Dáil Éireann debate -
Thursday, 15 Nov 2018

Vol. 975 No. 1

Saincheisteanna Tráthúla - Topical Issue Debate

Infectious Diseases

Deputy Catherine Connolly

Is oth liom go bhfuil orm é seo a ardú sa Dáil mar tá an t-ábhar chomh tromchúiseach sin. I regret having to raise this matter. I wish I was asking about when the new hospital will be built or the extraordinarily long waiting lists. However, it has been brought to my attention that a patient with active tuberculosis, TB, was admitted to hospital in Galway. Of course, that can happen. However, in this case the patient was not suitably isolated and another patient contracted TB as a result, as did approximately 12 or 13 staff who have been diagnosed with latent TB and are undergoing treatment with antibiotics. Some have suffered adverse reactions to the antibiotics.

I am obliged to raise the matter because it should have been dealt with efficiently and effectively. The patient should have been isolated and other relevant protocols immediately enacted. It seems that did not happen quickly enough and the patient who came in with active TB and had a history of active TB was not isolated for several weeks, during which time the patient was resident on multiple wards and several people were exposed. Contagious diseases are a risk in the helping professions for nurses and doctors and for patients. However, we need a system that anticipates such risks and rolls out appropriate protections. That does not seem to have happened.

The infected staff, who include nurses and care assistants, do not feel that the system has looked after them. For example, they had to attend their GPs for treatment and pay for those attendances. They had to make a case to be granted sick leave. Having suffered the trauma of contracting latent TB, they must also deal with the feeling that they are not being cared for and are expected to just get on with it.

The staff were not tested in a timely manner. One of those to whom I spoke asked to be tested and was told that tests are not carried out willy-nilly and that he or she was only exposed to the patient for a short time. Subsequent testing of other care staff indicated they had contracted latent TB as a result of a short exposure. The staff member in question had to again request a test, fill out a form for a second time and was then diagnosed with latent TB and all the consequences thereof.

I am disappointed that the Minister, Deputy Harris, is not here to address this issue, although that is no reflection on the Minister of State, Deputy Catherine Byrne, whose attendance I appreciate. This is a very serious matter involving an infectious disease and an apparent failure to urgently roll out the proper protocol and procedures in order to protect staff and patients.

Minister of State at the Department of Health (Deputy Catherine Byrne)

The Minister, Deputy Harris, asked me to pass on his apologies for not being present to take this Topical Issue. On his behalf, I thank the Deputy for raising the matter. I will read the script and then respond to some of Deputy Connolly's concerns.

I wish to assure the Deputy that the incidence of tuberculosis in Ireland is low. The World Health Organization categorises Ireland as a low incidence country, with fewer than ten cases per 100,000 population. The annual notification rate of TB in Ireland has declined since 2007 when the rate was 11.3 per 100,000, or a total of 480 cases. In 2010 and 2011, the annual TB notification rates were 9.2 per 100,000 or 420 cases in 2010 and 424 cases in 2011, which were the lowest rates recorded since surveillance of TB began in the 1950s when up to 7,000 cases were recorded per year.

Tuberculosis is a preventable and curable disease. It can be contracted by breathing in the bacteria mycobacterium tuberculosis which may be sneezed or coughed by a person who has TB in his or her lungs. However, although it is contagious, the HSE has advised that TB is not very infectious: close, prolonged contact with a sick person is usually required to become infected.

On the specific case referred to by the Deputy, the HSE has advised that a small number of cases of tuberculosis are identified in Galway University Hospital each year. That is within the expected range for the population size served by the hospital. When a case of TB is diagnosed, the hospital works with the HSE department of public health to provide screening for the family and for patients and staff who had close contact with the person, in line with best medical practice. This is called contact tracing and may involve a skin test, blood test or chest X-ray. Infection with the TB bacteria may not lead to developing the TB disease. Most people exposed to TB are able to overcome the bacteria. The bacteria become inactive, but remain dormant in the body and can become active later. This is called latent TB infection. People who have it do not feel unwell and cannot pass TB on to others. They may develop TB disease later in life and are offered up to six months' treatment to prevent that.

Staff can be exposed to TB in any healthcare setting. A patient suspected to have TB is isolated and the necessary precautions are put in place. If other patients or staff are exposed to TB, the department of public health follows up in regard to patient contacts while the department of occupational health deals with staff exposure.

On the specific case referred to by the Deputy, several staff in Galway University Hospital are being followed up by the departments of occupational health and public health following exposure to a patient earlier this year. It was not initially known that the patient had TB. The patient was admitted as an inpatient and subsequently found to be infectious. A review of the case will take place under our quality and safety processes. Education sessions have taken place for staff and the hospital is currently reviewing operating procedures for the management of TB.

Deputy Catherine Connolly

I acknowledge the Minister of State delivered a prepared reply. She read out ten or 11 paragraphs but only the final one dealt with my question.

I live in Claddagh in Galway and am fully aware of the background to TB, that it is treatable and that patients with active TB attend hospitals. All of that is accepted. I ask the Minister of State to please address the question as to whether the appropriate protocols and procedures were followed in this case. Why was a patient with active TB resident on at least two wards without being isolated? How could the TB be undiagnosed when the patient had a history of TB?

The Minister of State confirmed that a review will take place. The patient was admitted early this year. Why has a review not yet taken place? Surely, a review should have taken place immediately to determine why the TB was not diagnosed, why the patient was not isolated and why a significant number of staff on different wards contracted latent TB. Those questions should have been answered by the Minister of State. Was there an internal review? If not, why not? Did the hospital not realise the importance of this matter?

I do not want to have to raise such issues in the House. I am very proud of Galway. I want a public health system of which we can be proud. However, events of this nature keep occurring and it is only when the matter is raised in the Dáil that a review is carried out. That does not engender confidence in our health system. I want to build confidence in it. I want the hospital in Galway to function. It has many problems relating to a lack of staff and so on and I fully support it in that regard. However, the Minister of State should be able to tell me whether a review of this matter was carried out, what was learned and what action was subsequently taken.

I should be hearing that a care package was provided for the staff in a caring manner. I should not be hearing comments to the effect that tests are not carried out willy-nilly.

Deputy Catherine Byrne

I apologise to the Deputy if she feels that the answer I read was not adequate. However, I cannot answer the specific questions she asked. All I can do is read the material I have been given. It does not set out the specific pattern of what exactly happened in this case. I have taken note of a number of the concerns raised by the Deputy and I will bring them back to the Minister. I will ask for more comprehensive information on the individuals who have been affected by this case of TB, particularly staff members, to be given to Deputy Connolly as soon as possible. If I had the relevant information in front of me to enable me to answer the questions asked by the Deputy, I would give that information to her. I just do not have it. There is no point in me pretending that I have it because I do not have it. I will ask the Minister and his officials to contact the Deputy to outline the exact information they have received from the hospital in respect of the cases that have been mentioned.

Deputy Catherine Connolly

I thank the Minister of State.

Medicinal Products Availability

Deputy Alan Kelly

It is very disappointing that the Minister for Health is not here to deal with this and other issues. This is a particularly important issue. I want to know why a drug, pembrolizumab, is not being made available to cancer patients who require it. The issue has received a great deal of publicity in the context of the case of Vicky Phelan, to whom I spoke before I came into the Chamber for this debate. Pembrolizumab is produced by a drug company here in Ireland - in County Carlow - and is at least two years away from being approved. It has had very significant effects on Vicky Phelan's tumours and on her cancer and has given her a much better quality of life. Like many others, Vicky Phelan has been inundated with requests from people who want to know how they can access this drug. It is not a drug that is on a clinical trial. It is off licence. It is a unique drug because it has been shown to have a significant impact on tumours in many of the cases of those affected. Two leading oncologists in this country, Professor Crown and Dr. Fennelly, have written to the Minister and the Department to ask for this drug to be trialled, or for some method to be found so that it can be provided to cancer patients. These patients need this drug.

Pembrolizumab is unique because patients can be tested in advance to determine their potential responses to it. This makes it cost-effective. The test in question, which is known as the PD-L1 test, costs approximately €2,000. In order to show that one is suitable for this drug and that it will have an impact on one's life, one must score over 55% in that test. Vicky Phelan scored up to 75% in it. Even though this drug is very expensive, it is cost-effective when compared with all the ancillary costs of other treatments, including potential hospital stays. Given that this drug has been trialled in the US, and in light of the US Food and Drug Administration's call for it to be released and approved immediately, I would like to know why a programme has not been put in place in this country to allow it to be used on a trial basis. The Government and the company could work together or some other method could be used to that end.

It is not acceptable that the 221 women affected by the CervicalCheck scandal have access to this drug, but others do not. It is morally right that the State is paying for the 221 women in question to access this drug, as a result of a Cabinet decision. While that decision is morally the right one, what distinguishes those women from people who are not in the group of 221? Why are they not entitled to access the drug in the same way? How is it legally possible for this country to say that a cohort of women who are absolutely devastated by what has happened - I know about this because I am fighting for the women in question - should have access to a drug, and have it paid for by the State, but women outside that cohort should not have the same entitlement? I do not even think that is legal. I think it is illegal. I do not think a Government decision can distinguish between two categories of people in this way. We need to have a plan in place to ensure there is equity in access to this drug for those who need it. We need to put a plan in place quickly because time is not on the side of many of these people. This point also applies to forms of cancer other than cervical cancer and to drugs other than pembrolizumab.

I encourage the Minister of State, Deputy Catherine Byrne, to go back to the Department. I am very disappointed that the Minister is not here. I have raised this issue with him directly. He knew I was probably going to bring it up soon. We need an answer to this. I am speaking with the support of Vicky Phelan and others who have raised the need to get wider access to this drug in a fair and compassionate way.

Deputy Catherine Byrne

I apologise for the inability of the Minister for Health to be here for this debate. Deputy Kelly could have withdrawn his Topical Issue if he had wished. I have been asked to respond to him on behalf of the Minister. I will read the reply that has been furnished to me. If the Deputy is not happy with it, I am sure some other arrangements can be made.

I thank him for raising this issue. The Minister appreciates that cancer diagnoses place enormous stress on patients and their families. Sadly, very few people in Ireland have been untouched by cancer. Access to potentially beneficial medicines for cancer treatment is an extremely important issue for people. The Oireachtas put in place a robust legal framework when it agreed the Health (Pricing and Supply of Medical Goods) Act 2013, which gives the HSE full statutory power to assist in making decisions on the reimbursement of medicines, taking account of a range of objective factors and expert opinion as appropriate. The 2013 Act specifies the criteria to be applied when reimbursement decisions are being made. Those criteria include the clinical and cost-effectiveness of the product, the opportunity cost and the impact on resources available to the HSE. In line with the 2013 Act, a company that would like a medicine to be reimbursed by the HSE must first apply to have the new medicine added to the reimbursement list.

HSE decisions on which medicines are reimbursed by the taxpayer are made on objective, scientific and economic grounds on the advice of the National Centre for Pharmacoeconomics, which conducts health technology assessments for the HSE and makes recommendations on reimbursement to assist decisions. The National Centre for Pharmacoeconomics uses a decision framework to assess systematically whether a drug is cost-effective as a health intervention. The drug mentioned by Deputy Kelly, pembrolizumab, is reimbursed for four indications: advanced melanoma in adults, first-line treatment for non-small-cell lung cancer, advanced melanoma in adults with combination therapy, and Hodgkin's lymphoma. The HSE has commissioned health technology assessments on the use of this medicine for two other cancers. When the output of this process for each of the additional indications is available, it will be considered by the HSE under the statutory process. The HSE is also deliberating on one further indication for reimbursement.

In May 2018, a Government decision put in place a package of support measures for women and families affected by issues relating to CervicalCheck. As part of this package, all out-of-pocket medical costs incurred by the women affected may be met if they are not already covered under existing public schemes or by private health insurance. This exceptional commitment includes medicines which might not be approved for reimbursement, as long as they are prescribed by the treating clinician. Therefore, pembrolizumab would be encompassed under the support package if it is prescribed by a woman’s consultant.

Deputy Alan Kelly

I thank the Minister of State. Obviously, I would prefer if the Minister were here. I appreciate the presence of the Minister of State, Deputy Catherine Byrne, and I acknowledge that she is doing her best. Tomorrow, I have to go to the funeral of a young man and father of three children in Clonmel. He was trying to get on this drug, but unfortunately he never made it. May he rest in peace.

The issue is that the health technology assessment, HTA, for the drug will take two years. Too many women and men in this country will be affected by that timeline. Consultants are willing to administer the drug. The company that produces it is based in Carlow. The drug is available here and there is a test that would determine whether it would give the people affected quality of life or a chance. We cannot tell these people who want a chance that they must wait two years because of all the rules and regulations that are necessary. They do not have time. It costs €8,500 for a three-week shot of this drug and €2,000 for the test to be done. People want the chance to spend the €2,000 and have the test. I beg the Minister of State.

Vicky Phelan said on the "Ray D'Arcy Show" that she had to fight tooth and nail to get on this drug and only for her persistence that would not have happened. She is alive and has quality of life. I want the Government to work with this company and the people who need this drug to give them some hope in the same way that Vicky Phelan has given so many people hope. I stress the inequity involved in paying for this drug for the women affected by the scandalous CervicalCheck issue, while having other people outside that. It is not legal to discriminate between people, notwithstanding that it is morally right to treat these women and give them as much as possible. I urge the Minister of State to give the people affected hope, consider this drug, approach the company, consider the trial and some sort of system quickly, given the impact we know this drug has had on some people's lives, particularly Vicky Phelan's.

Deputy Catherine Byrne

I thank the Deputy for raising this Topical Issue matter and I apologise again that the Minister is not here. I cannot give a definite response to the Deputy. I can see his compassion for, and passion in speaking about, people who are fighting the scourge of cancer daily. There is no family in this country, including mine, that is not affected by somebody who has either passed away from cancer or is in the throes of that terrible disease. I offer sympathy on my part and that of the Minister for the young man and to his family. I do not know his name so I cannot be more specific.

Deputy Alan Kelly

His name is Martin.

Deputy Catherine Byrne

I assure Deputy Kelly that I will speak to the Minister, as I always do when I leave the Chamber. I always make sure that if I cannot get the Minister who has asked me to stand in, I give an outline of the question to a member of his or her staff and request that the Minister respond more comprehensively to the Deputy in question.

Unfortunately, I am not able to say we will be able to reimburse people but I believe that for those who are struggling against this horrible disease, we have to do whatever we can, not only in this House but through medicine and compassion to work on their behalf.

Public Transport

Deputy John Lahart

I thank the Minister for Transport, Tourism and Sport, Deputy Ross, for attending. I am always grateful when he is here and in fairness to him he always makes an effort to respond to Topical Issue matters. The Minister is very familiar with this issue. As I speak, trade union representatives are on national radio again, having raised this issue on national radio this morning. I and one of my councillor colleagues are members of the Luas-Dublin Bus forum in Tallaght. There have been some incidents recently in which bus services have been withdrawn. This occurs in other parts of Dublin as well, thankfully not too frequently, but often enough to cause some degree of concern to people.

What we hear at the Luas-Dublin Bus forum, and what is often raised in the newspapers, are dramatic incidents culminating in serious assault that have occurred on Iarnród Éireann services several times. I am equally concerned by the low-grade menacing level of anti-social behaviour on all public transport. A person may be sitting upstairs on the bus and someone who is drunk or not even drunk, or worse, someone on drugs, becomes aggressive. There is no provision for Luas security personnel to stop, search and arrest. They can simply escort someone off the tram. Since before 2016 Fianna Fáil has been calling for a dedicated public transport police to ensure, at a minimum, that random checks are carried out so that members of the public can take a journey on public transport, which we are encouraging them to use, in the knowledge that a random check may take place on any public transport service to dissuade anti-social behaviour.

Acting Chairman (Deputy Bernard J. Durkan)

We will not have a fourth Topical Issue matter today.

Deputy Robert Troy

I do not know why Deputies submit Topical Issue matters when they are not going to be here to take them. I thought there was always a reserve Topical Issue matter to make sure that four issues are discussed.

I add my voice to Deputy Lahart's in asking the Minister to tackle a growing problem on public transport, namely, anti-social behaviour and assault. By 9 September this year, 500 such incidents had been reported on Irish Rail and 11 drivers had been assaulted. Last month, four Bus Éireann drivers were assaulted. Dublin Bus has a protocol under which drivers who do not feel safe withdraw a service. Unfortunately, that is becoming very frequent.

This morning, on "Today with Sean O'Rourke", we heard two drivers, one from Irish Rail, the other a bus driver, share examples of their experiences, which included drivers being spat at, one driver being hit with a snooker ball in a sock and a ticket inspector who had three fingers broken. Only last weekend, a train on the Sligo line had to stop at Kilcock, causing a 45 minute delay for passengers while they waited for gardaí to come and remove an unruly passenger.

It is not good enough that workers in State companies do not feel safe going to work and that passengers are afraid in certain instances to use public transport or are delayed because of the need to deal with anti-social behaviour on public transport. Unfortunately, as with many of the commitments from his Department, the Minister is failing to act on this. I hope he will use the opportunity over the course of the next four minutes to outline exactly how he plans to deal with this issue.

Minister for Transport, Tourism and Sport (Deputy Shane Ross)

I thank Deputies Troy and Lahart for raising a matter that is topical. This is an unusual occurrence in this House and it is very welcome that they are doing so.

As the Minister for Transport, Tourism and Sport, I have responsibility for policy and overall funding for public transport. However, I am not involved in the day-to-day operations of public transport. The safety and security of passengers and staff, including arrangements to deal with anti-social behaviour on public transport, are matters for the operators, in conjunction with, as appropriate, An Garda Síochána. I am, however, concerned to ensure that the necessary arrangements are in place to ensure the safety of all passengers and staff travelling and working on our public transport network.

I am advised by the Department of Justice and Equality that there is a range of strong legislative provisions available to An Garda Síochána to combat anti-social behaviour, including provisions under the Criminal Justice (Public Order) Acts, the Criminal Damage Act and the Intoxicating Liquor Acts. An Garda Síochána remains committed to tackling public disorder and anti-social behaviour by working with communities to enhance safety.

There were 45.5 million passenger journeys in 2017 on Iarnród Éireann trains. The vast majority were without incident. However, I have been advised by Iarnród Éireann that the number of recorded anti-social incidents has risen in recent years; hence the concern expressed by the Deputies and others. Iarnród Éireann has been actively encouraging employees to report all safety critical issues, including threatening and violent behaviour. In the first nine months of this year, 584 incidents were recorded. However, Iarnród Éireann has advised that anti-social behaviour has receded significantly since the summer, when it would be typically at its highest level. Security patrols by the company have increased by 21.8% since 2016, and it has advised that it has enhanced general security cover and provides for enhanced security patrols for major events.

Iarnród Éireann liaises on a quarterly basis at a minimum with An Garda Síochána in major districts. In addition, there is ongoing liaison by the company with employees and their trade union representatives to assess reports of anti-social behaviour and direct security resources based on the issues reported. Closed circuit television, CCTV, is available on the vast majority of trains and has been used successfully numerous times in securing prosecutions. It is also in place in stations. In addition, Iarnród Éireann has advised that it has commenced the deployment of on-board customer services on intercity services. While the primary focus will be on customer service, the company will ensure a presence on these services to deter anti-social behaviour and to alert security or the Garda should urgent responses be required. Both Dublin Bus and Bus Éireann have stated the level of anti-social behaviour on their services is relatively low and note a declining trend, which is very positive. Both companies stress the strong and close working relationships with An Garda Síochána.

Following representations from the National Bus and Rail Union on the establishment of a dedicated police force for public transport, my Department wrote to Iarnród Éireann, Bus Éireann, Bus Átha Cliath and the Railway Safety Advisory Council to seek their views. Subsequent to that engagement, I contacted the Minister for Justice and Equality to seek his views as to how we might best address the issue. I have asked that the Minister consider this issue in conjunction with An Garda Síochána given that the allocation of all Garda resources, including the manner in which Garda personnel are deployed, is solely a decision for the Garda Commissioner and his management team. I will continue to work with the Minister for Justice to resolve this important issue.

Deputy John Lahart

I thank the Minister for the response. There is good news in it, particularly in respect of Iarnród Éireann and the deployment of on-board customer services on intercity services. I appreciate that. I believe passive security is being suggested.

The Minister does not want to get involved in the day-to-day running of any of the companies. He is responsible for policy. What is his view on this given that the union has made multiple calls for a dedicated transport police? It obviously sees good reasons for doing so. CCTV does not capture low-grade anti-social behaviour but it does capture physical assault, quite clearly. The Minister outlined some of the issues. Will he publish the responses from Dublin Bus, the Luas, Iarnród Éireann and the DART? What was the response from the Minister for Justice and Equality?

The Minister has travelled on a bus and used the tram. There is nothing more scary and anxiety inducing than being on a bus when there is anti-social behaviour taking place. One is simply trapped. At least on a bus or the Luas, one knows there will be a stop in three or five minutes but one can be on a train for an hour. There is simply no escape. That is the fundamental point to take on board.

Deputy Robert Troy

The Minister says he has responsibility for policy. The policy of ensuring the security of passengers using public transport and the staff working thereon should be key. The Minister has responsibility to ensure appropriate action is taken. It is not that he can prosecute somebody caught acting in an anti-social manner or who has assaulted somebody but he can prevent this behaviour on public transport.

The Minister said it is the responsibility of the Minister for Justice and Equality and that it is a decision for the Garda Commissioner but, in respect of the Judicial Appointments Commission Bill and the reopening of Stepaside Garda station, he had no problem in expressing his tuppence worth on their responsibilities. Therefore, I ask him to take on board what the union and workers are saying, in addition to what Deputy John Lahart and I are saying about passengers who are using public transport.

Only last week a senior citizen in my constituency who travelled from Connolly Station to Mullingar said she was relieved getting off at Mullingar train station because she was afraid on the train. That is not right. It is certainly not proper and the Minister is responsible for doing something about it. I hope he will.

Deputy Shane Ross

I fully understand Deputy Troy's concern about the incidents he is mentioning, particularly when they affect his area and constituents. He really does not expect me to get involved in any specific incidents that happen on trains or buses. It might make good copy for his local newspaper to come in here and say what he said but if he expects me-----

Deputy Robert Troy

It is national policy.

Deputy Shane Ross

-----to say I should intervene in respect of a specific incident, I am not going to do it. I have no intention of doing it.

Deputy Robert Troy

I did not ask the Minister to do so.

Deputy Shane Ross

What I said quite specifically is that this is for other people, agencies and authorities. They are well capable of dealing with the incidents. My concern overall is, of course, for the safety of staff and passengers. I am as concerned as the Deputy about the matters he addressed. My duty is not to interfere when an individual passenger has an unfortunate experience, however. It is to express my concern in very clear terms to the relevant bodies, including Bus Éireann, Dublin Bus, Iarnród Éireann and others, if I believe there is a trend or incidents or if not enough is being done to ensure the safety of passengers. That is what I will continue to do. I will continue to take seriously any individual representations made by Deputy Robert Troy and Deputy John Lahart. I have applauded the fact that they are prepared to bring this matter to the House. It is appropriate to do so but it is not appropriate to expect the Minister to intervene in individual incidents in Mullingar or elsewhere. I will not do that.

Deputy Robert Troy

It is dangerous going off script. The Minister is contradicting himself.