4.1 CAD A DEIR NA GEARÁNAIGH...
"Persons who, while maintaining themselves at home had full eligibility under the Health Act, 1970, may be regarded as not coming within that definition while they are being maintained in long-stay care and may, therefore, be subject to the appropriate long-stay charge. ... a full review of the regulations governing long-stay charges is at present in progress in my Department." - Mary O'Rourke T.D., Minister for Health, Response to PQ, (17 December 1991)
"The South Eastern Health Board is endeavouring to deal with the complaint that was received by the Ombudsman [re. charging medical card holders for long-stay care]. ... As you are aware, I have sought legal advice on the issue. The Board has received this legal advice and were advised to seek definitive guidance from the Department of Health and Children before proceeding on the matter.
The Board have had discussions with the Department on the advices received. The Department have indicated that they have legal advice, which contradicts the Board's legal advice. This is now being studied by our legal advisors." - South Eastern Health Board letter to the Ombudsman, (14 February 2003)
"Over 300,000 people were charged illegally during 28 years. This was entirely wrong. They were old, they were poor, they suffered from mental illness, they had intellectual disabilities, they were physically disabled. As vulnerable people, they were especially entitled to the protection of the law and to legal clarity about their situation. [...] We are a society ruled by law. No-one and no organisation can dispense with or alter a law." - Statement by Mary Harney T.D., Minister for Health and Children, on publication of the Travers Report, (9 March 2005)
Cuireadh na boird sláinte faoi dhlínse an Ombudsman an 1 Aibreán 1985. Ba bheag nár tosaíodh láithreach bonn ag déanamh gearán faoi chúram fadchónaithe. Ní dhearnadh a lán gearán ar dtús ach tháinig méadú suntasach ar líon na ngearán i ndiaidh 1990. Tá 1,200 gearán ar a laghad faighte ag an Oifig le 25 bliain anuas, nó 48 in aghaidh na bliana ar an meán, maidir le cúram den chineál a thugtar i dtithe altranais.(Nóta 1) Ba ghearr gur thosaigh an tOmbudsman ag tarraingt aird an Oireachtais ar na gearáin seo ina Thuarascálacha Bliantúla chucu.
Tugaimid súil siar sa chaibidil seo ar na gearáin a rinneadh chuig an Ombudsman maidir le cúram fadchónaithe ó 1985 i leith. Tugtar sampla ionadaíoch de na gearáin sin ag deireadh na caibidle. Is é an rud is suntasaí nuair a chaitear súil siar orthu ná an méid gearán den chineál céanna a rinneadh bliain i ndiaidh bliana ó 1985 go 2010.
Breathnaímid sa chaibidil seo ar an gcaoi ar phlé na boird sláinte (FSS) agus an Roinn leis an Ombudsman maidir leis na gearáin sin i rith na tréimhse sin. I bhfianaise Thuarascáil Travers is léir gur choinnigh na boird sláinte agus an Roinn faisnéis ríthábhachtach ón Ombudsman ar feadh mórchuid den tréimhse sin. Teip an-suntasach ab ea é gan an fhianaise ábhartha go léir a sholáthar i gcás thuarascáil 2001 an Ombudsman Nursing Home Subventions.
Nóta
(Nóta 1) Tá gach aon seans ann go bhfuil an figiúr seo ró-íseal agus nach léiríonn sé méid iomlán na ngearán sa réimse sin. Tá sé deacair figiúirí cruinne a fháil faoi láthair ós rud é nach raibh comhaid na hOifige curtha ar ríomhairí sna blianta tosaigh agus nach raibh na cóid maidir leis na catagóirí gearán leagtha síos chomh sonrach agus atá anois.
4.2 CAD A DEIR NA GEARÁNAIGH... Cruatan
B’fhéidir gurb é an chéad cheist a tháinig chun cinn ab ea an cruatan a d’fhulaing teaghlaigh nuair a ghearr boird sláinte táillí i gcomhair cúram fadchónaithe in institiúidí poiblí nuair nach raibh aon cheart dlíthiúil acu a leithéid de tháillí a ghearradh. Sular ritheadh an tAcht Sláinte (Leasú) 2005 ní raibh aon bhunús dlíthiúil ann le táille a ghearradh ar othar maidir le cúram fadchónaithe má bhí cárta leighis ag an othar sin, nó mura raibh cárta leighis ag an othar go raibh duine cleithiúnach aige nó aici. In ainneoin go raibh cás measartha soiléir ann ó thaobh an dlí de lean na boird sláinte orthu ag gearradh táillí go minic i gcásanna ina raibh cártaí leighis nó cleithiúnaithe, nó an dá rud, ag na hothair. Phléadh gearáin faoi na cúrsaí sin go sonrach i dTuarascálacha Bliantúla 1988, 1989, 1991 agus 1994 an Ombudsman. Sheas an tOmbudsman leis na gearáin a tuairiscíodh agus d’admhaigh an bord sláinte a bhí i gceist go raibh bearta míchearta déanta acu.
Bhí cruatan i gceist freisin i gcás teaghlaigh ar cuireadh ball díobh i gcúram i dteach altranais príobháideach ach nach raibh sé d’acmhainn ag an teaghlach costais an chúraim sin a íoc. Bhí cuntas ar chás i dTuarascáil Bhliantúil an Ombudsman i 1990 inar fágadh gearánaí scothaosta faoi bhun tairseach na bochtaineachta, arna áireamh de réir ráta seachtainiúil an Liúntais Leasa Fhorlíontaigh (LLF), toisc go raibh sé ag caitheamh formhór a phinsin seanaoise ag íoc costais a mhná céile a raibh stróc fulaingthe aici agus a bhí faoi chúram i dteach altranais príobháideach. Rinne an pinsinéir an gearáin i 1989 (Féach an Díolaim Gearán). Bhí sé soiléir nár roghnaigh sé cúram príobháideach i gcomhar a mhná agus go raibh sí i dteach príobháideach toisc nárbh fhéidir áit in ionad cúraim poiblí a fháil di. Ní raibh ach £12 fágtha aige in aghaidh na seachtaine tar éis íoc as costais tí altranais a mhná rud a bhí níos ísle ná an t-ioncam íosta a bhí ráthaithe faoin scéim LLF. Chuir an tOmbudsman brú ar an mbord sláinte agus réitíodh an scéal nuair a mhéadaigh siad an fóirdheontas a bhí á íoc acu go leibhéal a chuir ar chumas an phinsinéara méid a choinneáil arbh ionann é agus an ráta seachtainiúil LLF.
Is é an chuid spéisiúil den scéal ná gur thóg sé cúpla bliain sular tháinig sé chun solais go raibh dualgas reachtúil ar na boird sláinte chun cúram tí altranais a sholáthar. Atoradh a bhí ar sin ab ea nach rachadh othair isteach i gcúram príobháideach ach amháin nuair a bheadh cinneadh dearfa déanta acu é sin a dhéanamh - seachas iallach a bheith orthu dul isteach i gcúram príobháideach toisc nach raibh cúram poiblí ar fáil.
4.3 CAD A DEIR NA GEARÁNAIGH... Tuarascáil Bhliantúil 1992
Bhí píosa toirtiúil ag an Ombudsman ina Thuarascáil Bhliantúil in 1992 inar phléigh sé na ceisteanna dlí agus na ceisteanna daonna á dtarraingt anuas sna gearáin faoi thithe altranais a bhí á bhfáil aige. D’fhéach sé siar ar shraith gearán a bhí faighte aige sa dhá bhliain roimhe sin agus d’aithin sé roinnt téamaí agus saincheisteanna. Ar an drochuair tá siad sin le sonrú sna gearáin faoin réimse sin gach bliain ó shin i leith. Dúirt sé gur mór an chúis tráma a bhí ann i gcónaí nuair a bhí ar dhaoine seanbhall den teaghlach a chur i gcúram fadchónaithe agus dúirt sé freisin gur cuireadh leis an tráma sin go mó de bharr rud a mheas sé a bheith ina "lack of clarity regarding the elderly person's entitlement to long-term care and regarding the financial and associated arrangements which need to be made”. Thug an tOmbudsman le fios "[that] there can be a great deal of confusion regarding entitlements and financial arrangements at this difficult time”. I bhfianaise a bhfuil tarlaithe ó shin, is fiú an méid a dúirt an tOmbudsman ina thuarascáil i 1992 a lua:
“The common thread in all of these complaints is an absence of information and a general lack of clarity regarding the health boards' obligations in respect of such long-stay patients. In the case of some of the boards concerned, it would appear that the situation is made worse by the shortage of long-stay beds and the resultant need to place patients in private nursing homes. It would appear that patients and their families are not being informed of the statutory obligation on the health board in relation to such cases and, accordingly, do not have accurate information regarding the financial implications of this situation.
From my examination of these complaints to date, I am satisfied that these elderly patients would be considered to be in need of "in-patient services" and that this is a service which health boards are statutorily required to make available. ...
At present, health boards can meet their obligation either by caring for patients in their own institutions or, alternatively, by placing their patients in private institutions (e.g. nursing homes) under a contract arrangement. Whatever arrangement health boards make for their patients, the essential fact is that they are obliged to ensure their patients receive the service to which they are statutorily entitled. In some situations health boards may impose a charge for the provision of in-patient services. However, a charge may be imposed only after 30 days, and only where the patient has no dependants. Furthermore, where a charge is to be imposed, this charge is determined by reference to the income of the patient only; there is no statutory provision to have regard to the income of other members of the family.
[...]
In the complaints I received the patients and their families were encouraged by the health board concerned to make arrangements with private nursing homes. In doing so, it would appear that some health boards did not explain their own legal obligations and encouraged the view that they had little, if any, responsibility for such patients.
In the cases I have examined typical private nursing home fees range between £150 and £200 per week. The typical patient would have a pension of about £65 per week leaving a shortfall of £85-£135 per week. The health board, for its part, would in certain cases, pay a weekly subvention of about £40. However, this subvention is payable subject to a means test which has regard, not only to the income of the patient, but also to the financial circumstances of the patient's wider family. Even where the £40 subvention is paid - and it was not paid in all the cases I have seen - there would be a weekly shortfall of between £45 - £95. This shortfall would have to be met by the patient's family. For very many families, meeting this shortfall is a crippling financial burden.
There would appear to be no statutory basis for a means testing system which includes the income of the family as well as that of the patient.
In the course of examining these complaints one health board involved acknowledged that such patients are entitled to be provided with in-patient services. Furthermore, the health board said it intended to meet its statutory obligation "subject to availability of resources". I take this to mean that the health board is not able to meet its statutory obligation from within its existing financial allocation. However, this health board appears to have continued its practice of encouraging patients into private nursing home care without alerting them to their existing statutory entitlements."
Feicimid mar sin gur aithin an tOmbudsman i 1992, agus gur fhoilsigh sé os comhair an tsaoil, na deacrachtaí cráite sin atá fós sa réimse seo den tseirbhís phoiblí ó shin i leith. Meascán mearaí, easpa faisnéise, gan teidlíochtaí reachtúla a sholáthar, easpa comhsheasmhachta, tástáil mhaoine a úsáid gan bhunús dlí - ba hiad sin na saintréithe a bhain leis an bhfreagra a thug an Stát orthu siúd a raibh cúram fadchónaithe riachtanach dóibh agus d’fhan an scéal amhlaidh. Ar an drochuair ní dhearnadh mórán de thoradh an méid a scríobh an tOmbudsman i dTuarascáil Bhliantúil 1992. Pléadh an Tuarascáil sa Seanad i Meán Fómhair 1993 ach níor luaigh aon duine a labhair na tráchtanna mionsonraithe a bhí déanta faoi cheist na dtithe altranais. Níor pléadh an Tuarascáil sa Dáil ach rinne an tAire Sláinte tagairt di i bhfreagra i scríbhinn ar Cheist Pharlaiminte (22 Meitheamh 1993) nuair a dúirt an tAire:
"I am aware of the comments of the Ombudsman in his report for 1992 about the provision of services in private nursing homes for persons eligible for services under section 52 [of the Health Act 1970]. The implications of his comments are being examined by my Department in the context of the Health (Nursing Homes) Act, 1990 which will be implemented shortly."
Ba é a tharla ná gur cuireadh an tAcht Sláinte (Tithe Banaltrais) 1990 i bhfeidhm is cosúil beag beann ar na ceisteanna a bhí tarraingthe anuas ag an Ombudsman. Chuaigh na fadhbanna a d’aithin sé chun donais le himeacht na mblianta de bharr athruithe déimeagrafacha agus na n-athruithe a bhí ag teacht ar na socruithe a bhí ag teaghlaigh, agus toisc go raibh daoine ag súil le seirbhísí níos fearr.
4.4 CAD A DEIR NA GEARÁNAIGH... Táillí Mídhleathacha
Rud eile a luadh arís agus arís eile sna gearáin ab ea an nós forleathan a bhí ag na boird sláinte i gcás daoine a raibh cártaí leighis acu agus a bhí i dteideal cúram fadchónaithe a fháil saor in aisce, caitheamh leo amhail is dá mbaineadh a gcartaí leighis díobh nó gur cuireadh a gcartaí ar fionraí a luaithe agus a tugadh áit dóibh i dteach altranais poiblí. Nuair a bhí a gcartaí leighis bainte díobh nó curtha ar fionraí bhí na boird sláinte in ann seasamh leis an gcaoi a raibh siad ag gearradh táillí orthu i gcomhair cúraim tí altranais. Chosain na boird sláinte an nós seo ar an mbonn gurb é sin an chomhairle a tugadh dóibh i gciorclán a eisíodh i 1976. Ba é a dúradh sa Chiorclán ná go raibh sé de chead ag bord sláinte glacadh leis i gcás duine a bhí á c(h)oinneáil i dteach altranais poiblí nach raibh an té sin clúdaithe ag an sainmhíniú maidir le “hincháilitheacht iomlán” (stádas carta leighis) agus go bhféadfaí táille a ghearradh air nó uirthi dá bharr sin. Tugadh le tuiscint go raibh an nós sin slán ó thaobh an dlí de óir mhol an Roinn é agus toisc go raibh sé á chur i bhfeidhm ó 1976 i leith.
Cúis imní don Ombudsman ab ea dlíthiúlacht an nóis sin agus tharraing sé anuas é arís is arís eile leis na boird sláinte agus leis an Roinn ar feadh na mblianta. D’fhéadfaí a rá agus muid ag breathnú siar ar an scéal go raibh an tOmbudsman soineanta sa mhéid is gur glac sé leis go bhfuair an Roinn comhairle faoi dhlíthiúlacht an chiorcláin sular eisigh sí é. (2)
Tharla cor nua sa scéal in 2001 maidir le cártaí leighis a bhaint de dhaoine i dtithe altranais poiblí. Leasaíodh an tAcht Sláinte 1970 an bhliain sin le go mbeadh cártaí leighis (“incháilitheacht iomlán”) ag gach duine os cionn 70 bliain d’aois gan aon tástáil maoine ná cruatain a bheith i gceist. Níor athraigh an scéal agus bhí gearáin á bhfáil i gcónaí ag an Ombudsman thar ceann daoine a rabhthas ag gearradh táillí orthu i gcomhair cúraim tí altranais poiblí bíodh is go raibh cártaí leighis acu. Ós rud é go raibh na hothair sin os cionn 70 bliain d’aois bhí siad i dteideal cártaí leighis a bheith acu agus ba chuma cén ioncam a bhí acu nó cén acmhainn a bhí acu íoc as a ndochtúirí ginearálta, a ndrugaí nó a seirbhísí ospidéil. Ní raibh lánrogha ag na boird sláinte sna cásanna sin cárta leighis othair a aistarraingt nó a chur ar fionraí. Nuair a thug Oifig an Ombudsman na gearáin sin chuig Bord Sláinte an Oirdheiscirt go hairithe, áitigh Oifig an Ombudsman gur cuma cén socrú a bhí ann roimh 2001 nach raibh ceart dá laghad ag na boird sláinte anois aon chárta leighis a thógáil ó dhuine a bhí os cionn 70 bliain d’aois, agus dá réir sin, nach raibh aon bhord sláinte i dteideal táille a ghearradh ar a leithéid de dhuine i gcomhair cúraim tí altranais.
Fuair Bord Sláinte an Oirdheiscirt comhairle dlí faoi na pointí a bhí tarraingthe anuas ag an Ombudsman agus iad ag plé leis na gearáin sin. Is léir gur thacaigh an chomhairle a fuair an Bord Sláinte le seasamh an Ombudsman agus go ndúirt an comhairleoir: "We are not aware of any statutory justification for the practice of removing medical cards from patients in receipt of long-term care." (3) Dúirt an Bord Sláinte, áfach, ina fhreagra don Ombudsman i bhFeabhra 2003 go raibh curtha in iúl ag an Roinn " that they have legal advice, which contradicts the Board's legal advice. This is now being studied by our legal advisors." . Theip ar iarrachtaí réiteach a fháil idir an dá sheasamh dhlíthiúla agus níor réitíodh an scéal go dtí go ndearnadh ceist mhór pholaitiúil i ndeireadh na bliana 2004 den nós mídhleathach táillí a ghearradh ar othair fadchónaithe. Ghlac an tAire Sláinte agus Leanaí leis ag an bpointe sin gan aon athbhrí gur nós mídhleathach a bhí ann cártaí leighis a bhaint de dhaoine agus táillí a ghearradh orthu i gcomhair cúraim fhadchónaithe, agus go raibh sé mídhleathach ó 1976 i leith.
Foilsíodh Tuarascáil Travers in 2005 agus pléadh na saincheisteanna sin go mion i dTithe an Oireachtais mar thoradh. Sa deireadh thiar thug an Chúirt Uachtarach breith ar bhunreachtúlacht an Bhille Sláinte (Leasú) (Uimh. 2) 2004. Chinn an Chúirt Uachtarach go raibh an Bille míbhunreachtúil sa mhéid is go raibh sé d’aidhm aige bailíocht siarghabhálach a thabhairt do tháillí a bhí gearrtha roimhe sin, agus a bhí mídhleathach ag an am a gearradh iad. Ní gá dul siar arís go mion anseo ar na cúrsaí sin.
Cúis mhór iontais i gcónaí is ea gur cosúil gur mhaígh an Roinn agus í ag déileáil le Bord Sláinte an Oirdheiscirt in 2003 go raibh comhairle dlí faighte aici (ó Oifig an Ard-Aighne, is cosúil) gur nós dleathach a bhí ann cártaí leighis a bhaint de dhaoine a bhí curtha i gcúram fadchónaithe. Tá a fhios againn anois, agus a bhuíochas sin do Thuarascáil Travers, ní hamháin nach raibh comhairle dlí faighte ag an Roinn ag tacú leis an gcleachtas sin ach go raibh comhairle dlí faighte aici a cháin go tréan é. Léiríodh sa Tuarascáil nárbh iad comhairleoirí dlí na Roinne féin a thug an chomhairle sin ach beirt Abhcóidí Shinsearacha (ceapadh duine díobh ina Phríomh-Bhreitheamh ina dhiaidh sin).
Tuigimid anois gurb é a spreag an Roinn agus na boird sláinte gníomhú sa chaoi sin ná easnamh mór ó thaobh an mhaoiniú sláinte a bhí á chur ar fáil agus an riachtanas a bhí ann foinse maoinithe a choinneáil trí tháillí a ghearradh ar gach othar fadchónaithe. Ní leithscéal ar bith é sin maidir leis an gcaoi a raibh an Roinn agus na boird sláinte ag ceilt na fírinne, agus nár nocht siad riamh í thar thréimhse fiche bliain (1985 - 2005) agus iad ag plé leis an Ombudsman, go raibh an cleachtas a bhí ar siúl acu glan in aghaidh na comhairle dlí a bhí faighte acu. Ní hionann é sin agus a rá gur chóir d’údaráis phoiblí ligean do chomhairleoirí dlí cinntí a dhéanamh thar a gceann, agus is léir don Ombudsman ón taithí atá aici anois go bhfuil claonadh i measc lucht na seirbhíse sláinte poiblí anois urraim rómhór a thabhairt do chomhairle dlí, ach ba chóir d’eagraíocht phoiblí a bheith an-chúramach agus í ag diúltú do chomhairle dlí, go mór mór nuair a tugadh an chomhairle sin arís agus arís eile thar thréimhse ama agus gur comhairleoirí éagsúla a thug í.
Is fíor, faoi mar atá tugtha le fios ag FSS (4), gur léirigh na boird sláinte ábhar imní don Roinn i gcaitheamh na mblianta faoi na socruithe sin maidir le gearradh táillí. Sa mhéid sin féadfar a thuiscint go raibh an Roinn níos ciontaí ná na boird sláinte. Is mór an mí-ádh áfach, nár ghníomhaigh na boird sláinte ar bhonn na n-ábhar imní a bhí acu.
Nótaí
(Nóta 2) Tuigimid anois ó Thuarascáil Travers go raibh a fhios ag na boird sláinte agus ag an Roinn ó thús nach bhféadfaí an cleachtas seo a chosaint ó thaobh an dlí de.
(Nóta 3) Luaite i dTuarascáil Travers, alt. 3.35 (iv)
(Nóta 4) Thug FSS le fios (ar Lch 6) ina freagra ar dhréachtleagan na tuarascála seo go raibh ábhair imní ag na boird sláinte "around the legality of raising such charges and raised these concerns on a number of occasions [between 1977 and 2003] with the Department ...". Thug FSS le fios freisin gur iarr na boird sláinte ar an Roinn comhairle na hArd-Aighne a iarradh tar éis do Bhord Sláinte an Oirthir comhairle dlí a fháil in 2003. Sa deireadh thiar, tugann FSS le fios gur dhearbhaigh an tArd-Aighne gur tugadh an chomhairle cheart do Bhord Sláinte an Oirthir; tharla sé sin go déanach in 2004.
4.5 CAD A DEIR NA GEARÁNAIGH... Freagra an Ombudsman ar Thuarascáil Travers
Ba é a rinne an tOmbudsman de thoradh na faisnéise a léiríodh i dTuarascáil Travers ná aighneacht a dhéanamh an 3 Meitheamh 2005 chuig Comhchoiste um Shláinte agus Leanaí an Oireachtais. Tá an aighneacht sin an-ábhartha sa chomhthéacs reatha agus ar an ábhar sin tá an sliocht fada seo leagtha amach thíos
“From the late 1980s onwards, the Ombudsman dealt frequently with complaints about the entitlement of medical card holders to long-stay hospital services. Many of these cases concerned elderly people receiving what is now being termed 'nursing home' care; some concerned people, not necessarily elderly, in long-stay care because of a psychiatric condition or some long-term debilitating illness. The complaints related to the fact that these patients were being charged despite the fact that they had medical cards and/or despite the fact that they had dependants. In many instances, the health board concerned would have revoked the medical card of the patient - though not on the basis of a proper and procedurally fair process. The Ombudsman's thinking on these cases was (a) that the type of care being provided constituted an "in-patient service"; (b) that such a service should be provided, as a matter of right and without charge, to medical card holders and to people without a medical card provided they had a dependant; and (c) that the practice of removing a medical card from a person, once hospitalised, was not tenable.
The Ombudsman discussed these matters frequently with the particular health boards involved and with the Department centrally. The logic of this approach was that, without the support of the Department, the individual health boards were not likely to change their practice. What actually happened was that health boards, often with the encouragement of the Department, changed their practice in particular cases; but, as is now well known, the impugned practices continued generally and the law was not changed to validate those practices.
During those years, the Ombudsman drew attention to these matters by way of items in his Annual Report to the Oireachtas. Annual Reports for the years 1988, 1989, 1991, 1992 and 1994 dealt specifically with the issue. The matter was referred to as a related issue in the report 'Nursing Home Subventions' (January 2001) but it was something which the then Ombudsman very explicitly raised in his oral presentation to this Committee on 21 June 2001. Annual Reports for 2002 and 2003 again reported cases in which these matters figured. By any reckoning, this was an exhaustive effort to draw attention to practices which the Ombudsman believed to be invalid.
What we now know, arising from the Travers Report, is that throughout this extended period the Department and, to a lesser extent the health boards, had solid and uncontroverted evidence to support the position taken by the Ombudsman. Very regrettably, the Ombudsman was never made aware of this evidence.
The Travers Report shows the following:
- that in June 1976 the Department received legal advice that a person with a medical card (full eligibility) could retain eligibility for in-patient services irrespective of how long hospitalisation lasted; and that a hospital patient could only have a medical card removed where the health board was satisfied that the patient could provide general practitioner services for himself and his dependants; [Para. 3.4]
- that in July 1977 the Department received legal advice that its Circular 7/76 "would not stand up in court" in so far as it encouraged health boards to remove the medical card from long-stay patients; [Para. 3.7]
- that in July 1978 the Department received, via the Eastern Health Board, the legal advice of two eminent Senior Counsel which confirmed the opinion of July 1977; [Para. 3.10]
- that, over the years, the Department's legal adviser expressed dissatisfaction with the Department's continued reliance on Circular 7/76; [Para. 3.13]
- that an internal Departmental review of January 1982 acknowledged the legal invalidity of the practices in question; [Para. 3.14 - 3.16]
- that in February - March 1987 the then Minister for Health brought a Memorandum to Government with a legislative proposal to deal with the matter; [Para. 3.17 - 3.22]
- that in August 1992 the Department produced a report entitled 'Review of Long Stay Charges Report' which again acknowledged the legal invalidity of the impugned practices. [Para. 3.25]
The Department omitted to inform the Ombudsman of these crucial developments and related legal advice. Disclosure of this information would have established, in the language of section 4 of the Ombudsman Act 1980, that the Department's actions (and those of the health boards in reliance on the Department's position) were being 'taken without proper authority'.
In its discussions with the Ombudsman, the Department purported to have been unaware of the Supreme Court judgment in the McInerney case. (This judgment established that persons in long-term care, in health board institutions which provided nursing and other para-medical care, were receiving 'in-patient' services as defined at section 51 of the Health Act 1970. Persons with medical cards were, at that stage, entitled to 'in-patient' services without charge.) Whereas at one point it appeared to accept the Ombudsman's analysis in full, it later resiled from its acceptance of a key aspect of that analysis and refused to accept that the Health Act 1970 conferred a legally enforceable entitlement to in-patient services.
[...]
Had the Ombudsman been aware that the Department had been provided, over successive years, with definitive legal advice on the matter, and been aware that the analysis he was offering was no more than that already provided to the Department by its own and health board legal advisers, he would have reported to the Oireachtas on the matter both more fully and more definitively. He would also have drawn the weight of evidence to this Committee's attention when he appeared before it on 21 June 2001. Furthermore, in dealing with complaints in this area, it is very likely that the Ombudsman would have completed investigations and made recommendations providing for appropriate redress. However, in a situation in which he did not know of this evidence, and despite the strength of the argument he was himself making, the Ombudsman stopped short of making recommendations in individual cases.
If it had been possible to provide the Oireachtas with a detailed analysis as outlined above, it could have ensured that the necessary legislative steps would have been taken either to validate the existing practice or to provide a valid legal alternative. Had the matter been resolved in 1991- 1992, when there were intensive discussions between the Department and the Ombudsman, a very substantial portion of the overpayments (now required to be refunded) would never have arisen.”
4.6 CAD A DEIR NA GEARÁNAIGH... Díolaim Ghearán 1985 - 2010
Tógadh na sleachta thíos den chuid is mó ó chomhaid ghearán an Ombudsman agus tá siad bunaithe ar litreacha ó ghearánaigh nó ó nótaí comhad a rinne cásoibrí an Ombudsman. Bíodh is nach bhfuil cúis ar bith againn a chreidiúint nach ndearnadh na gearáin le hintinn mhaith, níl an tOmbudsman ag maíomh gur iniúchadh gach éileamh díobh agus go bhfuarthas go raibh siad cruinn. Tá na sleachta á gcur ar fáil mar léiriú ar chásanna na ngearánach. (Nóta 5)
1986
Nóta Cásoibrí an Ombudsman, (3 Nollaig 1986)
"Her mother is in [a private nursing home]. Costs £20 per day i.e. £600 for 30 day month... mother's Garda Widow's Pension of £400 does not cover this and daughter pays the rest. Has tried to get Health Board subvention and can't understand why it is not coming through. ... She told me her husband is on £62 Invalidity Pension ... and she is on £45.80 Disability Benefit ... Their 17 year old son is left school and won't qualify for anything until he is 18 years ...of this income they have to meet the shortfall of £50 to £55 per week for the Nursing Home.
[...] She said her mother is happy in [the private nursing home] and would die if she had to move to another. Whatever happens, they will starve themselves rather than move the mother who is aged 88. She looked after her for as long as she could but now she needs nursing care.
I told her that her only hope short-term was to apply for Supplementary Welfare Allowance for themselves. I said I'd check to see if anything could be done to help."
1989
Litir chuig Oifigeach Achomhairc Bhord Sláinte an Oirthir (20 Iúil 1989)
"I am in receipt of a contributory old age pension at £93.00 per week. My wife, Mary, is in X Nursing Home on X Road, which costs £130 per week. I asked the Community Welfare Officer ... for help with this, and they got the Nursing Home Section in St. Mary's Hospital to increase the grant to the nursing home to £65.00 per week. This means that I also have to pay £65.00 per week to the nursing home, leaving me with only £28.00 to live on. Out of this I have to feed and clothe myself, pay bills, and also buy essentials for my wife and sometimes a few "luxury" items like diabetic orange and sweets.
I went back to [the] Health Centre, but they said they couldn't help and to contact the Nursing Homes Section again. My Social Worker wrote to them, but they said they couldn't help either."
1990
Nóta Cásoibrí an Ombudsman, (21 Bealtaine 1990) - cárta leighis tógtha ó dhuine i gcúram fadchónaithe
"... persons with full eligibility are entitled to hospital in-patient services free of charge. ... As charges are being imposed [in this case], the grounds for so doing would seem to be that on entering hospital they cease to be persons with full eligibility. The rationale for this is presumably that while they are in hospital they are no longer persons who, without undue hardship, are unable to arrange general practitioner, medical and surgical services for themselves and their dependants as required by Section 45(l) of the Act i.e. for the duration of the hospitalisation these services are provided for them by the hospital. This is the kernel of the issue. The question is: have the health boards the legal right to alter a person's status on their entering hospital i.e. to decide that a person is no longer a person with full eligibility who is entitled to hospital in-patient services free of charge but is now a person with limited eligibility who can be charged after 30 days if there are no dependants. I would suggest that the health boards do not have such a right.
[...]
I find it incongruous that when that person comes to avail of the service a second decision is then taken that they no longer have full eligibility. ... It would seem that the health boards are ignoring the provisions of the legislation and the question of their actions being ultra vires must arise."
1993
Nóta Cásoibrí an Ombudsman, (16 Lúnasa 1993)
[Bhí an gearánach ag tabhairt aire dá máthair scothaosta sa bhaile; bhí cúram cónaitheach riachtanach i gcomhair a dearthár a bhí le scaoileadh abhaile ó ospidéal géarmhíochaine; bhí an t-ospidéal ag cur brú ar an ngearánach a deartháir a thógáil abhaile. Is nóta é seo faoi dhíospóireacht le dochtúir ó Bhord Sláinte an Oirthir a a bhí ina C(h)omhordaitheoir Seirbhísí i gcomhair Daoine Scothaosta.]
"Dr. X told me that she has advised Ms. Y not to allow [the] Hospital to pressurise her into taking her brother home when she clearly is unable to look after him. Dr. X accepts that Ms. Y is under intense pressure from [the] Hospital to take her brother away.
Dr. X confirmed almost all of the detail given by Ms. Y in her letter to us. In particular, she confirmed that Ms. Y suffered greatly while trying to cope with both her brother and her mother and that her own health is at risk. Dr. X mentioned that the family doctor has also been making every effort to have the matter resolved but has failed.
In the course of my discussion with Dr. X it became clear that she had no understanding whatever of the obligation on the health board to provide long stay care for patients such as [Ms. Y's brother]. She said she had seen the Irish Times piece by Padraig Ó Móráin which summarised comments made by the Ombudsman. She asked to be sent a copy of the Ombudsman's comments. She agreed that neither the EHB nor [the] Hospital would have advised Ms. Y that it was open to her brother to seek to have the EHB provide for his long stay needs under Section 52 of the Health Act 1970. Indeed she did not know that this was the case herself."
1994
Tuarascáil Bhliantúil an Ombudsman, 1994
[Bhí sé de nós ag boird sláinte, le moladh na Roinne Sláinte, cásanna aonair a réiteach nuair a tugadh dúshláin táille mídhleathaí i gcomhair cúraim fhadchónaithe ach leanúint ar aghaidh i gcónaí leis an gcleachtas mídhleathach sna cásanna eile.]
"A woman, whose husband had been hospitalised for almost a year, complained that she had been requested by the hospital to pay a sum of £40 weekly for his maintenance. Her complaint related to the difficulties she was having, as a dependant on her husband's Social Welfare pension, in maintaining herself and her home on the balance of the pension. In an initial contact with the Health Board on the matter, my investigator pointed out that the circumstances as outlined suggested that no charge should apply. The man in question had a medical card and he had a wife who was a dependant on his pension. Health Regulations exempt such a category of person from in-patient charges.
The Health Board responded that, by imposing a charge determinable by reference to domestic financial commitments, they were acting in accordance with legislation. Eventually, the Board conceded that such a legislative basis did not, in fact, exist but they continued to defend the practice by claiming to have the right to charge for maintenance. They also claimed that the residue of pension available to his wife was reasonable.
I became very concerned at the apparent failure of the Health Board to recognise that the statutory provisions specifically precluded charges in the circumstances of the complainant and that this imposition had resulted in continuing difficulty for the woman in question. Following the intervention of the Department of Health, at my request, the Health Board informed me that the case had been reviewed and that the maintenance charges had been raised in error. They said that they would cease the practice immediately and that all charges paid would be refunded."
1996
Nóta Cásoibrí an Ombudsman, (6 Meitheamh 1996)
"Complainant's wife, Mary, has been in a nursing home since 16/6/94 following a serious illness. She is 83 years old as is complainant. Initially the fees were £130 pw but were raised to £170 pw from 1 January 1996. An application for subvention, made before his wife went into the home, was refused. Complainant appealed this unsuccessfully. When the fees increased in January 1996 he again applied but was refused. An appeal was unsuccessful. The health board takes the view that his married daughter, who lives in X, is able to subsidise the costs. Complainant rejects this as his daughter has been gone for 26 years and is independent of her parents. In fact, the daughter does contribute by meeting all the extra costs (his wife is doubly incontinent) - clothing, equipment, laundry etc. and also travels regularly to see her mother.
Complainant says that, after paying the nursing home fees, he has only £35 pw to live on - and this is inclusive of the income tax relief for medical expenses. He says he runs a car as it is the only way he can get to visit his wife - whom he visits four times a week. Whatever savings they had are being gradually eroded and they will not have sufficient to bury themselves, he feels."
2001
Litir ó Ghearánach chuig an Ombudsman, (18 Feabhra 2001)
"...my mother has been in the [private] Nursing Home for the past 10 years. She is a widow with no assets (she only had a rented house). She is just 93 years of age. ... As a family we have been making up the shortfall [between nursing home fees and health board subvention] for the past 10 years. My husband and I are both over 60 years of age, and he needs to retire shortly. I am a full-time housewife and do not work myself. In the past 12 months we have paid over £6,500 to the [nursing home]. During the course of the past 10 years it has cost us over £35,000 and all our savings have disappeared.
At present we are trying to place my mother in a cheaper nursing home but unfortunately due to her age, infirmity and dependence it is proving very difficult."
2005
Nóta Cásoibrí an Ombudsman, (11 Márta 2005)
"His late mother had been in a private nursing home for three years from 1999 to 2002. She had a medical card and was over 90 years of age when she died (R.I.P.) in August 2002. Mr.X had no option but to put her in a private nursing home as there were no public beds available. She was getting a subvention from the [health board], handing up her pension and he (Mr. X) had to make up the shortfall in nursing home fees. In order to do this he had to vacate the family home and rent it out. His only income was his Contributory Old Age Pension. He is 76 years old now. He went to stay with friends and paid rent there. While his mother was in the nursing home he had just finished a course of chemotherapy for a tumour on the lung. He had been attending Hospital for check-ups and treatment."
2007
Litir ó Ghearánach chuig an Ombudsman, (5 Deireadh Fómhair 2007)
(Mháigh an gearánach seo go raibh uirthi a máthair a chur i gcúram príobháideach toisc nach raibh cúram poiblí le fáil. Tugadh leaba a raibh maoiniú poiblí le fáil faoina comhair dá máthair tar éis sé bliana.)
"In December 2005 the HSE finally provided a contract bed for her in ... this happened after 6 ½ years of negotiation. [...]
The situation of public versus private care is totally and utterly discriminatory. Can you please explain to me the difference. My neighbour has a loved one in a public Care Centre and I have my mother in a private home. My neighbour is being paid back (i) for being overcharged by the State and in my position this is being refused to me just because the State forced my mother into private care because they couldn't provide it. This is totally discriminatory to the Constitution of this State which states all citizens are of equality.
I don't know if the Office of the Ombudsman can take this case forward ... to recover our losses ... which stand between €80,000 and €85,000. If this can't be progressed via these means the only way forward is through the courts."
(i) Is tagairt é seo don Scéim Aisíoca Sláinte faoina raibh daoine ar gearradh táille mídhleathach orthu i gcomhair cúraim fadchónaithe in institiúidí poiblí i dteideal aisíocaíochta a fháil mar aon le hús ar na táillí sin. Ba é a bhí á mhaíomh ag an ngearánach ná go riabh daoine gur theip orthu áit a fháil in institiúid phoiblí agus nach raibh an dara rogha acu ach dul go cúram príobháideach faoi mhíbhuntáiste dhúbailte (a) toisc go raibh orthu íoc as costais an-arda tithe altranais agus (b) toisc gur eisíodh iad ó bhuntáistí na Scéime Aisíoca Sláinte.
2009
Ríomhphost ó Ghearánach chuig an Ombudsman, (5 Iúil 2009)
(Tá breoiteacht thromchúiseach ar mháthair an ghearánaigh agus tá cúram fadtéarmach i dteach altranais riachtanach di. Tá a máthair faoi bhun 65 bliain d’aois, áfach, agus níl sí in ann seirbhísí FSS i gcomhair daoine scothaosta a fháil agus ní raibh sí in ann cúram tí altranais phoiblí a fháil. (Nóta 6))
"My mum has no property and no other income but her social welfare so she qualified for the full subvention of 340 euros a week and I've to make the difference i appealed it straight away to be told 6 months later when i was growing concerns of lack of finances at home how i was going to pay for my mums care and applied for an enhancement payment of which i haven't heard of anything back of yet.
At present I'm finding things very difficult keeping up my job and bills and our mortgage with my husband not with regular employment and I've tried to get hse care for my mum and she doesn't qualify because she doesn't fall into the elderly until she's 65 there is nothing or no services for her illness even ...
I don't know how much more of all this i can take emotionally or physically my children are suffering emotionally with me not here
i know i am going to have to give up my right to contribute for her care as i cant afford it and don't want to loose my home because of my lack of funds and how will i pay to Berrie her that was to come from her savings and there nearly gone, i don't know what will happen if i have to do this and its a horrible thing to have to do but it looks like my only option."
Nótaí
(Nóta 5) Rinne an Roinn agus FSS araon agóid ina n-aighneachtaí faoin ábhar seo a bheith curtha san áireamh. Deir FSS go bhfuil sé deacair trácht a dhéanamh ar na cásanna toisc nár aithníodh na gearánaigh ar leith, bíodh is go ndéanann siad trácht ar chúigear díobh. Cáineann an Roinn an chaoi a bhfuil an tOmbudsman ag braith "upon complaints which, it is conceded, were not investigated ... and found to be accurate" agus "have not been notified or brought to the attention of the Department during the course of the investigation and which it has not had an opportunity to examine or to comment upon".
Ba é cuspóir an Ombudsman maidir le cuimsiú an ábhair seo (ar ábhar stairiúil é den chuid is mó) ná léiriú a thabhairt, ina focail féin go minic, ar an bhfrustrachas a d’fhulaing a lán daoine agus an mearbhall a bhí orthu agus iad ag iarradh cúram fadchónaithe a fháil i gcomhair ball teaghlaigh. Ins na cásanna sin go léir chuireamar an bord sláinte ábhartha nó FSS ar an eolas sa ghnáthbhealach ag an am. Bíodh is nár cuireadh próiseas foirmiúil ar siúl chun na cásanna sin a imscrúdú, próiseas a dhéanfadh cinntí agus a d’eiseodh moltaí, mar sin féin rinneadh iniúchadh ar na cásanna sin in Oifig an Ombudsman. Níl bheadh sé réalaíoch anois iarracht a dhéanamh breith a thabhairt ar fhiúntas na gcásanna faoi leith. Ar an ábhar sin níor iarr an tOmbudsman freagra ó FSS ag an bpointe sin agus ní raibh sí ag súil lena leithéid uathu. Maidir le hábhair imní na Roinne, rinneadh na gearáin in aghaidh na mbord sláinte (FSS) agus níor chásanna iad ar chóir an Roinn a chur ar an eolas fúthu.
(Nóta 6) Tá máthair an ghearánaigh seo ag baint leas as Scéim um Thacaíocht Tithe Banaltrais anois agus ní gá anois don ghearánach cabhrú chun íoc as costais tí altranais a máthar.