asked the Minister for Health if he is aware of the grave hardship caused to the many categories of persons who have been removed from the general medical services register; and if he will make a statement on the matter.

7.

asked the Minister for Health if he is aware of the serious distress caused to many families by his decision to withdraw medical cards from students attending third level institutions; and if he will make a statement on the matter.

8.

asked the Minister for Health in view of the widespread hardship likely to be caused in many cases by the decision to withdraw general medical services from those between the ages of 16 and 25 who are dependants of persons who do not have full eligibility for these services and of the widespread opposition among parents and students to the move, if he will reconsider his decision.

9.

asked the Minister for Health if he will reconsider his decision to remove medical cards from all students in view of the fact that more than 50 per cent of our third level student population receive their education only because they provide for much of their own maintenance through summer employment, borrowing, etc., and through their eligibility for higher education grants.

I propose to take Questions Nos. 6 to 9, inclusive, together.

Medical cards are issued to persons with full eligibility for health services. These persons are defined in section 45 (1) of the Health Act, 1970, as adult persons who are unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their dependants, together with dependants of such persons. The criterion for issue of a medical card is hardship in paying for general practitioner services.

The issue and withdrawal of a medical card is a matter for the chief executive officer of the appropriate health board. A medical card is withdrawn only after a review of the holder's circumstances and a decision that he no longer qualifies under the criteria set out in section 45 (1) of the Health Act, 1970.

There is also provision in the Health Acts which enables the chief executive officer of the appropriate health board to provide a particular service without charge if he considers that the person concerned is unable to provide that service for himself or his dependants without hardship.

In the case of students who may lose medical cards under the provision of the Health Services (No. 3) Regulations, 1983, special provision has been made in the regulations to ensure that the safeguards against hardship will apply. In addition, such students will retain their entitlement to free hospital services, both in-patient and out-patient, including free consultant services without reference to the means of their parents.

In the light of the foregoing I consider that adequate provision has been made to deal with cases of grave or undue hardship and I do not propose to ask the Government to reconsider the decision.

Does the Minister accept that his decision to withdraw the cards from students is a retreat from his party's position on a comprehensive medical service and from his position expressed in the Programme for Government which sought a shift from hospital services to community based services; and that his present attitude will pour students into the hospital service in direct contradiction to the policy in the Programme for Government? Can he tell us the cost of means-testing the students whose cards have now been withdrawn?

I strongly believe in the provision of comprehensive services for those in need of them. There are 120,000 students in second level education and, on average, these students attend GPs twice a year. As the Deputy knows, they are the healthiest section of the community. In such circumstances the imposition on a family for sending a person to a GP twice a year on average is not great. Notwithstanding that, 35,000 to 40,000 students of the 120,000 will, of course, come under the medical card guidelines—they have automatic entitlement to medical cards because of their parents. It is estimated that 38½ per cent of the Irish population hold medical cards. There are 50,000 or 60,000 more this year because of the increase in the eligibility guidelines. There is a further increase in the number of people over 65 years of age.

I do not think this particular withdrawal will impose any pressure on the hospital services because in the first instance the use of hospital services by students is extremely low in any event and the withdrawal will not pose any great hardship. In circumstances in which I had to make very difficult choices in the allocation of money for the health services this was a choice which will impose the least hardship. If any students suffer hardship or are likely to suffer hardship the CEOs will make every possible effort to help them. We are now in the second week of February and I can recall that very few medical cards have been withdrawn. Great care is being exercised to see that people will be given information.

Will the Minister define what he considers to be hardship, for the information of those deprived of medical cards?

A general definition applies: 38 per cent to 40 per cent of the population are deemed by virtue of the eligibility criterion to be entitled to medical cards. In other words, four out of every ten people hold medical cards and are entitled to completely free GP, hospital and consultant services, as well as free drugs. In other words, six out of ten of the population have to pay. In the case of drugs, anything more than £1 per day, £28 per month, would be refunded. In the case of the VHI, subscribers are entitled to total remission even in the case of the top tax rate. Therefore, the provision by the State for the health services is quite comprehensive and extremely expensive.

Would the Minister substantiate his statement that approximately 35 per cent of students who had medical cards will continue to hold them because their parents do so? I find it difficult to accept that the parents of 40,000 students hold medical cards and can still, if their incomes are under £100 a week, afford to send their children to universities. Did the Minister make this decision on the basis that parents who are not eligible for medical cards should cancel automatically the eligibility of their children? Does the Minister not accept that over 50 per cent and possibly as high as 80 per cent of third level students can only continue in third level education because of their own resources and not their parents' resources? I am sure that is the case in the west. This sweeping decision is extremely unfair because the Minister did not take these points into consideration.

It is only an estimate but it is reasonably accurate. The estimate of 35,000 to 45,000 students being eligible to retain medical cards is based on a careful analysis of income profiles of students particularly in second level. Many students from 15 to 18 years of age are in secondary schools and many of their families have low incomes. The number of low income families with children at third level is only 4 or 5 per cent.

The Minister's reply clearly indicates that it is only an estimate. He is pulling the figures out of the woods.

There is a highly computerised system, probably the best system in the country, located in Finglas. If the Deputy would like to come with me and look at the computer read-outs on medical cards I would be willing to show them to him. The estimate we have is accurate. There are 35,000 people out of 120,000 at second and third level education. I do not regard that figure as an exaggeration. It would be roughly in keeping with the number of people who have medical cards. In the Deputy's constituency where well over half the population have medical cards, the sons and daughters of those people will retain the medical card. The income eligibility criteria applied in respect of some farmers and self-employed might be open to question but I will not go into that now.

Deputy O'Hanlon wishes to ask a supplementary.

On a point of order, the second part of my question——

I have called Deputy O'Hanlon.

The Deputy is trying to raise a point of order.

Is the Minister aware that a husband and wife with three children who earns £6,500 per annum and who has one child at third level education would not be eligible for a medical card? Would the Minister accept that people who are just above the income guidelines would find it a hardship not only to maintain their children in third level education but to care for them generally? The Minister said that the CEO can issue a medical card to a student who is likely to suffer hardship, to use the Minister's words. The nature of illness is such that one cannot tell who is likely to suffer hardship because illness strikes unexpectedly. If a child is sick it may need to see a doctor six or seven times. When the Minister speaks about an average of two visits to a doctor a year, it does not mean that every student saw a doctor twice a year. It could be that they saw a doctor a number of times. Does the Minister not consider that the Government's decision will cause an amount of unnecessary hardship?

I would remind the House — I do not wish in any way to hold Deputy O'Hanlon responsible — that the proposal as a result of which this decision was made and the argument in favour of it, occurred under the former Ministers for Health, Dr. Woods and Deputy Haughey.

The Government refused to implement it.

The Minister has just made his political point.

If there is any difficulty in elaborating on that——

If the Minister had dug deeply into his socialist handbag he could have reversed that.

It was part of the Estimate decisions of 1982.

The then Government refused to accept it.

The Minister lost his handbag.

We could spend another £200 million on the health services, which is the Deputy's proposition and have a universal general medical services scheme.

The Minister is a great man for words.

That money is not available. We must have a cut-off point. It affects about 40 per cent of the population. We would need to have negotiations with consultants. I would not worry about that but as the Deputy knows as a member of the medical profession, the consultants demand that they should have total access to 50 per cent of the top income groups of the community. That is a major problem which would arise under the common contract for the delivery of health services. The Deputy mentioned the case of a man earning £6,500 a year with three children. It is worth nothing that the average income of a male adult industrial worker is about £7,500. Any expenditure over £100 a year on the general medical side can be offset against income tax. There is also general relief for anything spent over £28 a month on drugs. People who are not eligible for medical cards have free hospitalisation and free consultant services up to a limit of £11,000 a year. These services are provided for and that is why we are spending £1,020 million this year. We are providing it on the basis of a 1 per cent health contribution. The income to the Exchequer from the working population towards the health services is fractional. It is only £70 million a year. I could provide services for those at university at an extra cost of £200 million a year on the GMS side and £100 million on the hospital side. Where medical cards are generally available the incidence of take-up of the health services is about four times the level for the rest of the population. The medical profession have a massive visitation rate and drug dispensation rate. For every £1 of visit £3 of drugs are prescribed. All of this must be considered. I am not satisfied that we are getting value for money or that the people are getting the health services they are entitled to. However, that is a different question. There must be some cut-off point on the delivery of health services.

(Dublin North-West): Would the Minister agree that in a family where there is a serious medical problem, especially with a young child, the case should be dealt with on its merits and not on income guidelines? I know of a case which I brought to the CEO. He told me he had no option but to go along with the guidelines laid down by the Department. That contradicts what the Minister said, that if there was a serious problem one could contact the CEO. In this case the income is slightly higher than the guidelines laid down but the medical problem is serious. It involves a very young child and is causing considerable hardship. In such cases will the Minister ensure that they are dealt with on their merits?

I would stress that the hardship provisions under the regulations are implemented generally in a fair and reasonable way by the CEOs of the health boards. I am basing this on certain criteria. For example, the number of complaints received in my Department on the question of eligibility for medical cards is very low and the number of representations made to me through the health boards is exceptionally low. In cases of families who have very heavy medical expenses in respect of drugs and so on, provision is made by the health boards. That is why in County Donegal, for instance, almost seven people out of every ten have medical cards while the ratio in the Eastern Health Board region is only about three out of every ten and in the Western Health Board area 58 per cent of the population have medical cards. There are interesting questions to be asked. Are people in the west twice as badly off as people in the eastern region?

Would the Minister like to try living on 15 acres? Would he not agree that his decision is seriously discriminatory because of the fact that the majority of third level students are at college, not because of their parents' ability to keep them there, but largely because of their own ability, through summer employment, part-time employment and borrowing, to put themselves through college? Is the Minister not discriminating seriously against those people whose parents do not qualify for medical cards? Would he not agree, too, that for example the child of a road-worker can only be at college through his own resources but that he will be seriously affected by this sweeping decision of the Minister's? Regarding the Minister's remarks about the west, as a Minister who represents well-heeled, middle-class people, his situation is reflected in that remark.

If it is any consolation to the Deputy, my constituency is the one that has been hit hardest by this decision. I think I would be supported in that by Deputy Andrews.

Never.

Not too many of the Minister's supporters qualify for medical cards.

I would make the point that in the case of students who are dependent on part-time work, who indicate the income they are receiving from that part-time work or from holdiay work and who can indicate to the health boards that they have a very limited income from their parents in terms of support, that will be regarded as an assessment of income. In addition there would be an inquiry by the health board as to the actual income of the parents. There is flexibility within the decision to allocate medical cards. Even where it is patently obvious that persons between the ages of 16 and 25 are well above the guidelines in terms of income and consequently would not suffer any hardship, the only services being withdrawn are drugs and GP services. For such people there will continue to be access, free of charge, to in-patient and out-patient hospital services and to consultant services.

In the course of the first question I endeavoured to find out exactly how much will be saved by the Minister's decision and I have been informed that the estimate in this regard is £2,500,000. However, we know also that merely to notify the 85,000 students whose entitlement to free medical cards is to be discontinued will cost £50,000. Can the Minister tell us what will be the cost of means testing those 85,000 students? Would it not have been more in line with the Minister's declared philosophy to have gone after the £20 million which he says can be saved by removing the subsidy to private hospitals?

The Deputy is well aware that I have taken strenuous and rigorous action in respect of the private hospitals. This action has resulted in major reductions in costs in these hospitals. On the question of the saving, I would estimate that it is, as the Deputy has said, £2,500,000 but £500,000 of that is being given to the elderly by the provision for the first time in the history of the State of additional income allowances in respect both of those over 65 and of those over 80. In other words, there is a substantial transfer to those in greatest need.

This must be the final supplementary on this question.

He has not answered my question about the cost of means testing the students concerned.

Would the Minister not accept that his decision creates a particular problem for students living away from home and how does he expect a CEO to decide on the question of students who are likely to suffer hardship? Most illness happens unexpectedly so how can a CEO be expected to make a judgement on the likelihood of hardship? I am thinking especially of students living in flats away from home and who would not have the money readily available to pay doctors' fees.

There is a considerable exaggeration in relation to the situation facing such students. I stress strongly that on the basis of the analysis we have undertaken, on average the 120,000 students throughout the country need the services of a GP about twice yearly.

What, then, is the point in taking the cards away from them at all?

I have yet to hear of a doctor refusing to attend a student on the basis that the fee was not readily available. If a GP is called to where a student is in digs and if the student has not at hand the money to pay the fee, one expects that what happens is that there is an arrangement whereby payment will be made subsequently.

I have yet to meet a student who was not in severe hardship so on that basis they should all get their cards back.

The Minister has still not answered my question.

We must move on to Question No. 10. We have spent nearly an hour on nine questions.

The Minister would be as well off to write to the CEOs and tell them that students may retain their medical cards.