We do not want to crash the debate because it is an important one and, obviously, everybody went short. As I said, I certainly was not expecting to have to speak tonight. The Bill has five Parts, each one amending a different aspect of existing health legislation. I will deal with some of them separately and we will see how we get on.
I will start by looking at Part 4, which amends the Health (Pricing and Supply of Medical Goods) Act 2013. The amendment to that Act will allow the HSE to include non-prescription medicines on the reimbursement list applicable to medical card and other drug schemes. From that point of view, such a measure is to be welcomed. However, this Bill limits the drugs that can be reimbursed to emergency contraception and nicotine replacement therapy drugs. While it is great to see these two categories of drugs being reimbursed, there are a number of issues about how it is being done.
As it currently stands, medicines must only be available by prescription in order for people with medical cards and long-term illness cards to be able to access them without charge. The Health (Pricing and Supply of Medical Goods) Act 2013 included a provision that medicines to be reimbursed must be available only on prescription with the reimbursement list to be reviewed every three years. In essence, that meant that in June 2016, any drugs that came off the prescription list since the introduction of the Act had to be removed from the reimbursement list. We saw that one of the morning-after pills was made available without prescription in February 2011 but another was reclassified as non-prescription in April 2015.
This Bill aims to ensure the morning-after pill is reimbursed by the HSE but it falls far short of making emergency contraception easily available to women with medical cards or long-term illnesses. In that sense, the manner in which it does is regrettable because this is a huge area in terms of women's reproductive health. The morning-after pill should be easily available, accessible and free to those on medical cards. What we have here is discrimination or two-tier access to reproductive health care products and drugs because women with medical cards or long-term illnesses will still need to go to a doctor to get a prescription for the morning-after pill. The morning-after pill is freely available without prescription to women who are lucky enough to be able afford it and only involves a trip to the chemist. It is ridiculous and utterly discriminatory that women who have a medical card or a long-term illness have to go to a doctor to get a prescription. It goes against the very sound rationale that made these drugs available without prescription in the first place and is completely unacceptable.
It is probably another instance of how the State has in a certain sense exercised control of women's bodies and has displayed distrust of the choices women made regarding their reproductive health. Who are the people who are most victimised by these decisions? In the same way as in all aspects, it is working class women, poor women and those who do not have the economic means who are targeted because they are the ones whose decision-making is affected because they do not have the means to exercise it. What other impression can a woman with a medical card come away with other than that this provision exists in order that a doctor can, more or less, keep an eye on her sexual choices and intervene if necessary by saying she is not getting one? It is ludicrous. It is like a throwback to decades past.
The rationale offered for forcing women with medical cards or long-term illness cards to jump through these extra hoops if they want to get access to what is, in a sense, essential medicine is pathetic, with the Department saying that a number of policy issues would need to be considered before this could be contemplated, including the potential cost from loss of prescription charges or otherwise. I would like to know what these policy decisions are. Is it an administrative issue? I cannot believe that it is insurmountable. If another group, for example, well-heeled businessmen, was affected by a decision, I am sure a way around it could be found. I do not accept the argument that no solution to the administrative difficulties can be found. Were any solutions explored because it is a bit of a double standard?
We expect women to take responsibility for their reproductive health - for when they have children - but if we are not going to give equal access to essential reproductive medication and drugs such as the morning-after pill, it does introduce discrimination. It is exactly the same mentality that gave us the eighth amendment and a scenario whereby if someone has money, she can travel and exercise her legal right to have an abortion in another jurisdiction but if someone is poor, a migrant or of limited status, she cannot. It is the old scenario whereby women who have money can travel while women who cannot travel have children, in some instances, when they are not ready or are without the means to support them.
It is worth looking back and pointing out that prescription charges were introduced by Fianna Fáil. It is the great hero of change now but it introduced prescription charges in July 2010 as part of the first round of the suite of austerity measures. The former Minister for Health, James Reilly, who is my constituency colleague, said it was vehemently opposed by Fine Gael at that time and that is true. What is interesting is that the former Minister anticipated the situation correctly. He said at the time, "it is clear that once the Minister gets this charge under the door, it will continue to increase". How right he was because the charge started out at 50 cent and after nearly six years of Fine Gael in Government, it is €2.50. The former Minister said in 2011 that it was very unfortunate that he had to defer the removal of the charge, which was then 50 cent, saying that getting rid of it had been one of his goals when entering office. Now we have Fine Gael building discriminatory provisions into legislation on the basis of a prescription charge to which it was once vehemently opposed. This is discrimination in an area where Fine Gael said it never wanted to go. Fine Gael campaigned in the previous general election on the basis that the economy was in recovery. Why then do we still have prescription charges for medical card holders given that they were supposed to be an emergency measure when they were brought in? Why are we endangering the health of women with medical cards or long-term illness cards on the basis of a charge that should not be levied in the first place? It does not make any sense. We are putting a barrier in the way of women who want to access emergency contraception and we could certainly address this aspect.
Apart from the discriminatory aspect of forcing women with medical cards to jump through hoops to get access to essential medicine, there are major health implications for forcing them to wait until they see a doctor. A person can often wait a considerable period of time to see a doctor to get a prescription before they can then take the emergency contraception. The morning-after pill declines in efficiency the more time passes between having unprotected sex and taking the pill, so it is 95% effective if it is taken within 24 hours of having sex, but is only 58% effective if it is taken within 48 to 72 hours of having sex.
In my area, one would be doing well to get an appointment with a GP within 24 hours. One would be very lucky to get one. It is unacceptable to force people who have medical cards to do this to access that to which the rest of us have access.
In April 2015, the Irish Pharmacy Union, IPU, called on the HSE to make the morning after pill directly available to GMS patients from pharmacies free of charge, calling the system whereby GMS patients have to get a prescription for the pill "farcical, discriminatory and unacceptable." Yet, that system is enshrined in legislation. The IPU pointed out that 77% of pharmacy consultations about the morning after pill occur within 24 hours of unprotected sex and noted that this shows how important it is that the pill be readily available to women as soon as they need it. It is a basic health care product and it would be regrettable if we maintained that discriminatory concept in this piece of legislation. The IPU presented a proposal to improve access to emergency contraception to the Minister for Health's predecessor, Deputy Leo Varadkar. The proposal made the Minister aware that, "The process of [a woman] attending her GP for a prescription puts an unnecessary barrier in her way and causes unnecessary delay and inconvenience." It outlined practical steps for the cost of the drug to be reimbursed by the HSE without the need for a prescription using unified claims forms carrying the patients' medical card number. I do not see why this could not be done and I do not know why the Government did not listen to the sensible proposal which could have been adopted as part of the Bill.
We are left with a farcical, discriminatory and unacceptable system being enshrined in law. The Bill should have addressed the issue of access to the morning after pill, without prescription, for medical card patients. This is being ignored and it is regrettable. I hope the Minister will take on board some of these points, which are critical against the backdrop of the debate in which Irish society is engaged regarding reproductive rights and women taking responsibility for decisions about their reproductive systems and bodily autonomy. Crisis pregnancy is common. Let us be clear - one in three women with an experience of pregnancy has experienced a crisis pregnancy. In Ireland, if one cannot access emergency contraception, or if one accesses it too late because the Government has forced one to make an appointment with one's doctor in order to get a prescription, and one finds oneself pregnant and unable to deal with the situation, one's only option is to travel abroad if one wants to end the crisis pregnancy. The fact that the Irish State forces women to travel for abortions makes it very difficult for poorer women to access this essential medical procedure. Again, the poorer women are those before whom the legislation will put up barriers regarding their ability to access emergency contraception. That is not right.
I do not accept that the administrative hurdles that need to be leaped in order to make it possible for women to access emergency contraception without a prescription could not have been addressed relatively easily. Provisions regarding women's health, particularly reproductive health, are utterly demoralising. No bar is too low. We see it in abortion access, maternity services and, now, the discriminatory provisions in the Bill. It is ironic that lack of access to emergency contraception is almost like enforcing pregnancy on some people. Yet the Minister for Health, Deputy Simon Harris, came before the health committee last week and apologised for the manner in which maternity services had let women and their children down. Maternity services are brutally understaffed and women's lives have been placed at risk as a result. At least eight maternity services are under investigation due to safety issues regarding the deaths of women or children. It is estimated that there is 20% understaffing of midwives in the three Dublin hospitals, at which 40% of births in this country take place. Nationally, we are down more than 200 whole-time equivalent midwives. This is serious. Forcing somebody to carry on a pregnancy is not something I would favour. We need to level the playing field in terms of access to emergency contraception and I appeal to the Minister to examine the issue.
Part 3 of the Bill amends the Nursing Homes Support Scheme Act 2009 to allow payments from certain redress schemes to be exempt from means testing for the fair deal scheme. The fair deal scheme involves elderly citizens paying 80% of their income towards nursing home care plus 7.5% of the value of any assets per annum up to a maximum of 22.5% of the value of their principal residence if that is their only asset. The State pays the balance. There is a major crisis in nursing care provision, caused particularly by over-reliance on the private market and the deliberate running down of what used to be State nursing homes which people could access. It is frightening. Nursing home care costs between €800 and €1,200 per week. The vast majority of nursing homes are private. There are approximately 84 private nursing homes in Dublin compared to 20 public homes. This is the wrong way around. The result is that huge sums of money are channelled into private pockets every year from elderly citizens and the State to provide nursing home care. I have mentioned before how investment in nursing homes is advertised as a no-brainer for private investors, given the high rate of returns on investment they can expect. The return on investment and the profit they can expect comes out of the pockets of elderly citizens and the State. It is reprehensible.
The way we treat older citizens in Ireland is at variance with what happens in many other European countries. In countries such as Italy and Spain, older people are respected, looked after and recognised for the contribution they have made through rearing families and during their working lives. Here, older people are nearly viewed as a sort of hindrance that should be cast aside and forgotten about. The fact that we have allowed the care of the elderly and nursing home provision to remain in the hands of the private sector is criminal.
The Bill specifies that the symphysiotomy redress scheme is one of the schemes to be exempt from means testing for the fair deal scheme. While I welcome the exemption for the symphysiotomy redress payments, I could not allow the scheme to be mentioned in legislation without using the opportunity to highlight the enormous problems with the structure and administration of the symphysiotomy redress scheme. It is a travesty that international media outlets such as al-Jazeera have publicised the damage done to older Irish women as a result of the procedure whereas the Irish media have given it hardly any consideration. The scheme was designed with budgetary considerations in mind rather than justice and making a right from a wrong that was done to those women.
It is a scheme that is antagonistic and distrustful of the women involved.
Let us be clear about what it is and how it came about. These women were butchered against their will and, in many instances, without their knowledge of the procedure having been carried out. Their pelvic bones were sawn in half, often while they were awake and watching, in order to facilitate their having multiple pregnancies. We are back to pregnancies and reproductive rights. Surprise, surprise. As a result of this butchery, many of the women were left incontinent, with pelvic and back pain, difficulty walking, psychological damage, difficulty connecting with their kids and so on. It was an horrendous abuse of women who often were very young. Of a slight build, they were deemed unable to undergo Caesarean sections because that would have limited their childbearing years and they would only have been able to have perhaps three children. To let them at it and procreate as was intended, their pelvic bones were instead cut open. What was done was disgraceful.
The scheme was set up to redress some of the pain and injustice that these women experienced, but we must be honest, in that the manner in which the scheme has been implemented has actually resulted in more pain and distress for them. Payments from the scheme have been paltry relative to the damage done. That payments are anchored at €50,000, €100,000 and a maximum of €150,000 for lifelong pain and disability is crazy. According to the figures, the majority of women were restricted to smaller payments. In this sense, they were denied even basic compensation. They were asked for records and were scrutinised for validity, as if anyone would make this stuff up and look for that money based on records that, in some instances, did not exist. Given the pain that had been suffered, this was poor. The scheme was limited, offered no right of appeal and provided no protection for the women's legal rights. As some of the participants have mentioned, the scheme forces women to indemnify their abusers as the price for getting a bit of redress. The scheme refused to take on board the oral testimony of survivors, depending instead on a paper trail that traced back more than 50 years. That trail can be incomplete and, without a complete record, the scheme will reject an application or offer a lower payment. It is unreasonable to expect that those records would survive after so long.
If no trace of a general practitioner's record dating from the 1950s can be found, which we know is most likely because it has been destroyed, then the scheme tells the women that they do not actually have the chronic incontinence or whatever they have had their entire lives and will not pay them the compensation. They are told that they do not actually have the disability that has meant they have been unable to go to the shops or wherever, that the reality they have been living is not true. I have seen some of the letters sent by the justice who administers the scheme, although "justice" is the wrong word in this regard. The letter more or less told the woman to buy herself something nice out of the money. That is an utter violation of these women's experiences and negates the good in the scheme.
Of course, exempting the payments that the women have received from an assessment under the fair deal scheme is good. It is the least that the Government can do. To be honest, though, a reconstitution and re-examination of the scheme and a recognition that a payment of €50,000 for lifelong agony is inadequate would be a better and more respectful way to deal with these women.
The final aspect of the Bill that I wish to discuss relates to payments to board members of the Health Products Regulatory Authority, HPRA. According to the explanatory memorandum accompanying the Bill, there is "an onerous responsibility and significant time commitment placed on members of the Authority" and, as such, they should be paid for it. That is kind of fine but, viewing this in a balanced way, the HPRA failed to include a warning about possible kidney damage that had been issued by the maker of the drug Lariam on its website for more than one year because of what the authority called an administrative error. It is good if efforts are being made to reduce the chance of administrative errors being made by the authority, since the HPRA needs such measures. If that is the reason for this provision in the Bill, I welcome it. However, I am unsure because some of the drugs licensed for use in this country are profoundly dangerous. It is a fact. Lariam is a perfect example. It is fortuitous that we are discussing this Bill on the day that PDFORRA, the soldiers' organisation, held its annual conference and spoke about this matter.
The HPRA has an important job because it is the body that licenses drugs and publicises their dangers. A drug like Lariam, which is neurotoxic, can leave those who take it with permanent psychological impairments, psychosis and depression. We have met many survivors, dignified members of the Defence Forces who served this country proudly, went abroad and were prescribed Lariam and whose lives have never been the same since. On the HPRA's list of the ten medicines most frequently associated with suicide attempts, suicidal ideation and self-harm, Lariam is at the top and miles ahead of the other drugs. There is a strong link between taking Lariam and self-harm, thoughts of suicide and suicide. While the HPRA issues warnings about Lariam on the one hand, members of our Defence Forces are still forced to take it by our Government on the other because it believes that Lariam should be the first choice for soldiers going to sub-Saharan Africa. For other armed forces, including those of the US, France and Germany, Lariam is the last resort drug. In most countries, it is not even used. The British House of Commons Select Defence Committee published a highly critical report on the use of Lariam, going as far as recommending that its use by Ministry of Defence personnel be banned. The Australian Department of Defence has acknowledged that short-term and long-term side effects can result from the use of Lariam and that those suffering such side effects can claim compensation.
I have a problem. Given that we are discussing payment for and the enhancement of an organisation that oversees how drugs are advertised and monitored, we should examine this situation. He who pays the piper calls the tune and so forth. If so, we must demand a transformed system of accountability for how drugs are administered. I used the example of Lariam because it was in the news today and because of its devastating consequences for the lives of young people who served the State loyally. We have seen them - they have been in the Public Gallery. Their lives have been ruined, their families left with loving parents and spouses who cannot function properly because of how this drug was administered. If we are beefing up and making improvements to the authority, we must be sure that it is doing its job properly.
We absolutely need to be sure that these people are doing their job properly. In that sense, there is a long way to go. I will leave it at that and we can continue the debate later.