Dáil Éireann - Volume 347 - 14 February, 1984

Ceisteanna—Questions. Oral Answers. - Medical Cards.

2. Mr. D. Andrews asked the Minister for Health the number of students at third level education who have been removed from the general medical services register from 1 January, 1984.

3. Mr. D. Andrews asked the Minister [2359] for Health the number of third level students who have been removed from the general medical services register in the constituency of Dún Laoghaire from 1 January, 1984.

4. Mr. P. Gallagher asked the Minister for Health the number of students in County Donegal that have been removed from the general medicine services register as a result of his recent action.

5. Mr. Foley asked the Minister for Health the number of students in County Kerry who were removed from the general medical services register from 1 January 1984.

Minister for Health (Mr. B. Desmond): I propose to take Questions Nos. 2, 3, 4 and 5 together.

Arrangements are being made by the health boards to implement the provisions of the Health Services (No. 3) Regulations, 1983. This involves writing to all medical card holders in the 16 to 25 years age group informing them of the provisions of these regulations.

An opportunity is being given to claim exemption where the regulations do not apply. Until such time as those arrangements are implemented in each area, students from that area are not being removed from the general medical services register by virtue of the regulations.

The information which the Deputies are seeking would tend to vary from day to day as health boards proceed with the task of implementing the regulations. The total number of students removed from the GMS register in any area at any time is not available routinely in my Department. I suggest that the Deputies get in touch with the appropriate health boards in order to get the most up-to-date statistical information that is available on this matter.

Dr. O'Hanlon: In view of the serious problems created by the removal of medical cards from those between the ages of 16 and 25 and in view of the fact that a number of students are now in prison, would the Minister consider suspending [2360] the regulations and reconsidering the matter?

Mr. B. Desmond: I regret that I am not in a position to accede to that request.

Dr. O'Hanlon: Would the Minister not accept that the students are very concerned about the hardship this change would create and in these circumstances would he not reconsider the situation?

Mr. B. Desmond: I would not accept that generally there is hardship being created. On average, students use the general medical service for the purpose of visiting GPs about twice a year and for two to three prescriptions per year. That level of usage has been long-established. The only thing that is being withdrawn by way of automatic entitlement without charge is access to a GP or to drugs. For the umpteenth time I would stress that hospital services, inpatient and out-patient, and consultant services are not being withdrawn under the regulations. I repeat again that any student who informs a health board that he or she is suffering a degree of hardship will not have the medical card withdrawn. That is the position. Automatic entitlement is being withdrawn.

Mr. Tunney: If the students have been making so light a demand on the health services, will the Minister not accept that it was not worth his while establishing a whole administrative process to assess their eligibility for a medical card?

Mr. B. Desmond: The administrative process is not complex. Yesterday I was in the headquarters of the North Western Health Board — Deputy Gallagher's area. By means of a simple computer print-out and the automatic issuing of forms the whole business is done in a matter of a day. I will point out to Deputy Gallagher who has put down a question on the matter that to date no medical card has been withdrawn. Further, I would point out to him that since 62 per cent of the population of his county have medical cards, by and large 62 per cent of students will retain the cards.

[2361] Mr. Lenihan: Does the Minister not understand and appreciate that he has condemned himself out of his own mouth? In his last replies he has made the case for not bringing in the regulation which has alienated the student population.

Mr. B. Desmond: The Deputy will recall being a member of the Cabinet who proposed this measure but who did not implement it.

Mr. Lenihan: That is untrue. The Minister had better answer my question without those smark aleck tactics.

An Ceann Comhairle: Order. The Chair will decide about such matters.

Mr. O'Kennedy: Arising from that comment of the Minister——

An Ceann Comhairle: I will not allow argument on this matter.

Mr. O'Kennedy: The Minister has considered himself free to disclose matters that were considered as distinct from matters on which decisions were made. A decision was not taken.

Mr. B. Desmond: The Deputy was not a member of the Cabinet.

Mr. O'Kennedy: What the Minister has said is outrageous.

An Ceann Comhairle: Deputy O'Kennedy is being disorderly. He should allow the Minister to answer.

Mr. O'Kennedy: By comparison with the way the Minister replied——

An Ceann Comhairle: We must have order. The Minister was asked a supplementary question and he answered it.

Mr. Lenihan: He has not answered it, that is the point.

[2362] An Ceann Comhairle: He was not allowed.

Mr. Lenihan: I am asking the Minister to answer the question and not engage in smart aleck remarks. We are used to enough of that from this Minister.

An Ceann Comhairle: Deputy Lenihan must cease interrupting.

Mr. Lenihan: We will be indulgent to the Chair in view of the day. I offer the Chair congratulations on his birthday.

An Ceann Comhairle: I thank the Deputy. I am calling Question No.6.

Mr. Tunney: Before we move to the next question I should like to ask the Minister another question with regard to students. In deciding to withdraw medical cards from students, did he take into account the dramatic increase in fees for third level education that was introduced by his colleague?

Mr. B. Desmond: I wish to point out to the Deputy, and I take no great pleasure in it, that there is major State subsidisation for students in second and third level education. There will be a saving to the health services of approximately £2,500,000 per annum by no longer giving automatic entitlement to second and third level students irrespective of income. Approximately 120,000 students are involved. However, more than 40,000 students, by virtue of the fact that their parents' incomes are below the limits of income eligibility for medical cards, will automatically retain their entitlement. I find it incredible that Deputies on the opposite side should suggest that people in the upper income group who are quite wealthy and whose children are in third level education should automatically be given entitlement to free access to GPs and to drugs. The cost on average is about £30 per year: two consultaions to a GP and about two attendances to a pharmacist to get drugs. The total cost on average is between £25 and £30 and for 80,000 people we will save approximately £2,500,000 in a full year. Despite all the [2363] special pleading by the Opposition with regard to this matter, I reiterate that this measure was included in the Government memorandum of June 1982 and was approved by the then Government for implementation. However, Deputy Woods and Deputy Haughey ran away from it.

Mr. Lenihan: That is not true.

Mr. Tunney: The Minister was allowed to make a speech but he has not answered the question. I am asking the Minister if, in calculating eligibility for medical cards, he will allow the parents of the students to take into account the dramatic increase in third level fees.

Mr. B. Desmond: I suggest that parents might take into account that in relation to family medical expenditure there is full income tax relief on expenditure in excess of £100 per annum. In relation to covering their dependants for VHI, there is full income tax relief at the top tax rate and in relation to the attendance of their children in second and third level institutions there is a substantial tax allowance available. My son who is in third level education has lost his medical card and this should apply also to students whose family are in the upper income group.

Mr. Tunney: I wish to state——

An Ceann Comhairle: I have been very generous with the Deputy.

Mr. Tunney: The Chair has allowed the Minister to make a very lengthy speech when he could have said yes or no at the beginning.

Mr. Lenihan: The Minister should be removed from the House.

An Ceann Comhairle: The Chair may have a different style of answering questions compared with that of a Minister. However, the answering of questions is not a matter for the Chair. Deputy Tunney well knows this and I am surprised at him raising the matter.

[2364] Mr. E. O'Keeffe: The Minister made a speech.

Dr. McCarthy: Will the Minister not agree that the vast majority of students who will be affected by this regulation are children of middle-class parents, not of the upper income group. The vast majority of students in third level colleges belong to the middle income group. This will impose a very severe hardship on the parents. They are the new poor.

An Ceann Comhairle: For the benefit of Deputy O'Keeffe, I would point out that the Chair has discretion and a control over the asking of questions but not with regard to the answering of questions.

Mr. O'Kennedy: By way of elaborating on what Deputy McCarthy has said——

An Ceann Comhairle: This just shows how far away we are getting from the question.

Mr. O'Kennedy: Is the Minister telling us that all those who are above the limit for medical cards are in the upper income group?

Mr. P. Gallagher: When referring to his visit to the Donegal — Sligo — Leitrim headquarters yesterday, did the Minister say in his reply that all children in the North-Western Health Board region who held medical cards prior to 1 January can continue to use those cards? Is he saying that a man with seven children, with £150 top line is in line for a medical card, but men with six children, five children, or four children with £140 top line are not eligible? Are these the rich people the Minister is talking about, because they are some of the people I represent? If we had 100 per cent medical cards for the people in Donegal-Sligo -Leitrim I would not be ashamed to stand here——

Mr. Barrett (Dún Laoghaire): We are implementing Fianna Fáil policies.

[2365] Mr. Lenihan: The Deputy is behaving like a child. He is going too far.


An Ceann Comhairle: Question No. 6.

Mr. P. Gallagher: May I have an answer?

Mr. B. Desmond: Six out of ten families in Donegal have medical cards and automatically their children have medical cards and cover. That cover is not being taken from them. They can continue to use their cards. They will get a notification and all they have to do is return the number of their parents' medical cards and they will continue to have automatic cover. There will be no difficulty.

Mr. P. Gallagher: The Minister stated——

An Ceann Comhairle: I have been more than generous. We have been at these questions for 20 minutes.

Mr. P. Gallagher: It would be very unfair if this went out from this House: The Minister stated, and the record will show, that anyone in the north-west region who held a medical card prior to 1 January will not have his card taken from him. I wanted to get that on the record.


An Ceann Comhairle: Question No. 6.

6. Dr. McCarthy asked the Minister for Health the reason he has decided to exclude students over the age of 16 years whose parents are not medical card holders from treatment under the general medical services scheme; and the medical reasons that were considered before taking this decision.

Mr. B. Desmond: The present economic situation has made it necessary to examine critically the costs of providing [2366] our health services. In the light of this economic climate the granting of medical cards to students and other young dependant adults without reference to their parents' financial circumstances was considered to be unjustified. Such persons whose parents have medical card eligibility will retain their medical cards.

The medical needs of those from whom medical cards were withdrawn was taken into consideration and special provision was incorporated in the regulations whereby the service would still be provided free of charge if the chief executive officer of the appropriate health board considered that its withdrawal would cause undue hardship. In addition, it was provided that persons from whom medical cards were withdrawn under the regulations would retain their entitlement to free hospital services, both inpatient and outpatient including free consultant services.

Dr. McCarthy: In his attempt to remove one anomaly, has the Minister created another anomaly within families? Students over the age of 16 on AnCO courses, irrespective of their parents' incomes, will be eligible for medical cards whereas brothers and sisters of the same age attending third level colleges will be ineligible if the parents do not hold medical cards.

Mr. B. Desmond: It was anomalous that a person drawing unemployment assistance was obliged to go to the local employment exchange, complete the form and return it to the health board as proof of his income prior to the issue of a medical card while other members of the family, even those students with part-time employment, automatically had medical cards. In my view, the removal of that anomaly was of greater benefit.

Mr. B. Lenihan: In the interest of a peaceful settlement of this matter and to remove the growing alienation among students, would the Minister not agree that the issuing of this directive has been a very blunt instrument? If he suspended the implementation of the regulation and [2367] got down to serious talks about these anomalies with students' representatives that would be a constructive way towards a resolution of what could be a very serious matter.

An Ceann Comhairle: That is a separate question.

Mr. B. Desmond: It is far more serious when politicians indulge in special pleading, for example, when they visit young people in prison and indulge in special pleading on their behalf. The reason young people are alienated and disappointed in politicians is that they are not told the truth about the realities of the situation by all politicians. The choices facing me were that I could impose charges on out-patients; I could insist on everybody, including students, paying for full consultant services, irrespective of their incomes; I could have proposed charging students availing of public wards or, I could have allowed them retain their medical cards and impose a charge on every prescription. I did not do any of those things. Instead I decided to introduce a measure which would not cause hardship for students. A sum of £2.5 million has been saved and I deliberately transferred £500,000 of that money to the elderly, giving for the first time in the history of the State, additional income eligibility for people over the age of 65 and 80 years of age, people who are in far greater need——

Dr. O'Hanlon: What about the medical cards withdrawn from the pensioners last year?


An Ceann Comhairle: A final supplementary from Deputy McCarthy.

Dr. O'Hanlon: Did the Minister meet the students in this House on 27 October and promise not to withdraw their medical cards?

An Ceann Comhairle: A final supplementary from Deputy McCarthy.

[2368] Mrs. O'Rourke: Arising out of the Minister's reply——

An Ceann Comhairle: We have spent 30 minutes on six questions. I have called Deputy McCarthy for a final supplementary and I am sticking to that.

Mrs. O'Rourke: May I have one supplementary?

An Ceann Comhairle: No.

Dr. McCarthy: Arising out of the Minister's earlier remarks that he would not withdraw medical cards——

Mrs. O'Rourke: May I——

An Ceann Comhairle: This is basically a medical question.


An Ceann Comhairle: I am calling Deputy McCarthy.

Mrs. O'Rourke: Arising out of an earlier reply from the Minister——

An Ceann Comhairle: I am sure the Deputy will find another way of asking her questions on some of the numerous subsequent questions on the Order Paper.

Mrs. O'Rourke: This is on an educational matter relating to health.

An Ceann Comhairle: I am sorry, Deputy. I am calling Deputy McCarthy.

Mrs. O'Rourke: May I have——

An Ceann Comhairle: Not even all your charm could persuade me to let you ask another supplementary question.

Mrs. O'Rourke: I want to put a final supplementary to the Minister for Health.

An Ceann Comhairle: No, I am calling Deputy McCarthy.

[2369] Mrs. O'Rourke: May I ask the Minister for Health——

An Ceann Comhairle: No. If you continue you will be disorderly.

Mrs. O'Rourke: I am not disorderly.

An Ceann Comhairle: I am calling Question No. 7.

Mrs. O'Rourke: I want to know if the Minister for Health is an advocate of preventative medicine.

Dr. McCarthy: May I ask the Minister——

An Ceann Comhairle: I am calling No. 7. I have done my best to let Deputy McCarthy have a final supplementary, but I cannot. I am calling Question No. 7.

Dr. McCarthy: Is the Minister not torpedoing his entire health policy — in which he suggests that people should have out-patient treatment as much as possible — by the introduction of this regulation because this will ensure that students will go to casualty departments of hospitals rather than resort to general practitioners, costing a lot more, when probably they will be admitted needlessly as a result? Would the Minister say whether he has considered the facts, that young students are indifferent about their health, because of their immature age, that they tend to regard themselves as normally healthy? For that reason they will be reluctant to go to doctors but, as a result of the Minister's new regulation, they will have the added obstacle that they will have to have emergency money in their pockets to finance any health problem as it arises? Would the Minister say whether he has considered these facts?

Mr. B. Desmond: In taking this decision I have also considered the fact that by and large £2 million goes to doctors and pharmacists in relation to what might [2370] be called casual income for them — which they will no longer have — and a lot of the arguments I am receiving are coming from that direction, not from the students.


An Ceann Comhairle: Question No. 7.

Mr. Lenihan: The Minister is a mean little man.

Mr. O'Kennedy: He did not answer the Deputy's question.

An Ceann Comhairle: Question No. 7.

7. Mr. P. Gallagher asked the Minister for Health the savings to the North-Western Health Board as a result of his decision to remove persons between the ages of 16 and 25 years, whose parents do not qualify for medical cards, from the general medical services scheme.

Mr. B. Desmond: The general medical services scheme is funded largely by the General Medical Services (Payments) Board. The expenses of the board are provided for in subhead G.3. of the Health Estimate. The provision for such expenses in 1984 has been reduced to the extent of the estimated savings arising from the decision to withdraw medical cards from persons between the ages of 16 and 25 years who are dependants of persons who do not qualify for medical cards.

The overall savings resulting from implementation of this decision are estimated at £2 million for 1984 and £25 million in a full year of which about £170,000 might be associated with the North-Western Health Board area. As mentioned, however, the benefit has been reflected in the provision under subhead G.3. of the Health Estimate. Finally, I might make the point that the provision for the GMS in 1984 is £85.25 million and the provision, reflecting savings estimated at £2 million this year and £2.5 million in a full year, is included.

Mr. P. Gallagher: I appreciate that the [2371] Minister has given me more information than I sought. Would the Minister accept that the decision he took was wrong? I believe the Minister is big enough to rescind that decision — £170,000 to the North-Western Health Board and £2.5 million to the rest of the country — would he not rescind that decision then the people would applaud him? I do not believe this was the Minister's own decision but rather that of his Fine Gael partners in Government who insisted on this and that the Minister now, as a Labour Minister, should rescind that decision?

Mr. B. Desmond: No. I have no intention of rescinding the decision.

Dr. O'Hanlon: Would the Minister tell us whether he met students and representatives of the students in this House on 27 October and if he gave them a commitment then that he would not withdraw medical cards from students?

Mr. B. Desmond: I did not give any such commitment. I indicated at that time — it was pre-budget time — that the matter was under consideration; that was the indication.

8. Mrs. O'Rourke asked the Minister for Health the number of persons in County Westmeath who have been removed from the general medical services register from January 1983 to date.

Mr. B. Desmond: The information which the Deputy is seeking will tend to vary from day to day as the health board removes some persons from the general medical services register and adds on others. The total number of persons removed from the general medical services register in any area at any point in time is not routinely available in my Department. I suggest, therefore, that the Deputy might get in touch with the Midland Health Board in order to get the most up-to-date statistical information available on this matter.

Mrs. O'Rourke: When a question is put down demanding a simple answer it [2372] is not good enough to be told by the Minister that he cannot obtain the information, that I should go to the Midland Health Board. I understood that the machinery of putting down questions to a particular Minister was to extract a specific answer. I do not accept that a Minister can say to me he cannot readily get it or that I should go to the Midland Health Board and get it. I am entitled to receive it here in this House.

Mr. B. Desmond: In no way do I not want to provide information to the House on any matter. But the latest information I have relates to the year 1983 which ended only six weeks ago. For the information of the Deputy, there were 1,488 medical cards covering 2,583 persons cancelled last year in County Westmeath. In the same year there were 1,997 new cards issued covering 3,397 persons, a net increase at the end of the year of 814 persons. I might stress that, in the first year of my term in office, there was a substantial increase in the cover given to the population, which increased from 38 per cent to approximately 39.5 per cent.

Mrs. O'Rourke: That is not the question I asked. Quite naturally the increase is reflected right across the country, not alone in the Midland Health Board because, sadly, the growing number of unemployed and people who must have recourse to medical cards, whose disposable income has dropped enormously has increased. The question I asked and to which the Minister, under pressure, gave a reply related to the number of medical cards withdrawn from applicants in the Midland Health Board which he said was 1,488 affecting 2,500 people. Arising out of an earlier reply of the Minister I might put it to him that surely he, as Minister for Health — as all Ministers for Health — should be advocating preventive medicine and not advocating, as he is, to students to go to hospitals, to casualty officers and partake of the hospital services when preventive medicine with one's local friendly general practitioner is by far the best type of medicine particularly for young people who would seek to establish a rapport with their doctor?

[2373] An Ceann Comhairle: I felt the Deputy would find a way of asking that one.

Mr. B. Desmond: Whereas I support the continuation of the general medical services scheme it is not necessarily proving to be the best in terms of preventive and community care. For example, for every £1 of a visit which a person makes to a GP at present approximately £3 of drugs is issued, that is for 40 per cent of the population. For the other 60 per cent the ratio is about one-third of that. Therefore, there is something very wrong in terms of our expenditure in that area when we are spending £85 million a year, £50 million of which is on drugs. Quite frankly, I have the gravest reservation about the extent to which that has an impact on preventive and community care. I should like a different system to be agreed between myself and the medical profession of real preventive and real community care, not based on a fee per item of service, that every time one walks into a doctor £X is paid and there is then the incentive to issue a prescription for more drugs to be consumed, for example, giving £10 million to pharmacists, £40 million to drug companies and approximately £20 million to doctors for doing what I regard as not necessary in the interests of the best preventive care or health system.

Dr. O'Hanlon: Is the Minister aware that those who hold medical cards are those at high risk, the elderly, large families and poorer families in society? Would he accept that that is the reason they demand a higher level of service than those without medical cards? Would the Minister not accept that?

Mr. B. Desmond: I agree completely but I fail to see a differentiation of 5:1 whereby people who are holders of medical cards, 40 per cent of the population, have an incidence of visitation five times greater than the rest of the population and an incidence of consumption of drugs four or five times greater as well. There are some very serious questions to be posed about that — whether the system as it operates is an incentive, not for [2374] health care but for visitation, for the issuing of prescriptions and for drugs consumption.

An Ceann Comhairle: I have given the last question to Deputy O'Hanlon.

Dr. McCarthy: Could I ask the Minister the reason why?

An Ceann Comhairle: I am sorry, Deputy, no, I have given the last question to Deputy O'Hanlon.

Dr. McCarthy: Could I ask the Minister——

An Ceann Comhairle: I am sorry, no, Deputy.

Dr. McCarthy: In view of his reply, he does not understand the difference with regard to patients at risk.

An Ceann Comhairle: I said that that was the last question.

Mr. B. Desmond: The trouble is that we understand far more than we are prepared to admit.

9. Miss Flaherty asked the Minister for Health when a medical card will be given to a person (details supplied) in Dublin 11 as her application was made over eight months ago.

Mr. B. Desmond: Determination of eligibility for medical cards is the statutory function of the chief executive officer of the health board. I understand from the Eastern Health Board that there is no record of a medical card application having been made eight months ago. The person concerned applied on 30 January 1984. She was immediately considered eligible and given medical cover with effect from 30 January 1984. Her medical card will issue in due course.

Mr. Tunney: That is fairly up to date information, Deputy Flaherty. You [2375] could not get it six months ago for Westmeath.