Only a quarter of the promised 200,000 GP visit cards have been granted. Is the highly bureaucratic application process to blame, asks Theresa Judge.
Only a quarter of the 200,000 GP visit cards promised by Minister for Health Mary Harney two years ago have been granted to date. The number issued at the end of last week was 50,400 according to the Department of Health.
A department spokesman says further efforts are to be made to try to ensure that people who are eligible for the card actually receive it, particularly in the cities, where take-up has been much lower than expected. Take-up in rural areas has been proportionately higher.
However, while the department and the Health Service Executive (HSE) emphasise that huge efforts have been put into advertising the card, and that income guidelines have been raised twice to make more people eligible, their attempts are clearly failing to ensure that everybody who is entitled to the card is getting it.
The Department of Health spokesman says there is no way of knowing the numbers of people who are eligible because there is no reliable database that takes into account both the income and outgoings of a person or family. Eligibility is based on income after tax, but also takes into account outgoings on mortgage or rent, childminding costs and travel to work expenses.
One Dublin woman who is currently trying to obtain the GP visit card tells a story that goes some way to explaining why the uptake remains so low.
When she initially applied for the card during the summer, she provided all her bank statements showing her income and outgoings. She had also got a GP to fill in part of the application form as required.
Three months later she was contacted to say she would have to provide pay slips, details of her separation agreement with her husband, and a letter from him confirming maintenance payments, a letter from her mortgage provider, and evidence of a car loan. She was also sent another form for her GP to fill in, which asked for details about how often she visited him and about medical conditions of each family member.
She was given 21 days to produce these documents, but there had been a three-month delay since she had applied. When she questioned this, she was told there was a three to four-month backlog and that if she wanted her application to proceed she should return the documents within three weeks or she would have to submit a whole new application.
"They really don't make it easy for you. They wouldn't give me any indication as to whether I would be eligible or not, and I don't see why they couldn't give you the two forms for the doctor at the same time, instead of me going back to the doctor a second time," she says.
She also points out that she was sent out a form with no return address. "I had to make four or five calls before I found out which office I had to send it to. When I asked them about this they said it was a universal form and people had to return them to their local office, but the office I had to send it to is not in my area so it wasn't obvious."
The mother of three has one child with a serious illness, who is on long-term disability allowance. She was also told by one official that she could not get a GP visit card as well, that you either get one or the other.
She points out that she wanted the card for herself and her other children.
Overall she found the staff condescending and, on one occasion, she asked to speak to a supervisor because she found one official so rude.
She points out that even though she is working, medical costs can be a burden. She was advised that two of her children should get anti-flu and anti-pneumonia injections because of underlying conditions, and while these vaccinations are technically "free", she had to pay the GP €80 to give the injections.
On another occasion one of her children fell and needed four stitches. Because it happened on a Sunday she had to pay €80 to have the stitches put in and another €50 to have them removed.
The Department of Health spokesman says the department has asked the HSE "to modernise" the way it deals with people to ensure the application process was made easier. "If questions are asked, it is to qualify people, not to disqualify them," he says.
However, uncertainty about eligibility is obviously a problem. While there is a calculator on the HSE website to allow people to calculate if they might be eligible, it is often difficult to be sure. And people would not want to go through the process of disclosing personal financial details if they don't believe they have a good chance of getting it.
Controversy has surrounded the GP visit card since it was first introduced. Many claim it was an attempt to muddy the waters to distract attention from the fact that the percentage of people on full medical cards has been steadily declining since the late 1990s.
In its election manifesto of 2002, Fianna Fáil said that, if elected, it would provide an extra 200,000 medical cards. However, this specific figure did not make it into the programme for government, although there was a pledge to extend medical card eligibility.
The Department of Health says there are now a total of 1,219,829 full medical cards, which is 28.8 per cent of the population. When GP visit cards are included, 29.99 per cent of the population have free access to GPs. In 1995 over 35 per cent of the population had medical cards.
The Department argues that unemployment is now lower and people are earning more but this argument is rejected by both the St Vincent de Paul and the Irish Medical Organisation (IMO).
Audry Deane of the St Vincent de Paul society says accessing healthcare is a problem for low-income families. GP visit cards are of limited use because the cost of medicines are not covered and some four out of five patients are given prescriptions. The society is concerned that the numbers on full medical cards is dropping consistently.
The number of full medical cards in 2002 was 1,168,745, down from 1,277,284 in 1995, and it fell by another 20,000 by 2004 to 1,148,914.
So while Fianna Fáil had pledged to increase medical card numbers by 200,000 in 2002, in the first two years of the re-elected Fianna Fáil/Progressive Democrats coalition, the number instead fell by 20,000. The Department of Health spokesman points out that it has increased by 70,000 since 2004, which is 40,000 more full medical cards than it promised then.
Dr Martin Daly, chairman of the GP committee of the IMO, says the low uptake of the GP visit card is because the public has "seen through the political manoeuvering of the minister". The public has decided, he says, that the bureaucracy involved "was simply not worth it". He points out that apart from the cost of prescribed medicines, there is a whole range of community health services available to medical card holders but not to GP visit card holders, including physiotherapy and ophthalmology. He says the policy has proved "a failure".
Instead of "political posturing" the minister should deliver the promised 200,000 medical cards, which could be done without any further negotiations with the IMO, Dr Daly says. He also points out that the granting of medical cards to all over-70s regardless of income means that the proportion of under-70s getting the card due to income level is even lower.
Dr Eamon Shanahan of the Irish College of General Practitioners says that, from experience with his own patients, he has found that people who were refused medical cards in the past do not want to go through the process again.
It was "a scandal" that up to relatively recently a person had to be below the poverty line to be eligible for a medical card, he says, and "there is still a belief among a lot of people that the system hasn't changed".
He has gone through the process of calculating eligibility on the HSE website with patients and says it is difficult for people to know if they are entitled to it or not.
Stephen McMahon of the Irish Patients' Association urges people to apply for the card saying they should remember that it was "a right and not charity".
Deane says health statistics showing that the less well-off are much more likely to be ill and to die younger reflect problems people experience accessing primary healthcare. The statistics, she says, are "shameful" when compared with European figures.
Information on medical cards and the GP visit card is on www.hse.ie or phone 1850 24 1850
Who is eligible?
Since the income guidelines were increased in June, the HSE says that a couple with two children earning €1,100 a week after tax and PRSI should be eligible if they have mortgage costs of 300 (per week), childcare cost of 250 and travel to work costs of 70.
A single parent with one child and earning €1,000 a week after tax should also be eligible. A single person with no children and earning €426 a week after tax should be eligible.