It is very clear that the policy choices that the Government made last year and in this year's budget impact far more severely on children, sick people and our older population. Since July, Deputy Kelleher and I have been raising consistently the policy choice that the Government took last year to cull discretionary medical cards on an ongoing basis. Two weeks ago I raised this with the Taoiseach and I asked him to listen to people in this House and elsewhere on the discretionary medical card issue. We gave a range of individual cases where this was happening, but the Taoiseach chose to deny reality and he did not listen. It took Lydia Cleary and many others to come on "Liveline" last week to confirm once and for all what everybody knew, namely, that there was a wholesale withdrawal of discretionary medical cards from very sick children, very sick adults and people aged over 70. It exposed the untruths that were being articulated by the Taoiseach and the Minister for Health on the discretionary medical card issue.

Jonathan Irwin of the Jack & Jill Children's Foundation has provided further confirmation of this. A glance at that organisation's Facebook page shares the experience of many parents of children who are cared for by the Jack & Jill Children's Foundation and their experience of the medical card issue, in particular the discretionary medical card.

In addition older people have lost their discretionary medical cards. A 67 year old gentleman at end-stage renal failure lost his medical card. A 70 year old with very complex ongoing medical conditions lost his medical card. There are many more in life-threatening situations. The Taoiseach keeps saying there was no change. However, the 2013 service plan, approved by the Minister for Health, Deputy Reilly, stated that policy changes would lead to a reduction of approximately 40,000 medical cards as a result of changes to income calculations, including for those over 70.

I thank the Deputy.

That has been the case from the beginning and it is why letters have been issuing all year to different families and communities. That is why people are terrified about next year and the provision in the budget for a reduction of €113 million on the basis of this wonderful word "probity". They know what happened this year when the edict went out from Government to start removing cards from people. That is why people are concerned about random reviews that were initiated last year.

Put the question, Deputy.

Will the Taoiseach acknowledge that there has been an ongoing policy of withdrawing medical cards and will he intervene to reverse that policy? It is never too late to change. This has been one of the most disgraceful manifestations of what the Government has been up to in the past 12 months. People throughout the country are witnessing it. Will the Government also withdraw the budget decision to take 35,000 medical cards from those over 70 as a result of the reduction of the income thresholds?

The Taoiseach should tell the thousands of people protesting outside that there has been no change.

This is Leaders' Questions.

Let him answer that.

One of the fundamental reasons we need to make difficult choices and difficult changes in the structure of our health system is to cut the cost while preserving the services for those who need them. The main thrust of the changes being brought about is to protect services for those who need them - children, the sick and the elderly. We are doing that against a background of unmitigated disaster, which was aided in the main part by the gentleman speaking opposite.

Hear, hear. The Deputy should put on his sackcloth and ashes.

We are on Leaders' Questions.

Deputy Martin was a member of a group that ran this country-----

Into the ground.

-----when we had more money that would have dealt with many of the major problems we have to face. He failed to reform that service. He promised to end hospital waiting lists within two years when he sat on these benches.

The Taoiseach made his fair share of promises himself.

During Deputy Martin's 14 years sitting at the Cabinet table, the overruns in health amounted to €2.2 billion. He was the architect of the PPARS debacle which started at €9 million and ended up at €200 million. Above all, he promised to extend medical cards to an extra 200,000 people during his term, when in fact he cut them by 100,000.

No, the Taoiseach is wrong again.

The Deputy should put on his sackcloth and ashes.

The Taoiseach could not be right on that.

He has the cheek to come in here now and use his opportunistic political opportunity to say these things. The Minister, Deputy Reilly-----

Great man.

-----against the most difficult economic background, has managed in these past two years to make serious changes to the structure of our health system, reducing the cost of the services, but protecting the services.

Tell that to the thousands outside.

Deputy Martin said the policy changes were directed at children, sick people and old people. I do not suppose, therefore, that he wants to change tack in respect of 240,000 children under the age of five having free access to GP care.

At whose expense?

I know Deputy Martin understands this because when he was Minister for Health and Children and the chief medical officer of the Department at the time suggested that free GP care should be extended to every child in the country, he supported it but then ran away and did nothing about it, just as he did with most other issues he faced.

In respect of discretionary medical cards, it is important to understand that the number of people with access to free GP care is the highest ever in the State. Some 43% of our population now have that access. There are 1.866 million full medical cards and 124,900 GP-visit cards, giving a total of 1,991,000. When people have a GP-visit card, it means they have free access to their doctor, which is the start of the analysis to determine what little problem they might have. On becoming Minister for Health, Deputy Reilly instructed the HSE to appoint a clinical panel to assist in the process of vetting applications for discretionary medical cards. That ensures the specific circumstances of a person with a particular diagnosis can be determined case by case. I want to say this to Deputy Martin, politician to politician, man to man, citizen to citizen: I saw some of the cases mentioned in the media and these were cases that the system should have been able to deal with-----

Blame the system.

-----but because of the process of change, something was missed. I know of two cases where the card has been granted in the meantime because of the full information becoming available.

Because of "Liveline".

Thanks to Joe Duffy.

Ring Joe.

According to the most recently published information, there was a reduction of about 24,000 in the number of discretionary medical cards between the start of 2011 and July 2013. Of those 24,000, some 23,000 were awarded a medical card on the basis of full assessment of their income. On Monday, 14 October, the Minister, Deputy Reilly, met the chief executive of the HSE and the primary care team to express concerns directly about the communications, the letters, the answering of phones, the interest being expressed in dealing with difficult cases.

This might be of interest to Members of the House. By 1 October 2013, of the 97,121 people who held discretionary cards at the time of the assessment in March 2011, 38,000, or 39%, still held a discretionary medical card, 43,000 had ordinary medical cards based on the assessment, and 17,000, or 18%, had no medical card. When that 17,000 was analysed, 2,361, or 14%, were deceased, 6,265, or 38%, did not respond to correspondence from the HSE and their medical cards were suspended, 12% engaged in the review process but did not follow it through, and 6,165, or 37%, completed the review process and were found to be ineligible for a medical card or a GP-visit card. That represents 6.5% of all the people who held a discretionary card on 1 March 2011.

I thank the Taoiseach.

Yesterday I had a meeting with the personnel involved in this. A completely new communications strategy has been put in place to deal with people and allay their fears and concerns that those who need a medical card will get one and that those who require services will get them. As the Deputy knows, we have full medical cards, GP-visit cards, discretionary cards, emergency cards, long-term illness cards and cards on review. Sometimes these things can be very confusing. In fairness to the people who work in the HSE and want to be able to deal with these things, sometimes the information is not supplied. We are rectifying that.

The Taoiseach did not answer the questions I asked. For example, I asked if the Government would reverse the decision in the budget to take 35,000 medical cards from older people and he studiously ignored and avoided answering that question. I think the Taoiseach must be the only person in the country who believes there has not been a consistent attempt and policy to withdraw discretionary medical cards from people. The Taoiseach should read up on the case of Ms Lydia Cleary and her daughter, Eirin. She made all of those points; it was not an issue of communications. It is not about hard cases. The Taoiseach should stop all of that nonsense. Thousands of cards have been taken from people throughout the country, as every Deputy in this House has acknowledged.

Eventually, the Taoiseach acknowledged it because his own Deputies got to him at their party's Ard-Fheis.

We all know what is happening and we have all instanced individual cases. Let us consider Katie Connolly's case this morning in the Irish Examiner. She is a young Down's syndrome child with juvenile arthritis. Her card is up on 13 November. It is policy. It should not have had to wait until yesterday when the Taoiseach intervened in this case. We have been saying this for months. It should have been when the service plan was approved last year, in 2013. The Taoiseach and the Minister for Health, Deputy Reilly, approved the plan in terms of a deliberate decision. It was a message to the HSE to find the savings in the General Medical Services, GMS, scheme. The Minister of State, Deputy White, confirmed it in May in the House before a committee. Let us consider the document that the HSE produced before the Oireachtas committee. It referred to the random reviews undertaken as part of the full suite of reviews to assist in determining that a medical card or general practitioner visit card meets the eligibility criteria. By God, the HSE has stuck by the new eligibility criteria.

Did anyone see the HSE official on "Prime Time" last Thursday night? Did the Taoiseach watch it? Christians among us would have been intrigued because on the third occasion he suddenly relented and it became evident that there was a change of policy. The interviewer identified one, two and then three policy changes in terms of the income guidelines in respect of medical card guidelines.

The Taoiseach should stop telling untruths to the public in respect of discretionary medical cards and stop all of this clever language to the effect that those who are entitled will get one.

What language is that?

It is waffling.

Those who have been entitled to it for the past year or two years have been denied it in case after case.

The pattern in the Taoiseach's replies is very consistent. For the Taoiseach, there is always someone else to blame for choices that are made on his watch.

Order, please. Calm down.

Today-----

Deputy Martin, you are over time.

I will conclude.

Go and face the people outside.

Today, very obviously-----

Go and face the people outside.

The Government is hiding.

Today, it is the system.

Go to the gate and face them. The Government ran from them today.

Deputy, I told you already. Deputy Martin, to conclude.

I am endeavouring to conclude, a Leas-Cheann Comhairle. There is always someone else to blame. Today it is the system. Now, we have learned the Minister for Health, Deputy Reilly, has had meetings with the officials to tell them how to do communications better. I suggest that some of those officials are laughing behind the idea that the Minister, Deputy James Reilly, would give them advice on how to communicate better. That is a bit rich too.

The real issue I am raising today-----

They should listen to Joan.

I am not into personalities. It should not take the mother of a very young sick child to come on the national airwaves to get a decision reversed in respect of her entitlement to a medical card. That is the bottom line.

This is affecting thousands of families throughout the country. I called on a family yesterday to whom the same thing happened. They have a five-year-old with a rare chromosomal condition and the card was taken from that young child. I do not want to come to the House every week listing case after case, because when one gets case after case one begins to realise it is systemic and not simply one individual hard case or a failure of communications. It is systemic. That is the point which I and Deputy Billy Kelleher have been trying to get through to the Taoiseach for the last number of months. There is something systemically wrong and it goes back to a policy decision that the Government took on health in last year's service plan and in this year's budget, although the budget is now up in the air in respect of medical cards.

The answer to Deputy Martin's question in respect of the change being brought about for over 70s and their medical cards is "No". There will be no change in that. I have already pointed out that 85% of the over 70s will still retain their medical cards.

He said it was 97% last week.

It will be in the high 90s and those who do not have a medical card will have the GP card which gives them free access to their doctor. The weekly income is €500 for a single person and €900 for a couple in order to receive a GP visit card and the House knows what that means. Even after the change, at least 93% of persons over 70 years will still have access to a free GP card. I said 97% last week on the basis of figures coming in.

I will say this much: I recall Deputy Martin saying on discretionary medical cards-----

I would be happy to debate that some other time.

The question has been asked.

It is not a case of having someone to blame. Deputy Martin put his foot in it and his footprints are all over the place. Deputy Martin said previously that there would be a clarification of the guidelines under which health board chief executives issue discretionary medical cards and that there were clearly variations between health boards in terms of how they administer them.

The health boards are gone eight or nine years.

We should not have situations like those involving the children and their mothers who I saw on the television. We have 1.9 million medical cards issued. I put it to Deputy Martin that after speaking to these people directly there was a systems failure that did not take into account or did not know about the information involved, whether it be a failure on some of the people in sending in information. I was given an indication this week that some do not reply.

Is the Taoiseach blaming the parents now?

Some get scared when a letter comes from the HSE but we are changing all of that so that where children need attention or, in particular, facilities, aides or appliances, the system is able to cope with that.

It is not.

There is a centralisation of it whereby the assessment is the same for everyone whether in Donegal, Kerry, Waterford or Louth. The change in that structure has led to these cases being highlighted. I hope that out of all this difficulty for the parents and their children the matter will be addressed and it will be. I have spoken to parents myself.

The question is asked.

I have spoken myself to parents in the last few days. We have had some exceptional cases where because of a lack of information or whatever they have been refused.

It is because of policy decisions.

The question of aides and appliances and the treatment of these will all be addressed. It may well be, as Deputy Martin rightly pointed out, that of all of the ministries, the Department of Health is the most challenging because one never knows what pressures may arise from difficulties in various parts of the country. The Minister, Deputy Reilly, is seeking, at central level, to cut the cost of the provision of the services and maintain services so that the children, the sick, the elderly and anyone else who needs medical attention can have it available as close as possible. The answer to Deputy Martin's question is that there will be no change now in the budgetary position which has gone through. These will be implemented.

There are challenges facing the health area but they can be met in the context of a change of culture and a change of structure which will bring about far more cost-effective services for all our people who need them. The evidence in respect of discretionary medical cards speaks for itself. Since the beginning of this year 20,000 new medical cards have been issued on a discretionary basis. Even in the middle of all that, when the assessments were taken into account, many of those people-----

There are 26,000 fewer medical cards now.

Many of them were well in excess of the guidelines for medical cards but because of the weighting attached to their particular discretionary requirements the cards were issued. Fully 20,000 new discretionary cards since the beginning of this year have been issued. Significant numbers of those people were well in excess of the guidelines set down.