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Vol 3, No 24
Summer Special 2001
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An Ombudsman to Protect Us
Interview with
Katalin Gönczöl [Part 5]

Gusztáv Kosztolányi

Click here to read Part 1, Part 2,
Part 3 and Part 4

The Ombudsman's Annual Report makes for fascinating, if somewhat distressing reading, furnishing invaluable insights into the gradual evolution of our society into a more humane environment in which to live, where citizens are not regarded as subservient to the powers that be, as labour units, whose existence is grudgingly tolerated as long as they contribute to the greater good of the state.

The best indicator of how far we have progressed along this road is to confront uncomfortable truths about how the poorest, weakest and most vulnerable sections of the population are dealt with by the authorities and to root out the injustices exposed. The stamina and sheer dedication essential to the completion of the task are both qualities Katalin Gönczöl possesses in abundance.

In what follows, I have singled out but two of the many passages of the report to illustrate typical problems.

The right to be cared for

In 2000, the Ombudsman conducted an ex officio investigation into the right to health care, with specific reference to the homeless:

The investigation extended to every level of health care provision, including a survey of emergency, GP and acute hospital care given to homeless persons as well as the situation of individuals in need of treatment for chronic conditions and of rehabilitation. Particular attention was paid to after care and the fate of patients requiring ongoing medical attention.

The on-the-spot investigations covered 15 health care providers in the capital, including some exclusively devoted to helping the homeless. We discovered that the homeless do not feature in the register of most institutions, which therefore means that no reliable data exists concerning the care they received or whether they were turned down for assistance. For the purposes of providing individual care a homeless person is defined as someone, who spends his nights in public spaces or premises not intended for habitation as a dwelling. Persons with fictitious addresses are also deemed to fall into this category.

Many homeless persons drop out of the primary care system, because they are not in possession of a sickness insurance card. They only see a doctor once their condition has deteriorated to the extent that they require urgent medical intervention. Following the provision of acute care, however, the vast majority is "released" by the hospital, which means that they end up on the streets once again.

On the territory of the Republic of Hungary emergency care is due to everyone, regardless of whether they have sickness insurance or not. The precondition of access to all other forms of state-provided health care service is being in possession of sickness insurance, which the homeless do not have at their disposal as a general rule.

Since 1993, however, the law on social administration guarantees them access to medical care. On the basis of a card issued by the relevant Mayor's Office attesting to their straitened social circumstances, they are entitled access to health care services and it is within this framework that several organisations in the capital lend assistance to the homeless. The necessary document can usually be obtained with their collaboration. It is not typical of the capital that the patient is refused health care due to the absence of the card. The vast majority of homeless are taken from the streets into the health care institutions by the National Ambulance Service [Országos Mentőszolgálat, OMSZ].

The Central Bed Management Service [Központi Ágygazdálkodási Osztály, KÁNY] attached to ÁNTSZ [Állami Népegészségügyi és Tisztiorvosi Szolgálat—State Public Health and Medical Officer Service] takes charge of places for patients, who need to be admitted to a hospital bed.

Since 1 January 2000, the underlying aim in bed management has been to distribute homeless patients evenly throughout institutions regardless of where they were found. In spite of these efforts, certain hospitals and wards continue to accept strikingly high numbers of homeless patients, whereas others hardly admit them or fail to admit them altogether. On such occasions the paramedics themselves ignore the instructions issued by KÁNY and take the patients to the "customary" destination. Every week there are cases whereby the hospital refuses to admit homeless patients brought to it on the instructions of KÁNY by paramedics.

In the interests of remedying the breach of constitutional rights, the Ombudsman proposed that the head of the Budapest ÁNTSZ Institute publish a circular aimed at the capital's hospitals. The letter would point out that wherever the requisite conditions had been fulfilled the health care institution was obliged by law to comply with KÁNY's decision to send a patient there.

At the Ombudsman's request, the Budapest Branch of the OMSZ registered separately the number of homeless persons it was called to assist in November 2000. Of the 468 cases a total of 154 led to hospital admission. Two thirds of the homeless registered therefore remained on the streets. In order to prevent cases of hypothermia arising as a result of the drop in temperature in winter, the head of the Budapest OMSZ ordered that the homeless should be taken from public spaces to a safe place, provided they gave their consent to that effect even if their injuries or general state of health were not such as to merit hospitalisation.

If the person in question protested, the ambulance team would have no choice but to leave them where they were found. The Ombudsman established that in such cases a properly trained and qualified social worker with an appropriate institutional background would stand a greater chance of persuading the homeless person to accept the offer of help. The organisations, which employ social workers specifically trained to help people on the streets, do not receive information about individuals left in public spaces.

By leaving homeless persons fully in possession of their faculties and who have protested against being taken to a safe place on the streets and by omitting to inform any social service or institution of their whereabouts, the ambulance service exposes them to further danger.

For this reason, the Parliamentary Ombudsman proposed that the head of the Budapest Branch of the OMSZ ensure that information about the homeless left behind on the streets be passed on regularly.

As a result of life on the streets, the patients taken to hospital by the ambulance service are unwashed as a general rule and are often infected by head lice. A disinfecting bath is one of the preconditions of admission to hospital, but hospitals themselves are unwilling to carry this procedure out themselves and most of them do not even maintain the appropriate facilities in order to do so. In such instances, the patients are dispatched to one of the disinfectant baths run by the ÁNTSZ. In certain cases this can be particularly dangerous for the patient, as it may involve several hours of travel and waiting before the doctor can intervene.

The report pointed out that pre-admission disinfecting is the legal obligation of the health care provider. Shifting the responsibility for it on to someone else may jeopardise the patient being provided care in time.

To remedy this breach, the Ombudsman proposed that the Metropolitan Local Council, in its capacity as the authority responsible for running and maintaining hospitals, should see to it that they implement the contents of the decree in an appropriate fashion by carrying out the disinfecting procedure on patients arriving at their doors wherever the need arose.

The three hygiene and disinfecting baths run by the ÁNTSZ in Budapest play a particularly important role in the health care of the homeless. At these premises, facilities also exist for heat-assisted mechanical disinfection and for washing. The institute takes care of the disinfectants and hygiene products.

Preventive individual treatments are also carried out with the help of experts on disinfection (in 1999, 72,664 such treatments occurred!), which afford protection against becoming infested with lice over a certain period of time for homeless persons, who have not yet been infected by the parasites. The baths are used to full capacity. The ÁNTSZ also runs a GP surgery attached to two of the baths, which also has a large turnover of patients and which is able to hand out free medicines to those in need.

In the course of the investigation, it was brought to the Parliamentary Ombudsman's attention that the Chief Medical Officer is planning a reorganisation exercise. The agenda of the restructuring includes transferring the GP surgeries attached to the baths to another service provider, which might entail the surgeries moving. The Ombudsman concluded that if the system—which currently functions as an organic whole—were to be broken up, this might lead to a cessation of medical treatment, which would adversely affect the homeless afforded treatment there. The Ombudsman proposed that the Chief Medical Officer take pains to preserve the service's present integrated system.

The second element of the planned restructuring was for the ÁNTSZ to pass on the task of mass disinfection to another institution in future. In conjunction with this plan, the Parliamentary Commissioner drew attention to the fact that closing down the current system, which functions both smoothly and effectively, would not only be to the detriment of the state of health of the homeless, but would also bring about an increased risk to public health in general. It is beyond doubt that the legal provisions concerning disinfection do not prescribe preventive treatment for individuals at risk of becoming infested with lice.

Withdrawal of the service provided by ÁNTSZ, however, would represent a breach of the constitutionally guaranteed right to the highest possible level of physical health. The Parliamentary Commissioner therefore proposed that the Minister of Health amend the relevant departmental order, to the effect that operating the disinfectant bath for individuals exposed to a greater risk of becoming infested with lice should be listed amongst the tasks to be dealt with by ÁNTSZ.

At the time of the investigation, ten GP surgeries treating the homeless were being run in Budapest. (Apart from these, a further nine exist throughout the country as a whole, which means that most of the county administrative seats have not availed themselves of the opportunity to conclude contracts to fund such work by GPs via the National Health Insurance Fund). In these surgeries, care provision is not dependent on the patient residing within the vicinity or any other condition.

The homeless are given treatment even if they do not have a sickness insurance number. With the introduction of the surgeries specifically providing care for the homeless, the basic health care system has been split in two, although it nevertheless appears as if this solution will cover the health care needs of the homeless in the capital in the long term. As far as hospital treatment for the homeless is concerned, there are various difficulties beyond the complications of prospective patients being admitted or turned away.

Generally speaking, once the emergency or acute treatment has been completed, the hospitals strive to rid themselves of the homeless patients as quickly as possible, but they have nowhere to transfer them to. Only a fraction of chronically ill patients requiring further care or those in need of rehabilitation can be admitted to the handful of institutions specialising in the field. The equipment at their disposal and the funding they receive are not always commensurate with the demands placed on them.

The Ombudsman established that wards run by the FSZKI [Fővárosi Szociális Központ és Intézményei—Metropolitan Social Welfare Centre and its Related Institutions], the Shelter Charitable Association and the Szent János Hospital's Second Chronic Pulmonary Ward fall into this category, and proposed that the Director-General of the National Sickness Insurance Fund should solve the funding problem for these institutions by adjusting it to take account of their actual activities.

Facts demonstrate that the state of health of patients discharged onto the streets before the period essential to a full recovery has elapsed rapidly deteriorates to an even worse condition than before. The investigation revealed that the question of health care for homeless persons, who are not able to return to the streets having undergone medical intervention such as amputation or who suffer from incurable secondary illnesses, remains virtually unresolved.

Multitudes of homeless persons unable to provide for themselves are not being accorded the care prescribed by law as an obligation of the state, because the number of care and nursing institutions with long-stay beds and the total places available within them is extremely small.

Since 1 October 1999, the metropolitan and county local governments have been under a statutory obligation to set up and maintain such institutions. Nor is there room available to the homeless in the existing social welfare homes, as they are already overcrowded; the waiting list for places is extremely long and, due to their general poor health, they do not extend a ready welcome to homeless persons in need of long-term medical care.

In this respect, there is an absence of co-operation between the health and social spheres. Deficiencies in the provision of aftercare constitute a direct injury to the rights to social security and the highest level of physical and mental health to which these individuals are entitled.

In the interests of remedying these irregularities, the Ombudsman proposed that the Minister of Health and the Minister of Social and Family Affairs jointly take stock of the real needs for care, nursing and rehabilitation facilities for the homeless across the country. On completion of the survey they should adopt the requisite measures to come up with solutions appropriate to ensuring that the local government tasks set down in law are actually fulfilled.

Discrimination against the disabled

The second excerpt reveals the enormous (yet easily overcome) practical difficulties faced by our disabled fellow citizens:

The largest group of the disabled is made up of persons with reduced mobility. The overwhelming majority of them live in our midst in the community. Although their ability to stand up for their interests and to have them taken into account is constantly improving, their situation continues to be very difficult in spite of the fact that relatively little effort would be needed to integrate them fully into society as equal members.

In 1999, the Parliamentary Commissioner carried out a comprehensive ex officio investigation into persons with reduced mobility and access to buildings, with particular reference to respect of their human rights. The Commissioner ascertained that irregularities pertaining to the constitutional rights of persons with reduced mobility have existed over a long period and that new irregularities continuously arise. Elimination of situations where discrimination occurs has begun on a sporadic basis, but the process has nevertheless proven slow and of variable quality.

The Parliamentary Commissioner proposed that the Ministers of Social and Family Affairs, of Agriculture and Rural Development, of Justice and of National Cultural Heritage work together to eradicate the shortcomings of the various legal provisions concerning full and unimpeded access, and that the Minister of Finance makes the necessary funding available.

The Commissioner requested the heads of the public administration offices to utilise their supervisory powers to examine the planning permission granted to all the new buildings in general use in every instance where full and unimpeded access has not been provided for. Where planning permission had originally been granted in good faith, use of the buildings in question could continue, but the officials were encouraged to take the necessary steps to see to it that the premises were upgraded to bring them in line with the access rules.

They were furthermore encouraged to ensure that, in future, neither planning permission nor operating permits be awarded to buildings which fail to comply with access guidelines. The Ministers accepted the recommendations. The rules on full and unimpeded access to buildings are in the process of being modified, and we have delivered our opinion on the draft. The heads of the public administration offices have adopted the measures called for. By organising training courses and carrying out follow-up inspections, they have prevented a repeat of the irregularities committed.

In 2000, we investigated the conditions for full and unimpeded access, not only in relation to buildings but also in relation to transport. The Parliamentary Commissioner made recommendations to four ministers and the Mayor of Budapest in conjunction with extending the system of stair lifts in the Millennium Underground and allowing for their use by a wide variety of groups. The addressees have accepted the recommendations in part, whereas they have not yet replied concerning the remainder.

In another category of cases, the petitioners have voiced grievances that as persons of reduced mobility they have been successively ousted from the free parking spaces earmarked for them; that if they have parked somewhere else, they have been fined for so doing; that the free parking facilities previously available to them have been abolished by local authority decree; and that changes in traffic arrangements have rendered it impossible for them to park in the vicinity of their dwellings. In every single instance, the Ombudsman substantiated the complaints.

On the basis of previous complaints, the Parliamentary Commissioner had already dealt with individual
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local government regulations and ascertained that there were no legal provisions emanating from a higher authority that would define a framework for local government regulations on paying car parks.

Paragraph 51/A of the Highway Code summarises the rules aimed at promoting use of private cars amongst persons with reduced mobility in possession of a driving license, which grants them certain privileges in comparison with other road users. It is on this basis that local authorities established divergent rules. Legal provisions from a higher authority are needed in order to bring the rules on local parking facilities in line with the special privileges accorded to persons with reduced mobility in road traffic in general.

The Commissioner put forward recommendations to the responsible Minister to amend the Highway Code accordingly. The recommendation was accepted and the text of the amendment to the decree has been drawn up. According to the amendment, the person with reduced mobility or the individual responsible for driving the vehicle transporting him may park in a restricted parking zone—if no disabled parking space has been specifically designated or if that parking space is occupied—without having to insert coins into the parking meter or purchasing a ticket from the machine.

At the time of publication of the report, the Ombudsman had been informed by the Ministries that the modified text had entered into force as of 1 January 2001 and that the question of free parking for persons with reduced mobility has been resolved. At the same time, the Ombudsman established that fee-paying car parks do not, as a general rule, accept the disability card presented by the person with reduced mobility, on the grounds that such an identity card can be easily forged.

There have also been cases where persons of full mobility have actually been in possession of such cards. The Ombudsman therefore drew the attention of the Minister of Home Affairs to the need for an official document of an acceptable standard to be accepted wherever shown to be made available to persons in need of it by the same time the provisions on free parking for the disabled in general entered into force via the Highway Code.

The Ombudsman proposed that he take the necessary steps to achieve this. The Minister of Home Affairs accepted the recommendation and is not opposed to the principle of free parking ID cards being classified as a forge-proof official document. Since the Minister of Social and Family Affairs is required to submit the proposal to change the relevant legislation, the Ombudsman also invited him to carry out the necessary formalities.

Gusztáv Kosztolányi, 2 July 2001

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