Leaders' Questions

A medical breakthrough that can double life expectancy is something that we should embrace and not shy away from. The discovery and emergence of the drug, kalydeco, is regarded as the biggest single breakthrough in relation to cystic fibrosis, CF, since the discovery of the gene mutation involved in 1989. Forbes has described this drug as "The most important drug of 2012". For all those involved in the treatment of cystic fibrosis, the drug is genuinely seen as a game-changer in terms of the quality of life and life expectancy of persons with the condition. The drug received FDA approval in July last. It is now available in the United Kingdom, Germany and Canada.

It is the first drug to treat the underlying cause of the CF condition, particularly those with the G551D mutation. Some 11% of Ireland's CF population has that particular gene. Ireland has the highest occurrence of cystic fibrosis in the world. It strikes me, to say the least, as very disappointing that we are so late to the game in terms of having this drug available for those concerned, given its impact. There are very convincing arguments for this life-changing drug, but it is still not cleared for use in Ireland. In the clinical trials alone, it decreased relapses by 55% in patients.

I thank Deputy Martin.

We have known about this drug for quite some time. Over the past number of years, it has been going through the various regulatory systems and clinical trials. It could have a significant impact on inpatient attendances, etc.

Has the Minister for Health or anyone in the Government met the drug company, Vertex, or has there been any proactive engagement with a view to ensuring the availability of this drug in the marketplace? Can the Taoiseach outline to the House the steps that have been taken by the Government to ensure the availability of this drug to those with this condition?

The Minister for Health announced on 15 October last that intensive negotiations involving the Irish Pharmaceutical Healthcare Association, IPHA, the HSE and the Department of Health had reached a successful conclusion on a major deal on the cost of drugs in the State and that the deal is an important step in reducing the cost base of the health system here. That deal, with a value in excess of €400 million over the next three years, clearly means reductions in the cost of drugs for patients and a lowering of the drugs bill to the State, but also timely access for patients to new cutting-edge drugs for certain conditions, with the cost attached to that of €70 million annually and, therefore, reducing the cost base of the health system in the future.

For Deputy Martin's information, the HSE received an application for the inclusion of kalydeco, with the generic name of ivacaftor, in the GMS and community drug schemes. That application is being considered in line with the procedures which have been agreed with the Irish Pharmaceutical Healthcare Association in recent drugs agreements such as the one I mentioned. These procedures include clearly documented processes and time lines for the assessment of new medicines in as timely a fashion as possible. In accordance with those procedures, the National Centre for Pharmacoeconomics, NCPE, conducted a health technology assessment which provides detailed information on the potential budget impact of the medicine involved. It also assesses whether the medicine involved is cost effective at the price quoted by the company in question, which, at €234,000 per patient per year, is very costly.

The NCPE published its report on 21 January. That report concluded:

In view of the very high drug acquisition cost, the significant budget impact, the absence of long term clinical data and the fact that the company has failed to demonstrate the cost-effectiveness of ivacaftor, we cannot recommend reimbursement of ivacaftor at the submitted price of €234,804 per patient per annum. A mechanism such as a performance based risk sharing scheme and/or a significant reduction in price could facilitate access to ivacaftor treatment for cystic fibrosis patients with the G551D CFTR mutation.

That report is an important input to assist decision-making and it will help to inform the next stage of the process which involves further discussions between the HSE and the manufacturer of the drug.

I understand that yesterday the Cystic Fibrosis Association of Ireland stated that it accepts the need for the HSE and the drugs company to get as good a deal as possible. I also recognise the concerns of cystic fibrosis patients, a number of whom have contacted me, that a decision would be made as soon as possible. I listened to Dr. Barry speaking about this on the news the other day. He stated that were one to proceed with providing this particular treatment at this level of cost, it would take 40% of the entire budget for drugs. This is obviously an issue that the NCPE took into account in its analysis.

I repeat that the drug is projected to double life expectancy. This is not any ordinary drug coming on the market in terms of advancing incremental interventions or treatments of particular conditions. This is truly a very significant game-changer in a condition which has not witnessed such breakthroughs over a long period of time.

In the United Kingdom, for example, the regime for licensing new drugs has been far stricter with an even stronger regulatory impact than here over the years, yet it is available in the United Kingdom. The National Institute for Health and Clinical Excellence, NICE, the authority in the United Kingdom which is responsible for the licensing of drugs, has approved it. In the language coming from the NCPE, it is without question overwhelmingly for budgetary and cost reasons that this drug is being rejected, not for reasons of clinical trials or the health outcomes and impact of this drug.

All such matters require balance. I asked the Taoiseach at the outset if the Minister had met the company. From speaking about quite a number of new technologies and new drugs that became available, I am aware that last year there was a complete delay in engagement on ipilimumab and a range of other drugs.

Disappointingly, from the Taoiseach's reply I get the sense that delay will be the order of the day. In the interests of the patients and the people with the condition, here is a case that justifies the intervention of the Minister and the Government with a company and all concerned to knuckle down and make this drug available. It happened last year with ipilimumab and others when it was raised. It is important that people do not engage in a stand-off on this issue because the quality of life and life expectancy issues are so profound that it demands a proactive response from the Government, one we have not seen on this drug to date.

Patients cannot wait - 120 people.

It is not the case that delay is the order of the day here. Let me repeat what the National Centre for Pharmacoeconomics, NCPE, stated when it conducted its health technology assessment. It stated that "In view of the very high drug acquisition cost, the significant budget impact, the absence of long term clinical data and the fact that the company has failed to demonstrate the cost-effectiveness of ivacaftor", it was not willing to assess it. There was a very rapid review submission on the drug submitted on 13 August 2012. That rapid review was completed on 22 August 2012 - no delay there. A full pharmacoenomic assessment was advised. Following submission of that dossier, the NCPE group met the manufacturer on 28 November 2012 to discuss the submission and request additional information. That was received on 11 December and I have given the Deputy the result of its assessment. It states that the evaluation of the economic dossier submitted by the company estimated the annual cost at €234,804 per patient. It also estimates that 113 to 120 patients could benefit from the drug. Based on those figures, the annual budget impact would range from €23.65 million to €28.176 million. No more than anybody in here, one cannot put a price on a life-----

The Taoiseach has put a price on it.

-----and obviously it is an effective drug, but there is an issue that needs to be followed through. The next step in this process is for the HSE to meet the manufacturer of the drug in accordance with the procedures set out by IPHA. When the Minister for Health met them last year-----

Did he meet them?

-----he concluded a deal for €400 million over three years. This is a new very expensive drug with an impact for an estimated 113 to 120 patients.

We do not know the answer. Did the company meet the Minister?

Has the Minister met them?

I do not deny anyone having the right to have the best quality of life we can give them. It is a €26 million to €28 million impact on costs and obviously ceilings for this year's budget have been set. The HSE will now meet the company to see if some deal can be worked out here.

The Minister or the HSE?

I do not want to pre-empt the conclusion of that.

The Minister has not met them.

Sure, the Minister is the HSE now.

We do not even have a Food Safety Authority

That is a real pro-life issue now.

On Sunday, the Taoiseach took to the airwaves to threaten public sector workers with pay cuts. Last week, at the outset of negotiations on a successor to the Croke Park agreement, the Government warned of compulsory redundancies in the public sector. This is not the way to negotiate in good faith. The case for public sector reform is unanswerable and is accepted by those in the public and Civil Service. Equally, the case for finally tackling the excessive pay and pensions of a tiny minority at the top is now unanswerable. Ministers, special advisers and senior civil servants all need to have their pay cut. To add insult to injury, we have seen today reports of former taoisigh and former Ministers, many of whom presided over the economic collapse in this State, on lavish pensions.

The protection afforded to this class of person contrasts starkly with the plans of the Minister, Deputy Reilly, to slash the pay and conditions of graduate nurses and midwifes. The Government is expecting these graduates to accept yellow pack jobs and greatly reduced pay rates within the health service. What happened to equal pay for equal work? The Minister has indicated that he intends to extend this yellow pack strategy scheme to other workers in the health service. Public sector reform will not be achieved by driving down wages for those on the bottom. In the course of the negotiations for a Croke Park agreement nua, will the Government defend pay equity? Will it defend equal pay for work of equal value? Will it finally deal with the glaring issue of the tiny minority within the public and Civil Service who are overpaid and over-pensioned?

I reject the Deputy's charge of threatening public service workers. We have set out a very clear position of mandating the Minister for Public Expenditure and Reform and his officials to negotiate with the unions in respect of savings that need to be made in the public sector, amounting to an additional cumulative amount of €1 billion between now and 2015. Those discussions are under way. I have made it perfectly clear, as is normal practice, that we would much prefer to have this by consent and agreement. I commend all of those who have changed structures in the public sector, in delivering front-line services with reduced numbers in changed environments. I have also made the point, as the Deputy is well aware, that the Government reserves the right to legislate for the savings that are to be acquired if they cannot be reached by consent and agreement. Our preference is that they would be reached by consent and agreement. I am glad that the negotiations, while they are obviously challenging and in a challenging environment, are making good headway.

I reject the Deputy's charge of doing down the opportunity for graduate nurses, who were trained in this country, to work in hospitals in this country. The two-year contract offered outside the framework agreement of ceilings for employment is an opportunity for men and women as trained nurses -----

Shame on the Taoiseach.

-----to work in Irish hospitals on a salary of €22,000 to €25,000, which is equivalent to what young accountants or teachers would get, in order to acquire experience and opportunities to build on their training in Irish hospitals and not to have the prospect of going abroad. I would have thought that somebody such as Deputy McDonald would welcome that 1,000 extra jobs are being made available for Irish nurses in Irish hospitals. I also understand the Sinn Féin leader went abroad to have treatment under a health system in the United States. He is entitled to do that, but as I understand all Sinn Féin Deputies are earning the industrial wage, these things are difficult to understand fully.

A Deputy's personal health is his or her own personal business.

As for Deputy McDonald's running down of the quality of graduate nurses in Ireland,-----

A Deputy

We are talking about yellow pack nurses.

-----I say to her that is not the way to look at the training of young Irish men and women who graduate to become nurses. She is saying to them that they should not take up these jobs in Irish hospitals. These 1,000 jobs are outside the employment framework and I hope that many of those young trained nurses who have worked abroad and those from the three years' graduate classes involved will take up the opportunity to have experience and competence acquired in Irish hospitals. After all, they are the best-trained nurses in the world and we would like to see them work in our hospitals in their own country.

No doubt the Taoiseach is right to say that they are the best-trained nurses and midwives in the world, which is all the more reason to ensure we have them within our system. Sinn Féin Members met representatives of the nurses. In case the Taoiseach and his Government colleagues do not know, they are very angry about this scheme. They do not see it as some golden opportunity for them to contribute to the health service. They see it as a very cheap tactic to run down their terms and conditions and to run down the profession to which they are committed.

Shame on the Labour Party.

They were particularly outraged at the weekend when the Minister for Health suggested that if they were not happy with the scheme they should emigrate or perhaps get a job in a fast-food restaurant. Perhaps those are the kinds of choices the Government envisages for young highly qualified people. The position of equal pay for work of equal value is fundamental in any profession or job and must be defended.

The Taoiseach is clearly not minded to defend it. I hope those in the Labour Party might take a different position. The Taoiseach studiously avoided the core question I put to him in regard to high pay. The Government can slash the terms and conditions of a graduate nurse but will protect its own back and excessive salaries.

Thank you, Deputy.

The Taoiseach said that the Government is prepared to legislate for pay cuts for low paid public sector workers but it consistently refuses to legislate on the issue of the runaway gilt edged pensions-----

-----of former taoisigh and some of the Taoiseach's former colleagues. Why that contradiction? Surely, if the Government is to be fair there must be fair play all around. By any standard, young nurses, midwives and the health service are getting a raw deal from this Government.


Hear, hear.

What is involved in the health sector is a change in structures and the manner in which the health service is delivered. What the Government has set to be achieved before the end of life of this Administration is a situation wherein front-line services are operating more effectively and a system whereby money follows the patient-----

The patient has to follow the money.

Answer the question on high pay.

-----who can then get treatment based on medical needs rather than financial circumstances. We also propose to introduce universal health insurance for everybody rather than allow the situation which has obtained in this country for years to continue.

Answer my question.

Sinn Féin wants to perpetuate a system which involves agency nurses, premium payments and overtime.

That is not true.

What the Government wants to do-----

Pay yourselves more.

-----is to change the structure whereby agency nurses can be working one day in ICU, the next day in the respiratory treatment area and the following day in general wards. The system is not operating in the way it should. Savings made in this area will go directly to pay graduate nurses-----

They will be used to pay Government Members more.

-----who can gain experience and, based on their training, provide a first class service for patients.

What about your salary, Taoiseach?

What Deputy McDonald and others are saying, which I regret, is that these jobs are not suitable for young nurses. We are creating 1,000 jobs in Irish hospitals for graduate nurses, whom I hope will take up those positions. It is always the case, Deputy McDonald, that the people inside the system who are being paid to deliver the quality service often complain about it. The service will not be delivered in the manner we want unless the structure is changed. What the Government is doing, outside the framework for employment numbers-----

What about the excessive salaries of Government Members?

-----is targeting redundancies in the areas of education, health, agriculture and back office administration while at the same time increasing numbers on the front-line service through the employment of graduate nurses.

What about the Garda?

The Government is shafting nurses.

I would also point out that Government has already made decisions in the budget which will impact on those on high salaries, not only in respect of people who have properties valued in excess of €1 million-----

Get off the stage.

-----but in respect of pension reliefs for those with pensions in excess of €60,000, which, as the Deputy is well aware, will bring in €250 million. It is a case of not having increased income taxes for everybody but of making those who earn more pay more.

It is a case of the Government protecting itself.

That is equitable and fair and will be seen to be so.

As regards the former politicians to whom Deputy McDonald referred-----

-----I do not speak for them. I commend all those who did abide by the agreement. I listened to the news this morning and heard the names mentioned. This Government has made decisions for the future in respect of all politicians, including the abolition of severance pay and the reduction in salaries, which will impact on pensions. Sinn Féin only wants to pick out issues which it thinks will make news for it. That is not how it is going to be.


Westminster salaries.

Sinn Féin Members could accept the normal industrial wage and hand the remainder of their salaries back to the Exchequer instead of putting it into its party coffers.


Deputies, please. I call Deputy Boyd Barrett.

Take it easy Einstein.

Deputy Tóibín is no Einstein.

Deputies, please allow Deputy Boyd Barrett to speak.

Members on this side are not out of control.

I am not addressing Deputy Healy-Rae. Do not be adding to the chorus. I call Deputy Boyd Barrett.

The Whip is out of control.

The Deputy will have to get a permit.

I suggest that the concern expressed earlier by the Taoiseach for the young men and women of Ireland is belied by the grim reality facing young people in this country as a result of the austerity cuts and unemployment that are resulting from this Government's policies. This grim reality was revealed in the recently published report of the Public Health Agency in Northern Ireland and the National Office for Suicide Prevention which reveals the appalling fact that 165 young people in the South of Ireland took their own lives last year and that the suicide rate among young people in Ireland is one of the highest in Europe. That report linked this directly to recession and unemployment. It also noted that the countries with the highest increases in suicide were Greece, with a 17% increase, and Ireland, with a 13% increase. I put it to the Taoiseach that these facts speak for themselves.

The austerity policies being pursued by this Government and the troika are resulting in despair and hopelessness among many young people, leading directly to this shocking increase in suicide. Is there not a direct connection between young nurses being asked to work for 20% less than nurses who qualified a few years ago, young teachers being asked to work for 30% less than teachers who qualified a few years ago, young junior doctors, a number of whom committed suicide last year, being asked to work unsafe hours in our hospitals, cuts in guidance counsellors for young people when early intervention is so vital to protect them from despair and hopelessness and chronic unemployment and emigration, which disproportionately affect our young people?

A question please.

Do our young graduates and workers deserve to pay the price for the crimes of others and a crisis that is not their fault? Does the Taoiseach recognise that if young people are treated as second class citizens they will feel like second class citizens and therein lies the road to despair? What does the Taoiseach propose to do to give hope and a prospect of a future to our young people so they do not feel this level of despair?

We had some questions on this issue yesterday. In the three years prior to the election of this Government to office 250,000 jobs were lost in the private sector in this country, which directly affected many of the people of whom Deputy Boyd Barrett speaks.

There are now more than 400,000 people unemployed.

It is the challenge of Government to rectify the problems it inherited in this regard, to rectify our public finances-----

The Taoiseach is promising everything.

-----to change the structure of how we do business, to grow our economy and to create jobs.

The Government is taking its time.

This cannot be done unless there is trust and an understanding that this country will do as it says it will. At long last, there are signs of confidence in this country, including investor confidence, and our international reputation has been restored. We are moving in the right direction.

The Taoiseach is the only person who believes that.

I sympathise with every family in this country who has lost a family member through suicide. I have visited the homes of many such people and have heard them voice the unspeakable questions of whether they should have noticed something, asked a particular question or done something. Deputy Boyd Barrett made the point in his normal charge that this is the result of continuing austerity by Government. The Minister of State, Deputy Kathleen Lynch, who has a genuine interest in this area has been given a budget which is ringfenced for addressing this issue.

That budget was not spent last year.

Nothing happened last year.

Perhaps Deputy McGrath would be quiet for once while we discuss this serious matter.

The budget for the National Office for Suicide Prevention has increased from €4.1 million to €8.1 million.

That is not the issue.

The Deputy's colleague spoke about austerity and cuts in this area. Everybody understands the enormous amount of work that is being done to attempt to prevent this phenomenon from continuing at its current rate.

Treating the symptoms rather than the problem.

From that point of view the report by the Men's Health Forum in Ireland, published today by the Minister of State, Deputy Lynch, will indicate unfortunately that the suicide rate in Ireland is one of the highest in Europe for young males between 20 and 24 years of age and females aged between 50 and 54. The latest data show 552 people committed suicide in Ireland in 2009, the year for which the latest figures are available. The allocation of the ring-fenced €35 million for 2012 was used primarily to strengthen the community mental health teams in adult and children mental health services. Some of these funds will be used to advance further suicide prevention measures and to initiate the provision of psychological and counselling services in primary care, particularly for people with mental health problems. The announcement in the budget for 2013 of a further €35 million for the continued development of our mental health services is important and means the recruitment of 470 additional staff to implement these measures. It is not always about this. The young generation gets its information in a very different way than Deputy Boyd Barrett or I did when we were growing up. There are always different pressures on young minds. This is a sad fact. This is an issue for which there is now a huge range of organisations, groups, teams and agencies working. The Minister of State, Deputy Lynch, wishes to concentrate on having very effective connection with young people so this issue, which is so tragic, can be prevented. I am able to inform the House the National Office for Suicide Prevention has implemented most of the recommendations in the strategy in a four-way approach through delivering a general population approach to mental health promotion and suicide prevention; using targeted programmes for people at high risk; delivering services to individuals who have engaged in deliberate self-harm; and providing support to families and communities bereaved by suicide.

I agree with Deputy Boyd Barrett from the perspective that 26 million people are unemployed in the European Union and 29% of young people in Ireland are unemployed while the figure in Germany and Austria is 3%. Part of the EU Presidency priorities for the Government will be to work specifically in the area of youth employment and opportunities for young people. We all agree and understand they are the future of this country and of the European Union. The challenge for the Government is to get decisions made in the first instance which will allow indigenous confidence to come back, whereby young people can see motivation and opportunity and are given a demonstration that hope is not just an aspiration and that it can come by the people and the Government working together here and with their European colleagues to provide these opportunities.

In recent months I have met many people who are driven by an opportunity that presents itself. I see signs of confidence returning and the news from our colleagues in Europe in recent days, as the Minister, Deputy Noonan, pointed out is significant but not a game changer. We must help create this game changer ourselves.

It was a game changer last year.

To use the Tánaiste's phrase.

Well may Deputy Martin sneer, laugh and be cynical-----

I am not. I am just noting the differentiation in language between the Minister, Deputy Noonan, and the Tánaiste.

-----but he left behind a legacy that no other Government in the history of the State had to face and with which we are dealing.

He should not have bothered togging out if it is not a game changer. What did he go there for?

Is Deputy Higgins representing the Technical Group or is it Deputy Boyd Barrett?

The Taoiseach is not getting the point of the question. The report states while death rates from suicide decreased by 15% between 2000 and 2007, a reversal of this pattern coincided with the onset of recession in 2008. The countries with the highest suicide rate increases were those most affected by the recession, namely, Greece and Ireland. At the end of last year, the Taoiseach was written to, as were we all, by a junior doctor who has since emigrated. He stated the illegal working hours he and his colleagues performed were leading to suicide, burnout, depression, alcohol misuse, road traffic accidents and deaths. The same sense of despair is being felt by young people who either cannot find work or, in the case of young nurses and teachers, are being treated as second-class citizens, and being asked to work with the same responsibilities and long hours for 20% or 30% less than people who qualified a few years ago.

I ask the Deputy to put a question.

Is it the case that the policies of cuts and austerity which the Taoiseach is imposing are leading directly to the sense of despair and hopelessness felt among young people which is leading to this increase in suicide rates? Words about doing things and about youth unemployment are no good if the policies being pursued are leading directly to youth unemployment and despair among young people generally.

This is why there was no increase in income tax for anybody in the country, because we believe a tax on jobs is an imposition.

Where will they get the property tax? The Taoiseach insults us.

The Taoiseach is not talking to his own in Mayo.

Bring it out as a CD next Christmas.

The Deputies had their chance. I do not believe in having any discrimination among the citizens in the country. The Deputy fails to understand that it was assumed the veneer of invincibility of previous Governments in recent years could keep paying the rates at which money was being doled out.

The Taoiseach promised to spend a fortune when he was on this side of the House. Every day of the week he promised to spend millions.

We must now deal with the challenge. We will never get the country right unless we deal with our public finances and the deficit. We can only deal with it ourselves. Deputy Boyd Barrett seems to think one can continue to pay exceptional salaries on fantasy money.

The Taoiseach is doing that; he is in receipt of one.

I believe many of those young people would be more than willing-----

The Taoiseach's policies are only helping the bondholders.

-----to build on their graduate experience and work in Irish hospitals as Irish nurses on salaries that are equivalent to starting salaries in the accountancy sector or the teaching sector.

As a trainee, not a fully qualified person.

They are not as high as salaries were in the past but they are job opportunities for the future. For the information of Deputies, in 2012 of the €12 million allocated for suicide prevention €7.1 million went to the National Office for Suicide Prevention and the remaining €5 million was used regionally to fund resource officers for suicide prevention, self harm liaison nurses in hospital emergency departments and a number of local suicide prevention issues. A further €1 million is being provided to the national office from the additional moneys allocated for this year, bringing the total to €8.1 million. A special programme of measures to further advanced suicide prevention in 2013 is being developed by the Minister of State, Deputy Lynch. In 2012, 414 posts were approved, 135 posts were filled, 208 have been accepted subject to process clearances and Garda vetting, and the remainder are at various stages of selection. The same will apply for this year.

I admit the appointment of personnel and the money are not all the answer to the problem. What is the answer to giving hope and inspiration to young people is the Government working effectively with our colleagues in Europe demonstrating the economics of our country-----

It is not doing a very good job.

-----are coming right and there are job opportunities. The Deputy should have listened to the national media in the past three days as even they were surprised at the positive news of investment and job creation in the country.

This is where the hope lies for the future but the Deputy does not want to believe it-----

It is called spin.

-----because he has a vested interest in seeing the country not thrive and not prosper. We are moving away from his position of wanting demonstrations every day. We want to give hope and inspiration and a demonstration that things do work for young people.

The Taoiseach will have young nurses demonstrating in the near future.

I am glad to see it is moving in the right direction. Someday Deputy Boyd Barrett might realise it.