The Government’s decision to offer free GP care to all children aged five and under in the recent budget has provoked a strong reaction. Those in favour praise the move as the first step in implementing a system of universal healthcare; for others it raises troubling issues around the principle of ensuring care is based primarily on patient need.
In the current climate where medical cards are being precipitously taken away from people with established illness such as cancer and new applications for discretionary cards refused to patients with newly diagnosed motor neurone disease, the question must be asked: is it appropriate to offer free GP care to young children who do not have a chronic illness or whose parents have an income substantially above the qualifying limit used to determine medical card eligibility for the rest of the population?
Add the Orwellian phrase “medical card probity” – used in the budget speech to describe an exercise to reduce medical card costs by €113 million – to the mix and it is clear the GP care policy change for children aged five and under has been made very much against the tide of cutting access to free medical care in the Republic.
Having a medical card offers more than just free access to your GP and free medication (prescription charge excepted). It is the key to free care in hospital emergency departments.
Without a full medical card you will not be eligible for medical equipment deemed essential for managing your illness. Medical cards give access to wheelchairs, specialist seating and other aids to independent living. And the original full medical card is needed to obtain these benefits: a “doctor-only” medical card covers the cost of seeing your family doctor and nothing else.
As a measure of the inequities that already exist in the health system consider the following real cases: Adam is a six-year-old who was born with a hypoplastic left heart – a condition where the main pumping chamber of the heart is underdeveloped.
Significant needs
He underwent life-saving open heart surgery but suffered a stroke following his operation. He is looked after at home by his parents, but has significant needs in terms of equipment, medication and emergency care. Adam has had a medical card for a number of years, with an expiry date of August 2014. However, his parents were shocked when his card was suddenly cancelled some weeks ago.
Gemma is another six-year-old with a congenital, life-long condition. She has osteogenesis imperfecta type 3, a severe form of brittle bone disease which causes frequent fractures (necessitating regular visits to the emergency department) and which has inhibited normal growth.
She requires regular treatment abroad and also has significant equipment needs. Her card expires next month and has been placed under review rather than being renewed automatically.
Gemma’s mother is expecting another child in the new year. As things stand at present, it is likely that her (hopefully) healthy baby will have an automatic entitlement to free medical care while his or her substantially handicapped older sibling will not.
Jonathan Irwin, chief executive of the Jack and Jill Children's Foundation, has called for medical cards to be automatically given to terminally ill children before any expansion of eligibility for children aged five and under is introduced.
Describing the present system as thoughtless and cold, he said: “Medical cards for a palliative [dying] child should not be up for review and should not be issued on a temporary basis, but rather given to the family automatically and followed up by a range of supports to help parents to care for their child at home.”
GPs are also concerned.
The chairman of the National Association of General Practitioners, Dr Andrew Jordan, while welcoming the proposal in principle, said his members were not prepared to implement free GP care for children aged five and under "at the expense of the most vulnerable".
A recent correspondent to this newspaper has pointed out that, under the 1970 Health Act, income is not the only factor that must be taken into account when deciding eligibility for a medical card.
Under the Act, a person is entitled to a medical card if they are “unable, without undue hardship, to arrange general practitioner medical and surgical services for themselves and their dependants”.
In other words, the Health Service Executive must take into account the medical condition of an applicant and whether his or her income is sufficient to secure medical care to treat that condition.
Premature and unfair
All of which suggests the free GP care policy for children aged five and under is premature and unfair. With €3 billion taken out of the health budget, it is vital that stretched resources are focused on those with identifiable needs.
Laudable as universal healthcare is in principle, for economic reasons now is not the time to introduce it. One of the strengths of universality is the premium it places on equal access for all to healthcare regardless of ability to pay.
The ultimate irony is that the policy is being introduced against the backdrop of a ruthless cull of medical cards, denying essential care to many with established need.
This policy is arbitrary and inequitable. It is bound to cause suffering to many. How can it make sense to provide free GP care to healthy young children while denying those who struggle with chronic disease the care they need and deserve?
Names have been changed in the interest of patient confidentiality
Dr Muiris Houston is The Irish Times health analyst