Confusion about the scheme
An examination of the HSE file in this case showed that there was a certain amount of confusion about the nature of the LTI scheme among the administrators charged with implementing it. Some of this confusion appeared to arise from the (mistaken) idea that the LTI card is provided to people in order to obtain certain prescribed medications and that it is the medications which are covered by the scheme, not the condition for which they are prescribed. The letter sent to Ms Kelly on 10 July 2009 by the A/SAMO in response to her application said:
“I acknowledge receipt of your Long Tern [sic] Illness Book for Sam. I regret to inform you that the following medication is not currently available for you [sic] medical condition under this scheme...”
The letter then went on to name the medication which had been prescribed for Sam Kelly and to give details of the address to write to if appealing the decision.
This letter is confusing in its terminology and import. Ms Kelly had not sent the HSE an LTI book: she was applying for one. The basis of the scheme, as provided by the legislation, is the provision of medications free of charge to persons who have certain prescribed diseases or disabilities: the medications prescribed are not part of the eligibility criteria.
Ms Kelly then made an appeal in which she pointed out that the HSE application form lists the conditions covered by the scheme and it includes “mental illness (under 16 years old).” She said that ADHD is a mental illness and her son was under 16 years of age. She said that they were awaiting an appointment for a specialist as there was a possibility her son also had Aspergers syndrome. The Appeals Officer to whom the case was sent noted the confusing nature of the decision letter which had issued and raised the question with the writer of the letter, pointing out that “Ms Kelly appears to be appealing the refusal of a Long Term Illness book ... but your decision appears to be that the particular medication is not available on the scheme.” In response, the A/SAMO replied:
“... a diagnosis of attention deficit hyperactive disorder is not regarded as a mental illness and as such does not qualify for a [sic] long-term illness scheme. This has always been the case. I also note ...that there is a possibility that he might be diagnosed with autism spectrum disorder...
If he is diagnosed with autism spectrum disorder then he may well be eligible for an LTI and I would suggest the parents would reapply under those circumstances.”
The Appeals Officer accepted this information and refused the appeal on the grounds that “A diagnosis of ADHD does not qualify an applicant for the Long Term Illness Scheme.” Ms Kelly was told in the letter notifying her of the appeal decision that should Sam be diagnosed with Autistic Spectrum Disorder “... he will be considered for the Long Term Illness scheme” and she was told if that happened she should apply again. However, when a diagnosis of ASD was made by the HSE Consultant Child Psychiatrist in Wexford, and evidence of that diagnosis provided to the HSE together with a new application for the LTI card in September 2010, the A/SAMO who had suggested that this might allow Sam to qualify for the scheme wrote to Ms Kelly to say:
“...Autistic Spectrum Disorder and ADHD are not currently considered eligible under the current list of medical conditions listed for the Long Term Illness Scheme. The medication...which is used for the treatment of ADHD is also not available on the above Scheme.”
It is notable that this letter came from the same person who had advised the HSE Appeals Officer that if Sam was diagnosed with autism “then he may well be eligible for an LTI...” The mention, again, of a particular medication not being available under the scheme is not in accordance with the terms of the scheme as provided by legislation.
The A/SAMO commented on the preceding paragraphs when she was sent a copy of this report in draft form. She said that:
“In the HSE South what was the old South Eastern Health Board area, ADHD was classified under ICD code 10 and as such was not regarded as mental illness, therefore was not deemed eligible for the LTI scheme. I was informed of the policy when I started doing the LTI books and hence I was following established policy.”
She also said that in relaying the suggestion to the Appeals Officer that if Sam were to be diagnosed with Autistic Spectrum Disorder, he might be eligible she did not intend to give the impression to his parents that he would be eligible; she wanted to check with her peers in the Southeast if the disorder was eligible for the LTI scheme. She was told that it was not and, consequently, had no choice but to refuse the second application which was made on the basis of that diagnosis.
Use of different classification systems
The HSE said in its November 2012 submission to the Office of the Ombudsman that,
“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)”
Dublin North East and Dublin Mid Leinster have the highest population centres in the current division of the HSE into four administrative regions. Thus, it appears that a large cohort of Medical Officers accept ADHD and ASD as falling within the category of “mental illness” where a child is concerned and that, consequently, LTI cards have issued for these children. The Medical Officers who do not take this approach (mainly in the South East) appear to be in the minority.
How did it come about that Medical Officers in the HSE use different disease/illness classification systems for the purpose of administering a national scheme? The answer probably lies in the historic separation of the former health boards into different functional areas. This however, is not a sufficient explanation. The LTI card scheme, from the time of its inception in 1971, was always a national scheme with a statutory basis. There should, therefore, always have been a uniform and standardised approach to its implementation.