card in hand, seeking some service. Perhaps his previous claim that we gave cards to millionaires no longer made the headlines, so he changed the story a bit.
When the occasion demands it the commentators can come in here and paint a vivid picture of the deprivation being suffered by people in certain circumstances. They can make certain cases in an almost tearful manner. In spite of that, if they hold clinics, they know that some of the greatest cases of hardship were among elderly people without a medical card. These people were fortunate enough to have a small private pension, but they were unfortunate in the sense that it resulted in them being over the means threshold for a medical card. Desperation was evident among these elderly who were in need of health care. In some cases that might only amount to reassurance on their health concerns. This group was in need of particular help and attention and I am proud we gave them that assistance.
Much has been made of the scheme for two unfortunate reasons. First, the Departments involved could not supply a figure for the number of people who would be eligible. In other words, as Deputy Olivia Mitchell stated, they did not know the number of people in the country aged over 70. That was a fact. That should not change the concept of giving benefit where it was needed. The second reason is that the IMO, the doctors’ union, was able to hammer out a very good deal. It certainly got the last ounce out of that measure. I still believe that this was a good decision.
I cannot imagine any millionaire or billionaire going down to join a queue at a doctor’s surgery to get the benefit of his or her medical card. That type of emotive statement should not be made. What happens is that because of the negative things that have been said, people will shy away from worthwhile schemes. I ask that people be more positive, especially when dealing with the elderly.
The critics love to refer to the elderly as the people who built the State. They say that we owe them and should give more to them. However, we indulge in saying the opposite to attack the former Minister, Deputy Martin, or the Minister, Deputy Harney.
Mr. Dennehy: Deputy Sherlock’s party was on our side for a long time until we granted the cards and then the party voted against us in the House. I believe the IMO is in favour of this scheme. I am sure it will get the same rate as usual.
I welcome the review of eligibility guidelines for the full medical card. It is expected that at least 30,000 additional people will qualify. The actual increase is 7.5% on the 2004 figure. Two of my former Southern Health Board colleagues are in the House. We had concerns about how the guidelines were reviewed every year by the eight CEOs because their aim was probably to keep the budget as low as possible. The increase was usually 2.5%, but this year it is 7.5%. That will be of considerable benefit.
A great deal of honest comment and input is required if we are to succeed in establishing a proper system of care for the elderly. People are living longer and our elderly population is growing as a percentage of the population, which may create financial problems. The fiasco of the figures supplied for the over-70s medical cards should not prevent us looking at schemes like this.
Similarly the figures were incorrect in regard to the initiative which the Government took to benefit old age pensioners living abroad, also people who had built the State. Again, the figures were all wrong but the concept was right. It was the correct thing to do. We must provide for a proper service in the future. We have never achieved this to date.
The reason we have so many private nursing homes is that the State has failed to provide sufficient long-term care beds. Something has been achieved in terms of acute hospital beds but we have never attempted to provide step-down facilities. We have never handled it properly and we will have to look at that. Private nursing homes have filled that void, admittedly at a cost. They have done a good job. We are facing a changed situation. The age profile of the population is changing. The people who would have looked after family members in the home are no longer there. People are now going out to work who previously would have stayed at home. Many other factors also come into play.
We will have to look carefully at other options. I refer to home help and home care packages which appear to offer a solution in that people would be paid to provide a facility and the back-up service would be provided by local authorities. We will have to make decisions and take action quickly on these options.
As Deputy Olivia Mitchell stated, we were all concerned at the amount of money being taken in the past. Everyone who served on a health board has had that worry and voiced it in the past. We need to make changes and move on. It is essential that we have a level of charge. I hope the matter can be quickly dealt with and that the people who in the past made a great deal of money from Army deafness claims and other matters will not be the ones to benefit from this issue. It was amazing how quickly the legal profession had advertisements in place — they were in place almost as soon as the court decision was made. I found that a bit depressing.
I do not advocate a one-party approach. No doubt we will have arguments as people will hold different opinions. I will voice my concerns at parliamentary party meetings, with Ministers and decision makers. We must have the debate on the future care of the elderly.
I read a timely article today by Liam O’Sullivan, the national development officer for Care Alliance Ireland in today’s Irish Examiner which referred to that organisation’s upcoming conference. It asks questions such as whether we want to live in a society where care of elderly and vulnerable people is provided mainly by paid care workers. I will leave that question hanging. It also asks a number of other questions such as whether we want to facilitate people to stay at home. Every report on the subject has concluded that the elderly wish to be in their own homes and their own environment.
Although it is not always possible because of medical reasons, we must try to provide for this. We must have a debate about what can be done, who will fund it, how much it will cost and what is the best way in which to spend the money. All Deputies will support this Bill because they all accept there must be some level of charge. We need to divert money into different aspects of the care of the elderly.
The article to which I referred is a very balanced piece in which compliments are paid to the Government for its initiatives as well as criticism where it is due. Anyone interested in this Bill would do well to read it. We must increasingly examine this issue. We know that our elderly population will grow in number, that the dependency level will increase and that there is a shortage of long-term care beds and funding for carers. We also know within reason how much money will be available this year and for the next three or four years if the Government is still in power. We will try to keep the economy going well in any case. Nonetheless, the money will have to be provided.
Decisions must be made on these issues. For example, Mr. Liam O’Sullivan has posed the question whether the public is willing to pay another 2.5% in taxation or PRSI to provide health care for the elderly. The question will never be put that baldly to people but we need to examine the package of money we have and decide on priorities for its use. When the Government does something well, it must be recognised and supported and when it does something wrong, it must take the criticism, which it has done. We will also voice that criticism as quickly as anyone else.
The medical card was called for by general practitioners and representatives of all parties. It is therefore no good to criticise it now. If we could get another 200,000 people fully covered by the GMS, it would be great, but we are told this is what we can afford. The initiative is a welcome move. The 7.5% increase in the eligibility rates is also welcome and people should congratulate the Government on it. We would like for drugs to be covered next year.
Deputy O’Connor said that the appointment of a Minister of State with responsibility for the elderly was a step in the right direction. However, we need to continue to move in that direction. Other than holding on to the job for a while, Deputies hope that, when we need it, there will be a good environment and someone to care for us. We will be thankful for it and, I hope, live long enough to enjoy it.
Ms Enright: I am concerned that this Bill, unusually, has been introduced to the House without an explanatory memorandum. This has not happened in my short time in the House. It may have occurred in respect of the previous Health Bill, although I am open to correction. This Bill will be sent to the Seanad where, had it been introduced there, would have required an explanatory memorandum under that House’s Standing Orders. This matter should be examined in this House. When Bills have come before the Supreme Court in the past, explanatory memorandums have been examined prior to the court giving its judgment. This is a strange departure from precedent and one which has not been adequately explained by the Minister for Health and Children. I call on her to explain why this is the case.
I commend Deputies Perry and Kenny for their pursuit of the issue of illegal charging in nursing homes. It is clear from the Supreme Court decision that, despite Government attempts to muddy the waters in recent months and the Tánaiste’s statements, the issue of overcharging became much more apparent from 2001. Moreover, there is strong evidence to suggest that the Minster for Health and Children at the time, Deputy Martin, and his Ministers of State abdicated their responsibilities in their handling of the issue from December 2003.
Part of the reason for this Bill being presented is the outcome of this position. It is a shame that the Travers report is not available to the House. We are told we should learn from our mistakes but it is very difficult for the former Minister for Health and Children, Deputy Martin, current Minister, the Tánaiste, Deputy Harney, and her Ministers of State when they and we cannot see the report into the handling of the issue before we discuss another Bill which effectively deals with the same issue. This is a pity because it would have been good to have had recourse to the report while discussing the Bill prior to its enactment after Friday, 11 March next.
I refer to the issue of overall care for the elderly. The Minister of State, Deputy Seán Power, attempted to deal with the matter in his speech to the House. It is nice to have noble aspirations, a term used by other Ministers in recent times, but we need more than that. We must have long-term planning, not only in terms of public and private nursing home care, but also in terms of the adequate provision of long-term care of the elderly within their homes. There are people who would rather be cared for at home if all the facilities were in place.
Many inroads have been made in this regard and better facilities have recently been provided for the care of people in their homes than existed ten or 15 years ago. However, we have a long way to go to make it a viable alternative to long-stay nursing home care and we have not yet bridged that gap. This is an important consideration which requires long-term planning because stop-gap measures will not work.
We will perhaps never reach the optimum number of nursing home beds but we must aspire to it. The community nursing unit in Birr opened recently having lain idle for two years. I am glad it is finally open now, the staff having been provided to run the beds as promised. However, this goes back to long-term planning. How can we decide we need a unit, provide the money for it and yet leave it lying idle for two years? It is a serious question. People are concerned to see other facilities supposedly coming on stream but which could be left lying idle. For example, Riada House in Tullamore and Ophalia House in Edenderry, where extensions were promised years ago to provide the needed beds, have not come on stream. This brings one back to the issue of overcrowding within hospitals and the use of beds by people who would perhaps be better cared for elsewhere. The lack of available beds is unfortunately forcing people into private nursing homes at great cost to themselves or their families. The care is not necessarily any less but it is not always the optimum choice for people and many find they cannot afford it. In this context, one must consider the issue of the variation in the cost of subvention.
It is difficult to describe the position one is in since the abolition of the health boards. People write the same letters to the same people with similar titles and addresses, except that it is the Health Service Executive midlands area rather than the Midland Health Board. I had hoped that the one good aspect of the abolition of the health boards would have been that anomalies between regions would have been addressed and we could have achieved a better, fairer and more equal standard of care throughout the country. However, this has not happened yet. Subvention is a perfect example in this regard.
I accept that owing to pressures of population, private nursing home care may be more expensive in some parts of the eastern region than others. It might be more expensive in some parts of the eastern region to secure private nursing home care but I cannot understand why enhanced subvention in the eastern region should be up to €520 whereas in the midlands region the rate paid is only between €50 and €90. That is a huge difference of up to €430. It is unacceptable.
The midlands region borders the eastern region and many of the same population pressures affect places such as Portlaoise, Edenderry, Mullingar and even Longford. I do not understand why such a disparity exists. Furthermore, 1,098 people in the eastern region were able to avail of the enhanced subvention whereas only 32 people in the midlands region could avail of it. These matters must be addressed. It is important that the Health Service Executive deals with such anomalies and ensures that people are treated properly and equitably. It certainly is not happening at present.
Recently, I attended a meeting of an Alzheimer’s group in my constituency. The difficulties it faces are no different from those faced by other groups. However, the main points the group raised with me were the cost of care, subventions and the availability of care. Not every nursing home is willing to take in a person suffering from Alzheimer’s disease. They generally require a greater standard of care than other residents of nursing homes. Care is often far more expensive because of the greater care requirements. This must be addressed.
I believe there is only one bed dedicated to Alzheimer’s patients in County Offaly. Compared with the number of people at the meeting who have relatives suffering from Alzheimer’s disease, it is a negligible allocation and has no impact. That is unfair and wrong. Certainly, public community nursing units and nursing homes have a duty to address this. It might be more difficult to force private nursing homes to do it although I would have no difficulty with such a decision being taken. They should not be in the position of picking and choosing the residents they accept. When they have the facilities available they should ensure that everybody is able to avail of them.
There is a lack of help for carers in their homes. Due to the shortage of spaces, many people are forced to deal with patients and relatives suffering from Alzheimer’s disease in their homes. That imposes huge burdens and involves 24-hour care. There is no way around it due to the nature of the illness. The Government should examine and address this issue.
Deputy Dennehy spoke about opposition to charging for public nursing home care. It certainly did not come from this side of the House. We accept the principle that people must pay for care and nobody in Fine Gael has stated otherwise. The Bill provides for an 80% charge across the board. The Minister should consider that different people have different needs. A person who is bedridden in a nursing home might not need the same amount of money by virtue of the fact that he or she is bedridden and might be incapacitated either mentally or physically.
However, there are others in nursing home care who might be able to go to Mass or to the shops for the newspapers and so forth. This leaves such people with a small amount of disposable income. I am not suggesting a scale but we should examine this provision to ensure that it could be applied in a fairer manner. Everybody, regardless of whether they are in a nursing home, has the right to a quality of life, and a resident of a nursing home has the same desires as other people to buy things, have their hair done and the like. We must ensure that we give them the dignity and quality of life of being able to do that. It is important that this point is made.
The current Minister for Health and Children has not handled this issue well — she has handled it badly. There has been little clarity. Legislation was rushed through the House before Christmas, despite warnings from all sides of the House. The end result is as expected. Despite the fact that the Minister was rushing the legislation through the House, she made a tokenistic and patronising gesture of paying everybody €2,000. There is a different figure for everybody in terms of what the care cost, what they paid and how they were illegally charged. The payment of €2,000 across the board was nonsense. The end result is that this matter will cost us a fortune, while dealing with it will be an administrative nightmare. There should be clear guidelines from the Government on how it intends to deal with the issue.
The doctor-only medical card was a good idea. Deputy Twomey suggested it initially, before the Tánaiste, but as a temporary measure. The means-testing method in the Bill is extremely interesting. There will be another trip to the Supreme Court if the Government is not careful and if the Minister does not accept amendments to it. It is certainly discriminatory and an attack on marriage. That is unusual and a pity. Why should a married couple be treated in a more negative way than a couple who are cohabiting? A married couple will be means tested against the spousal income but that will not happen to a couple who choose to live together and not get married.
Mr. Connaughton: The Government is trying to put a spin on this Bill. I heard a Minister describe it as a good news Bill but if we consider its background, we will soon find out from where the good news came.
The Minister for Health and Children, the two Ministers of State and a secretary of the Department discussed this subject in 2003. Somehow, however, the senior Minister neither heard nor knew what happened. It was obviously troubling the Department and the Minister; they knew they were sitting on a time bomb. After this, the Ombudsman wrote about the issue and the former chairman of the Committee of Public Accounts, Deputy Perry, raised it. It was then raised by the leader of Fine Gael, Deputy Kenny. That is what one could call whistleblowing. Had that not taken place, a Bill would not have been rushed through the House before Christmas and we would not be dealing with this Bill today. That explains the origin of the current mess.
Why are the most vulnerable people in society, people with nothing, asked to carry the can all the time? It would not happen to the higher level professions in this country. Invariably, it happened to people who had nobody to speak for them. A chain of events led to this Bill. It is fortunate that the President acted as she did and that the Supreme Court did what it had to do. Let nobody tell me the Government was the originator of this Bill; it was brought screaming to it.
I have much to say but, unfortunately, I do not have sufficient time. I believe the Government will be back before the Supreme Court before long, as Deputy Enright mentioned, on the question of eligibility for the medical card. There will be an uprising throughout the country. The Government has decided that a married couple are less likely to get a medical card than a couple who are cohabiting. There will be a remarkable reaction, and rightly so.
There is another important matter. The Supreme Court found that the people who were affected are entitled to compensation. I sincerely hope they get it. I hope they will not be pushed into the courts but that they will get it by right. The advertisements Deputy Dennehy saw in the newspaper are a matter of concern. However, at the end of the day, the Government is in office to govern. A serious mistake has been made and insult given to those at the bottom of the ladder in our society. I hope they will be treated with respect and dignity in the coming months.
I do not have time to comment on the rest of her contribution. How does this statement square with the situation of an 80 year old man in north Galway who recently had circulation problems in his legs, suffered serious pain and was hospitalised for several weeks? The man and his wife, who is crippled with arthritis, have medical cards. He was told that an appliance, like a big shoe, which would put pressure on the veins to help the circulation of blood in his leg could be hired from a Dublin firm. The man must use this appliance at home for five hours each day. If it was not in his house, he would have to take up a bed in one of the hospitals in Galway. What did the Health Service Executive do? It slapped the man with a bill for €1,550 for a 90 day rental. When 90 days is up, he will have to pay another €1,550.
It was put to the former health board and the Health Service Executive that this man was helping by not taking up a hospital bed and that he has a better quality of life at home, where he should be, as the Tánaiste stated in the comment referred to above. Moreover, he would be less of a financial drag on the State. I hope the Tánaiste takes notice of this. There is no relationship between her statement referred to above and what is happening in the country. Unless she gets her act together, many will not believe a word the Government says on anything to do with health.
If we do not treat people, particularly the elderly, with dignity and respect, it will be a mark against society in general. There must be a major input by the Government. These elderly people worked hard, paid their dues and, as such, should be treated with respect and dignity, which many are not.
I highly commended Deputy Twomey for his courage in openly stating that the doctor-only medical cards were a means to an end, which was not opposition for opposition’s sake. He never stated, and neither will I, that this development should finish at the first stage. We sincerely hope that whatever Government is in place in the next couple of years will try to change doctor-only cards to full medical cards to give people that to which they are entitled. However, despite the 30,000 extra cards which were to be issued this year, some 10,000 cards were taken out of the system last year, which reduces the number of extra cards to 20,000. If my figures are correct, the increase in wages means it is doubtful 20,000 extra cards will be granted despite the 7.5% increase in the eligibility threshold.
Mr. Moloney: I wish to share my time with Deputy Cooper-Flynn. I welcome this attempt to address the difficulties caused. I recognise the point made by Deputy Connaughton in regard to Deputy Twomey. Opposition for the sake of opposition was not Deputy Twomey’s role and I recognise his responsible attitude on this issue. However, it should also be recognised that it is not the Government’s role to create difficulties for the elderly. I will not rehash the statistics on increased funding for the elderly in all areas because this has the effect of annoying Members. However, I will not accept condemnation of the Government as being miserly towards the elderly as that is not the case
I welcome the Bill and the opportunity to clarify some issues related to it. In recent weeks the impression has been created that the Government is intent on removing supports for the elderly and ensuring that they must pay for all of their care and attention. There is a belief that this care and attention should be free across the board. While I have not heard it suggested in the House, this impression has been created.
Over the years I have noted major improvements to nursing homes and care centres for the elderly in my constituency. I do not highlight this to justify the difficulties created in recent months and years. I fully accept difficulties exist and that we have a job to redress these. If elderly people are entitled to a refund in full of money taken, I would fully support this. However, it should also be noted that over those years great strides were taken to put in place proper facilities for the elderly. I have visited care centres in my constituency, including at Mountmellick last week, and witnessed the major improvements made. It galls me that people suggest the Government intends to remove entitlements.
It is difficult for me to address this issue as I may be asked why I do not support the elderly. However, I must recognise the huge costs involved. I was surprised to find that the cost of catering for a patient in my local hospital for the elderly — I am sure it is the same across the board — amounts to €1,200 per week. As pensions are approximately €170 per week, the level of care now extended to the elderly could not be considered unless there was an adequate funding base — I understand the cumulative figure for this is approximately €2 million per week.
I am delighted supports are in place. This issue does not only concern board and lodging but many aspects across the spectrum. I was delighted to note the advances in services at Mountmellick, Shaen in Portlaoise and Abbeyleix, the centres for care of the elderly in County Laois, and similar advances in County Offaly. A range of services which were not available five years ago are now in place, properly so. However, they could not have been initiated or continue unless funding was in place. I am glad we have moved away from the ordinary issues of board and lodging. My local hospital, quite properly, contains a wide spectrum of facilities for crafts, art, music, reflexology and relaxation.
It should not be imagined, though in our minds it unfortunately is, that the only way to care for the elderly is to locate places for them in nursing homes. I take the point made by Deputy Connaughton. I do not see this as a good news package. Why should we see it as such? I see it as focusing on the needs of the elderly. That is not a cop-out by way of admitting that we have been wrong on this issue and now have the opportunity to right it. We should not do so by suggesting that the only way forward is to provide nursing home places. The former health board members among us have regularly made the case for the need to increase subventions in the area, though I recognise that over the past few years, the level of funding in that area has quite properly increased.
It is also fair to recognise that the age profile of the elderly is ever on the increase and the demands placed on the State by that situation are also increasing, as is the demand for further Exchequer funding. We must debate how we care for our elderly. It has often been said that a state is judged on such care, and I accept that. The most important aspect of this debate must be how we move towards providing funding for the elderly and towards recognising that it is not just a matter of finding health board care centre places for them. The possibilities of further grant aid or tax breaks for nursing homes must be opened up.
I welcome the debate. I greatly regret the pain caused but do not think that handing €2,000 to individuals to make up for times past is just a gimmick. I see it as an honest attempt to recognise that a mistake has been made and to rectify it.
I also welcome the medical cards initiative. I do not see it as a yellow pack answer, a quick fix or a cheap gimmick. It is clearly focused on bringing a further 200,000 people into the net. From talking to GPs in my area I am satisfied that a certain barrier has been removed in the case of families, particularly where asthma is a problem, who are often reluctant, especially if there are two, three or maybe four people in the family, to attend their local GP. The initiative has been worthwhile. I take the point that there are fewer people on medical cards than there were. I do not want to throw in a red herring but surely that is related to the fact that we have a growing economy with more people at work, so clearly there are more people outside the previous medical card net.
I welcome the initiative. I do not see it as an attempt to downgrade the elderly. It is a way of focusing on how we can further support them. I thank the Tánaiste for recognising that. On the day of her press conference I thought it was a bold initiative on her behalf to recognise that while we could not immediately extend the medical card numbers, this action could be taken. I believe the initiative showed great promise. Goodwill has been shown towards it and I too welcome it.
Ms Cooper-Flynn: I welcome the opportunity to speak on the Health (Amendment) Bill for a number of reasons. It is important to focus our attention on looking after elderly people within our communities and on low income families who found it so difficult to avail of GP services over recent years.
I welcome the legal framework set out in the Bill for charging patients for the maintenance element of inpatient services in publicly funded long-term care residential units. After 29 years, it is important that this be put on a sound legal basis. From speaking over the past few weeks to people in the community and those working for the former Western Health Board in my area, now the Health Service Executive, I know that people find it incredible that a situation like this could have been allowed to develop over the terms of successive Governments for 29 years.
The number of written and telephone inquiries to the Health Service Executive on this issue has been unprecedented and it is clear from public debate on the radio that people have been unable to get through to the helpline. Calls to my constituency office show that this issue will be a major one and an administrative nightmare over the next few months but in the end, people have a sound legal basis for their claims. I welcome the statement by the Tánaiste that this matter will be dealt with as quickly as possible.
Regarding nursing homes and people being looked after in the community, people recognise that nursing homes provide a valuable service. The contributions of people towards the cost of this service represent a small percentage of the overall cost so it is important that it is put on a sound legal footing.
The matter gives me an opportunity to raise an issue in the programme for Government which affects my constituency, namely, providing for elderly people in their own community. Coming from Mayo as I do, I draw the Minister’s attention to the claim on behalf of the people of the Ballinrobe area who have been seeking a nursing home in the town for over 25 years. I was chairperson of the Western Health Board in 1999 and the board purchased a site for the purpose just before 2002, for £300,000. Unfortunately we are still waiting. It was not included in the national development plan for capital projects in the Western Health Board area. We were awaiting funding from the Department of Health and Children to honour a commitment given by the parties in government that they would provide for community nursing in the areas where the elderly people are. I hope that a nursing home in Ballinrobe will be considered a high priority by the Government in the near future because the community there has worked very hard in achieving its objective.
When the Tánaiste came before the Joint Committee on Health and Children a number of weeks ago, I raised the issue of the level of subventions paid in different parts of the country. It is completely discriminatory that within the former Western Health Board area a person can get a subvention only up to a maximum of €220 weekly, while someone living in Dublin or in the eastern part of the country can get up to €500 or €600 weekly. That is unacceptable. Looking at the costs involved, even for example the cost of providing a nurse on the east coast vis-à-vis the west, there is no massive discrepancy involved. It is unfair to expect nursing home owners in the west to provide an essential service when they are treated unfairly.
I congratulate the Tánaiste on the fact that she acknowledged to the committee that this was discriminatory. Indeed the situation is worse in the east where one could have a nursing home on one side of the road getting a €300 subvention per client while one on the other side of the road gets €600 per client. That needs to be addressed and I ask the Minister to look at it in the near future.
I welcome the Supreme Court decision that it was unsound that retrospective provisions would be put into a Bill making lawful the imposition and payment of charges for something that occurred in the past. That is welcome because it would have set an unfortunate precedent. One would have to call into question the legal advice given when the Bill was brought to the House before Christmas. It is important that we take our time with legislation that is vitally important to all citizens. We now have to deal with the position in which we find ourselves. It is important to move forward, to recognise the excellent work being done by the State and by private nursing homes in our community and to put them on a sound footing in the future.
The other significant issue this Bill deals with is the doctor-only medical cards. I draw the Minister’s attention to the fact that within the former Western Health Board area, particularly in my county, we had the biggest decrease in medical cards in the country from the period 1997 to October 2004. In County Mayo during that period, 8,319 people lost their medical cards. I put a number of parliamentary questions to the Tánaiste at the time noting that income levels in County Mayo have not increased sufficiently to sustain that level of decrease in the number of medical cards. The programme for Government states that medical card eligibility would be extended in line with the recommendations of the national health strategy. How may that tally with a reduction of 8,300 cards in County Mayo? I welcome the 7.5% increase in the income threshold, which will result in the provision of 30,000 additional medical cards. I also welcome the provision of 200,000 doctor only medical cards. When the annual review of medical cards is carried out next year, I hope there will not have been another significant reduction in the number of traditional card holders in County Mayo and that there will be an increase in doctor only cards. I hope doctor only cards will not be a substitute for traditional medical cards because the value of such cards to families is significant. I welcome the provision of the doctor only cards, as they will enable many low income families to avail of GP services. Many of them have avoided bringing children to their GPs and, unfortunately, the consequences have been serious. I hope we will not witness the demise of the traditional medical card through its substitution by the doctor only card.
Under the legislation, an individual can attend a variety of doctors. Will the Minister of State explain how that will work? I tabled a parliamentary question to the Tánaiste and Minister for Health and Children seeking reasons for the loss of 8,300 medical cards in County Mayo and she replied that 8,047 cards were lost because the holders had died. A total of only 253 people, therefore, lost their medical cards on the basis of income. In addition, the doctors involved were paid as if the medical cards were still in use, even though the holders were deceased. That money will be recouped over time but it was a serious waste given that the money could well have been used to provide medical cards for people in need. The figures must be analysed and money paid on foot of a card held by a deceased person should be refunded.
The post polio group appeared before the Oireachtas Joint Committee on Health and Children recently. A finite number of people are affected by this illness, which they want covered under the long-term illness scheme. Unfortunately, the Department has not extended cover to illnesses under this scheme in recent years. I ask the Minister of State to consider adding this illness, as it affects a finite number of people who have suffered greatly. Their needs are quantifiable and while, in a number of cases, they are being looked on sympathetically by the Health Service Executive through the discretionary arrangement available to chief officers, unfortunately, the discretion is not applied consistently throughout the State, resulting in discrimination between HSE areas. When I sought the issuing of guidelines to chief officers regarding the use of discretion, I was informed that if guidelines were put in place, the discretion would be removed. However, there is discrimination between various HSE areas and the Department could easily solve this problem if it was willing.
While I welcome the legislation, it is unnecessary. If more time had been put into planning and drafting the original legislation before it was introduced in the House in December, we would not have to debate the issue again.
I ask the Minister of State to re-examine the position of Ballinrobe nursing home. The community has campaigned for 25 years because there is a serious need in the area. Both Government parties reiterated their commitment to the area in the programme for Government and it should be forthcoming. I look forward to a positive response in this regard in the near future.
Mr. Sherlock: I wish to share time with Deputy Lynch. The Bill will amend the Health Act 1970 to address two matters — the charging of patients for maintenance and inpatient services in residential hospitals and the introduction of doctor only medical cards. The issue of who is entitled to be refunded as a result of illegal charges in community hospitals where contract beds were provided is clear but many elderly people were told they had to take beds in private nursing homes because no beds were available in community hospitals. One can imagine the trauma experienced by elderly people who knew their own families were involved in debating with the liaison officer at the time. They accepted the transfer because they had no choice. They were given application forms, which were all but signed for them in many cases. They had no choice but to accept a private nursing home. Over the years the Government provided private nursing homes and provided substantial tax breaks to private enterprise to build them but the Government did not consider nursing home subvention payments. The families of elderly people transferred them to private nursing homes but did not realise the subvention payments were much less than the weekly cost of care in the homes. In some cases elderly people were forced to sell their homes to pay the charges. Most people I know from rural areas in my constituency had to sell their cottages, even though they were entitled to full subvention because of their medical needs.
The Labour Party does not object to charging elderly people through deductions from their pensions but we are seeking justice and fairness for everybody. I followed this issue closely as a former member of the Southern Health Board. The former Ombudsman stated that under section 52 of the Health Act 1970 an elderly person in need is entitled to inpatient accommodation in a public or private nursing home. I hope the Minister of State will address this issue when he replies. Will people who were resident in private nursing homes receive refunds? It is staggering to consider that the previous Minister for Health and Children, Deputy Martin, spent €30 million on consultant reports but continually ignored the issue of nursing home charges.
I refer to the provision of doctor only medical cards. The saddest aspect of the nursing home scandal is that medical cards provide good value for money, speedy access to GPs and can reduce the cost of prescription drugs and hospital charges for individuals and families on low incomes. A few years ago 39% of the population had medical cards. I remember approximately eight years ago it was 49%. I understand that it is now 27%, and that gives one an idea of what has been happening. Many people who find themselves marginally over the limit are refused a medical card and are offered doctor-only cards instead. The Minister says this allows a patient to avail of a doctor’s services for free and to claim back the cost of drugs in excess of €85 a month. I am well aware that there are people who do not have a medical card who visit doctors and do not go to the chemist because they cannot afford the drugs. They are marginally over the limit. In my region there is a community welfare officer, a superintendent community welfare officer and a referee. There was a time some years ago when one person would do all that in his or her own time. It might have taken a little longer but that person knew what was happening. They did not have the problems we do now.
In 2001 we were told that every person over 70, irrespective of wealth, was to have a medical card. That the cost of the scheme was underestimated is a further example of the maladministration of this Government. I listened to the Minister’s colleague, Deputy Dennehy, speak at length on the subject, but he did not know what he was talking about. I would give the following example. A person refused a medical card because of being marginally over the limit went into a chemist despite the fear that it would be impossible to pay. Beside that person was a farmer with three farms and one of the wealthiest people in the locality. He presented his medical card to the chemist while the other person could not afford what was prescribed. That is not an exaggeration, and that is the issue. A means test should have been carried out to determine whether the person was entitled to a medical card. For people on fixed incomes, it is simply not possible to pay prescription charges even though general practitioner charges are covered by these new cards. The scheme does not work for those on a low income.
I know that the Minister will address these questions when replying. I have said over the years, especially during health board meetings, that the way the most vulnerable elderly people have been treated in terms of health services is appalling. The current Health Service Executive is not inspiring confidence.
Ms Lynch: This is probably the longest debate that we have had on the care of the elderly and how we are to treat them in future that I can remember having taken place in the Dáil. That is an indictment when one considers that all the statistics tell us that we have an aging population. That may have changed slightly in the last five or six years, but the bulk of our population will soon be heading into the elderly bracket. Despite this, the only occasion that we take time to debate this issue is when we put right a grievous wrong perpetrated over almost 30 years. That is an indictment of the Government.
There are several matters regarding this issue that we must discuss. For instance, not one of three Ministers came away from a meeting they all attended questioning the legality of what was taking place. Not one of them has been held to account either. The former senior Minister in the Department of Health and Children, Deputy Martin, has walked away from the issue in such a way that one could almost swear that he had never had anything to do with health. He has left a minefield in his wake. The current Minister for Finance, Deputy Cowen, was right when he said that he felt that the Department of Health and Children was like Angola. The current Minister for Health and Children, the Tánaiste, Deputy Harney, must surely feel that way given what she has been landed with.
No one can walk away from the blame. It was clearly an issue that was known. The Ministers attended that meeting, yet none of them has said in the House that the matter was raised or spelt out or if it was clear or unclear. We do not know, but the meeting was clearly called to discuss something and was ignored because it was near the time of a general election and the Government cares about nothing other than winning such elections. It will sacrifice everything else as long as it wins the election.
We in this House are discussing for the first time how we treat the elderly. Each of us at our advice centres receives calls every day from daughters, husbands, wives and sisters about an elderly relative who needs full-time care and attention that is not available. I remember, eight or nine years ago, listening to Deputy Sherlock talking about this very issue and that it was illegal to charge elderly people who were in the care of the State and had full eligibility. I am not simply saying that today; I have been saying it for a long time. I remember Deputy Sherlock raising the issue on the Southern Health Board and his being ignored. He and others knew it, but the matter was not to be discussed because no one wanted to deal with it.
Up to last year there were terms in the Irish Examiner such as “bed blockers”. The reason there was such a crisis in accident and emergency departments is that we had bed blockers. In the main they were elderly people too sick to go home and with nowhere else to go. The geriatrician in the Southern Health Board region had declared that they were in need of full-time care and attention — the same geriatrician who was on the team that produced the Hanly report. He was very well thought of and clearly an expert in his field. He assessed elderly people and said that they could not go home since they were in need of full-time care and attention. However, none was available from the State. Just as Deputy Sherlock has said, they were handed the subvention forms and told to apply. On top of that, they were given a list of nursing homes and told where beds were available. That is still happening. It is not past history because it occurs today. That is how we still treat the elderly. Exactly that happened to someone today in hospital after an assessment.
When it first arose, being recommended for a subvention of any kind took up to two months. Enhanced subvention at health board level is now taking up to 12 months because the funding has been cut back. We now know who is to be refunded, but to suggest at this late stage that it will be €2,000 per family or per person is premature. We do not know how much it will cost, and people have rights in that respect too. To try out the figure of €2,000, as was provided in the legislation before Christmas, is premature, and the Minister needs some advice on that. That is not how it will pan out. However, those really put to the pin of their collars were those who had to enter private nursing homes that cost €600 or €700 per week and whose families had to try to scrape together what they could. The entire network of family is being put under tremendous pressure to pay it and it continues to happen. We are not talking about history; this is happening now.
We are not putting enough money towards providing places for the elderly. A Government backbencher spoke earlier about the marvellous strides we have made. We have made strides but from a very low base and there is much more to be done. Was that not the slogan during the election — much done, more to do?
Ms Lynch: That is not the case, but that is a debate for another day. When it comes to the elderly we should have debates like this regularly. We should not try with sleight of hand to put right what we did wrong in the past. That must not happen. We must take responsibility for the elderly. The two greatest needs in society now are child care and services for the elderly.
The issue of institutional abuse arose on “Liveline” with Joe Duffy today. The next major inquiry into the way the State treated people or ignored their needs will be about the care of the elderly. We will be sitting at home or in a home one day and remembering when this issue first arose and that we should have taken much more interest in it at the time. The next major scandal that will break will be the way we have treated the elderly, and we had better start doing something about it while we have the money. The rest of the world has done it and I do not understand why we cannot do the same.
On the medical card element of the Bill, and I am glad Deputy Cooper-Flynn raised the issue, these cards will be more than welcome to families who have lost their medical cards because they went over the income limit. I am talking about people with young children or those who have a teenager suffering from asthma, which is not a long-term illness and does not carry the same entitlement to a medical card.
Like Deputy Cooper-Flynn, I have a sneaking suspicion that we are not adding to the medical card scheme but dismantling it. We are seeing the first step towards the replacement of the medical card which provides access to doctors’ services and medication. More of these cards will probably be issued next year and at the same time we will see a decrease in the number of full medical cards issued. Only a Progressive Democrats Minister could introduce a scheme such as this. While I feel sorry for the Tánaiste in terms of what the former Minister, Deputy Martin, left behind him in the Department of Health and Children, I will have no sympathy for her if that is her intention, which I believe it is.
This measure is much more sinister. We are beginning to see a dismantling of the medical card scheme that has served this country well. As Deputy Sherlock rightly said, the percentages have dropped dramatically. Fewer medical cards are issued in every county than was the case in 1997. That is happening; it is not a gimmick. It is a planned initiative to dismantle the medical card scheme and no better Minister to do that than a Progressive Democrats Minister.
This short but significant Bill is no more than the first step in a debate which must take place on the manner in which we care for the elderly. There is one element of it which really annoys me — the notion that elderly men and women would be left with €30 in their pockets each week as if they were children. One’s needs do not diminish as one gets older. If anything, they increase. As a woman I know that women only realised in recent years that the dignity that comes with financial independence cannot be replaced. Even if people are well cared for, they still want to be able to put their hands in their pockets and pay for their little comforts. For someone to be left with €30 at the end of their years is a scandal. In replying, perhaps the Minister would indicate whether this measure represents a dismantling of the medical card scheme and explain what happened at that meeting. When will we hear about that?
Dr. Devins: I welcome the opportunity to speak on this important and topical Bill. It is important and topical because of the immediate impact it will have on the lives of many people. There are two aspects to the Bill and I would like to deal first with the section on long-term stay.
Every Member of the House will be aware of the decision of the Supreme Court regarding the Health (Amendment) Bill 2004, which was passed by this House just before Christmas. While most media attention has focused on the findings of the Supreme Court that retrospective charges are unconstitutional, another finding by the court which received much less coverage is that the practice of asking patients in long-term stay institutions to contribute something to the cost of their bed and maintenance is constitutional.
This practice has existed for many years but the underlying legislation has been defective. Why the practice was allowed to continue in the light of such defective legislation is an important issue, and I welcome the speed with which the Tánaiste has moved to clarify this point. The report by Mr. Travers into this point will be published in the next few days and we will then be able to ascertain the reason this unsatisfactory position was allowed to continue for so long.
It is important to remember that this situation has existed for 30 years under 11 Governments of all political hues and nearly every party in this House was in Government at some stage during those 30 years. This report will clarify the reason that position existed. The openness of the Minister for Health and Children and the speed at which she has moved has displayed a welcome example of transparency.
It can never be correct to charge people for a service when the basis for that charge is defective in law. To do so to a group of people who are among the most vulnerable in society — the elderly and, in many cases, the infirm — is wrong and must not be allowed to occur again. Any such charges were deducted from the old age pension. That was, in many if not all cases, the only source of income for those elderly people. For many of the years during which the practice continued, the old age pension was at a derisory level and it was only in 1997, when the Fianna Fáil-Progressive Democrats Government came to power, that the old age pension started to attain a reasonable level.
The result of all of this is that many elderly people had no disposable income to spend on the essentials we all need such as toiletries, clothes etc. I know from attending long-term stay residences that the quality of their lives would have been intolerable had it not been for the generosity of their families and friends who spent their own money to give some dignity to their elderly relatives and neighbours. It is easy to forget today, when the old age pension is approximately €166 per week, how much more difficult it was to survive on a pension of £30 or £40 per week. I understand some health boards were in the habit of taking all the pension entitlements of people who were in long-stay accommodation. I welcome the speed at which the Government, in particular the Minister, moved to stop deductions as soon as it became apparent that there was a legal difficulty with these charges.
I ask that the Health Service Executive increase the number of people manning the information hotline, advertised in today’s newspapers, because many of my constituents in Sligo-Leitrim are experiencing difficulties in obtaining information on the repayment scheme. There is a great deal of confusion among members of the public regarding when and how repayments will be made. The sooner this confusion is cleared up the better. The Supreme Court ruled that such charges are illegal under the existing legislation, and the sooner such moneys are repaid the better.
I wish now to deal with the second aspect of the Bill, namely, the introduction of doctor-only medical cards. As I stated on many occasions, despite the widespread and welcome growth in our economy in recent years, there are still people who find it increasingly difficult to access medical services, particularly those at primary or general practitioner level. This is especially true of those whose incomes just exceed the threshold relating to medical card qualification. In many instances, these people have families with three or four children. In the normal course of events, children succumb to the usual childhood illnesses such as upper respiratory tract infections. In many cases, these illnesses are self-limiting. Occasionally, however, they may progress to become more serious illnesses such as pneumonia.
I am aware of instances where parents delayed attending their GP in the hope that the ailment affecting their child might be self-limiting. Unfortunately, this has sometimes had disastrous consequences leading to patients requiring urgent admission to hospital. Cases such as those to which I refer came about purely as a result of patients’ parents being unable to afford the cost of a visit to the doctor and not through any negligence on their part.
Inability to access medical care should not be allowed in any society. It is an affront to all standards of decency. I and my colleagues in Fianna Fáil have agitated for some time for an extension of the general medical service to cover an increased number of people. Some weeks before the recent budget, a formal motion I proposed was unanimously adopted at a meeting of the Fianna Fáil parliamentary party. I was delighted when the Minister for Finance announced the provision of the additional 200,000 medical cards on budget day.
The Bill provides the legislative basis for these welcome medical cards. Some members of the Opposition have tried to deride these cards. I have no doubt that the people who will benefit from the cards do not share that viewpoint because they will enable them to avail of medical care when they might otherwise, for the reasons outlined, be reluctant to do so. I understand that the additional funding of €60 million being provided in the current year will allow for approximately 200,000 of these cards to be issued and that it is the intention of the HSE to set the income threshold relating to the cards at approximately 25% above the existing level. These cards should be available next month. I urge the Health Service Executive to process applications for them as soon as possible. Any person who is just outside the current financial limit and who believes that he or she will come within the 25% range should apply immediately.
Ms F. O’Malley: Little did any of us think we would be welcoming legislation of this nature so early in the new year. There is much reason to welcome the Bill. However, the fact that this is happening so soon after the introduction of the Health (Amendment) (No. 2) Bill 2004 must make us aware of the dangers of bringing forward hasty legislation. I do not believe anyone on this side of the House was not aware of the difficulties of bringing forward such legislation in an attempt to save the State some money. The previous Bill was brought forward on good advice from the Attorney General, and a Minister can only act on such advice. The President, in her wisdom, saw fit to refer the Bill to the Supreme Court to test its constitutionality. We must be grateful to her for that because it has been determined that the previous Bill was unconstitutional. It is our job now to remedy the situation.
I welcome the Bill because it provides legal certainty in respect of charges. I do not believe the House is divided on the question of charges. Everybody recognises that the State is not in a position to provide total care free of cost. With one or two exceptions, no one in the House is seeking that the State make such provision.
We must thank the Tánaiste for her swift action in terms of dealing with this issue. It has been stated that people knew the position regarding charges for over 20 years. True to form, the Tánaiste was prepared to do something swiftly about it. The only criticism one could level at her is that she moved hastily but, as stated, there were good reasons for her doing so.
With the Bill before us, we are now in a position to deal with the legal certainty of providing for the imposition of charges. The House is not really divided on that matter. However, this is an area in respect of which we must act responsibly. Demographics indicate that the population is getting older and we must consider how we will provide for care of the elderly. The latter is particularly relevant because we will all grow old in the not too distant future and we would like to believe that there will be adequate services available to us. One of the Government’s priorities is to put in place a proper and sustainable care programme for the elderly.
I wish to refer now to the difficulties that arise when dealing with the monolith that is the Department of Health and Children. The Department must be reorganised and streamlined in order that the money goes to the patient and not necessarily be spent on infrastructure or bureaucracy. I accept that beds and buildings must be provided. Where these are in existence, however, they must be opened and operated in a cost-effective way. In the area I represent, beds are available at the Blackrock Hospice and Leopardstown. I would like the Tánaiste to ensure that these beds are opened to elderly members of the population in the area I represent, Dún Laoghaire, who need them.
I welcome the provision in the Bill relating to GP-only medical cards. When one is in a position of responsibility, as is the case with all governments, one must set priorities. The Government cannot sign blank cheques to be used for the provision of services. Of course we would like to provide optimum services for every patient but that is not feasible. When the Tánaiste recognised that parents frequently did not go to their doctors, either in respect of themselves or their children, because they could not afford to do so, she determined to provide them with the reassurance of access to free visits. We had been faced with an either-or situation, namely, should we provide more full medical cards to a smaller population or provide the security offered by free GP-only medical cards? The Government has wisely chosen the latter route. Even Deputy Twomey knows these cards are a good idea and I am sure he will support them, particularly as they represent an effective use of the resources available.
As a result of the Supreme Court decision, resources will be ever more stretched. We need to ensure, therefore, that resources for patients are provided in the most appropriate way. The IMO has welcomed GP-only cards and the Health Service Executive is about to enter into discussions in respect of them because of anxieties relating to administration of the scheme. However, I am sure the latter will not delay the introduction of the cards. We all know a GP’s priorities are for the patient and swift intervention so that any anxieties are allayed or that the required treatment may be undertaken as soon as possible. That will not be much of a barrier because when both parties to any negotiations have the same objective in hand, there is no reason consensus may not be delivered quickly.
The question of legal certainty for the future is another matter that is welcome. It was something that needed to be addressed and the Minister has courageously decided to do this promptly. That it is being done through legislation dealing with medical cards is significant as well. I suppose a type of belt-and-braces approach is being taken in that it is not being done by means of a statutory instrument so that we will not find ourselves in the current position in future.
I welcome the introduction of the Bill. I hope it has a swift passage through legislation. I hope people who deserve whatever recompense they are entitled to because they had their contributions taken from them, illegally as it now transpires, avail of the service. It is the least the State can do to provide a more transparent service for people while making a charge for what is a very good care service.
Mr. Gogarty: I wish to share time with Deputy Cowley. I do not wish to talk about the introduction of the doctor-only medical card under this proposed legislation. My colleague, Deputy Gormley and other members of the Green Party have spoken and will speak on it. I broadly welcome it, although I share some of the reservations already expressed.
I want to use this opportunity to outline my absolute disgust, which is probably too weak a phrase, for this legislation. Deputy Fiona O’Malley has just left the Chamber. She praised the Tánaiste for her clarity and foresight in identifying this little glitch whereby taking money from the elderly for services they had already paid for over the years through graft and taxation was illegal. The Tánaiste brought the matter to public attention. However, it is an even greater sin, having known that it was illegal and morally unjustifiable, to proceed with it and try to legalise this robbery.
I could not help thinking of the analogy with Robin Hood and his merry men. There were many merry men in the Fianna Fáil backbenches, but in this context this Administration and previous Governments are “Robbing Hoods”. The Tánaiste, Deputy Harney, is the sheriff of Newcastle who, having collected the taxes from the local villages, proceeds to legalise the law that says, in effect, that they can be plundered and the money taken off them again. I believe my parents, grandparents and great-grandparents who contributed to this society over the years deserve better.
This is a timely opportunity to outline the sort of policy we have towards the elderly for the future. Older people lived through the Emergency or the Second World War. They saw the first boom in the 1960s, the oil crises of the 1970s, the recession of the 1980s and the emergence of the Celtic tiger in the 1990s. They, more than any other segment of society, contributed to this. They are the people who paid tax at 48% during the dark days. It is they who contributed to the economic miracle which is world renowned but which has not done much for people’s quality of life. The people who contributed to this have paid with their blood, sweat and tears, from the mothers who reared children or worked outside the home to the fathers who minded their children and who paid taxes at 48%. In this context I am also talking about people who emigrated and sent money home to keep the local economy going, and who are not treated with as much disdain as they reach the twilight of their years. I am thinking in particular of the emigrants in London, but that is for a later debate. I want to confine myself to the elderly in Ireland seeking care who are being treated with contempt.
People who have already paid in spades through the taxation system should not be asked to pay a large proportion of their pension for residential care. It is what Deputy Joe Higgins would describe as an unfair double taxation. I believe that giving someone the best part of €30 in pocket money is an insult to his or her dignity. Teenagers these days earn more than this in one night working in a pub or in McDonald’s. It is a joke and an affront to a person’s human rights and dignity. Fianna Fáil might be complacent in thinking the majority of voters over 60 vote for it or its Thatcherite spawn, the Progressive Democrats. Looking at how society is developing, however, it is the older generation in particular which believes that quality of life is diminishing. They are coming to realise that what Fianna Fáil Governments have given them over the last 30 years is not what it appears to be. I would not be so smug at the next general election in thinking that the elderly will take this ignoble insult on the chin and continue to vote for this Government. I certainly hope they do not.
I would like to make a few suggestions about how quality of life may be improved for the elderly. The Progressive Democrats seem to think that if a person is incapacitated and has no economic merit, he or she is dross and should wait to have life terminated or wither away. I have news for the Tánaiste. The majority of older people are active and contribute to life and society. They should be provided with better opportunities to do this and there are ways and means.
Although I am a Catholic, I disagree with Pope John Paul II on a number of moral issues. However, here is a shining example of a person of advanced years who has made a unique contribution to society. Let us listen to some of his words. He said the elderly should not be allowed to think of themselves as a burden on the community and sometimes even on their families. He also said they represent a resource to be valued. This beacon for millions of Catholics said as much in his Lenten homily this year. It is a message the Pope can convey, even in his ill-health. I hope the Government takes his words into account.
Age Action Ireland has made a number of proposals in terms of what may be done to help elderly people. They can get financial aid in residential care and if that means abolishing this measly tax, this is fair enough because while it is only 10% of the overall cost of care, it is a much larger proportional share of an older person’s income. Services could be provided to older people in rural areas. That means keeping post offices open and the social fabric alive. It means allowing proper public transport systems to be set up so that the elderly may network and get out and meet people.
It is a very ageist attitude but many people think that older people are just waiting to wither away and die. When a person finishes active contribution in terms of work, he or she is often seen as not having anything to do. Dr. Garret FitzGerald made a proposal which should be considered, even though I have no opinion on it one way or the other at the moment. He proposed raising the retirement age to 70, which would also have a beneficial economic impact. All the studies have shown that for a person to be kept active in his or her older years by contributing to and being valued in society has positive health and economic benefits. Community employment schemes have a contribution to make in this regard, and not just for training which was their original purpose. Older people can make a contribution through part-time work as part of community employment schemes, through job sharing etc. These are ways through which older people, who are a major resource as Pope John Paul II has said, may continue to contribute and be valued and cherished.
Reports have shown that proper nutrition and proper exercise such as weight training and yoga represent the way to ensure that health care costs are kept to a minimum. The Heidelberg guidelines, as proposed by the World Health Organisation, suggested that there are ways and means of promoting physical activity among older people. An independent older person is a happy, vibrant person. We should not aim just to treat people who are sick, but to ensure that fewer elderly people are sick. People are living longer and they should be able to live healthy lives. Anything that is done to promote a healthy, active life should be considered and it would also save the State some money. Education courses are another way forward because keeping someone’s mind active is another way of saving the State money.
I urge the Government to think about planning before the demographic time bomb explodes. It should think about providing homes for elderly people mixed in with homes for younger people. Due to the high price of housing in the greater Dublin area, people have moved to Meath and Kildare. Their parents live in the city centre and suburbs, but they cannot spend time with their parents as their time is spent commuting. If we want to build a real sense of community, we have to give incentives to elderly people so that they can live near their families, or to families so that they can afford a house in the area in which they grew up. That sense of community will also save the State money because rather than paying large amounts in crèche fees, the elderly member of the family can perform some of the child care duties. That has a cost saving and is a way of valuing older people. Rather than looking at it as a cost and a burden by trying to take 10% of the total cost of care, we should consider giving pensioners their dignity and rights and consider ways of saving the State money.
Dr. Cowley: This Bill is a fiasco and is 29 years too late. Serious questions need to be asked on how we arrived at this situation. There should surely be some mechanism in this State to ensure that this sort of thing does not happen. We have already had the situation regarding medical cards for persons over 70, where the Department of Health and Children did not know how many people were over 70. That scheme cost many more millions of euro than was ever anticipated. In the course of time, memos from the Department will tell their own story, but I wonder will the report that we are to receive tell the full story.
The Minister has spoken about systemic maladministration in her Department, which shows how she feels about it. I do not think that anybody is blameless here. The entire fiasco does not augur well for the organs of the State and it cries out for reform. I do not begrudge anyone the repayment from the scheme to be set up. It is estimated that €6,000 will be paid for each year that someone spent in public care. However, I fear that relatives who had very little to do with older people will do well out of this. There will certainly be people who will have passed away and on whom little or no records will have been kept. There will, therefore, be money that will go unclaimed. The dormant accounts fund might be considered as a source of money which could be made available where it was impossible to repay it to the people concerned. This has been a great victory for the property rights of older people.
There are many things that could be done with such a fund. For example, we have no social workers for the elderly in many of our health boards. Older people must try to find the wherewithal to go to medical clinics which they are obliged to attend. They are unable to go because of lack of funds from the Government. There has been a campaign running for a home for elderly people in south Mayo since 1971. Just €400,000 would bring this project to design stage. I met the Minister of State, Deputy Power, with the people of Ballinrobe to discuss this. An assessment of need was done and it was designated a priority. It would certainly do wonders for the trolley count in Galway and Castlebar.
I ask the Minister to consider guidelines on how this money can be distributed. Guidelines must also be drawn up for staff in institutions. When they see relatives arriving like flies to a honey pot, they need to know what to do, what to say and how to say it. There is great room for the exploitation of elderly people so the Minister should set guidelines to address this issue. An old colleague of mine, who has since passed away, used to say that where there is a will, there is a relative. That will be the case in this instance more than ever. Elderly people need someone to represent them. When they cannot have a guardian or a ward of court, they need some advocacy system.
I am calling for an advocacy system similar to that proposed under the Disability Bill. A group such as Comhairle should be set up under this Bill to act as an advocate for older people. Where people can afford it, a small amount should be deducted for maintenance. However, it would be much better if the amount deducted from the pension left more to the older person so that they could keep body and bone together. For example, 70% should be deducted, rather than the proposed 80%.
Does this Bill represent the beginning of the process where doctor-only medical cards end up becoming the only medical cards? This is not what was promised. We were promised 200,000 medical cards, but now we have 200,000 doctor only medical cards. I welcome the fact that the parents of children will be allowed to continue to get treatment without having to reapply, but this will only apply to a small number of children with very serious illness, according to the Minister. The Minister can surely do better than this. I ask him to look at this measure again and extend it to children suffering from any illness.
Pharmacists have been saying that the new doctor-only medical cards will create great confusion. There is a suggestion that some letter be put on the prescription so that when someone presents at a pharmacy looking for a GMS prescription, the pharmacist will understand that this is a doctor-only medical card. Confusion arising in this regard might represent a roundabout way of introducing a prescription charge. There is a great need for fair play. What has been happening speaks volumes on how we treat our older people.
There has been a diminution in the number of beds in institutions for elderly people. In my area, we are down about 100 beds in the past few years. People have been forced into the more expensive, profit-driven, non-community nursing home sector. This is not a criticism of nursing homes, where the staff are doing a good job in the absence of a community alternative. People should have the opportunity to stay in their own area. It is not acceptable that beds are taken out of the system and not replaced. The Minister should give serious consideration to breaking down the barriers that prevent communities from looking after their old people. I have yet to meet someone who wanted to leave his or her own area. Nobody wants to leave his or her own area and be part of the sad, silent migration of older people to institutions, where they lose heart and die like the old Indian.
I have considerable experience in this area and our older people can be maintained at home for a longer period if they have the necessary supports to stay at home. Such supports include proper home help provision and appliances, neither of which has always been available. When a person can no longer be maintained at home, the least they should expect is to be maintained in their community. While it may be second best, it is certainly an option people should have. Services provided through facilities like St. Brendan’s village in Mulranny include low, medium and high support at home together with day centre support. The service guarantees that no matter how old or disabled a person is, he or she can remain in the local area. It is what we would all like to do.
We must ensure the continuation of the trend to reduce the numbers in institutional care in State facilities. With the increase in the number of private nursing homes comes the need to ensure the provision of a community alternative. An alternative can never be provided in the absence of proper support. Communities have been involved in providing sheltered housing which successfully caters to people who do not have great needs. People with greater needs who can forget to turn the heating on and the cooker off pose a danger to themselves when they are on their own. While sheltered housing and alarms allow them to be maintained in the community for longer, when they can no longer look after themselves they must enter a nursing home. If it is a strange place, they will not do well there. Communities should be involved in the provision of high-support facilities.
It is possible to support older people in the community. Low-support facilities require a defined funding scheme to meet people’s needs. The necessary high support facilities require capital funding as well as a revenue stream. These can only be provided if the Government has the will to replace lip-service to community care with the resources to make it a reality.
Cecilia Keaveney: I am delighted to be able make a brief contribution on the Bill, the purpose of which is twofold. It seeks to provide a framework to charge patients for the maintenance element of inpatient services and publicly funded long-term care residential units and to facilitate the introduction of general practitioner medical cards. Since I entered the House, I have pursued the introduction of something which is more than a medical card. Rightly or wrongly, medical cards have become more than a way for a person to see a doctor and obtain medicine. They are associated with everything in the system, including free examinations in schools. People often direct at public representatives comments to the effect that they cannot take up work because they will lose their medical cards if they do. The medical card has so many implications beyond health that there is a need to create more tiers in the provision of available services.
If I were Minister, I would consider creating cards for services at stages between doctor visits and the entitlements of a full medical card. For example, a person with an income exceeding the threshold by a certain amount should receive ten free doctor visits and ten free prescriptions per year. At another income level, a person should receive five free visits and five free prescriptions. While there will always be people who fall outside whatever categories are established, an approach like the one outlined would greatly advantage those who are not regular visitors to their doctor but would find some provision valuable. I would like to think that the proposed general practitioner cards represent an initial point on a journey to a different form of provision. I noted in the Minister’s speech a reference to a review of the system after a certain period to ascertain its operation for the 200,000 card holders. As no Member would describe the medical card income limits as generous, the 25% increase represents a necessary starting point. Many people have great needs which relate not only to health but to associated factors.
Visiting a doctor should be as much about prevention as treating illness. I was astonished to discover at a recent briefing in Buswells Hotel at which the Irish Cancer Society informed Members about cervical smears that medical cards do not cover prevention. It is an issue which needs to be examined. It is much cheaper to intervene early to stop something from happening than it is to treat it afterwards. At the Joint Committee on Arts, Sport, Tourism, Community, Rural and Gaeltacht Affairs, of which I am Chairman, we discuss the issue of obesity. If one addresses such matters early, one will not have to spend significant sums later. The concept that a medical card can be used to provide only treatment in an age in which so much knowledge of prevention exists is outdated. Prevention should be top of the list.
As I was a student in Belfast, I am called for smear testing every two years. Despite my Donegal address and attempts to encourage the practice in question to accept that I am no longer a patient, I continue to receive the communication. I imagine there is a legal requirement to continue to inform me that the practice is available to perform a smear test. It is very comforting to think that someone is watching out for people and calling them for testing rather than leaving matters in their hands. It was recently said that if one did not have to take one’s car to the car testing centre, one would not do it. It is because one gets a letter that one attends, despite that the test is provided ultimately for one’s safety.
It is important to find out if something is wrong before it becomes a problem that can kill. The faster we create screening programmes which call people for tests, the better. Such programmes should include cervical smears, breast examinations and tests for male cancers, including prostate cancer, which kill just as many people per year as their female counterparts. While I acknowledge that there are cost implications in extending the medical card system, I implore the Tánaiste and her officials to consider the long-term gains rather than the short-term pains. As with the smoking ban, any short-term pain such as expenditure on medical cards is bound to yield a preventative result.
Previously, the Minister discussed the efforts of successive Governments to keep older people at home or within their communities in residential care. There have been tremendous advances in primary care provision in my area. I attended another briefing recently at which a group sought to promote a holistic approach to primary care. When I asked them what could be done to improve services in the north west, they had to apologise and say that if they had realised I was from the region, they would have told me how proactive the former North Western Health Board had been in improving services.
Many people want to help people to stay at home, but there are simple problems. A few months ago, a constituent of mine was assessed for a home subvention which was approved. The family has not received any support to this day. None of them is particularly wealthy and every one of them is involved in activity. Some of them are students and some of them work. However, they are doing their best to keep the show on the road. They could easily have told their father they were going to leave him in a home or in one of the hospitals, but they chose not to because they wanted to deal with the matter themselves. However, they need a break and a bit of support. Spending months trying to get home subvention is not in keeping with what is said about the policy of trying to help keep older people in their own location.
I wish Ms Gertie Monagle, the former matron of Carndonagh Community Hospital, well in her retirement and wish her replacement, Ms Maura Gillen, every success. She said her goal is to ensure that people coming to the hospital live until they die. One hopes this is the goal in many district hospitals. In Ms Gillen’s case, Carndonagh’s gain will be Buncrana’s loss. However, she is in the area and will make sweeping changes.
There is a question whether money should have been taken in the past, but this Bill will ensure that money is taken in future. It is important that money will be applied exclusively to the health services and will not go back into the general Exchequer. The Minister said earlier that it is part of health funding and should be maintained in that area because it is needed there.
The new doctor visitor medical card will attempt to target 200,000 people. There are adjustments in the income guidelines in respect of standard medical cards, and changes will help 30,000 people qualify for the standard medical card. Perhaps there could be a certain number of free prescriptions or doctor visits for people who fall just outside the general guidelines.
I welcome the new provisions for parents of children with illnesses which persist from year to year. This is a new concept and I hope it will help the vast number of people who need it. The provisions mean that they will not need to reapply for the medical card every year. I know many people affected by this and, unfortunately, the children will never get better. Until medical science advances significantly, the types of conditions they have will not improve, yet they are subjected to medical card income reviews. These are not even based on income but on medical evidence. I am glad the system is being changed.
The Bill refers to a small number of children with serious illnesses who will be involved. The number will not be very small, but neither will it be very large. I have come across people who, at a very young age, have degenerative rheumatoid arthritis. At the age of 20 they have to get two hips or possibly an elbow replaced, yet they must prove every year that they have a problem with their health. I do not understand this situation. They have a serious medical condition and a doctor can reasonably state they will not get better. It is similar to disability benefit in that somebody whose case is solid and whose situation will never substantially change should not have to go on to a scheme to prove him or herself for a year. Perhaps we are being optimistic in thinking that something might change.
I have a problem with the drugs payment scheme increasing considerably because for many of the people to whom I refer, the prescription might be the bother. Some people try to be clever or prudent by going at the start of the month to get their medication and then again on the very last day of the month to get the next month’s supply. The pharmacist tells them they cannot do that and must come back tomorrow and pay another €85. I am unsure of the standard procedure in this regard. Is the pharmacist right or is the individual right in trying to maximise what he or she gets in the month? I would like the matter clarified at a later date.
A figure for gross income might suggest that a household earns a great deal of money. What if the spouse does not get a fraction of that money? Often a spouse can have a medical problem but may not be in a position to go to the doctor because he or she does not get a fair share of the money coming into the household. I know of cases where people are living on very meagre weekly allowances and must save to get the money to go to the doctor. We should be aware of genuine cases, flexibility should be maintained with regard to welfare officers and people must realise that sometimes such shocking situations exist.
I was trying to attain a broader modernisation agenda with regard to medical cards. Section 4 of the Bill deals with those who are exempt, a person’s reasonable expenses needs are taken into account in the application of section 45, and the issue of undue hardship is reflected in that.
We have potentially one of the best health systems in the north west. The hospital in Letterkenny constantly strives to have more facilities and is achieving more specialties. It is also achieving great birth rates because the population in Letterkenny has increased by 42%. Hospital facilities, however, have not expanded to meet population needs or the ageing profile of the demography or the new specialties which need space. However, we have one of the most committed staff in the country, if not Europe.
I raised this issue on the Adjournment debate last week. This is not bed blocking or a case that one hears of in another part of the country where people are crying wolf. These are genuine facts backed up by statistics. Thirty thousand people cannot go through an accident and emergency department with only six bays. People referred by general practitioners and in need of inpatient terms of stay cannot be dealt with without support for the accident and emergency unit — which is being progressed — and providing a significant number of new beds. There is no viable reason for a delay. We can talk about the need for money, but if the statistics and facts are irrefutable, the matter must be progressed.
A nursing unit in Buncrana needs simple stuff such as tarmac in the car park, PVC windows, fascia board and work on the main entrance. Given that an application has been made to the minor capital works scheme, that will happen. With regard to the hospital in Carndonagh, I hope the extension to the dining area, the day hospital, the required painting and decorating and the tarring will proceed.
The Tánaiste should speak to the Minister of State, Deputy Noel Ahern, with regard to voluntary housing schemes where volunteers develop a number of sheltered housing locations. In some cases, particularly at district hospitals, people are fit to leave hospital but their families are not in a position to deal with them. However, with a little support, these people would be able to live on their own. There should be a move between the Departments of Health and Children and Environment, Heritage and Local Government to ensure sheltered accommodation for people who are fit to leave hospital. It would be worthwhile if they could move into sheltered accommodation with either a nurse or a caretaker to oversee them and ensure they are in safe hands.
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