I read two opposing accounts on the controversy in US healthcare this weekend and ironically enough I agreed with both. One was contained within the ‘Open Door’ magazine, a catholic pamphlet that is generally picked up on the way out of church (although this particular copy caught my eye in Tesco Maynooth), the other was in the UK Guardian, a left-leaning publication not normally given to religious regards.

Obama’s health service plans are in the news at present of course, as a debate ranges in the States over his plans to replace the current insurance only system with a national program for state cover. Some right wing critics in the States have seized upon supposed failures of the British public (or socialised as they say) health system to beat the reforming ideas of the new Healthcare push.

The ‘Open Door’ led with a front page missive upon the sanctity of human life and railed against the evils of disconnected secular beauracracies and the spectres of ‘death doctors’, putative panels with deity like powers on life and death. Forced euthanasia and mass abortions were cited as catastrophic consequences of socialised system.

I agreed with the author in the sense that I too would regard such consequences as apoclayptic if they were indeed to happen and I would very much concur with the author’s view on the sanctity of human life. However neither am I convinced that such things are contained within the healthcare package, rather a case of misrepresentation.

Which allowed me to find common cause with a quite different assessment of the plans contained within the Guardian newspaper this weekend, one which defended the plans and vilified the state-side critics. Private healthcare at the extreme as practised in many ways in the states literally is a life and death sitation for those caught in the middle. In this case of course ability to pay is the decider rather than either man or god which is a far less christian conundrum altogether.

Whilst many conservatives may take issue with Obama’s pro-choice views I believe such considerations to be misplaced at the heart of this debate. I believe him to be a fundamentally good man (in every sense including the classic biblical connotation of the word) and I believe the Democrats to be a good party. So Whilst I empathatise with the concerns of the religous orders, I fear the financial fire power of the US insurers is skewing the debate on many axes and for far baser motives, thus obscuring the real benefits the plan can bring at a very fundamental and christian level. As much as God must want to protect the unborn child, equally he must want to protect the poor sick and needy. So let’s get the balance right with an informed debate, but let’s make sure we throw out neither the baby nor the bathwater…

Now I had concerns around the site, as being a national facility, somewhere at least on the outer ring of Dublin as opposed to city centre, would seem more accessible to the wider nation. Given transport links are expected to improve but nonetheless the M50 is currently easier to aim for than D1 from most places.

What worried me more though, in the more immediate term, was the provision of childrens’ A&E services at local level in North Kildare, given that the current national childrens’ hospital, at Tallaght, now serves that catchment. In fact Naas hospital will turn children away at A&E and redirect them into Tallaght.

With two juniors of my own, and having had to use the facility there on a few ocassions, I am very familiar with the setup there. I would have to compliment the staff and services there in fact, all my experiences thankfully have been positive, and the Tallaght Childrens hospital and provides a very high level of care.

However whilst I had full confidence in the staff and facilities at the unit, I had a major concern on the future situation if and when the childrens’ hospital centralises into the city centre location as proposed.

I was one of the few fans of the Hanley report, all those years ago, and I understand we cannot have a hospital at every crossroads. However I do think we must have an emergency unit within every constituency or within striking distance. The proposed move would add at least an hour to the journey in, and would be a real worry especially in emergency circumstances. So I raised these points with the Minister, and explained North Kildare residents deep dependence on childrens’ services as currently provided at Tallaght Hospital.

I put a question to the Minister for Health, Mary Harney TD, and a related one to the Minister for Children (Barry Andrews TD). The answer I have received states that, while the current plan remains for a centralisation of services at the Mater site, a new ambulatory care programme will be rolled out around the country which will provide acute services at regional locations. Tallaght Hospital, according to the Minister, will be the first such centre of ambulatory excellence serving the new national paedriatic hospital, and this should ensure those vital A&E services are maintained at that location.

I think this is absolutely key for the Naas area and I will stay close to this one all the way through.

I don’t generally believe in dealing on the basis of media frenzy, as there is often a ‘rent-a-mob’ element at work (the Joe Duffy effect) and also I have often found an amount of artificial outrage can be manufactured on the airwaves which is not in fact matched by people on the ground. A good example is the last general election when the media weaved tales of Fianna Fáil canvassers being ran from the doors, whilst in fact I canvassed night after night and met with little, if any hostility, rather an occasional robust debate, in many cases a hearty welcome and probably the majority a polite but brief interaction as people get on with their busy lives.

But I digress. My point is that, media reaction regardless, on this occasion I feel there is substance behind the controversy and my sympathies extend across the divide. I think most people understand in tough times, tough measures are called for and I think most people, whilst they may grumble, will in the long term thank a government for taking necessary but unpopular decisions for the long term greater good. That being so, I believe many measures in this budget present bitter pills but will be swallowed, in a spirit of solidarity and the end justifying the means. The new income levies for example represent tough but fair measures.

However the particular issue of medical card cuts and education cuts I believe are a step too far. I have always believed Fianna Fáil to be a broad church, one that can harbour many ideologies within but I personally have always identified with an ethos of social democracy which I believe runs throughout the party and would have been shared by many of the founding fathers. From the radical polemicism of Liam Mellowes on the “men of no property” to Frank Aiken (a proud Republican if ever there was one) “workers and small farmers republic” right through to men like Lemass, and that ethos continued in greater or lessening degrees right into the current decade when the party pledged to prioritise the old age pension as a manifesto promise I was proud to see honoured in many successive budgets over the past decade. Arguably even this year social welfare payments have been increased as perhaps the only payment moving against the otherwise downwards tide.

However it is not acceptable after a decade of growth, much of it fostered by Fianna Fáil policy and prurience over previous years (I will put it to anyone that MacSharry, Haughey and Ahern in departments of Finance, Taoiseach and Labour laid the path for which Ireland would travel from ‘sick man of Europe’ to ‘An economic miracle’ in the turn of a decade) to be in a situation where classroom sizes are now being threatened with once again climbing, threatening to jeopardise the pivotal but pain-staking progress of recent times. The school building programme thankfully continues but I would rather sacrifice my beloved transport projects than see class sizes go backwards.

As for the medical card scheme there are a few points to be made. The proposal is not, as some would have it, an out and out wrestling of the card from people’s grasp in an across the board gesture. Rather the proposal is to end the automatic age-based entitlement that currently exists. As such it is less draconian than may first appear, but nonetheless I have stated my belief in social democracy and social justice, and I count it a principle in a civilised society that certain things are provided on a universal basis, independent of means or ability to pay. Fundamental services should be delivered to our citizens in an advanced society irrespective of means, income or social status. Fianna Fáil pioneered this philosophy when it was still regarded almost subversively radical, introducing free education for all, a public health system, the creation of the welfare state, free old age travel scheme, numerous assists for heating and energy bills many the latter benefits specifically targeted at older people. Are we now to lose decades of policy progress to squeeze a few extra pound from the exchequer purse?

I listed and agreed with much of what Deputy Joe Behan said on tonight’s news after resigning the party whip. He came across a noble and decent man and I hope he will come back to the party because we need people like him to help us to be all that we can be, as a party, and by extension because the Fianna Fáil party is passionately patriotic if it is anything, as a nation. For the first time in a long time I heard Joe Behan give voice on the airwaves to what I know the Fianna Fáil party to be. The voice of cumann secretaries, of grass roots activists, of local councillors and backbench deputies. What to me is the real social democratic heart of the party, an ethos that prizes community values and social justice for all. The voice that will speak up for the bowed whilst encouraging the brave. The party that will enable enterprise whilst nourishing the needy. That will allow progress to prosper but with noone being left behind. The voice and the will that I know the party to have.

I have raised issues of social justice before, at a time when I felt strongly on a an issue of fundamental fairness. I wrote to the Minister at the time, in correspondence that has echoes of the current dilemma where it appears GP contracts are not facilitating the intended workings of the scheme. It is not the first time I have exchanged such correspondence with the present health Minister. I was heartened to see An Taoiseach appear in public view tonight on the nine o’clock news when he said he would progress a ‘pragmatic response’ to what he acknowledges was a far more wide reaching reaction than anticipated.

The over-70s medical card was not up until recently an automatic entitlement. It was introduced only at the start of this decade in an earlier Fianna Fáil budget. It was a progressive move to bring it in. It was a regressive one to take it back. Let’s hope that social justice prevails and that the real soul of the Fianna Fáil party now has the courage of its convictions. I know there is the will. Now let’s find the way.

The GP Visit Card is sometimes termed a ‘Medical Card Lite’ and is a middle ground offering for people who do not qualify for a full medical card yet can be covered for the cost of primary care under the system. The income limits are much more generous than under the full medical card scheme and take into account expenses such as mortgage, childcare and commuting costs.

It struck me there are two aspects to this issue. The first is the situation where someone is living in a rural or other location where there is only one GP facility within reach. If that person, on either Medical or GP Visit Card, is turned away from that facility they have limited other options especially if they do not have own means of transport.

The other situation which appears relatively common, is where people have been paying patients with their GP until such time as they applied for these new GP Visit Cards, whereupon they are refused service from the same GP that has done and will continue to see them privately.

There is undoubtedly an issue of capacity as the population has grown so rapidly – but there is also an issue of fairness and equal access to services, particularly in the cases where the same person finds they can be seen on a cash basis but not on their card.

So I made some enquiries and put a question to the Minister for Health, via Deputy Áine Brady. I include responses received below. It appears the system is under review and subject to ongoing negotiations with the IMO and so forth. However in the short term there is a ‘get-out’ clause for anyone caught in this predicament. In a nut-shell, three refusals is the limit and the HSE will intervene. If someone has been refused from their initial GP what they need to do is contact two other surgeries, request services from them, and if they are turned away again, send details of the three refusals – that is the names and addresses of three surgeries that could not accommodate them – and send those details into their local HSE centre which in our case is HSE ; Kildare / West Wicklow Local Health Office, Poplar House, Poplar Square, Naas, Co Kildare (or Tel 045 876 001).

The preferred or local GP should be indicated amongst the three, and the HSE will then intervene to ensure the person is accomodated – and usually in the facility of first choice. It’s not ideal but at least it’s a work-around for now. And we’ll watch this space for the Minister’s review.

Full Responses Below:

• Minister’s Response:

Reply to Deputy Brady
Under the Health Act, 2004, the Health Service Executive (HSE) has the responsibility to manage and deliver, or arrange to be delivered on its behalf, health and personal social services. This includes responsibility for arrangements to ensure appropriate service delivery for General Medical Services (GMS) Scheme (medical card and GP visit card) patients.

Services under the GMS Scheme are provided by general practitioners (GPs) holding contracts with the HSE. The terms of these contracts were agreed on foot of negotiations with the Irish Medical Organisation (IMO). Under the terms agreed, contracts are made available where the HSE decides, after consultation with the IMO, that there is a need for a service having regard to a range of factors, including whether the needs of the population in the area are met by the services already available. The agreement also provides that the number of persons on a GP’s patient panel may not exceed 2,000, save in exceptional circumstances. Not all GPs hold GMS contracts, as they may not qualify or wish to provide services under the Scheme.

When a person qualifies for a medical card or GP visit card, he/she accesses services by choosing a GP from a list of local GPs who have been contracted to provide services under the GMS Scheme. The person will be assigned to the GP he/she has chosen from the list subject to the GP’s acceptance and his/her total patient list being within the agreed limit. If a person is unsuccessful in locating a GP who is able to take on additional patients, the HSE may in certain circumstances assign an eligible patient to a medical practitioner’s list.

The arrangements for the provision of publicly funded GP services, including those provided under the GMS Scheme, are under review. I regard the existing arrangements in relation to access by GPs to public contracts as unnecessarily restrictive and it is my wish that new contractual arrangements for the provision of publicly-funded GP services should ensure that HSE contracts are open to all suitably qualified and equipped doctors.

As aspects of the Deputy’s question relate to the management and delivery of health and personal social services, which are the responsibility of the Health Service Executive, my Department has requested the Parliamentary Affairs Division of the Executive to arrange to have this matter addressed and to have a reply issued directly to the Deputy.

• HSE Response:

Office of Assistant National Director PCCC- Contracts,
National Contracts Office,
Health Service Executive,
Marlinstown Office Park,
Mullingar,
Co. Westmeath.
Phone: 044 9330762
Fax: 044 9330763
Date: 18.4.08
Ref: PQ ref no: 11427.08

Deputy Aine Brady,
Leinster House,
Dublin 2.

Re: Parliamentary Question 11427.08

PQ: To ask the Minister for Health and Children the guidelines in place for medical centres and general practitioners which allow or facilitate medical cards to be used with them (details supplied); and if she will make a statement on the matter.

Dear Deputy Brady,

I refer to the above Parliamentary Question and set out the reply hereunder.

Under the Card Scheme patients are given a choice from a list of General Practitioners who hold contracts for the provision of services under Section 58 or the Health Act 1970. This list is available from the local Medical Card office. On checking with the local Primary Care Unit they were not aware that patients were not being accepted by General Practitioners in the area mentioned.

There is a facility whereby the HSE may assign an eligible person to be included in a medical practitioner’s list in the case of a person who has unsuccessfully applied to all those medical practitioners or to at least three of them, whichever is the less, who have entered into agreements to provide services in the area.

If a particular Medical Card patient has difficulty in accessing a GP in the area they should be advised to contact their local Primary Care Unit, which for the area in question is located at Block E Second Floor, Westland Park, Nangor Road, Dublin 12.

I trust this clarifies the issues raised and please do not hesitate to contact me should you require further clarification.

Yours sincerely,

Pat O’Dowd.
Assistant National Director – PCCC (Contracts)