Health (Miscellaneous Provisions) Bill 2016: Second Stage

I move: "That the Bill be now read a Second Time."

I am very pleased to have the opportunity to address the House on the Second Stage of the Health (Miscellaneous Provisions) Bill, which was published in January this year. The Bill has five Parts, with 16 sections. Part 1 sets out the Title of the Bill and all Parts will be commenced on enactment.

Part 2 amends the Irish Medicines Board Act 1995 to allow for the payment of fees to members of the Health Products Regulatory Authority, formerly the Irish Medicines Board, as such fees are payable to the members of other boards. Currently, under section 8(7) of the Irish Medicines Board Act 1995, as amended, only the chairman of the authority is entitled to a fee. There is an onerous responsibility and a significant time commitment placed on members of the authority, and we wish to attract the highest calibre of people to apply to be members of such boards. Some people may be self-employed, and without the fee that will be paid under this amendment, it would be very difficult for them to give the time commitment involved. There is no additional cost to the Exchequer relating to paying board members of the authority, as it is mainly self-funding. The fee approved for payment to each board member, in keeping with the guidelines issued by the Department of Public Expenditure and Reform, is €7,695 per annum. The additional cost to the authority will be up to approximately €61,560 per annum. However, some members may choose to waive their fee and the one person one salary principle will also apply to members who are in receipt of a salary from the public service.

Part 3 aims to amend the Nursing Homes Support Scheme Act 2009, otherwise known as the fair deal scheme, to exclude certain ex gratia payments which have been or will be made to people under specific schemes approved by Government for the purpose of assessment of means under fair deal. This is a very important amendment. Several groups within the State have been in receipt of, or will receive, ex gratia payments as a result of Government decisions which acknowledge the hardship, pain and suffering which the people affected underwent. The schemes being covered in this legislation are the Lourdes Hospital Redress Board, involving 119 women; the Lourdes Hospital payment scheme, which compensated women who were excluded from the redress board on age grounds alone, involving 47 women; the surgical symphysiotomy payment scheme, which has made awards to around 400 women; and payments made either by the Government or by the German Contergan Foundation to 32 Irish survivors of thalidomide.

The Bill will also amend section 36 of the 2009 Act, giving regulation-making power to the Minister to allow for an exemption for other similar groups that may receive ex gratia payments from being taken into consideration for support under fair deal, provided such schemes have been approved by Government. This is the way that such exemptions under various social welfare schemes are managed also by the Department of Social Protection. The key principle underlying this legislation is that a person should not be disadvantaged because of acceptance of a payment under an ex gratia scheme which has been approved by Government. Fair deal applications are means tested and the people themselves or their partners could be over the income threshold for availing of fair deal supports because of receipt of their ex gratia awards. The proposal will not give access to free nursing home care to the various groups, but it will mean that the payments they receive under Government-approved ex gratia schemes will be not be considered as part of their income for the purpose of assessment under the fair deal scheme.

Part 4 amends the Health (Pricing and Supply of Medical Goods) Act 2013, Part 1 of Schedule 3. This amendment is required to ensure over-the-counter products which do not require a prescription can continue to be available under the General Medical Service, GMS, and community drug schemes if so required. This will ensure over-the-counter medicinal products, including emergency contraception and nicotine replacement products, can continue to be reimbursed to medical card holders after May 2018. The amendment proposed will allow the HSE not to apply the criterion regarding prescription-only medicines when considered appropriate in the interests of patient safety or public health.

Another amendment proposed is to paragraph 1(e) of Part 1 of Schedule 3 of the Health (Pricing and Supply of Medical Goods) Act 2013, which currently specifies that medicinal products must have a marketing authorisation referred to in paragraph (a) of the definition of "authorisation holder" in section 2(1) of the Act. The reference to paragraph (a) is unintentionally restrictive as it excludes products which are authorised by the European Medicines Agency and parallel imports. Parallel importation is the importation from a European Union, EU, member state or a country within the European Economic Area, EEA, of a medicinal product, which is essentially similar to a product already authorised in Ireland, by an importer who is someone other than the importer appointed by the marketing authorisation holder of the product on the Irish market. The parallel trade of medicinal products is based on the principle of the free movement of goods within the Internal Market of the EU, Articles 28 to 30 of the EC treaty. It was never the intention to exclude such products and any such inference would be contrary to free trade principles.

The explanatory memorandum which accompanies the Bill notes that, "Allowing reimbursement of certain over-the-counter medicines under the GMS and community drug schemes will give rise to some additional cost from loss of prescription charges over time, but this is not expected to be significant." However, this is not correct. My officials have now confirmed that there are in fact no additional costs arising from the amendments proposed in Part 4. My Department will ensure this is clarified in any further briefing on the draft legislation.

Part 5 seeks to amend sections 2, 7, 9, 10, 13 and 14 of the Public Health (Standardised Packaging of Tobacco) Act 2015. Section 2 of the Act sets out the definitions used in the Act, section 7 deals with retail packaging of cigarettes, section 9 with roll your own tobacco products, other tobacco products including cigars are dealt with in section 10, presentation of tobacco products in section 13 and features of retail packaging in section 14. The regulation of the appearance of tobacco packaging is intended to contribute to improving public health by reducing the appeal of tobacco products to consumers, increasing the effectiveness of health warnings on retail packaging and reducing the ability of the packaging of tobacco products to mislead consumers about the harmful effects of smoking. This country has led the way through successive Governments in respect of tobacco control and moving towards a tobacco-free Ireland.

The Act currently provides for a number of elements to be prescribed by the Minister, including the colour of the outer and inner surfaces of tobacco packaging, the form and manner of barcodes and the manner in which a name may be printed on tobacco products. The amendments to the 2015 Act put forward in this Bill are to provide, by way of regulations, for a number of other matters relating to the appearance of tobacco packaging. Some of these matters are of a technical and practical nature, and some seek to provide basic information to the consumer. These amendments will permit the following elements to be included on tobacco retail packaging: text to indicate the type and weight or number of tobacco products contained in the packet; the inclusion of a tab to allow consumers to reseal the package; the inclusion of a calibration mark, which may be necessary for the automated production of the packaging; the contact details of the manufacturer; and additional information on cigar bands.

This Health (Miscellaneous Provisions) Bill serves to make important changes to four Acts in the interests of equity or, in some cases, patient safety, and of course the tobacco legislation is to help protect public health. I look forward to the passage of the Bill so that we can get on with making the improvements regarding the fair deal scheme, which is being led by my colleague, the Minister of State, Deputy Helen McEntee, and the job of introducing the standardised packaging for tobacco being led by my colleague, the Minister of State, Deputy Marcella Corcoran Kennedy, which is the next important step in terms of our move towards a tobacco-free Ireland.

I commend the Bill to the House. I hope Members on all sides can agree to support the legislation and have it passed as quickly as possible by the Oireachtas so that we can get on with making these important improvements.

I am also delighted to have the opportunity to address the House on Second Stage of the Health (Miscellaneous Provisions) Bill, which was published in January.

As Minister of State for mental health and older people, I am particularly pleased about the provisions in sections 6 to 8, inclusive, in Part 3 of the Bill to amend the Nursing Homes Support Scheme Act 2009. As the Minister, Deputy Harris, pointed out, this is a critically important provision for many of our senior citizens as it will exempt payments made to persons under the ex gratia schemes approved by Government from being included in the assessment for support under the nursing home support scheme. This provision applies to persons who have received awards under four schemes, namely, the surgical symphysiotomy payment scheme, payments to the 32 Irish survivors of thalidomide, the Lourdes Hospital Redress Board and the Lourdes Hospital payment scheme. I am particularly pleased that the Bill provides for the Minister to make regulations to allow for this exemption for other similar groups that may in future receive ex gratia awards where the Government has approved the schemes.

Any individual who has received an ex gratia payment under the Government approved scheme has experienced much pain and suffering in their lives. It is an extremely important principle that these same people, on reaching a more senior stage in their lives, should not be in any way disadvantaged financially when it comes to making an application under the Nursing Homes Support Scheme Act or the fair deal scheme, as it is more widely known. The nursing homes support scheme is an important scheme that provides financial support for those in need of long-term nursing home care. Participants contribute to the cost of their care according to their means, while the State pays the balance of the cost. The scheme aims to ensure that long-term nursing is accessible and affordable to everyone, and that people are cared for in the most appropriate settings. The cost of the standard components of residential care is covered by the scheme, including all appropriate nursing and personal care, and any basic aids and appliances that are required by residents. It is an extremely important scheme, therefore, for many older people. To put it in context, at the end of August 2016, the scheme was supporting in excess of 23,000 older citizens in nursing home care. The net budget for the scheme this year is €940 million, which represents an increase of €43.1 million on the 2015 outturn.

All applicants to the scheme must undergo a financial assessment which is carried out by the Health Service Executive, HSE. That determines how much the participant in the scheme will contribute to the cost of their care. The scheme has a number of important safeguards built into the financial assessment to ensure that nobody will pay more than the actual cost of care and to ensure an applicant will keep a personal allowance of 20% of his or her income or 20% of the maximum rate of the State pension, whichever is greater. In addition, the Bill provides a statutory basis to exclude the ex gratia payment for the purposes of the HSE assessment of income for the nursing homes support scheme. It should also be noted that a person's eligibility for other State schemes such as the medical card scheme or the drugs payment card scheme are unaffected by participation in the nursing homes support scheme or residence in a nursing home.

The Health (Miscellaneous Provisions) Bill is important legislation that includes key age-related provisions in respect of persons who have received ex gratia awards and who now in their older years are seeking supports under the nursing homes support scheme. The Bill also proposes valuable changes to a total of four Acts to ensure equity in the case of older persons, and in the case of tobacco, drugs and medicines to help protect public health. I hope the Deputies will support this important Bill and I look forward to the debate.

I endorse what my colleague, the Minister, Deputy Harris, said and I commend the Bill to the House.

Fianna Fáil will be supporting this Bill which makes necessary changes in a number of important areas of health provision. The Bill was originally published last January, and the delay in bringing it before the House is somewhat unfortunate. Nonetheless, the Bill is to be welcomed. While the Bill is described mostly as being technical in nature, it addresses a number of key issues affecting very vulnerable people in our society, and in that respect it is to be very much welcomed.

I will address a number of key aspects of the Bill. Part 4 amends the Health (Pricing and Supply of Medical Goods) Act 2013. I would point out that last May, Deputy Kelleher introduced a Bill to amend the Health (Pricing and Supply of Medical Goods) Act 2013 in a number of ways. The Minister recommended that it would allow prescribers, consultants and doctors to use biosimilar drugs or other biologics instead of existing medicines, with the aim of reducing the cost of drugs supply, which, as we all know, is a bone of contention. The second Part of the Bill would allow prescribers to prescribe newly diagnosed patients with generic, more affordable medicines instead of branded products. The House would welcome an update in terms of the Minister's view of that area.

I wish to raise the issue of Orkambi. The Minister will be aware that cystic fibrosis, CF, is a genetically inherited disease that primarily affects the lungs and digestive system. Ireland has the highest rate of CF in the world, with one in 19 of our people suspected of having the allele. Last January, CF patients were dismayed by a ruling by the National Centre for Pharmaeconomics, NCPE, which recommended that this groundbreaking drug, Orkambi, would not be made available or funded by the Government. I seek clarification on the stage the Government is at in its negotiations with the supplier, Vertex, to ensure the supply of this desperately needed drug. The NCPE gave it a positive health impact assessment and recognised that Orkambi would have substantial benefits for people who suffer from CF and alleviate their suffering. It seems to be solely a pricing issue. CF patients are particularly distressed by what they see as the current stonewalling by the Department of Health in giving them information on the stage of the negotiations, or even if they are ongoing. The lack of consultation both by the Department of Health and the HSE is unacceptable. In fairness, the Minister should not have to accept these outrageous prices. In terms of ethics, Vertex and other similar companies should address the issue of the prices they are seeking. Unfortunately, we have seen a trend develop throughout the world recently of companies buying drugs that are coming off patent and jacking up the prices. We have seen that happen with regard to the EpiPen and a number of other drugs. Orkambi is a new drug that has a real effect.

I ask the Minister to explain the steps the Department has taken to challenge the unjustified prices and outline whether he has raised this issue at EU Council, EPSCO, level because the pricing of Orkambi seems to be an issue in a number of countries across the EU. I believe Germany has licensed it but there is an issue with the update because of the costs. France, the United Kingdom and other countries have an issue with the pricing also. While these issues are ongoing, and the Minister has to get a fairer deal, it is a travesty that this drug is not available for CF sufferers. Any significant delay is affecting these people. I understand the Minister's difficulties, but he must show CF sufferers the steps he is taking to address these issues, get a fairer price and, importantly, make this drug available for them as soon as possible.

The second issue I want to address is tobacco. Tobacco companies invest huge sums of money in advertising and marketing their products to recruit new customers, who are nearly always children and young people. That is the reason the 2015 Act to introduce plain or standardised packaging was so crucial. Plain or standardised packaging limits the tobacco industry's ability to attract young people by using marketing techniques that are intentionally misleading. Making tobacco products less attractive to consumers, making health warnings more prominent and reducing the ability of the packs to mislead people, especially children, about the harmful effects of smoking, are critical steps to reducing the attractiveness of tobacco products. The further amendments to the Act, which will help to enable that, are very welcome. However, sections 7 to 14, inclusive, of the Act have still not been commenced.

They must be commenced as soon as possible to address the issues and to take away the ability of these tobacco companies to continue to market tobacco products to young people and new customers. Fianna Fáil seeks the commencement of this absolutely critical step as soon as possible and I urge the Minister to do this. As the Minister noted earlier, Ireland has been a leading country in this area and we can take the lead once again. On commencing this legislation, Ireland once again will become a leader in the implementation of Articles 11 and 13 of the World Health Organization, WHO, Framework Convention on Tobacco Control. However, as we will not be in that position until the Act is commenced, I ask the Minister to so do as a matter of urgency.

I thank the Acting Chairman. I am sharing time with Deputies Jackie Cahill and Marc MacSharry.

I have good news for both Deputies because although I had intended to speak, I cannot do two jobs at once. Consequently, they will have an additional few minutes.

I thank the Acting Chairman and will focus on the fair deal aspect of this Bill. Fianna Fáil will support this Bill, which makes necessary changes in a number of areas. I specifically wish to speak on the provision for the amendment of the Nursing Homes Support Scheme Act 2009 to exclude certain ex gratia payments, which in the future will be made to individuals under specific schemes approved by the Government for the purpose of assessment of means under the Nursing Homes Support Scheme Act 2009. Part 3 of the Bill seeks to amend the aforementioned Act. The nursing home support scheme, also known as the fair deal scheme, provides for financial support for people who need long-term nursing home care. Those who use the scheme make a contribution towards the cost of their care and the State pays the balance. The amount paid by each person is determined by a financial means assessment. The 2009 Act has been amended in the past to exclude from financial means assessment ex gratia payments from the Magdalen laundry redress scheme and this Bill provides that ex gratia payments from other redress schemes will also be excluded from any assessment, which Fianna Fáil supports.

However, I am disappointed that while there have been media reports about family farms being treated differently under the fair deal scheme in the future, there is no mention of it in this Bill. As matters stand at present, if the owner of a family farm must enter a nursing home and is still the owner of that family farm or has only transferred it within the past five years, the entire value of that family farm is taken into account under the fair deal scheme calculations. In the case of a principal family residence, the contribution is capped at 7.5% per annum for three years, that is, 22.5% in total, and I believe this should be done for family farms as well. It is completely unfair and puts family farms at a serious disadvantage. There must be recognition that a family farm is simply a means of providing a livelihood for that family and not having a cap on the value of that farm for the fair deal scheme is completely unfair. While something may be done in this regard as part of next week's budget, it was remiss of the Government not to include such a provision in this Bill and Fianna Fáil seeks its consideration in the future.

How much time do I have?

The Deputy has more than 12 minutes.

First, as our senior spokesperson and Deputy Cahill have noted, Fianna Fáil supports this Bill. It contains some good measures with many more to come. However, while the Ministers of State are present in the Chamber, I will use the opportunity to raise a number of other issues. First, I wish to raise the issue of arthritis services for children in Ireland, which are in a bad state. I gather there are precisely 2.5 whole-time equivalent rheumatologists in Ireland. That is the second worst provision in the European Union. Given the prevalence of the disease, there should be five to six rheumatologists for a population of our size. Although the World Health Organization recommends waiting times for children of no more than six weeks, the current waiting time for a child in Ireland with arthritis is a staggering two years and four months. Essential appointments for children are being cancelled regularly due to the consultant paediatric rheumatologist being called for on-call emergency treatments in Crumlin hospital. On foot of the cancellation of these essential appointments, many children who are on what are highly dangerous drugs are not being viewed with the frequency required to give them the optimum care and treatment plan that is needed. In essence, what is needed is an increase in the number of paediatricians and, in particular, an increase in the number of rheumatologists here in Ireland. In addition, I note this service is only provided for in Dublin. While Manorhamilton is a centre for arthritis and related matters in north County Leitrim, it is an adult-only service that children cannot attend. What is required to avoid children being obliged to make long journeys or to have such long waits is to have a regional locum clinic for this condition visited by the appropriate paediatric rheumatologist. As I noted, the WHO recommends six weeks whereas in Ireland, a poor service is being delivered at present with waiting times of two years and four months. Clearly, children who are obliged to wait for so long while suffering from such an acute illness could be irreparably damaged. As they are growing, they obviously need ongoing care of a specialist nature and children in Ireland are being failed at present.

I also wish to raise the issue of home help hours, which has become an issue in all Members' constituencies. All Members are aware the cupboard is bare in terms of resources but it is about the management of what is being done. Older person services are covered under the social care division, which in turn is a division within the community care area. The Ministers of State opposite may be able to find out the name of the national lead in this regard but I understand, and anecdotal evidence certainly confirms, this individual is directing nationally that all help hours are to be reduced. Moreover, the direction is not to go over a certain amount regardless of the level of needs or dependency. I ask the Ministers of State to look into this on a national basis because this is what is coming back anecdotally from the social care professionals throughout the country.

In addition, I refer to the many people who wish to be cared for in their own homes and who are surviving quite well there with the appropriate level of home help hours. The reductions arising from the new directive that appears to be coming down from the aforementioned lead person in older person services, which is under the aegis of the lead person for social care, will mean these people will not be able to cope. In turn, this will put more pressure on the nursing homes throughout the country and as Members are aware, there is a shortage of nursing home beds with an ageing population and in turn, that will put even more pressure on the acute services. Moving on from that, the winter initiative in effect means that patients being discharged from hospitals are receiving priority over those who are already receiving home help in their homes. This will put further pressures on that scheme and there should not be such a prioritisation at the expense of people who already are being cared for in the community.

As I do not wish to be seen as merely moaning without at least suggesting some solutions, I will reiterate a suggestion I made as a Member of the Seanad and in the Dáil earlier in this term. Costings should be carried out on the partial abolition, at least, of the means test on the carer's allowance. To my mind, everyone has a relative, be it a sister, a brother, an aunt, an uncle, a father, a mother or a grandmother, for whom a family member would be more than capable of caring in the home with the benefit of the carer's allowance. This would enable that person to keep the relative in his or her home. In addition, one could ensure the person was in receipt of a medical card. To add further to this point, even if home adaptation grants were required for that purpose, it still would be a fraction of the cost when compared with the average weekly cost of a nursing home, which is between €800 and €1,600 per week depending on the part of the country and whether they are public or private, which is a colossal amount of money. To go further, the cost of an acute bed per day is approximately €1,000. Consequently, these figures certainly justify carrying out a costing on this proposal and being prepared to push the boat out to ask whether there is a better way to keep people in their homes. Clearly, that is where people would like to remain and if there are family members who are in a position to care and to do this, why do we not at least examine the potential to give such people the carer's allowance, as well as some additional supports? To my mind, a cursory glance suggests the large amount of money that could be saved, not to mention the pressure that would be taken off what is a small number of nursing home beds. Moreover, from listening to the spokesperson for the emergency medicine practitioners in Ireland, Mr. Fergal Hickey, all Members are aware of the difficulties being experienced in respect of bed numbers in acute hospitals. He suggests, for example, that 300 people die every year because not enough beds are made available for people on the acute side and I ask the Ministers of State to take this on board as well.

My colleague mentioned the drug Orkambi. I cannot stress enough the importance of making this drug available to patients throughout the country who are suitable for treatment. Orkambi is a game-changer. By changing the game, we can equally reduce the burden on the State in terms of caring for these patients when they become more ill because Orkambi is not available to them. Young people have passed away in every constituency. In my own constituency, in particular, the late and courageous Gráinne Golden and her family, her sister Aisling and mother Terri, have been exemplary in promoting the need to make this available. Former Senator John Crown and I brought forward a suggestion in the previous Seanad to the effect that rather than people being obliged to fight, through Joe Duffy's "Liveline" and other means, to get access to certain life-saving cancer treatments and drugs, it should be the case that the Government opts out of the provision of a drug if the cost per life saved is not justifiable. We had the ipilimumab crisis in terms of skin cancer some years ago. Orkambi is no different. We can change the lives of these young people and their families. As I said, if it is merely down to pounds, shillings and pence, we can also remove some of the burden on State because if people are not treated with this drug, they will become a greater burden down the line.

All politics is local, as Tip O'Neill famously said. I do not want to lose the opportunity to comment against the backdrop of a Minister of State perpetrating a charade whereby he sought to have an additional cardiac catheterisation laboratory facility put in place in Waterford where, from a clinical point of view, one is not needed. There is an existing lab there and cardiac care is available. In addition, there is also a motorway to Dublin. There is good proximity to Cork, where there are many cardiologists. The position in the north-west of the country is somewhat different. Indeed, I must give the analogy of two maps I came across lately - one showed the road network in 1729 and the other was for the motorway network in 2016. These maps mirror each another. Indeed, many of the acute health services are the same - north of a line between Dublin and Galway and west of Mullingar, or, for want of a better expression, the greater Dublin area, there are no cardiac catheterisation laboratory facilities. If one has a heart attack in that part of the country, one has a lesser likelihood of survival than somebody in Dublin or, indeed, Waterford who suffers a heart attack. Prior to the election, the Government announced that there would be a cardiac catheterisation laboratory in Sligo to serve the north-west region. Deputy Tony McLoughlin can confirm this in the event anybody in the House has a short memory. We are anxious to know when we will move to a position where tenders will take place and these services will be available so that the people in the north-west have the same possibility to survive as those equal citizens from other parts of the country.

We have had an issue with follow-up mammography, in respect of which a pre-election promise was also made. As the Minister will be aware, cancer services were stripped out of the north-west in what, quite frankly, was a shameful act by a previous Government. In fact, my own party was in government at that time. It was the wrong decision then and it remains equally wrong today. Follow-up mammography for those ladies who require it was promised prior to the election and now it seems what we will have is a truck visiting for two weeks per annum to facilitate only those women who, thankfully, have been five years clear of cancer. That is all that will come.

In terms of other capital plans that also were announced, one which dates back to 2010 is a new 90-bed facility in Sligo University Hospital, formerly Sligo Regional Hospital. I wonder how much the rebranding cost. Perhaps that money could have been better placed in upgrading the facilities that have been promised by successive Governments over the years. There is a 90-bed facility somewhere in the mix and I would very much like to see an update on that. That hospital serves a population in the region of 280,000 and we are interested to know when precisely that will be up and running.

I refer to a new 21-bed facility at the existing mental hospital. Currently, there is a facility where, no matter what their complaints, people are all put together in wards. In terms of its practice, it is almost medieval. There is a 21-bed facility in the mix somewhere in the capital plan within the HSE but rumours abound that the priority of this Government is only the national children's hospital and that everything else will be placed on hold as a result. We would like to get some clarification on that issue also.

Finally, I wish to ask in connection with waiting list times throughout the country. I touched on the position regarding rheumatologists and, specifically, the need for more consultant rheumatologists to be appointed on the children's side. In the context of psychology and psychiatry, the waiting times for children with issues are beyond a joke. In some instances, the waiting period is a couple of years. In others, it is many months. This is simply far too long for people to be obliged to wait. I appeal to the Minister. While I appreciate that we are discussing the Health (Miscellaneous Provisions) Bill, which my party will be supporting, and rather than waste the time that was available, it was important to highlight some of the genuine needs of the north-west and, indeed, children throughout the country. I would also ask that the Minister would reminisce upon and embrace some of the pre-election promises which the people of the north-west have waited far too long to see fulfilled.

I thank Deputy MacSharry for that valuable contribution.

Obviously, I am here to discuss the Health (Miscellaneous Provisions) Bill but given that Deputy MacSharry raised the issue of home helps and home help hours, I would say for the record that, unlike him, I do not accept that the cupboard is bare in terms of resources. In fact, the cupboard is far from bare. The problem lies with the officials who stand between those who need the services and the cupboard. There are plenty of under-utilised and unused home help hours available in the system. The difficulty stems from the Department of Health and the HSE not sanctioning those staff who are available and willing to work. That said, I will talk about the matter in hand and hope that whoever else is sitting in the Chair exercises the same kind of latitude that I have just seen when I speak in the future.

On behalf of my party, I welcome the Bill. It is important that the provisions specifically relating to plain packaging will finally be enacted following the passage of the Bill. In the past year, since the successful passage of the plain packaging legislation through these Houses, we have missed a crucial deadline in respect of the circulation of plain packaged tobacco products. This has rightly been a source of a lot of discontent to those organisations, such as the Irish Cancer Society, the Irish Heart Foundation and ASH Ireland, which have been campaigning hard on this issue for a long time.

When the Public Health (Standardised Packaging of Tobacco) Act 2015 was passed, there was a collective sigh of relief. Ireland was to be one of the pioneering countries to introduce plain packaging. We had stood up to the unscrupulous tobacco companies and their extensive lobbying efforts. Public health trumped corporate interests. It is regrettable that the 20 May 2016 deadline was missed. Factors, such as the general election and the protracted negotiations relating to the formation of the Government, meant that this Bill did not come to the House soon enough. In that regard, I, as the Sinn Féin health spokesperson, wish to see the smooth passage of this Bill through the Oireachtas so that we can finally ensure that plain packaging for tobacco products begins. This is vital as the commencement of the provisions of the 2015 Act relating to standardised packaging will be deferred until the enactment of this Bill.

What strikes me, and what is important when we talk about this particular provision, is that despite what the tobacco companies may crib and moan about, despite how many billions of euro they pump into public relations, advertising and lobbying worldwide in order to talk about profits, the industry and trade, they always neglect to mention that they are peddling death. There is no other way of saying it - they are profiting directly from death, familial and community decimation and heartache.

Profit, turnover or the needs of the industry do not lie at the heart of this Bill or the legislation passed last year. I am not my party's spokesperson on jobs, enterprise and innovation; I am its spokesperson on health. This is a public health issue. It is an issue that, should we choose to ignore it, would result in a lose-lose situation for the public. The public would lose out in terms of their own health outcomes as they risk capture by - on foot of heavy marketing, branding and the lure of the tobacco industry - getting hooked on a deadly drug. We must also consider the cost to the public health system from treating the diseases caused by that same drug. Some people use the term "nanny state"; I call what we are doing being responsible legislators. This is a matter of public health.

It is important that we give people all the information they need in order that they can see the effects of smoking and will be 100% in no doubt of how this drug affects them and those around them.

When preparing for this debate, I read the transcripts relating to the legislation passed last year. In that context, I was struck by how far public health legislation has come in terms of restricting the advertising relating to and packaging of these deadly products. Looking at some old advertisements from the United States, it is blatantly clear why we cannot trust nor expect tobacco companies to have any regard for public health. If they had not been regulated, they would have continued to make such ludicrous claims for their products such as "For your throat's sake", "Scientifically proved far less irritating to the nose and throat", "I protect my voice with Luckies", "More doctors smoke Camels", "Just what the doctor ordered", "For digestion's sake", and "To keep a slender figure". They cannot be trusted with public health and that is why decisive legislation such as that before the House is badly needed. When those same companies tried to challenge democratically elected governments which were looking out for the public interest of their citizens, we should not have been surprised.

I, like many others, was happy to discover that the European Court of Justice rejected a case brought by big cigarette companies, which has meant that the passage of this legislation is now the last hurdle to the practical introduction of plain packaging for tobacco products. In a preliminary ruling last December, the advocate general of the European Court of Justice found that the standardisation of labelling and packaging is a proportionate measure. As we all know, the EU tobacco products directive, which was adopted in 2014, had been held up by a series of court cases. Earlier this year, this ruling was reaffirmed when the court said that such packaging requirements are "such as to protect consumers against the risks associated with tobacco use and does not go beyond what is necessary in order to achieve the objective pursued ... the EU legislature did not go beyond the limits of what is appropriate and necessary." We should not run scared of these companies. We should stand confident in the fact that the research available to us demonstrates that standardised plain packaging will have a positive impact on health and that it is a proportionate and justified measure. Let us never forget that more than 5,000 Irish people die prematurely every year form the effects of smoking.

To return to the slogans used in the United States, think of the false and misleading nature of the health claims attached to them and the allure the companies employed. These items of legislation permanently consign that to the annals of history. Standardised packaging can reduce the appeal of tobacco products and increase the effectiveness of health warnings. It reduces the ability of branded tobacco packaging to mislead people about the harmful effects of smoking. When we consider that almost 80% of smokers start when they are children, these public health measures stop the normalisation of smoking before it starts.

When we speak of the legal threats of big tobacco companies and of the bully-boy tactics by these profit moguls who peddle their wares irrespective of the consequences or risks, it would be remiss of me not to mention one of the biggest threats to the success of this legislation, the Transatlantic Trade and Investment Partnership, TTIP. Countries across the globe have introduced legislation to protect citizens from the risks of smoking and to promote healthy lifestyles. As in the case of Ireland, this has included plain packaging for cigarettes and tobacco products. We have seen tobacco companies try to block such moves from becoming law. We have witnessed the extent of their lobbying. They tried to go even further with Philip Morris attempting to sue the government of Uruguay over anti-smoking legislation. This was the first time a tobacco group challenged a state in front of an international court and the first investment arbitration concerning tobacco control. Thankfully, it lost that case earlier this year. This David-and-Goliath situation is iconic because it is indicative of the way that corporations can use international investment treaties to attack those regulations made in the public interest.

The Guardian newspaper earlier this year quoted Juan Fernández-Armesto, a Spanish lawyer and expert on investment arbitrators who said:

It never ceases to amaze me that sovereign states have agreed to investment arbitration at all ... Three private individuals are entrusted with the power to review, without any restriction or appeal procedure, all actions of the government, all decisions of the courts, and all laws and regulations emanating from parliament.

The ability of tobacco companies to take this action with European governments may be made possible because of the investor-state dispute settlement, ISDS, mechanism. This is why Sinn Féin opposes TTIP, which contains the ISDS. TTIP is not just a free trade deal. It will extend beyond the removal of tariffs to include the opening of markets on investment, services and public procurement and the removal of any so-called barriers to trade. The stated aim of TTIP is to remove unnecessary barriers to trade through regulatory convergence. However, these barriers are some of our most prized standards. Changes to regulation can have negative impacts at great social cost. We cannot have a situation where big tobacco companies can try to undermine the legislation and the public health concerns of individual countries because specific laws jeopardise their profit margins. The health of citizens is more important than the wealth of tobacco companies.

It would be a slap in the face in the context of this legislation and all the work that was put in by the Oireachtas and the relevant non-governmental organisations, stakeholders and health professionals if TTIP were not opposed. While I welcome the passage of the legislation and look forward to seeing plain packaging in operation, I worry that, should TTIP succeed and should the ISDS mechanism be introduced, all this hard work will have been in vain. I invite the Minister to outline the Government's position on TTIP in this regard.

Regarding the part of the Bill that amends the Health (Pricing and Supply of Medical Goods) Act 2013, I recognise the importance of ensuring that over-the-counter products continue to be available under the General Medical Services, GMS, and community drug schemes. Public health is paramount. Any measures we can take in the Legislature to ensure it remains paramount should be welcomed.

I wish to revert to comments I made, and to which the Minister responded, during a motion on pharmacy fees a week ago. One of the amendments I tabled sought to look at how dispensing fees could possibly be reduced for patients. In that regard, we recognised that the switching of medications from a prescription to a non-prescription basis could do this in some small way. The Health Products Regulatory Authority, HPRA, oversees the reclassification of both prescription-only medicine to over the counter, OTC, in pharmacy status and from OTC to general retail sale. In our Better4Health policy document launched late last year, we note that at that time the authority identified more than 30 products that could be reclassified. These include topical antifungals, steroid creams and proton-pump inhibitors. The Minister noted that this was an issue for the statutory agency and I understand that the HPRA actively seeks applications from suppliers and gives ongoing consideration to the relevant issues. Following on from this debate, it would be interesting if the Minister could advise - perhaps not now but at some point in the future - how successful this call for applications has been, at what rate suppliers are seeking reclassification or why, perhaps, there is not a greater take up of this reclassification option. Similarly, if these medicines were reclassified, would they continue to be available under the GMS and community drug schemes or would further amendments to the Health (Pricing and Supply of Medical Goods) Act 2013 be required?

I do not wish to speak for too long but I would like to encourage the swift passage of this legislation so that we might finally see plain packaging for tobacco products become a reality. This is a critical public health matter and, ultimately, I would like to see smoking eradicated completely. In our pre-budget submission today, Sinn Féin has proposed an increase in excise duty of 50 cent on a packet of cigarettes. This is on public health grounds, obviously, and is not intended to be a revenue-raising exercise, as I am sure the Ministers of State will appreciate. My colleague, Deputy Ó Caoláin, Sinn Féin spokesperson on disability rights and older people, will use a later speaking slot to discuss the amendment to the Nursing Homes Support Scheme Act 2009.

While I have the attention of the two Ministers of State who are present, I would like to put on record that I was outraged to read media reports to the effect that a member of the Government will seek to oppose any measures designed to increase the cost of a packet of cigarettes. I am a former smoker. I understand it is incredibly difficult to give up smoking but I also understand it is incredibly important that we encourage people to do so in whatever way that we can. I would like to hear a clear statement from either of the Ministers of State or any member of Government that would distance this Administration from those potentially dangerous remarks. Remarks such as those that were reported in the media with regard to smoking do damage to any person who is considering giving up smoking. It is against public health policy. I would like to see members of this Government clearly distance themselves from those shameful and outrageous remarks.

It is not acceptable that a member of Government would seek to block an increase in the cost of a packet of cigarettes. I am sure there are no members of Government - at least I hope not - who are unaware of the damage, danger and cost to our public health service of smoking and smoking-related diseases.

Deputy Alan Kelly has 30 minutes.

I will not use all of the 30 minutes. I will break my contribution into three components. The first is on the Bill, which I will go through in a small bit of detail. I have two very capable Ministers of State in front of me, one of whom is leaving the Chamber. I want to make a number of short pre-budget contributions. I will raise a very serious issue which is not one I have raised before with the Minister. It is on something very specific which I want to raise on the record of the House.

The Labour Party will support the Bill but I am perturbed with regard to why it took so long to come before the House. It was drafted and in place over six months ago while I was still in government. It is not contentious; it is something the House will, by and large, support. This is the "Go slow" Dáil and the "Whatever you do, do nothing" Dáil. This is a Bill that could have been brought before the Houses before now. Why was it not? It should not have been delayed.

There is no issue on the fees in the amendment to the Irish Medicines Board Act so long as everything is done within the regulations set out and normal caveats apply to things like double jobbing. The amendments to the Nursing Homes Support Scheme Act are long overdue. Anomalies existed with regard to the different groups that received settlements down through the years and the amendment is necessary because of that. It is long overdue, it is common sense and we very much support it. On the amendment to the Health (Pricing and Supply of Medical Goods) Act 2013 and the over-the-counter medicines, we welcome that this change will be brought about. It is necessary to update it to ensure that all of these are covered under the GMS scheme so that people will be protected and will have the medicine they require.

I have very strong views on the issue of tobacco packaging. Unlike the previous speaker, I have never smoked. I absolutely despise the practice. I have zero tolerance of it. I am perturbed that it took so long to bring this forward. I accept all the amendments; they are a necessity. It is a pity the Minister of State with responsibility for public health is not still in the Chamber because this is an area in respect of which we need to up our game. We need to up our game with regard to public health, smoking and young people. The percentage of young people smoking is unacceptable. We have a huge awareness campaign across a range of different areas. Public health policy needs to improve dramatically in respect of this matter and we must use new mediums to connect with young people. We have to intervene very quickly with them, show them it is not cool to smoke and that the health impacts over their lifetimes will be disastrous. The number of young people one sees smoking is disheartening. From a public health point of view, we will have the full support of the House. The Minister will have everyone's support, although possibly not the support of one of the Ministers of State in the Department of Health, particularly in light of some of his recent comments.

This an area in respect of which there is a need for an increase in funds. We should ensure we are using every medium and social media in particular. There should be a concentrated campaign in schools and colleges to ensure the effects of smoking on health are brought to their attention. A discourse should be encouraged in Irish society to the effect that smoking is not an acceptable practice, that it has impacts beyond one's own health and that it affects other people's health. It is something we need to improve on. We need to be very honest. Such a practice and such honesty from all Ministers of State in the Department of Health would be helpful in light of the recent comments by one Minister of State in this area. I compliment the Minister of State with responsibility for health promotion on her honesty in how she is tackling some of the issues. I hope all other Ministers of State in the Department of Health take up this practice, particularly in trying to ensure we limit the damage smoking is doing to our young people in particular and to everyone in society.

I want to raise a number of pre-budget issues. We will be putting forward our budget proposals in the coming days. I will get a great deal of time to speak on this matter on many different occasions, so I will not take up too much time doing so now. I want to be very specific. We have to completely change tack in the area of community interventions, home help hours and home-care packages. Like a number of other Deputies who are present in the Chamber, I am a member of the Committee on the Future of Healthcare. A submission was made by one of the hospital groups. If one breaks that submission down, it was saying that in order to prevent the overcrowding in some of our hospitals, which is obviously a serious and critical issue, we need to redistribute the funding in the community sector and ensure that it is actually administered, real, and having results. That will do more to prevent the overcrowding we see in our hospitals all the time. Given the ongoing discussions, I implore the Minister of State to make provision for a dramatic increase in home help hours and home-care packages. I also ask that in the administration and coverage of community intervention teams, we create a situation where they are consistent across the country. We should not have a situation where, for example, they work certain hours in the south east, other hours in the south west and another group of hours in the mid west. Some are working Monday to Friday and others are working Sunday to Sunday. It is just crazy. We need a consistent approach and one that is working all over the country.

There is a necessity, from the point of view of the backlog, to invest serious funding in the area of dental health care for children. I am nearly ten years at this and in my time in politics I have never seen backlogs such as those which exist now in terms of the provision of dental care for children and particularly for young teenagers. The indications I am getting with regard to waiting times are absolutely scandalous. It needs to be dealt with because it will create other costs down the road if it is not dealt with. It means we are only pushing problems down the road which will cost us more so we might as well put in the intervention for these people as early as possible.

The final issue on which I wish to comment has nothing to do with the budget or the Bill. It is something I have not raised before but it is very important. I want the Minister of State to take some account of it. I refer to the treatment abroad scheme. This is a scheme whereby treatment that cannot be brought about in Ireland happens elsewhere, in many cases in Northern Ireland or Britain. The costs are quite severe and the cases that are brought about in this area are unique. In the past, this was managed through the HSE but part of the management of the costs has transferred to the Department of Social Protection in recent years. Some of those who have to avail of this scheme are not being treated well and are falling between the two stools of the two Departments. I would like the Minister of State to investigate this. I have one example of a young boy who is four years of age. I will not give his full name. His first name is Billy and he loves tractors. He suffers from transverse myelitis, which is a neurological disorder caused by an infection. He is paralysed. He had a home-care package at three years of age, with which I was able to help him.

He does not live in my constituency, if anyone thinks so, but actually in the constituency of the Minister of State, Deputy Marcella Corcoran Kennedy. Although he received great treatment at Temple Street hospital and a fantastic reception from the Health Service Executive, HSE, with a home care package, Billy’s condition in the rehabilitation centre could not be improved. Subsequently, he had to go under the transfer abroad scheme to Stoke Mandeville Hospital in the UK. In fairness, under the scheme, Billy’s associated costs are covered as well as flights for his mother. Billy’s condition is very rare and the quicker the intervention he gets, the more chance he has of making a recovery. He will have to spend one week of every five weeks going to Stoke Mandeville. The issue is that the one week he already has gone over to Stoke Mandeville has cost his family €3,000. If his treatment will take up to four years, this cost will not be sustainable for his family.

I thank the Acting Chairman for giving me some latitude on this. The family has asked me to highlight this case and has already made it public, so I am not stepping outside on this. There is a precedent with the exceptional needs payment from the Department of Social Protection. It is a unique case and there seems to be a gap between the HSE and the Department of Social Protection. The community welfare officer has said they cannot do any more. It needs a quick rethink to impact on the life of a beautiful young boy who has a great future in front of him. I have visited him myself and he has a huge personality. His family is looking for the State to match up and do its best for him too.

I will pass on the personal details of the case to the Minister of State. I hope she, along with the Minister for Health, Deputy Simon Harris, and the Minister for Social Protection, Deputy Leo Varadkar, will examine this to find a solution for Billy and others who may be in this situation. I do not believe what has occurred in this case is deliberate. Simply put, since the transfer from the HSE to the Department of Social Protection, a gap has emerged in how it is being dealt with. I would appreciate it if it could be looked into.

One aim of the Health (Miscellaneous Provisions) Bill is to amend the Health (Pricing and Supply of Medical Goods) Act 2013 to allow the reimbursement of some over-the-counter medical products, including emergency contraception, to medical cardholders. I, along with Members from the Anti-Austerity Alliance-People Before Profit, AAA-PBP, will vote for this. It is better that those on medical cards and those on low incomes can have access to emergency contraception rather than being forced to pay for it. However, I draw attention to some of the problems with the current system in this regard.

Emergency contraception is more likely to be effective the sooner it is taken. A woman who has need of emergency contraception and can afford to pay for it over the counter in a pharmacist is one matter. What about the situation facing a woman who has to go to her general practitioner for a prescription for emergency contraception? What happens if the GP is closed for the weekend, as is the norm? It means the woman has to wait until such time as she can get a prescription. The longer one waits, the less effective the emergency contraception is likely to be. This discriminates against those on medical cards and low incomes who, because they are forced to wait, will have an increased chance of an unwanted pregnancy.

How do we overcome this situation to get rid of this problem? A simple way would be not to require a prescription for emergency contraception for a woman on a medical card. A better way would be that emergency contraception should be available at pharmacists and free of charge. This is a health priority for women faced with an emergency situation and who want to take steps to avoid an unwanted pregnancy. It is not like this is not done in other countries. One need look no further than the UK. A woman in London, Birmingham or Glasgow who finds herself in such a situation can go to some pharmacies, a contraception clinic or most National Health Service walk-in centres to avail of emergency contraception free of charge. If it can be done in the UK, why can it not be done here? We believe it would be the right course of action.

I draw attention also to another incredible fact. In Ireland in 2016, a pharmacist is legally entitled to refuse to dispense emergency contraception on the grounds of conscientious objection. Such a pharmacist is obliged by law to refer the woman to another pharmacist who will provide emergency contraception. However, in practice in some rural areas, where there may not be a significant number of pharmacies, it can mean emergency contraception becomes extremely difficult to access or even inaccessible. That is completely unacceptable. This conscientious objection get-out clause should be scrapped. This is the 21st century and this country has to stop facilitating those who would drag us back to the 19th century. Women’s health is too important for that.

The Bill provides for plain packaging for tobacco products, a measure I strongly support. I would warn, however, against this progressive measure being trumped by new trade agreements. For example, the Transatlantic Trade and Investment Partnership, TTIP, currently under negotiation between the European Union and the United States, would provide for the possibility of the establishment of investor-state dispute settlement courts. These would be business courts which would allow big business interests to sue governments for hindering their attempts to maximise profits. As such, these courts could regard the plain packaging for tobacco products measure as an illegal restriction on the right of tobacco companies to maximise profits and sell their products. It has happened in other countries with similar settlement courts. This measure is a progressive one that should be adopted. Instead, the likes of the TTIP agreement should be scrapped, along with its investor-state dispute settlement courts. They are courts for big business and are not in the interests of ordinary people.

I am delighted to see Deputy Clare Daly. She has just saved me from having to suspend the debate.

I know, but I am utterly shocked that not only do I have to speak tonight, I must speak for half an hour.

The Deputy can speak for ten minutes if she so wishes.

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.

I apologise to Deputy Shortall as we are just out of time.

Debate adjourned.