On 24 January 2012, the HSE wrote to the Ombudsman to say that the case had raised wider issues for the administration of the LTI scheme. It said that the case,
“...highlights the disparity across the country in the way Attention Deficit Hyperactivity disorder (ADHD) and Autistic Spectrum Disorder (ASD) are classified by individual Medical Officers in processing Long Term Illness (LTI) card applications. In some areas children under 16 with these disorders are classified as having a mental illness and as such entitled to an LTI card, in others they are not.
It appears that individual Medical Officers have made their determination in relation to eligibility for an LTI card based on the clinical classification they use for ADHD and ASD. The two systems currently in use are the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the World Health Organisation’s International Classification of Diseases (ICD 10). It would appear that Medical Officers using the ICD 10 have not recognised these conditions as mental illness, however those who use the DSM-IV have.”
These systems classify ADHD and ASD differently. The DSM-IV classifies them as mental illnesses. The ICD 10 classifies these conditions, using slightly different terminology to describe them, as a “behavioural and emotional disorder” (in the case of ADHD) and as a “disorder of psychological development” (in the case of ASD).
The use of different classification systems led to children in certain parts of the country qualifying for the LTI card on the basis that their illnesses were covered by the scheme while others, with the same conditions, were refused the LTI card. In November 2012, in response to the Ombudsman’s notification of this investigation, the HSE said,
“LTI cards for children with these conditions have been awarded in Dublin North East; Dublin Mid Leinster; North West; former Southern Health Board area; Midlands (some Local Health Offices) and have not been approved in the South East, Mid West, Dublin North and Midlands (some Local Health Offices)”
The HSE accepted that this system was inequitable and went on to say,
“The matter is under active consideration by the Department of Health, however the specific issue is being considered within the broader policy development of the LongTerm Illness Scheme under the Programme for Government. This has not yet been finalised.
In the absence of any formal policy direction in the matter, the HSE has convened a group of appropriate clinical and management personnel ... to agree an interim operational policy ...This group is expected to provide its recommendation before the end of November 2012 after which the decision and formal direction will be issued to the relevant clinical and management personnel across the HSE.”
In January 2013, the HSE informed the Ombudsman’s Office that the group had held a number of meetings to consider the issues and “is currently consulting national experts to determine a definition for the condition, i.e. whether or not ADHD is a mental illness.” At the time of writing this report this particular issue was still undecided.
However, when asked for its comments on a draft of this Report, which is at Appendix 1, the HSE said in its submission to the Ombudsman of 15 April 2013 that as an interim operational policy, the issuing of new LTI books to children should be suspended, pending a formal decision from the Department on the matter.