Dáil Éireann debate -
Wednesday, 7 Nov 2018

Vol. 974 No. 5

Ceisteanna ó Cheannairí - Leaders' Questions

Deputy Micheál Martin

It is now nearly two years since the Minister for Health, Deputy Harris, promised to establish a compassionate access scheme for the medicinal use of cannabis in certain circumstances and for patients with specific conditions, namely, drug-resistant epilepsy, spasticity in multiple sclerosis patients and nausea and sickness in cancer patients who are being treated with chemotherapy. However, progress in establishing this scheme has been very slow. It is close to two years since the original promise was made. We are all aware that there are many families under great stress and strain because of the absence of such a scheme. I meet them on a regular basis. We all know the story of brave Vera Twomey who had to spend three months in Holland with her daughter Ava under the supervision of a paediatrician with an interest in neurology so as to validate the utilisation of cannabidiol, CBD, and tetrahydrocannabinols, THC, for Ava's epilepsy. Ava is doing well and her quality of life has improved. However, there are many other families under stress and strain.

There are now 12 patients in Ireland who receive CBD and THC via an import licence arrangement. That involves families of patients with cancer or other very difficult conditions having to travel to Holland, in the main, to secure the medicine in the Transvaal Pharmacy. As many in the House will recall, the access programme was proposed as an alternative to the legislation that was put to the House by Deputy Gino Kenny, which many of us felt was not a realistic or pragmatic approach. The medicinal cannabis access scheme was recommended by the Health Products Regulatory Authority, HPRA, expert group and would allow for the monitoring of usage, refinement of dosage and so on. The absence of a compassionate access scheme represents the absence of compassion for the many families and patients who seek legal access. Unfortunately, many families are accessing this medicine illegally, which has its own dangers.

I received a letter yesterday from the Minister for Health, Deputy Harris. It is a bit disingenuous towards the end in suggesting that the Department has no control over commercial operators. It also refers to difficulties in sourcing medicinal cannabis thus: "The Department of Health has no control in relation to business decisions taken by commercial product manufacturers and has no powers to compel companies to supply their products to the Irish market." No-one ever said that the Department had such powers. What is required here is proactive and intensive engagement with companies. I am aware that there has been engagement, although the correspondence does not suggest so. I also understand that it is within the capacity of a company to supply medicinal cannabis here in the first quarter of 2019 if a push can be made in terms of intense engagement between the HPRA, the Department of Health and the company concerned. It is simply not sustainable that people would continue to access this medicine through importation licences.

Minister for Agriculture, Food and the Marine (Deputy Michael Creed)

I thank Deputy Martin for raising this issue and I appreciate that there is cross-party interest in it. The Deputy made reference to Vera Twomey and her daughter Ava. I am very familiar with their case and have attended meetings on this issue with the Minister for Health and colleagues of Deputies Martin and Gino Kenny. There are two distinct issues at play here, as Deputy Martin has outlined. There is the issue of medical cannabis which has the component THC and is available under the ministerial licence system. It is my understanding that up to 12 families have been approved under that system to date. There is also the parallel issue of a medicinal cannabis access programme. The process of setting up such a programme is under way in the Department. Departmental officials recently visited Denmark to see at first hand how the process there works. We are looking at best international practice in this area to make sure that any actions we take are appropriate, consistent and medically informed in the best interests of those families who have an interest in this. We are, in many respects, breaking new ground in this country. A limited number of families have access to the product containing THC and I do not believe that any consultant led application for such access has been refused. That said, I appreciate that there is a second part to this issue and the Department is currently considering how best to progress in that regard. This involves looking at international best practice and there has been engagement with stakeholders in other jurisdictions on the matter.

Deputy Micheál Martin

The Minister's letter states: "Until suitable cannabis products are made available in Ireland, it will be a matter for the presciber and their patient to source the prescribed product." We know this already. The letter also says that the Department is aware that "a Canadian company is in discussions with an Irish-based distributor to supply their products to the Irish market". It adds that "no further details are available on the date of availability of these cannabis products and no import licence application has yet been sought by the Irish distributor to bring these products into the country". The Minister signed the letter but the person who wrote it knows full well why an import licence application has not been made. This company supplies all of Europe and the bottom line is that someone needs to get moving on this. Having officials go to Denmark and elsewhere is simply going off in new directions. We are two years on from the initial promise. The Government must remember that many in this House co-operated constructively with the Minister for Health on this issue. The agreed approach was to set up a medicinal cannabis access scheme but progress has been too slow. This issue can be resolved. The product can be made available in Ireland early next year if a push is made. There has been an institutional resistance to this in certain areas. There has also been a cultural issue among some medical professionals. I understand the concept of a clinical, evidence based approach and the importance of clinical trials.

An Ceann Comhairle

The Deputy's time is up.

Deputy Micheál Martin

The bottom line is that this House and the Minister for Health committed to this two years ago. It is time to get this sorted on a compassionate basis for the sake of the many patients and their families who need this medicine.

We should not be forcing families to travel to Holland and elsewhere every three months to access it.

Deputy Michael Creed

I appreciate the points made by the Deputy. I do not believe there is any foot-dragging in the Department as the Deputy seems to allege there is. The Department established an expert group to assist in dealing with this issue. It comprised all of the appropriate expertise required to make an informed decision. Collectively, there is a willingness to move, but we need to make sure that in so doing we will not be taking any undue risk in accessing the product. The Minister for Health has engaged with many people, including individual families who have an interest in accessing the product. I am certain that there is no resistance politically. I am not aware of any resistance medically, but we have to make sure the steps we take will be in the best long-term interests of patients.

Deputy David Cullinane

Yesterday the Taoiseach let the mask slip again in his latest attack on nurses and doctors in what was a vindictive attempt to shift the blame for hospital overcrowding away from him and his track record as Minister for Health, the performance of the Minister for Health and the Government. He attempted to put the blame on the shoulders of front-line staff in hospitals - nurses and doctors. There are moments when we see the true character of the Taoiseach in his attitude to workers and others. We got a glimpse of it when he was Minister for Social Protection. We all recall his welfare cheats crusade which turned out to be a ball of smoke and a publicity stunt, but it hurt many in receipt of welfare payments. We also saw it when he exposed his attitude to workers when he proposed in the run-up to the Fine Gael leadership election a Thatcherite ban on striking. We saw it again yesterday. It was little wonder when he was confronted with his record and that of his party in dealing with hospital overcrowding that he sought to shift the blame away from his performance onto the shoulders of hardworking nurses and doctors.

To be clear with the Minister and the Government, nurses' and doctors' leave is not the problem. It does not contribute to the problem of patients languishing on trolleys and hospital overcrowding. It is not why almost 1 million patients are waiting to see a hospital consultant or why we see record numbers of patients lying on trolleys in acute hospitals every day of the week. There are thousands, many of whom are older people who need support. The problem is the lack of capacity in public health services and the difficulty in recruiting and retaining front-line staff. The majority know that when they get into the system, they receive a very good service. That is because of the professionalism of front-line staff - nurses and doctors - and despite the fact that the Government has not invested in the public health service. It was appropriate and right that nurses and doctors pushed back against the Taoiseach's narrative yesterday because it was deeply unfair.

We all know in our constituencies - I can give the example of University Hospital Waterford - that when there are major problems in the emergency department, the people who must try their best to make sure patients are treated as quickly as possible are the nurses and doctors. The Government should stop blaming others for its failures. The Taoiseach should stop blaming front-line health workers for the problems in the health service. What plan will the Government put in place to deal with overcrowding? It should forget about blaming the nurses and doctors. What is its solution? What are the increased investment strategies which will be put in place to make sure patients will not have to languish on hospital trolleys in the coming weeks and months?

Deputy Michael Creed

On the contrary, the Taoiseach's comments yesterday were clear evidence that the Government's priority - it is also the priority of front-line staff - was to make sure we would deal with patients in an effective and humanitarian way. It is highly distressing for patients to have to wait for long periods on trolleys in emergency departments. In any business, as I think the Taoiseach said, there are periods when peak demand can be anticipated. For example, in the hospitality sector peak demand is probably in the summertime, while in teaching it is probably when schools reopen. We have known for decades that peak demand in the public health service is in the winter, immediately after Christmas. The Taoiseach's comments were a clear recognition that front-line staff - doctors, nurses and supporting ancillary staff in laboratories, etc. - were critical in resolving the issue. Far from denigrating them, the challenge the Taoiseach posed yesterday was to HSE management.

Deputy Brendan Howlin

He did not say that.

Deputy Michael Creed

We have more doctors and nurses in the service. What we need from HSE management is appropriate management of the most valuable resource in the health service, the human resource, to make sure it is deployed in the most efficient way possible to deal with patients in the most humanitarian and effective way.

There is another issue - capacity. We have been reversing the trend, the result of a decision taken by a previous Administration to reduce hospital capacity at a time when the resources available to the State were plentiful. Since 2014 we have been reversing it and increasing hospital capacity. It is not, however, like flicking a switch to open hospital beds. When hospital beds are opened, doctors, nurses and other supporting staff are needed. We have opened and will in a short time open additional acute hospital beds, all of which, collaboratively, will I hope address the issues to which the Deputy has referred.

Deputy David Cullinane

The Minister's response does not address the questions I put. What the Taoiseach said yesterday was very clear. It was not what the Minister has repeated today. The Taoiseach did put the blame on front-line workers. I sat here yesterday and listened to what he said and it was 1 million miles away from the response the Minister has given today. He was not talking about managers in the health service but about leave for nurses and doctors. In the view of nurses and doctors, whom the Minister admits do a wonderful job in the health service, it was clear that the Taoiseach was putting the blame and responsibility on them. We all know that it is not like flicking a switch, but the Government has been in place since 2011, since when record numbers have been trying to get into the system to see hospital consultants to be treated and too many have been left on hospital trolleys. It is not that long ago when the Taoiseach launched another attack on health workers when he said there had been no corresponding increase in activity in the health service. That is a falsehood because the Department of Health has noted that attendances at emergency department are up, that the level of surgical day case work is up by in excess of 70% in the past ten years and that the number of outpatient assessments has reached 3.3 million annually. The level of activity is up, but the Government is not putting in the resources to make sure there is capacity. It cannot blame anybody but itself. The Minister for Health and the Government need to take responsibility and stop putting the responsibility for failures in the health service on the shoulders of front-line staff.

Deputy Michael Creed

The Deputy has referred to the fact that we have been in government for several years. That is the case, but he cannot divorce where the health service is at from the economic catastrophe that befell the country for several of the early years when we were in government. Because of sound public finances we are now in a position to rebuild the public health service and increase capacity within it. There are 22 additional beds open today in St. Vincent's University Hospital, 29 in Our Lady of Lourdes Hospital, Drogheda, 17 in University Hospital Limerick and 30 in University Hospital Cork, with more to come on stream in the last quarter of 2018 and others early in 2019. We are recovering. We acknowledge that we need to do more to increase capacity, but the point the Taoiseach made was that in terms of the issues that were predictable in providing care in the period immediately after Christmas, we needed to make sure the HSE would manage the resources at its disposal in that critical period such that we would not have to deal with the consequences of having a backlog in emergency departments by having the appropriate quorum of critical staff - doctors and nurses - scheduled to work in that critical period.

Deputy Brendan Howlin

After 39 years, the Taoiseach made the startling discovery yesterday that Christmas comes every December. There may indeed be scope to change rostering at Christmas time, but the Taoiseach should not blame hospital staff, as he did, whatever the Minister says. He mentioned staff taking their annual entitlement to leave. Rostering and ensuring the presence of sufficient staff, as the Minister has said, is a management issue and should be addressed through constructive engagement with trade unions and not with abuse of people, either in this House or on public airwaves.

Another annual phenomenon in the health service is that, towards the end of the year, a number of budget lines run out. I am aware of several cases where people cannot access a home care package because the budget has apparently run out. They are told to reapply in January. That is ludicrous. If the Government is serious about using hospital resources effectively and efficiently, including very expensive acute beds, to take the pressure off the busy Christmas and winter period, surely it makes sense to provide step-down beds and home care packages to patients in acute hospital beds who are awaiting transfer home. Many patients are most anxious and could more appropriately be cared for at home. They want to be at home. In the budget of €17 billion just allocated by this House to the Department of Health, we know the money will be there in January. It is purely an administrative decision not to issue home care packages now. Telling people occupying economically acute beds which are very inappropriate with regard to health to apply again in January is madness. The decision will worsen our bed capacity and the capacity of hospitals to respond to emergencies in the critical winter period approaching. The Government management of the home care package budget makes no sense to anybody.

Will the Government undertake to unblock the delays in giving home care packages to the list of people that anybody in this House can provide? They are waiting to go home to a more appropriate and less expensive setting. Will the Government ensure that patients who need home care packages, such as those who are contacting my office in Wexford, whose details I can give, will be home for Christmas?

Deputy Michael Creed

I am sure the debate on this matter has familiar tones for the Deputy as a former Minister for Health and for Public Expenditure and Reform. It is not simply a case of throwing money at the issue. We need to make sure that the additional resources that we provide are used appropriately. In budget 2019, we provided a fund of €10 million for spending in the latter end of this year to facilitate appropriate discharge through an appropriate care setting of people who are in an acute hospital bed but who are deemed no longer to be in need of that level of care. We are taking steps to improve capacity in the health service. That is not to say that we are not responding accordingly. We are providing additional resources. The Deputy alluded to the resources provided for in 2019 being significantly increased from 2018. We also made provision in the budget for dealing with the issue of appropriate discharge, which itself frees up acute hospital beds for people who are awaiting admission.

Deputy Brendan Howlin

The Minister talks about throwing money at it. I am a former Minister for Public Expenditure and Reform. I am talking about value for money and much better health outcomes for people. Will the Minister not concede that it is ludicrous for somebody to be in an acute bed at enormous cost in an acute hospital when that person is willing, able and anxious to go home but community care cannot provide the money for a home care package? Much more money is available within the HSE to keep them in an acute bed than would be required to provide them with the dignity of going home for Christmas. If the Government cannot solve that conundrum, there is no management, no system and it is dysfunctional.

Deputy Michael Creed

I am informed by the Minister of State, Deputy Jim Daly, that the HSE and the Department commissioned a report on that issue of appropriate discharge to appropriate step-down facilities. That has just been completed.

Deputy Brendan Howlin

I am talking about home care.

Deputy Michael Creed

The Deputy chose to ignore in his supplementary question that we provided an additional €10 million to be made available-----

Deputy Brendan Howlin

It is not enough. Why would the Government spend more on acute beds?

An Ceann Comhairle

Let the Minister answer.

Deputy Michael Creed

We are responding with resources to address the issue of people who are inappropriately in an acute bed but who do not have the facility to be discharged because of a block in the system.

Deputy Brendan Howlin

It is not doing that.

Deputy Michael Creed

That €10 million should go some way towards resolving that issue.

Deputy Bríd Smith

Six days ago, we saw one of the most historic actions to be taken on a global scale by Google workers in Tokyo, New York, Dublin, Berlin, London and many other cities that were not mentioned. Tens of thousands walked off the job in protest over sexual harassment. It is little known that their other demands were for normal things such as pay equality, workers' representation on the board and more accountability from management on the question of sexual harassment. They deserve to be complimented on that. Given that this is a company which is not known for its trade union activity or membership, this bodes well on an international scale for how young workers are responding to demand equality, an end to harassment and to have representation. I hope the Minister will join me in congratulating those workers. One said: "I don't know what it will take to change the system, but I do know that we are a crazy force to be reckoned with."

In line with the theme of the two previous speakers, I want to talk about another crazy force to be reckoned with, the nurses in this country, who are about to ballot for nationwide industrial action to secure pay increases that will allow them to live decent lives, to be able to afford to pay rent and to afford childcare, and which will help them to address the serious shortage on the wards and in emergency departments. There are 200 vacancies in emergency departments throughout the country with more than 1,000 vacancies for nurses in the public health system. They have a problem with recruitment and retention because of the low pay. Nurses still work a shift for nothing every eight weeks. It sticks in their craw that they have to go in for an evening, work through the night and get nothing for it. Nobody in this House would do that. I would argue that we are overpaid for what we do compared with the low pay they get for what they do.

We are facing a winter of discontent. It is not just from Google workers but will be from nurses in hospitals, psychiatric nurses who are about to ballot about pay, and ambulance drivers who refuse to do overtime because they are not getting trade union recognition. This winter of discontent is about to see working people try to change that very system. The Minister may call them crazy and they may call themselves crazy, but they are definitely a force to be reckoned with.

Will the Minister congratulate the workers in Google, not just in Dublin but globally, for the example and action they have taken? Will the Minister deal with the question of low pay in our health service, specifically for nurses, and the issues in the ambulance service? That must be done. If the Government cannot do it now, then I suggest the Cabinet does not take a Christmas holiday and works hard over the holiday period to ensure these issues are settled.

Deputy Michael Creed

I would not call them crazy at all. They are a critical part of the public service and do invaluable work. I salute Google workers and acknowledge today that the CEO of Google has come out and said that they need to do more in that space. That is a very welcome development.

On public service and nurses' pay, we concluded a public service pay agreement, to which the public service unions signed up. Within the provisions of that, a review was undertaken of recruitment and retention issues in nursing. It made a number of specific recommendations that were considered by the Government recently, and all of those recommendations within that relating to nurses' pay and new entrants were accepted.

I appreciate that the INMO is in the throes of balloting members but the predictability that comes from a negotiated public service pay agreement across the public service has considerable merit. It is not open to the Government, as a party to the agreement, to unilaterally breach its terms and conditions without it having considerable consequences for all the public finances and public services the State tries to provide. Nurses are a critical element in delivering those public services in the area of health care. The initiative we have taken to deal with public service pay, and nurses pay within that, is based on looking at the issues agreed in the context of that agreement around retention and recruitment. The report, which the Government has accepted, is the basis for agreement for the years ahead.

Deputy Bríd Smith

The Government may have accepted the report but the people on the front line have not. I do not know if the Minister has looked at the details of the Public Service Pay Commission that is dealing with nurses. Nurses in certain specialties will get an extra €7 a week. One would not buy two pints of beer with that pay increase. It is an absolute insult to them and it is only certain sections of the nursing staff that will get it.

The Minister said it is not open to the Government to breach the terms of the public service pay agreement without serious consequences. I put it to him that the Government's failure to open proper pay negotiations with the nurses is having serious consequences. As I stated, nurses are balloting for a series of 24 hour stoppages. When nurses walk out of hospitals will the Minister congratulate them, as he just congratulated Google workers, on taking action to change the system that is crippling the health service, preventing recruitment and driving young workers, out of desperation, to walk off the job they care about? Will he congratulate them when they take action because he is worried about the serious consequences of breaching a pay agreement? Strikes are also serious consequences and the lives of those involved will be seriously damaged.

Deputy Michael Creed

My understanding is that the public service pay agreement and the pay commission’s review of recruitment and retention will deliver significant benefits for up to 10,000 members of the nursing profession. There is evidence of goodwill in respect of what was an independent analysis of the issues around retention and recruitment undertaken within the auspices of the public service pay agreement. That has delivered a specific additional financial package to up to 10,000 nurses. That is significant. Negotiation is key and it would be appropriate that the INMO would meet departmental and HSE management in an effort to avoid unnecessary strike action.