Topical Issue Debate

Medical Aids and Appliances Provision

FreeStyle Libre is a blood glucose measuring device to help patients manage their diabetes. On 3 April this year, the device was made available to insulin-dependent diabetics between the age of four and 21. It is a new form of technology. Our question is why there is such a restriction. The system, which is attached to the skin, gives real-time readings on blood sugar. It enables patients to individualise the management of their diabetes. It helps them to adjust their treatment, particularly in regard to diet and exercise, and it tailors their treatment to their specific needs. It also gives health professionals and patients valuable information in supervising their treatment. It is cost-effective, reducing the use of expensive blood testing strips and hospital visits, and helps to reduce the emergence of complications of diabetes such as eye disease, kidney disease and heart disease.

I want to ask why this technology is restricted to those age groups between four and 21.

On 18 April, up to 50 people representing the diabetes community presented a petition with 18,000 signatures demanding access for all to new life-changing flash glucose monitoring technology that affects 20,000 people with type 1 diabetes. The petition highlighted the fact that from 3 April 2018 the HSE has made FreeStyle Libre available to children and young adults with type 1 diabetes aged four to 21 years. They very much welcome that. However, we note that in 18 other countries this technology been allocated to all patients with type 1 diabetes. As Ms Gráinne Flynn, one of the campaign leaders, has stated:

The FreeStyle Libre provides more information than a finger prick meter about glucose levels to base our insulin dosing decisions on. This is more than just a game changer in diabetes, it empowers us to manage our diabetes better, reducing the number of dangerous low and high glucose levels.

Why was this not introduced for everyone?

I welcome the HSE's decision to reimburse FreeStyle Libre for children and young adults. As the Minister of State is aware, almost 190,000 people in Ireland have diabetes, which is a chronic disease that takes a lot of management. This device, which allows blood glucose levels to be monitored without invasive finger prick testing, is an absolute game-changer for anyone suffering with diabetes.

In some cases, patients must test their glucose levels up to ten times a day. While I welcome the decision to roll this out for children and young adults, it is an absolute necessity to roll it out to all type 1 diabetics to allow them to manage their illness actively in a meaningful and continuous way on the basis of real-time information as to their glucose levels.

I support the call to roll out the FreeStyle Libre device to all type 1 diabetes sufferers. This is a matter we have raised on a number of occasions. While we appreciate very much the fact that it has been made available to those aged up to 21 years, it is important to remember that all type 1 diabetes sufferers suffer in the same way. They all need the same treatment and access to this good modern technology which can help them to manage and control their condition. Why would we discriminate among type 1 diabetes sufferers and allocate the device to one sufferer and not another? It does not make sense and it is unfair. The Minister of State will acknowledge that. How soon can this be made available to all type 1 diabetes sufferers and why was the measure rolled out in a manner which discriminates among people suffering from this illness?

I thank the Deputies for the opportunity to address the issue of the management of type 1 diabetes and the FreeStyle Libre glucose monitoring device being provided by the HSE. Diabetes places a substantial burden on the individual, society and the economy. Much of this burden is attributable to short-term and long-term complications. Almost 190,000 people in Ireland have diabetes. As the prevalence of diabetes rises, diabetes-related complications represent a growing global public health and health service challenge.

Glucose monitoring allows people to self-manage diabetes by making adjustments to their diets, lifestyles and treatments to reduce the risk of diabetes-related complications. Current glucose monitoring methods include self-monitoring of blood glucose. This means finger-prick blood glucose monitoring using testing strips and electronic glucose meters, as well as continuous glucose monitoring, which needs to be calibrated with a blood sample. The FreeStyle Libre flash glucose monitoring system is intended to be used as an alternative to current methods for people who administer multiple daily injections of insulin. This innovative technology allows glucose readings to be taken non-invasively without the need to calibrate with a blood sample.

The HSE has statutory responsibility for decisions on pricing and the reimbursement of medical devices under the community drug schemes in accordance with the Health (Pricing and Supply of Medical Goods) Act 2013. In February 2017, an application by the manufacturer of the FreeStyle Libre device was submitted to the primary care reimbursement service, or PCRS, of the Health Service Executive for the reimbursement of its flash glucose monitoring system. The HSE's health technology assessment group carried out an appraisal of the evidence submitted with this application and considered the FreeStyle Libre application for addition to the reimbursement list in line with the 2013 Act. The health technology assessment group recommended that reimbursement for the device should be considered subject to certain conditions. The HSE accepted this recommendations in principle and has developed an application suite for hospital clinicians to use when proposing suitable patients for consideration of individual reimbursement support.

Continuous glucose monitoring is already available to some patients, including those whose endocrinologists have prescribed a particular type of insulin pump. The FreeStyle Libre device is now being made available under the long-term illness scheme and the criteria for approval are as follows: the patient has type 1 diabetes; the patient is aged four to 21 years; the patient uses multiple daily injections of insulin or insulin pump therapy; the patient has increased blood glucose testing requirements; the patient has frequent episodes of diabetic ketoacidosis, DKA, or hypoglycaemia which have included hospital admissions; and the patient is not pregnant. Patients must be individually approved by their hospital clinicians. I understand that adults who do not fulfil the criteria are concerned that the new technology is not available to them. While the first phase of access to this product is confined to children and young adults, the application process allows a consultant to make an application in very exceptional circumstances for a type 1 diabetic patient outside this group. There will be a review after 12 months to look at the evidence of the effectiveness of the device and to ensure that costs are in line with expectations.

We have made huge strides in treating and managing diabetes and I welcome the HSE's decision to reimburse FreeStyle Libre, which is good news for young people and their parents. The Minister for Health, Deputy Simon Harris, is aware that patients with type 1 diabetes must test their glucose levels up to ten times a day and it is his hope that this innovative device will help to minimise inconvenience and discomfort for many children and young people. The Minister must await the outcome of the review by the HSE of the effectiveness and efficiency of the FreeStyle Libre device before he is in a position to commit to its availability to all patients.

The Minister of State has not really outlined why this has been restricted to the four to 21 years age cohort. That is the reason the issue was raised. This is a new type of technology and the future of diabetes management, not only in Ireland but worldwide. It should be made available to all patients who need it. There has been an explosion of diabetes in Irish society and many patients will transition from non-insulin dependent diabetes to insulin-dependent diabetes. As such, the Minister of State must explain when he comes back in why there is a restriction based on age.

I repeat that. The Minister of State has not really answered the question. Why was it restricted to those aged four to 21 years? It seems there is discrimination here. It is a question of monitoring over a 12-month period. Surely, all patients should have been provided with the device for the purposes of the 12-month review. This does not make any sense and the Minister of State should reply in more detail on it. He could go back to the monitoring committee and ask it to extend this to all patients.

I request the expert group within the HSE to consider the additional roll-out to adults as a matter of urgency. I have no doubt the group will monitor closely how it affects children and young adults but we cannot have discrimination. My colleague, Deputy Frank O'Rourke, and I accepted a petition recently containing 19,005 signatures on behalf of people suffering from diabetes calling for equality for all sufferers. That is a lot of signatures. People are very concerned. I ask the Minister of State to explain the exceptional circumstances criteria. That is very important and I had not heard about it before.

I echo my colleagues' comments. I welcome the availability of FreeStyle Libre for children and young adults from age four to 21. It is an acknowledgement of how important this is for those who suffer from type 1 diabetes. However, I ask what "exceptional circumstances" means when everyone who suffers from type 1 diabetes needs the same help and support to manage the condition. It does not make any sense to have an age cut-off. When will this be reviewed and what can be done to fast-track the review so that all those who suffer from type 1 diabetes can access this equipment?

I assure Deputies that I will make known their strong feelings on this matter to the Department and the HSE. I will have to get Deputy Butler the detail on the exceptional circumstances ground. I suspect it is a clinical matter but I can find out exactly what it means. While I suspect GPs are aware of what is involved, I can get her the detail on what are those exceptional circumstances.

The Deputies asked why the scheme is restricted to those aged up to 21 years. This is an era of finite not infinite resources and with any scheme like this there are two aspects. There is the affordability aspect and there is also the question of ensuring something is a good and efficient product. The decision taken has been to provide for a 12-month trial period and to review the efficacy of the device at that stage to determine whether it is an efficient treatment which, in layman's terms, does what it says on the tin. As resources allow, we will progress it. We all want to see it extended to the whole population, but we have to begin somewhere as we did with the roll-out of free GP care. It is not a question of discriminating against a cohort of people, it is a question of starting somewhere. Earlier intervention with younger people was deemed to be a priority by the group looking at this.

Can the information on the exceptional circumstances be circulated to all of us?

I thank Deputy Collins. That is a good point.

Wards of Court

I thank the Minister of State for attending to take this matter. According to an article in the Irish Examiner by Caroline O'Doherty, 25,000 elderly patients may be held illegally in nursing homes or residential settings.

The article also mentioned that a new State agency, the Decision Support Service, was being established to oversee the Assisted Decision-Making (Capacity) Act.

When I read the article, I was reminded of a case in my constituency. I will not mention any names but I brought it to the attention of the Minister of State's predecessor. In this case, a gentleman had been living with his nephew and his nephew's wife from 2011. Unfortunately, he suffered a brain bleed in February 2014. He was subsequently admitted to hospital and on 18 February 2014 was deemed to require long-term care. At that time, there was significant pressure on bed capacity in the hospitals and, on 25 February, he was transferred to a nursing home funded by the State under the special delivery programme being run by the Government at the time. On 9 September 2014, the family was informed that the HSE was going to petition the courts for wardship. The family was not asked for its input on this but simply told about it. The family wanted their loved one back home to reside with them but the HSE would not allow it. The wife of the gentleman's nephew was a healthcare professional who was qualified to care for the gentleman and his condition, but the HSE still refused. It refused to let him out for christenings with the family or for Christmas. The gentleman had resided in this house. It was his life and he lived adjacent to his family farm. It had a hugely detrimental impact on the family. I was a county councillor at the time and I made representations to the HSE, but I was stonewalled and received no answers either oral or written.

When the gentleman was subsequently made a ward of court, the HSE, through the wardship process, initiated proceedings to sell his land. He had 50 acres of land. Again, there was no discussion with the family. It was on the basis of funding nursing care, even though the gentleman did not want to be there and his family did not want him to be there. Unfortunately, the gentleman passed away in October 2016. The HSE has put a charge on his property and land and is seeking to cash in on that through his estate. However, this gentleman was not allowed to be taken home by his family. The charge is driven by him being in care when there was a family that was fully capable of looking after him.

When I saw the article to which I refer, it struck a chord with me. The HSE wrote to me after a query was put to it by the Minister of State's predecessor. The HSE said that it was the understanding of its staff in the midlands area that it was not appropriate to transfer a person from a care location to another location while a wardship process was happening. Essentially, the HSE was acting illegally. It then clarified that, going forward, such a request would be considered on the basis of two criteria - the location of the person where the care would be provided and the necessary risk assessment in preparation. That is of no value to the family now. They are very distressed. I ask the Minister of State for a commitment that he will investigate this fully.

I will not comment on the specifics of the case because this is the first time I have become aware of it. However, I will give the Deputy and the House some general background information on wardships.

It is the policy of the Government to support older people to remain in their own homes and communities and maintain their independence for as long as possible. However, there will always be a cohort of people for whom this is not an option, despite the level of support that might be provided to them in their homes, and full-time nursing home care is best suited to meet their care needs. The nursing homes support scheme, also known as the fair deal, is a means-tested scheme of financial assistance for those who need long-term nursing home care, whereby participants contribute to the cost of their care according to their means while the State pays the balance of the cost. The aim of the scheme is to ensure that long-term nursing home care is accessible and affordable for everyone and that people are cared for in the most appropriate settings. Importantly, people can choose any approved nursing home, provided that it has availability and, of course, that it can cater for their needs.

There are circumstances where people require wardship when they are unable to make key decisions relating to their life choices. If such action is required, a key occasion will be when a person needs residential care services. In supporting such decisions and clarifying and resolving the person's finances, there is often a lengthy timescale involved. The HSE endeavours to support people through this time in the context of the agreement of the ward of courts, by addressing their care needs in the most suitable environment. In this context, some people will reside in residential care settings while the wardship arrangements are being organised. In many cases, an application for the nursing homes support scheme for funding to support long-stay care will be the outcome if long-stay care is the most appropriate care to be provided. The assisted decision-making legislation will provide a new set of arrangements in such cases once commenced and implemented.

While what I have just outlined reflects current practice, the Deputy may be interested to know that the Department of Health is currently drafting legislation to provide clarity on the issue of deprivation of liberty in nursing homes and other residential facilities. The deprivation of liberty safeguards will apply in circumstances in which it is proposed that a relevant person is to live in, or is already living in, a relevant facility and: he or she is or will be under continuous supervision and control; is not, or will not, be free to leave; there is reason to believe that the person lacks capacity to make a decision to live in the relevant facility. The Department recently carried out a public consultation on its draft legislative proposals and is currently analysing the submissions with a view to amending its draft heads of Bill as necessary. We intend to undertake this work as quickly as possible, while also ensuring that the system we are developing will work in practice and will provide sufficient safeguards in accordance with the requirements of international law, domestic law and relevant jurisprudence.

I thank the Deputy for raising this issue. The Assisted Decision-Making Capacity Act 2015 will ultimately replace the current wards of court system. This will provide a new set of arrangements once implemented.

I would be grateful if the Minister of State would confirm that he will investigate this issue or have the Department ask the HSE to conduct a review of the case. With regard to liberty and freedom in terms of bringing an elderly patient home, it is worrying for me to hear the HSE refer to putting the patient first when it said in correspondence to me that it was only clarified in early 2016, during pressures arising from winter pressures, that patients under the wardship process were allowed to go home. That is not really putting the patients first in an application process. Before that, debts were being run up and were being discharged against the patient, as in the case I outlined, and the family was fully capable and had the capacity to look after the individual in question. In addition, during the period in question, the HSE was not liaising with the family or giving them the key answers. It was appointing estate agents and auctioneers from the court to sell property to discharge debts when the family felt it could have this person at home. A number of files were opened up at that time. I am aware that one report was initiated through the elder abuse officer. It was fully found to be incorrect in favour of the family. Again, the family has no redress for that. It was being stonewalled by the HSE.

The article I mentioned points out that there is a fundamental issue here. We like to keep individuals in their homes but when a family has the capacity, setting and qualifications to care for an individual they should be facilitated to do that, rather than the individual being made to stay in a nursing home when a wardship process is under way.

The Deputy makes a fair, valid and what appears to be a reasonable point. He articulates it very well. I will look at the details of the case and I will ask for a report from the HSE on it. I will ensure that the Department oversees this process in order to ensure that we get to the bottom of the matter. The Deputy's concerns are valid and are very relevant to the work that is ongoing. We are trying to develop the Decision Support Service. It is a huge body of work to establish that in order that we might implement Assisted Decision-Making Capacity Act in full. I welcome the Deputy's input and his contribution today. I commit to undertaking the follow-up requested.

Disability Support Services Provision

I thank the Ceann Comhairle for allowing me to raise this issue. Deputy Lisa Chambers and I have been approached by the Alzheimer Society of Ireland and some of the 12 clients from across County Mayo who use the Castlebar centre on a Monday-to-Friday basis for respite and other services.

From the end of May, this will become a three-day service and no transport will be provided from various parts of the county to the Castlebar centre. As the Minister of State can imagine, this is causing huge distress to the families of the 12 clients involved, who depend on the service and on the transport to the service, and to the Alzheimer Society of Ireland, which provides an excellent service, along with Western Alzheimers, across County Mayo. Over the years, much of the response to Alzheimer's and dementia across County Mayo has been driven by communities, not the HSE. The HSE has taken on board some of the projects but has cut funding to other projects, leading to a very bumpy service across the county. What has happened in all these instances is that the patients who were using the community services, which were subsequently cut, and their families were then forced into either primary care providers across the county or Mayo University Hospital, thereby adding pressure to an already overstretched system.

In respect of the Castlebar centre, there is a shortfall of only some €30,000 annually. The HSE has not increased funding to the centre for a number of years. The clients contribute over €13,000 a year to the five-day service and the transport, with the HSE contributing just over €34,000 and fundraising led by the Alzheimer Society of Ireland just under €33,000. For want of this relatively small amount of money, which can be found within the budget, this service, this lifeline to families, and this transport will be restricted to three days and possibly to an even greater extent. The Alzheimer Society of Ireland has endeavoured for some years to try to engage the HSE on this issue. The HSE has written to both Deputy Lisa Chambers and me to tell us it is not cutting funding this year. However, the difficulty is that it is not increasing it either and the costs of providing the service are increasing. Transport alone has seen an increase in insurance costs. In addition, three people who have a relationship with the clients involved and whose relationship with the families of these clients is absolutely essential to the clients' well-being will be laid off this project. It is beyond me how a small, community-led service which is providing such a difference will now be curtailed in this manner because of a refusal on the part of the HSE to engage in the practical realities and practical, day-to-day expenses involved. This has happened previously. There was a wonderful project called Community Action on Dementia in Mayo, a community-led response project, which was providing a fantastic service. It had its money curtailed because the HSE took a decision locally not to support it. The services it provided were phenomenal.

I ask the Minister of State to engage with the HSE. It does not seem to understand the damage it is doing or the short-sighted nature of the decision it is taking. For the want of €30,000-odd, these 12 people will be put on a three-day service, thereby adding pressure to our primary care services and to Mayo University Hospital, which cannot stand any more pressure than that which it already faces.

I thank Deputy Calleary for raising this issue. Some 55,000 people in Ireland have dementia, and this number is expected to increase to 157,000 by 2046 as the number of older people in Ireland increases. The national dementia strategy emphasises that, with the right supports, people with dementia can continue to live well and participate in their own communities for a long lime.

A €27.5 million national dementia strategy implementation programme is being implemented. This includes dementia-specific intensive home care packages, a dementia information and awareness campaign called Understand Together and a programme to upskill GPs and primary care teams in dementia diagnosis and management. The HSE's National Dementia Office is undertaking numerous projects to progress the implementation of other strands of the strategy, including in the areas of dementia diagnosis, post-diagnostic support and acute hospital care.

Social care services are an important component of enabling people with dementia to remain living at home and participating in their own homes and communities. They also provide valuable supports to carers. The HSE, the National Dementia Office and the Alzheimer Society of Ireland have undertaken a project to identify what dementia-specific services are available in communities across Ireland and the results of this have been made available through an online service finder. In addition, the National Dementia Office and the HSE are working to identify the generic services that people with dementia access.

Regarding the specific issue of the day care centre in Castlebar, the Alzheimer Society of Ireland, ASI, receives annual funding from the HSE to provide services and supports in Mayo to people with dementia, their families and carers. These services are in addition to supports provided directly by the HSE.

Since its opening in 2006, the Alzheimer's day centre in Castlebar has offered a valuable service to people with dementia and their families and carers in Castlebar and the surrounding areas. The hard work of the centre's staff and volunteers has allowed people with dementia to remain living in their own communities with dignity and respect.

The HSE and the Alzheimer Society of Ireland have been engaging on the issue of service and funding in respect of this centre. The level of funding provided by the HSE to the ASI for this service in 2018 is the same as it was in 2017. However, due to an existing financial deficit, the ASI has informed the HSE that it cannot deliver the existing level of service without additional funding.

Regrettably, the HSE is unable to provide additional allocations to this individual service as the HSE must operate within the resources available to it. While all community health organisations endeavour to support such services in their areas as much as possible, they must do so within the context of the budgetary resources that exist.

The HSE understands the disappointment of people with dementia and their families who avail of the day care centre in Castlebar. Nonetheless, the centre will continue to operate for three days per week and provide services to clients during those days. I wish to emphasise that my Department aims to implement the national dementia strategy in full and ensure the provision of services to support and meet the needs of people with dementia and their families throughout the country, including in County Mayo.

That is an incredibly cold response on the part of the HSE. I know it is not the Minister of State's response or his feeling on the matter. One cannot just dispatch people from a five-day service to a three-day service. One cannot speak about a national dementia strategy and people in communities and then cut their service in this manner, give them a pat on the head and hope they will not be affected. They will be affected. The HSE funds Alzheimer Society of Ireland services to an average of approximately 63%, but the Castlebar-based service is getting 31% funding, so there is a major gap in the funding level. As I said, it is a relatively small amount, and it is within the HSE's gift. Considering the amount of money it spends and wastes in many areas, it could find this money and deliver it to maintain the five-day service. The biggest impact of a lack of funding would be the complete exclusion of transport on the other two days. Clients will be faced with a reduction from a five to a three-day service but will actually not be able to get to the service because their families will not be in a position to bring them to Castlebar and back on the two other days. There is therefore the cut from the five-day to the three-day service and the complete cut in transport. The service is being undermined entirely and all the HSE can say is, "Tough. There is nothing we can do about it." This is a consistent response. The Minister of State can speak about a national dementia strategy but these are community-led and community-based initiatives that are keeping people in their communities and, more importantly, at home and they face small, penurious cuts in funding. It is typical of the HSE's approach, which is penny wise and pound foolish. This people will end up in Mayo University Hospital or at the local GP, where there are already serious pressures on services.

I know what the Minister of State has read out is not his response. I ask him, on Deputy Lisa Chambers' behalf and mine, to intervene personally with the HSE to explore with it whether there is any way it will reverse this decision.

I absolutely accept the Deputy's invitation to take a look at this. I also accept his comment on the finite nature of the response. It could certainly have been a little more hopeful for the people who use the services. For my part, as the Minister of State with responsibility for this area, I will take the matter up with the HSE and have a look at it. The Deputy will understand how this works, that we devolve the responsibility to decide who gets what as opposed to the Minister deciding, but I know he is not suggesting that that is how it works. However, I have responsibility to ensure we do not just say the words but that we ensure people continue to live in their own homes, supported and enabled in their own communities, and that we actually back this up with action and the supports necessary. This is a responsibility I take very seriously, and I will take the matter up with the HSE locally. I do not know what the specific issues are. I am not an auditor and I will not comment on the financial situation in respect of the centre. There may be some aspect to it that I am not aware of. I will ask the HSE to come back to me with a much fuller and much more detailed brief and I will ask it to review this decision in light of the conversation we have had. I will come back directly to Deputies Lisa Chambers and Calleary, having done that with the HSE, without any delay.

Middle East Issues

I thank the Ceann Comhairle for allowing me to raise matter of the ongoing crisis in Gaza, for his interest in the plight of the Palestinian people generally, and for those in Gaza in particular. I am glad that the Tánaiste is present.

Many people in Gaza will watch the recording of this debate. The elected representatives of the Palestinian Legislative Council in Gaza have specifically asked that statements be made in the run up to the 70th anniversary of the Nakba, the events in 1948 when over 1 million Palestinians were ethnically cleansed and displaced from their lands. It was an event which marked the beginning of 70 years of tragedy, displacement, exile, dispossession, occupation and oppression for the people of Palestine that continues today and we witness in all its horror with 45 unarmed protestors, many young people, some as young as 14 years - one young man on his 14th birthday - killed by Israeli snipers in what can only be described as the cold-blooded execution of unarmed protestors.

These are protestors who have been marching to vindicate their rights under international law. I refer specifically to UN resolution 194, which gives people who have been ethnically cleansed or displaced from their homes the right to return. That has been denied to them for 70 years. In the case of Gaza, it has lead to a horrific humanitarian catastrophe since the imposition of a brutal siege by Israel that has been going on for 11 years. It prevents basic goods being brought into Gaza, a tiny area of land in which 2 million people live and which has been subjected to four savage Israeli military assaults against a largely defenceless population.

It is critically important that we speak up for the Palestinians and their plight, particularly in view of what has been visited on them in recent weeks and is likely to continue in coming weeks in the lead-up to the anniversary on 15 May. We must speak out and do something, we cannot just condemn. I have heard the Tánaiste and, indeed, the Taoiseach condemn what is happening. However, we need to do something for people who are suffering intolerably and unjustly.

One thing we can do, and which we have been asked to do, is something I have raised previously with the Tánaiste. The Palestinian Legislative Council has invited representatives from the various parties in this Parliament to go to Gaza - they are not asking for the Government to send representatives, although they would be very glad if the Government were to so do officially - and meet all groups, specifically the members of the elected parliament there. As the Tánaiste knows, at the heart of what is happening in Gaza is Israel's refusal - and, tragically, that of much of the international community - to recognise the outcome of a democratic election. That is what started this and the suffering continues because of it. I ask that we do something. Sanctions should be imposed on Israel for its flagrant breaches of international law and human rights. If, however, we do not impose sanctions, can we at least sent an all-party group there to witness what is happening and to meet and talk to everybody over there, specifically the elected representatives in Gaza, in order that we can point a way out of this horrific conflict? I hope to get a positive response.

I thank the Deputy for raising this issue - not for the first time - and I am happy to be here to respond because it is one about which I am also greatly concerned. I have been particularly concerned in recent weeks due to the appalling number of serious injuries and deaths among people engaged in demonstrations. To date, 47 Palestinians are reported to have been killed and 1,500 injured. Some of those shot may have been trying to cross the border fence but, clearly, many - or most - were some distance inside Gaza and posing no immediate threat. There are at least some cases where the persons shot seem to have been readily identifiable as children or as journalists reporting on the events.

Every country is entitled to defend its territory but international law clearly defines the circumstances in which force, particularly deadly force, can be used against civilians. Such force must only be used in cases of real and immediate threat to life, and only as a last resort, that is, when other methods have failed. The use of force should also be proportionate to the threat posed. I am not satisfied that these limits have been respected.

Israel is fully entitled to be vigilant and cautious when there are mass demonstrations close to its border with Gaza. However, Palestinians also have a right to protest. The use of live ammunition is not a normal approach to crowd control and the resulting number and nature of casualties in recent weeks has been shocking. Many of the injuries from live ammunition have been severe and life-changing, and many people have been killed.

I made two public statements regarding these incidents on 31 March and 9 April. I called on all sides to show restraint, particularly Israel in its use of force. Everyone needs to take responsibility to ensure young people particularly are not placed in harm’s way. I have also supported the calls by the EU and the UN Secretary General for an independent and transparent investigation into these events. I have expressed these concerns directly to the Israeli ambassador and our ambassador in Israel has conveyed my views to the Israeli Foreign Ministry.

The intensity of the clashes has decreased somewhat in recent weeks. However, with the cycle of protests in Gaza scheduled to culminate in the middle of this month, that is, next week, I am deeply concerned about the prospect of further casualties. I call on all parties, particularly Israel, to show restraint and to avoid confrontation. We should remember that next week will also see the official opening of the US Embassy in Jerusalem, which will add further fuel to this fire.

I would also stress the wider context in which these events have occurred. As I have made clear in all my contacts in the region, the situation in Gaza is untenable. If the cycle of violence and depression in the Gaza Strip is not ended, we know that events of this nature will recur. The long-standing blockade cannot be accepted as normal. It is for this reason that, in my many contacts at EU and international level, I have been particularly active in trying to encourage and promote international engagement on improving life in Gaza, which I visited in January on my second journey there. I have made this a priority in my work as Minister for Foreign Affairs. It will continue to be a priority. If people have practical suggestions for how we can assist, I will listen to them.

This year, we are increasing our spend significantly towards supporting Palestinians. One project that we are supporting is a very large solar energy project to power a water purification plant in Gaza in order to try to improve the quality of life there.

People in Gaza will appreciate much of what the Tánaiste said. They will also appreciate any additional support that can be given, including humanitarian support and support to develop and regenerate a shattered infrastructure. However, the problem is ultimately political in nature.

The question the people in Gaza, who are desperate, are asking relates to what they are supposed to do. How often have Palestinians been condemned for armed or military responses?

One can say that they were right or that they were wrong but in this case, the people of Gaza have stated they would march with their hands in the air, unarmed, behind banners of Martin Luther King and Mahatma Gandhi and that they would engage in peaceful protest to assert their rights under international law. This is not some right they made up or some aspiration they demanded but the right to return to their lands, which was set down under United Nations General Assembly Resolution 194. They are asserting their right to go home. Israel's border does not trump their right to return because they were ethnically cleansed in 1948. It most certainly does not justify shooting down people on unarmed protests.

The question is, what are we going to do about it? Unless sanctions are imposed on Israel it will be indifferent. The decision by Mr. Trump to move the US Embassy to Jerusalem is a direct provocation. What are we going to do? I am making a very simple request and I would appreciate a response to it from the Minister. The representatives elected democratically in free and fair elections in Gaza, whom Israel and the Americans refuse to recognise, ask that we send an all-party delegation not to meet Hamas specifically, but to meet all groups, including the elected representatives of their parliament, in order to hear what they have to say and to look at that destruction so that we can point in the direction which will allow for peace, which is through engagement and discussion, not through the brutality displayed by Israel.

First, the Deputy asked what these people can do. I can understand protests but there is some evidence to suggest that not all of the protest has been peaceful. There is an obligation on both sides to ensure that, by and large, teenagers are not whipped up and put in harm's way by getting involved in violent conflict. That does not excuse for one minute the fact that 47 people have been killed and well over 1,000 have been injured but I am saying there is also a responsibility to ensure that protests, while absolutely understandable, are peaceful.

I will be back in the Middle East in a few weeks' time. I do not know whether an all-party delegation would get into Gaza.

Quite frankly, I do not know whether it would be helpful right now but I am happy to talk to the Deputy about that. My only objective is to find a way to move forward a negotiated peace process that can provide medium to long-term solutions for people in Gaza in order that they can see some hope for the future. That could mean removing a blockade, trying to improve living conditions or making sure that in the medium term, the United Nations Relief and Works Agency for Palestine Refugees, UNWRA, keeps the funding it needs. Approximately 70% of the people in Gaza rely on UNWRA for some form of food support or healthcare. These are the practical day-to-day things in which I am interested as well as, obviously, the bigger political issues that need to be resolved. As Minister for Foreign Affairs and Trade, I have probably spent more time on this issue than on any other issue outside of Brexit and immediate EU issues. I intend to continue to put a lot of time into this issue. We would need to look at the practicalities of the request the Deputy has made on the floor this evening for an all-party delegation to visit Gaza before I could give him a definitive answer.