Topical Issue Debate

Middle East Issues

We have already discussed this matter to some degree during Question Time. We know that on Saturday, 9 September, four Irish citizens, Elaine Daly, Fidelma Bonass, Joan Nolan and Stephen McCloskey, were deported from Tel Aviv in Israel. They were deported because they were organising and travelling with a delegation of 31 people, primarily Irish citizens, on an awareness-raising visit to the West Bank. I understand their itinerary was to include meetings with Israeli and Palestinian human rights organisations and individuals, a visit to a refugee camp and a tour of settlements, together with day trips to some of the main towns in the West Bank. The aim of the trip was to bear witness to the everyday hardships suffered by Palestinian people as a result of the restrictions imposed by the apartheid wall, permanent checkpoints and settlements. The other 27 members of the delegation, two of whom are present today, were allowed to continue into Israel–Palestine and they arrived back to Ireland a week ago. The Minister accepted that we do not have a good explanation from the Israeli State.

For all four deportations, the grounds given were considerations concerning the prevention of illegal immigration. This is a utterly bizarre because the individuals were travelling on valid Irish passports. An additional reason was given for Ms Elaine Daly involving considerations associated with public security, public safety or public order. Again, this is complete nonsense. She did not even participate in the completely legitimate protests in Bil'in in which she was accused of participating.

The conclusion that is strongly pointed towards is precisely that the Israeli Government, at a time of increasing repression and oppression, is increasing the rate of illegal settlement-building and attempting to put an end to any possibility of a viable Palestinian state through brute force, effectively through house demolition, etc. It does not want people to make these trips. It does not want people to see the reality of what is happening. In doing so, ironically, it demonstrates in a small way the absence of freedom of movement, repression and interference by security forces faced by the Palestinian people on a daily basis. What is the Government going to do about it? It can rightly state the explanation but that it does not really know what lies behind it. More has to be done, however.

I was deported from Israel four or five years ago, or maybe more, along with others. At that time, the Irish Government said it was going to ask the relevant questions and that we would be out quickly and get back our laptops, telephones and everything else. The authorities still have all the stuff they took from me then. The Government did not make any very loud public pronouncements about it afterwards. What is the Government going to do about this to illustrate the oppression facing the people in Palestine on a daily basis? Has any contact been made with the Israeli ambassador in Ireland? Have we had a meeting with him and asked for a clear explanation? Has there been any mention of consequences if we do not get a clear explanation? Can we get a commitment that we will not have these deportations in the future? Will the Israeli Government just be able to discourage people from going to witness what is taking place and to witness the human rights abuses by deporting people in this completely arbitrary and illegal way?

I thank the Deputy for raising this issue. As he knows, the Department of Foreign Affairs and Trade was notified immediately by one of the persons concerned about their deportation. They have since written to the Minister for Foreign Affairs and Trade, Deputy Coveney, and his Department has further discussed the events with some of them to get a clear picture of what happened.

The organiser and leader of the group has led 17 private study groups to the West Bank over a ten-year period. The groups meet a range of Israeli and Palestinian NGOs and study issues relating to the occupation of the West Bank. The tour leader had responsibility and, as was her usual practice, advised the Department of Foreign Affairs and Trade in advance of the dates and itinerary of the tour.

Some 33 members of the group entered Israel, but four were deported. No detailed response or reason for refusing admission to Israel was given to them other than a generic explanation that it was for immigration reasons and, in the case of the leader, because of unspecified public security or public order considerations. No report or allegation has ever been made to the Department of Foreign Affairs, including by the Israeli authorities, of any concerns about the activities of these study groups.

All four persons were asked about alleged previous attendance at a well-known weekly demonstration in the Palestinian village of Bi’lin. The group leader has stated that she has never taken part in any demonstrations in Palestine nor have any of her group's programmes included attendance at a demonstration. I understand that two of those deported may have previously attended this demonstration while two had not done so.

The refusal of entry may also have been on foot of Israeli legislation enacted earlier this year which provided for admission to be refused to any person who has advocated or is a member of a group which has advocated a policy of boycott regarding Israel or Israeli settlements in Palestine. However, I am not sure that either explanation would apply to all four persons. It would probably be best not to speculate further on what may have led to this unwelcome attention being paid to these individuals.

Without a more specific explanation, it is difficult to do other than conclude that the exclusion of these persons contributes to efforts to suppress scrutiny and criticism of Israeli policies in the West Bank. The Irish ambassador in Tel Aviv has already called to the Israeli Foreign Ministry and requested an explanation for this action. We must, as a first step, allow the authorities to respond before commenting definitively and before further steps are taken with the ambassador here. However, I am happy to restate that the Government is not aware of any concerns about the actions of these individuals or their group which would be a legitimate basis for concern, or exclusion.

The Government does not accept the proposition that advocacy of boycotts is equivalent to support for violence. The Government does not support trade or other boycotts of Israel, but citizens are entitled to support them as legitimate political options. Similarly, we cannot accept that mere attendance at a legitimate and non-violent protest by Palestinians in their own village against the conditions of the occupation is a reasonable ground to exclude someone. Any response received from the Israeli authorities will of course be shared with the individuals concerned, and the Minister for Foreign Affairs and Trade may also comment further at that stage.

I thank the Minister of State. I welcome the fact the Government, in particular, has said it is difficult to make any other conclusion other than that the exclusion of these persons contributes to efforts to suppress scrutiny and criticism of Israeli policies in the West Bank. That is completely accurate and is, unfortunately, precisely what is happening. Will the Minister of State give us a timeframe in which we can expect a response from the Israeli Foreign Ministry? We expect an explanation, and if we do not get an adequate explanation at that stage, we need to have a response to that, be it public statements or discussions with the Israeli ambassador in Ireland.

I again welcome the fact the Government does not accept the proposition that advocacy as boycott is equivalent to support for violence. That is very important in a context where, globally, including in France and other countries, there is an attempt to criminalise the expression of support for BDS. Representatives of the Bank of Ireland came before the Committee on Finance, Public Expenditure and Reform, and Taoiseach today. The bank shut down the accounts of the Ireland Palestine Solidarity Campaign, one of a number of actions taken by banks around the world, it is to be presumed, under pressure.

I also welcome that the Government cannot accept mere attendance at legitimate non-violent protest by Palestinians as a reasonable ground on which to exclude someone. I refer to a statement from Stephen McCloskey, one of those who was deported. He said he was denied entry because he had participated in a protest in Bi’lin, a small village west of Ramallah, a year ago. Bi’lin has resisted the construction of Israel's illegal separation barrier, better known as an apartheid wall, on the land there for 12 years. Irish activists, Mr. McCloskey included, joined the villagers in their weekly non-violent protest against the construction of the wall which the International Court of Justice deemed to be illegal in 2004. In opposing the wall, Irish activists were upholding the law. By deporting him and three other Irish citizens, all of whom were non-violent activists, Israel denied them the right to travel and freedom of expression, just as it does to Palestinians every day. It was breaking the law.

I thank the Deputy. With regard to the timeframe, our officials were in contact immediately after this happened and, as I said, are in constant communication with the relevant authorities. It is currently a Jewish holiday, and while that may delay things, we would expect to have a response as quickly as possible.

While the deportation of pro-Palestinian activists from Israel is not uncommon, the Department has noted a marked increase recently in the exclusion of international activists or NGO workers. This case is very notable in that the persons concerned may have been excluded not on the base of the actions they undertook but because of a political view they may have espoused at home. That is something we have to consider carefully.

As I stated, if the individuals were to apply to return to Israel, they would most likely be excluded again. We need to observe the effects of these issues and the more aggressive policy on deportations. We are awaiting a response from the ambassador and will have to see what action can be taken following that.

Catalan Referendum

We now proceed to the second item, the political situation in Catalonia. It is rather unfortunate that both issues were raised rather unexpectedly during Question Time. There is an element of repetition.

We all have our different angles in regard to this. In recent years, millions of people have marched on the streets of Barcelona to demand, in a very colourful and dignified way, the right to vote in a legally binding and democratic referendum on independence from Spain. Just last week, on 11 September, Catalonia's national day, 1.5 million people joined the annual pro-referendum march.

Recent polls indicate that 70% of Catalans, not all of whom are pro-independence, want a referendum. Some will vote "No" in the referendum, but they all want the right to vote. The current Catalan Government was elected in January 2016 on a legitimate and reasonable platform which stated it would establish a binding referendum on independence. Despite the best attempts of the Catalan Government, the Spanish Government continues to deny this democratic mandate and the demands of the Catalan people for a democratic referendum.

My understanding is that a majority of the members of the democratically elected Catalan Parliament have approved legislation to allow a binding independence referendum to take place on 1 October 2017. Yesterday, some disturbing events unfolded in Catalonia when the Guardia Civil raided the headquarters of the Catalan Government, arresting 14 high-ranking civil servants and public officers and entered the offices of at least one major political party. That is unprecedented in recent times.

Furthermore, in recent days armed police have visited newspaper officers, shut down websites and raided storage warehouses and printing centres, seizing voting boxes, ballot papers and political posters. More than 700 Catalan mayors who support the referendum have been threatened with judicial prosecution. The President of the Catalan Government said Spain has now de facto suspended self-government and applied a de facto state of emergency. He described the move as an unacceptable situation in a democracy, and I agree with him. What is the position of the Irish Government?

When elected officials are detained for political reasons and ballot boxes for a popular and demographic referendum are seized, we have to speak out. If we do not, who will? When newspapers are threatened and democracy is denied, surely we have to say, "Stop. Enough is enough."

These raids and arrests have triggered massive demonstrations, all of which were peaceful despite some provocation in some areas, and which saw tens of thousands of Catalans demand the most basic of rights - the right to vote in a democratic referendum. In this country, we would like to see more and more people vote yet in this other part of the world, they are telling people that they cannot vote. Thousands of people in the Basque country and Galicia have also taken to the streets in support of their Catalan brothers and sisters.

These unprecedented attacks on fundamental rights and civil and political liberties are putting democracy in Catalonia at risk. Does the Minister of State share my concerns about these events? Is she in any way uncomfortable or even disturbed that government departments in Catalonia are being raided and that civil servants are being arrested for purely legitimate and, I would argue, reasonable demands for a referendum on independence?

I thank the Deputy for raising this issue. Ireland enjoys very close relations with Spain. These relations are, of course, deeper and more textured than simply involving periodic government-to-government relations, developing trade ties or occasional encounters at multilateral events. Our close friendship has at its heart an empathy nurtured by generations of contacts between our people. What happens in Spain is, therefore, of great interest to their Irish friends here in this House and in the society we represent. It makes complete sense that the differing opinions we are now seeing between different institutions and citizens in Catalonia and across Spain should find reflection in different opinions in this House. This is to be expected and respected and I welcome this opportunity to set out the Government's position on this sensitive matter.

Just last month, we were all shocked and saddened by the loss of so many innocent lives and the injuries caused to so many people as a result of the horrific attacks in Catalonia. As the Taoiseach noted in his letter of support and solidarity to Spain's Prime Minister, attacks of this nature are both wanton and cowardly and have no place in our society. We must continue to work together in Europe and with the international community to challenge ideologies of hatred and to uphold the values we hold dear.

At present, we are following developments with regard to Catalonia. We have enormous regard for the Catalan people. Europe is enriched by flourishing national identities across this European Union. This richness is explicitly promoted and protected in the Treaty of the European Union. As I said earlier in the House in reply to a parliamentary question on this topic, the Government's position is that the constitutional and political arrangements in any country of the European Union are matters to be determined by their own citizens through their own democratic institutions in adherence with the rule of law.

As I said already, clearly what happens in Spain is of great interest to us but we believe the issues at hand are domestic issues. Political developments in democracies take place within a legal framework. This is what protects the rights of all of our citizens. In a reply to a Spanish MEP on this topic, the President of the European Parliament wrote recently that the rule of law is the backbone of modern pluralist societies and constitutional democracies. Respecting the rule of law and the limits it imposes on those in government is not a choice but an obligation. The Government and I share this view. I believe it is for all Spanish citizens to determine for themselves, using their democratic institutions and legal safeguards, their preferred constitutional and political arrangements. I do not consider it either appropriate or helpful that Ireland would enter the debate. I am confident that our Spanish friends can chart their own internal political developments.

It is not the first time that an Irish republican said that what happens in Spain affects us all. Clearly, the idea of standing idly by and watching what is unfolding in Catalonia is unacceptable. The Minister of State's response is deeply disappointing. I do not think it reflects the views of people in Ireland. Yesterday, we saw heavily armed police try to frustrate attempts to have a democratic referendum and to stop a democratically elected government from carrying out its electoral mandate. I have a problem with that. Perhaps the Irish Government does not have a problem with it but I certainly do. As Ireland's Minister of State with responsibility for European Affairs, the Minister of State should have a problem with that.

On every level, this goes against the European values of democracy and the right of a people to self-determination. Yesterday, three ferries with capacity for 4,000 members of the Guardia Civil docked in Catalan ports. What did they plan to do? Where is this leading us? How is this an acceptable or credible response to a people's democratic demand for a referendum?

We have seen important referendums on independence in Scotland and Quebec in recent years. On both occasions, the pro-independence lost the popular vote but it showed how normal and important such referenda are in the democratic process. Yesterday, I met a group of Catalans outside the Dáil who told me why they were protesting against the Spanish Government's actions. They were extremely upset about the attacks on the democratic rights of the Catalan people and I can understand that. They pleaded with me and other Deputies to speak out and support Catalans' right to self-determination. We have a responsibility. We must stand up and speak out against repressive and regressive actions that threaten democracy in Ireland and around the world. This is one of those moments. A red line was crossed yesterday. As Minister of State with responsibility for European Affairs, the Minister of State has a responsibility to speak out against this policy and these actions. The people of Catalonia have the right to democratically decide their own future in a legal referendum on 1 October. The Spanish Government should refrain from using heavy-handed tactics in an attempt to stop this democratic vote.

I thank the Deputy for his response. I have listened to his contributions. My view is that Spanish citizens should be allowed to determine for themselves, using their own democratic institutions and legal safeguards, what their preferred arrangements within their own country will be. The range of options or opinions on the issue of Catalonia is to be expected. I am grateful to have the opportunity to discuss this in the House but, again, the interest reflects the respect and affection we hold for Spain. The Government believes that it is for all Spanish citizens to determine their own constitutional arrangements using their own institutions. As I said earlier, I do not think it would be right or proper for me to comment further on it. We did not interfere in the Scottish referendum when it took place and in the same way, we should not do so here.

Medicinal Products Availability

I welcome the opportunity to once again raise this very important issue. I understand that Deputy Sherlock put it down as a Topical Issue yesterday and it was not selected. He cannot be here today so I want to acknowledge that. Since we last spoke about this issue on which we hoped we would make some progress, unfortunately, we have regressed somewhat in that the HSE decided during the summer not to reimburse the drug for various reasons, to which I will return in a second. CSL Behring has been providing the drug as part of a compassionate access programme to 21 patients. I understand that 17 of them are in this jurisdiction. This will be withdrawn at the end of September.

I, along with Deputies Micheál Martin and Kelleher, have written to the Minister for Health on foot of this decision and the reply we got was interesting. The Minister outlined that the HSE suggested the drug has not proved itself to be clinically efficient. This is where the big problem lies. I have met the patients who are getting this drug. I have met most of the 21 patients who are getting it and they have made presentations to Members in the AV room. I ask the Minister to talk to John Hannon in Mallow who has been receiving the drug. That man was breathing with the aid of an oxygen tank before he got the drug. He had to retire early from this job as an engineer, a job he was very good at but where, unfortunately, he could no longer function. Since he has been taking that drug, he has been functioning as a normal human being. I ask the Minister to speak to James Coffey in Killorglin who has the combined condition of Alpha-1 antitrypsin deficiency and panniculitis, which basically rendered him bedridden for two out of every four weeks and put him in hospital for months upon months of each year. Seven years ago, he received the Respreeza double dose, which deals with the issue, and has been living a normal life ever since.

I might revert back to that particular situation because there are two other individuals in the country who suffer from the condition of combined alpha-1 deficiency and panniculitis and they are receiving a sister drug of Respreeza called Prolastin. They receive it from the HSE and get on with their lives and I think we have to do the same for James. We are caught in a dilemma. CSL Behring is providing the information. The HSE is saying, in good faith, I am sure, that the information is not sufficient. The cost of the drug is another issue that we have to come to terms with. In the meantime, there are 21 people, 17 of them in our jurisdiction, whose lives are being affected. Those are the people I represent and for whom I am trying to get reimbursement for the drug over the line, to let these people get on with their lives.

There seems to be more confusion in that the HSE has not been formally informed. The drug has been provided to the Alpha One Foundation which Professor McElvaney is involved with. The Alpha One Foundation administers and distributes the drug, and it has been informed that the compassionate access programme has come to an end. Lest there be any ambiguity, I have asked the Alpha One Foundation to contact the Minister's office directly and confirm to him and the HSE that this drug is no longer available as of 30 September, so we really have only one week to try to sort something out, in particular for the 21 people, of whom 17 are in our jurisdiction.

I thank Deputy John Brassil for raising this issue. I appreciate the sincerity with which he approaches it. I think we can all agree in this House that medicines clearly play a vital role in improving the overall health and well-being of patients. The pipeline for new medicines is very strong and it is estimated that in the region of 45 new molecules are due to receive market authorisation in Europe each year over the next five years. It is vital that all new medicines are thoroughly assessed to determine both their clinical and cost-effective value to ensure that resources are committed to medicines that deliver a high clinical and cost-effective return. The HSE has carefully considered the pricing and reimbursement of Respreeza through its decision-making process which was aligned with the statutory criteria set out in the Health (Pricing and Supply of Medical Goods) Act 2013.

I would like to highlight the importance of that Act. That was an Act that this House passed to give powers to the HSE, and not the Minister for Health, to decide which drugs to reimburse or not to reimburse. I do not mean this in relation to Deputy Brassil directly, but if Deputies in this House have a difficulty with that, they should come forward with an alternative. That is the law of the land. It is the law that was passed by this House. The HSE has the statutory power, not the Minister of the day, to decide to reimburse or not reimburse. It is important that, as legislators, we accept the responsibility that we have in that regard and the legal reality.

Following an extensive review process over the past 18 months, the HSE has written to CSL Behring, the manufacturer of Respreeza, advising it that the HSE will not support reimbursement at this time. The HSE informed me that it was unable to recommend Respreeza as there is not enough evidence to suggest that patients will derive a clinically meaningful benefit from augmentation therapy with the human inhibitor. It is not my view but the clinical view put forward by the HSE. The HSE also considered its cost-effectiveness and deemed that the current price was not a cost-effective use of resources. I appreciate Deputy Brassil's point in this regard. Many in this House have heard that this drug is being provided at a much cheaper cost to other countries and it is despicable that any drug company would try to exploit our patients or our taxpayers for a higher price than it is demanding in other countries.

I am aware that there are a number of patients on a compassionate access scheme for Respreeza which is operated by the drug company. Following recent media reports, it appears that the company could be considering terminating this scheme. However, no formal notification has been received by the HSE from the manufacturer of its intention to discontinue access to this scheme. I take the point Deputy Brassil makes about the Alpha One Foundation but I suggest that this company should come out and make a statement on this and on why, if it intends to do so, it would behave in such an unethical way. As I have stated previously, and I hope it is something that all politicians in this House would agree on, there should be no link between compassionate access schemes and reimbursement decisions. That is not just my view. The World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects indicates that, in medical research involving people, informed consent requires that these subjects are adequately informed of a range of criteria including post-study provisions and that post-study provisions should be provided for in advance of a clinical trial.

In fairness to our own Irish Pharmaceutical Healthcare Association, it is clear publicly, in its view, that there should be no link between clinical trials and reimbursement. There is no reason this patient should not receive the drug. While rightly raising it in this House, I would hope that we would all call on the company to comply with what is normal ethical practice with regard to decoupling clinical trials. It should be decoupling clinical trials from the reimbursement process. I have requested and directed the HSE to seek assurances from the relevant hospital, Beaumont Hospital in this case, that appropriate care arrangements are in place in the event that any access programme is discontinued in an unethical fashion, and that appropriate guidelines have been and continue to be followed in relation to all aspects of the clinical trial and access programme. It is the responsibility of both the company and what is known as the investigator, in other words, the clinician, to ensure that they have considered and made arrangements for their patients, including in circumstances where the product is not reimbursed by the HSE.

It is completely inappropriate and unethical for any company to link reimbursement decisions to compassionate access schemes. When I attend round table meetings with other EU Health Ministers, drug companies and the drugs industry, they are at pains to tell us that there is no link between reimbursement and clinical trials. I do not want a situation where they are using as leverage human beings who are concerned about their health and well-being. I genuinely appreciate the Deputy's issue of concern. I hope that in the next week, we can all work together to ask this company to behave in a normal ethical way. I do not think that is too much to expect.

I have no issue with the methodology by which Professor Barry operates. I have met him specifically on this issue and he has told me specifically that if the company comes forward with more detailed clinical information, he will look at it. The problem I have, as I stated in my earlier contribution, is that I can see the obvious clinical benefit by meeting the patients who are getting the drug. Something is falling between the stools here. Is the company not submitting enough data? Is it not presenting them in such away that it allows Professor Barry to get it over the line? We have mentioned reimbursement. We are led to believe that the costs of reimbursement offered to some countries is much lower than what is offered in Ireland. All those are issues but next week, and I have absolutely no doubt about this, regardless of how poorly the company may have informed or not informed as the case may be, those patients are going to lose their drug.

I ask the Minister, Professor Barry, John Hennessy, who heads up primary care in the HSE, Professor McElvaney in the Alpha One Foundation and CSL Behring to sit around the table and thrash out a solution, if not the long-term solution over the provision of the drug to the general population, then specifically for those who are on the compassionate access programme. We need to do something for those patients. I mentioned an individual who has the double condition of alpha-1 and panniculitis. That is critical for that particular individual. He will be in a hospital bed in a week's time if his drug is withdrawn from him. The likes of John Hannon and his colleagues who I met have had their lives changed. I feel it is my responsibility to ensure they continue to get the medication they need.

I ask the Minister to keep this issue live. The next week is critical. I ask the Minister to call all the relevant parties together and get a resolution. It does not matter to me that CSL is a company with a €1.2 billion profit per year. It does not matter to me that it has endless resources. It matters to me that the patients in our jurisdiction, who I represent, get the drug that allows them to live a normal life. I trust in the Minister and his Department to make sure that heads are knocked together to allow these people the access that they need to live a normal life.

The well-being of patients and citizens is something the Deputy and I share a desire to work together on. It is something all of us in this House want to see. What we cannot see is a drug company behave in an unethical fashion and blackmail the taxpayer and effectively, therefore, blackmail patients. As Minister for Health, each week I see more drugs become available.

This is good. These are drugs that can save patients' lives and make their ' lives better. However, we cannot have a situation where a drug company is breaking all the normal rules. The Irish Pharmaceutical Healthcare Association, the representative body for drug companies, does not behave or believe in behaving in this way. There is not meant to be, internationally or nationally, a link between clinical trials, compassionate access programmes which a company puts in place and the HSE reimbursement process. I have directed the HSE to make contact with the hospital and the clinician responsible to ensure that individual care plans are put in place for each of the patients. My concern is for 17 patients in this jurisdiction, and 21 patients on the island of Ireland.

I suggest, as the Deputy has done, that the company in this case should come forward with more information. It should reflect on the price it is seeking in this jurisdiction versus others. While that is happening, patients should not be used as pawns. The Deputy makes the point that while it might not be particularly relevant to the patients, it is important for the record of this House to state that, according to its annual report, CSL is a $45 billion company, with sales in 2016 of $6 billion and net profits in that year after tax of $1.2 billion. Its CEO was paid a salary and bonus of $8.1 million and the nine other directors of the management team were paid amounts ranging from $1.5 million to $3.2 million each in 2016. That is all in its annual report. Surely to God it can continue a clinical trial for 17 of our patients. I ask for cross-party support in sending out that very clear message from this House while at the same time expecting the HSE to engage in respect of any further information presented to it. That is very important and I will certainly keep in touch with the Deputy on the matter.

Hospital Waiting Lists Action Plans

The Minister and I have discussed the scandal of lengthening hospital waiting lists on many occasions. Thanks to the very great efforts of campaigners such as the Scoliosis Advocacy Network and staff in RTE, this issue has been highlighted. It is only a tiny part of what we now refer to as the "waiting list scandal". As the Minister is aware, the Government has presided over that scandal as it continues to worsen. As is the form with this Government, people who get the opportunity to appear on RTE then find themselves in a situation where they get an answer to some of the questions they have been asking. The Minister is looking at me quizzically but he knows that is true because it has happened on more than one occasion. I accept fully the Minister's bona fides and that he stated he regrets that this has happened. The Minister went on to say that this matter would now be a priority for the Government. I am at a loss to know what would be happening if it was not a priority for the Government, but I welcome that the Minister has set himself a target.

One aspect of the target to which I refer is a reliance on outsourcing some procedures, as I understand it, to two facilities in England and one facility in Germany. Five children have travelled to England to have procedures. Those children were on a waiting list of 300, so what is happening does not exactly represent making significant progress. Five children have had procedures but, to date, the Minister has not signed a co-operation agreement with the other two facilities - the second one in England and the one in Germany - which means that we are at least three months away from any child being able to access the relevant services. It is not simply a case that the Minister can snap his fingers and these children will be transferred.

I have some fairly particular questions to ask the Minister. The first relates to the theatre in Crumlin, which is only open three days a week. That is an scandal. If this matter was a genuine priority for the Government, that theatre would be open seven days a week to take account of the 300 children who are awaiting surgery. I ask the Minister specifically what can be done for those children who have been transferred from Crumlin to the Mater and then back again. It strikes me that is a way to massage the figures. Those patients disappear off the list in Crumlin and they do not appear for a while on the list in the Mater. When they do appear on the list in the Mater, they are then told they have to go back to Crumlin because they are not suitable for treatment in the Mater. That is cruel. Those patients have been waiting for years, notwithstanding the fact that it takes two years to even get an appointment. It strikes me that there is not a plan in place that will, by the end of the year, deliver on the commitment that no one will have to wait four months for treatment. I say this because it will take at least three, if not four, months to get these children to either Germany or England. Their parents have not even received letters initial appointments.

What will the Minister do for those children who are waiting. What will he do, specifically, for the 68 children who have conditions that are medically complex? These are not spinal fusion cases. I understand that the majority of the spinal fusion cases will be dealt with through outsourcing. The Minister knows well my views on that and I will not repeat them. However, what will happen to the 68 children to whom I refer? The theatre in Crumlin is only open three days each week. They are being shuffled around from Crumlin to the Mater and to Cappagh and then back to Crumlin. This is not fair. If the Minister has a plan, I ask him to outline it. If the targets are not going to be achieved, he should be at least honest with those children and their families.

I thank Deputy O'Reilly for concluding right on time.

I thank the Deputy for raising this serious matter and for giving me an opportunity to update the House on the position. I assure colleagues that improving scoliosis services is an absolute priority for both me and the Government. I am monitoring closely - indeed, on a weekly basis - the progress being made on addressing waiting lists.

As the Deputy will be aware, the HSE, working with a number of stakeholders, is currently implementing the action plan it developed for 2017 in order to ensure that, where clinically appropriate, no patient who requires surgery will be waiting more than four months for scoliosis surgery by the end of the year. Both the director general of the HSE and the Children's Hospital Group have confirmed that they are committed to ensuring that no child will be waiting over four months by year end - contrary to what I sometimes read in newspapers, they recommitted themselves to that publicly in recent days - and they are focused on maximising all available capacity, both internally and externally, to achieve this.

Additional nurses are now in post in Crumlin and Temple Street. An additional consultant orthopaedic surgeon commenced in Crumlin earlier this month. Up to 15 September, a total of 216 scoliosis surgeries have taken place in Crumlin and Temple Street and the hospitals are committed to delivering their activity target for scoliosis services this year.

The following important fact needs to be acknowledged because there is a great deal happening. These hospitals have already equalled the number of surgeries that were undertaken in the whole of last year, with over three months still remaining this year to undertake further procedures. Crumlin and Temple Street hospitals have appointed liaison officers to support patients and families during the treatment process. In addition, a project manager and co-ordinators have been appointed to ensure the efficient and timely management of this action plan. Since February of this year patients are also being transferred for treatment to the Mater, Cappagh and Stanmore in the UK and up to 15 September, 22 surgeries were completed in these hospitals.

The HSE, as the Deputy correctly says, has also completed an international tender for paediatric spinal fusion procedures and three hospitals have been successful in their applications. To assure the Deputy, two of those hospitals, the one in Germany and one of those in the UK, have already signed their contracts and begun reviewing patient files with a view to commencing treatment in October - there will not be a wait of three months. They are telling us, as per their tenders and the contracts signed, that next month they will start treating patients whose families take up the offer of having procedures carried out in overseas hospitals.

The HSE is also developing a forecasting model to predict, on both a weekly and a monthly basis, the numbers of patients expected to have surgery by year end. This will assist the HSE and my Department in continuing to monitor the progress made in achieving the target.

To improve scoliosis services in the long term - I agree with the Deputy that sending children abroad for treatment is not what we want to do and that we need to do when we meet the four-month target in terms of a sustainable service in this country - the Children's Hospital Group established a co-design group, which includes scoliosis advocacy groups, to design a comprehensive contemporary and patient-centred approach to the delivery of scoliosis services. This has provided an important and useful forum for discussing and working through issues of concern.

I am pleased to say that the overall number of patients awaiting scoliosis procedures has been reducing throughout the year and fell from 312 in February to 252 as of 15 September. Progress is continuing in order to deliver on the HSE's four-month target by the end of 2017 in a planned, safe and sustainable way.

Criticism of the HSE is often rife in this House and is often deserved. In this instance, however, I assure the Deputy that everything that can be done by a range of staff - in the individual hospital, at Children's Hospital Group level and right up to the director general - is being done. Progress is being made. The target of reducing the waiting time to four months is ambitious and would bring us in line with the position in the NHS. The HSE has recommitted to the target. I will come back to the Deputy on the specific cohort of 68 patients she mentioned.

I am assured by the HSE that it is going to move might and mane to achieve this target by the end of the year. That is its public commitment and we expect the executive to get on and deliver it.

I was contacted very recently by a mother whose 19 year old son was waiting for treatment in Crumlin. He was then transferred over to the Mater Hospital. She got a phone call about him yesterday. This is a young man with a 100 degree top curve. He needs surgery and the doctors have said that he must have that surgery but he has now been sent back from the Mater. She described her mood at the moment as both "confused and angry". She does not feel that there is a plan in place for her son. Similarly, the five families who have been waiting since last July to hear back from Stanmore in relation to their treatment do not feel there is a credible plan in place.

I welcome the fact that the Minister will come back to me about the 68 children with complex needs because they too need to be dealt with. The Minister did not say anything about the operating theatre, which is only operating three days per week. This is supposed to be a priority. The Minister is right that sometimes we criticise the HSE where that is in order. Indeed, sometimes we criticise the Government and individual Ministers where that is in order. We are also capable of recognising where progress has been made but it is cruel to tell parents and their children that they will have a procedure when that does not look likely in many instances. I have spoken to the parents themselves who have told me that a transfer abroad for treatment takes three to four months from the time a decision is made to transfer a child. I cite the cases of those children who have been waiting to hear from Stanmore since last July. The available evidence suggests that there is a time lag and that it stretches to months rather than weeks. I ask the Minister to give those parents an absolute commitment and assurance that surgeries will start in Germany and in the second site in England in October, as he has just said.

I only relay to the House information given to me that I believe to be factually correct. I am told that two hospitals, one in Germany and one in the UK, have signed their contracts and have begun reviewing patient files with a view to commencing treatment in October 2017 for those families taking up the offer of surgery in overseas hospitals. That is the information that has been made available to me as recently as today.

When I said last year, following the RTÉ programme on waiting lists, that I was ashamed of the way we treated these patients, I meant it. I mean it now and we have to get on top of it. We are making good progress and in fairness, Deputy O'Reilly has acknowledged some of the progress that has been made. The goal here is that the HSE is working to make sure that no child waits over four months. It is not easy because we are dependent on outsourcing overseas-----

There is a theatre here.

We are also dependent on parents being able to travel and in that regard, I understand that it is not always straightforward. In terms of the theatre, we had this conversation this time last year. Indeed, the same conversation was had by many others who were in government before my time in this post. We had a theatre that was closed, that was not performing surgeries. We have hired nurses, the theatre is open and we have an additional consultant. The Deputy is right - the theatre is operating three days per week. If it can do more, I am assured that it absolutely will but I am not going to tell people false information. The theatre is open and is providing more surgeries. Already Crumlin and Temple Street have done the same amount of operations this year as they did in all of last year. This year they will end up doing far more than they did last year. We are using the Mater, Cappagh and Stanmore. We are utilising everything at our disposal. There is no shortage in terms of funding or a determination to make this happen. However, it is complex and is an extraordinarily ambitious target. The HSE is right to have set an ambitious target because, as a country, we were so appalled at the waiting times. However, we need a longer-term, sustainable plan to deal with this within our own country which is why the work of the co-design team is so important. We will try to reflect that progress in the Estimates process as well.