Dáil Éireann debate -
Thursday, 28 Feb 2019

Vol. 980 No. 3

Ceisteanna ó Cheannairí - Leaders' Questions

Deputy Dara Calleary

Today is world Rare Disease Day, which is a day to raise awareness among the public and decision makers about the impact of rare diseases on people's lives. On 20 September last, more than six months ago, I raised the issue of spinal muscular atrophy, SMA, with the Tánaiste and the need for the HSE to improve the reimbursement for the drug, Spinraza. This has been raised on a weekly basis by many Deputies across the House since. As we stated, SMA is one of the most horrific diseases imaginable.

We had a meeting this morning, hosted by Deputy Ó Caoláin, in the audiovisual, AV, room where it would have broken a stone heart to hear the stories from the families and from those with the condition. SMA debilitates lives and until the arrival of Spinraza, there was nothing to tackle it effectively. Those living with SMA spoke this morning about the impact of Sprinraza, this miracle drug, and the new opportunities it presented to them. They laid out those testimonies in a painful and direct manner, but along with the pain, there was bravery, courage and a raw ambition to live lives to the fullest. There was an ambition on the part of those older patients with SMA and an ambition on the part of those parents who are seeing lives that they thought they would not see because before the arrival of Sprinraza, the average lifespan of somebody with SMA was two years.

The HSE does not seem to share that ambition or to understand that pain because, on Friday last, it told families again that it would not approve Spinraza for reimbursement and thereby took that chance away. It has sentenced sufferers and their families to continued suffering and to emigration to one of the 25 countries that have approved Spinraza medically and financially. It was laid out clearly to us this morning and I regret that this decision has potentially sentenced some of those sufferers to death because without Spinraza they will not survive SMA.

Twenty-five countries have approved Spinraza and can stand over the clinical effectiveness of the drug. Twenty-five countries have come to a deal with Biogen on the pricing of Spinraza, and yet the Government cannot. A number of Deputies have met Biogen representatives who have engaged with the HSE since September in a detailed manner. They have put a deal on the table, which is considerably less than the prices the HSE is quoting publicly. It strikes me that the HSE is deliberately misleading people about the potential cost of this drug in order to change the course of the debate.

An Ceann Comhairle

I thank the Deputy. The time is up.

Deputy Dara Calleary

At the same time, the HSE is ignoring a potential €90 million in savings that have been pointed out to it by Deputy Brassil through the use of what are known as biosimilars.

An Ceann Comhairle

Please, the time is up.

Deputy Dara Calleary

Why is the HSE using misinformation to add to the distress of families with SMA? Why will its staff not engage properly with Biogen regarding the deal that is on the table as opposed to a deal that they are making up? Can the Tánaiste ensure that the Minister for Health will meet directly with the families and the patients in the manner the Deputies did this morning to understand the consequences of this decision?

An Ceann Comhairle

Before we proceed, I implore Members to adhere to the time limits provided for questions.

The Tánaiste

I thank Deputy Calleary for raising this sensitive and important issue, which has been raised repeatedly. When I have taken Leaders' Question, it has come up almost every second week for many months now.

SMA, as has been described, is a terrible condition with awful consequences for sufferers, and I am sure extraordinary stress for families as well. I completely understand the stress and frustration that each family must be under and the anxiety caused as they wait for news about funding of this drug.

The Government wants an agreement to be reached so that sufferers have access to the best medication. However, we cannot ignore recommendations from the HSE in ensuring that we spend appropriate amounts on many drugs for rare conditions. Two have been approved so far this year through the system that we are discussing.

The price list sought by the company, according to information that I have, amounts to €600,000 per patient for the first year and €380,000 per patient per annum thereafter.

Deputy Lisa Chambers

That has changed.

The Tánaiste

Let me give the House the information that I have. I certainly stand open to questions.

Following detailed consideration of an application from the manufacturer, Biogen, the HSE leadership team made the decision that it was unable to recommend reimbursement of Spinraza at the price quoted on 12 February. On Thursday last, 21 February, the HSE wrote to the company informing it that the executive proposed to refuse reimbursement at the current price offering but had left the door open for the company to come back with a more realistic offering. Under the terms of the Health (Pricing and Supply of Medical Goods) Act 2013, as I am sure Deputy Calleary will be aware, the company has 28 days to come back to the HSE with a proposal.

The Government is keen to see agreement reached here. We want the HSE to work proactively with the company so that we can find a middle ground position that the company can accept in terms of pricing and that the HSE can recommend to the Government, which can allow this drug to be made available. That is where we are. The HSE has not recommended that there should not be reimbursement for Spinraza. It has made a recommendation that it cannot do it at the price on offer.

An Ceann Comhairle

The time is up.

The Tánaiste

I encourage the company to engage and ensure that we find a way, for patients and families who are stressed and suffering because of the anxiety and the wait on this issue, to bring that wait to an end if it is possible to do so.

Deputy Dara Calleary

Those prices the Tánaiste is quoting are out by up to 50%. He has been given information-----

The Tánaiste

I have been given a note by the HSE.

Deputy Dara Calleary

-----but we have spoken to the company. I accept that the Tánaiste has been given incorrect information. That is why he needs to take charge of this as deputy prime minister. The families have no confidence in the HSE or in the management of the Department of Health to see this through. Those prices are way out and they cannot be used to stop families accessing a better future.

The Taoiseach, of course, tweeted this morning, in the lack of anything of substance, that today is international Rare Disease Day and, "Up to 300k people in Ireland will be affected by a rare disease in their lifetime. We will do better in helping these patients & families in Ireland". Let the Government do better. Let it do better for the parents of children and adults with SMA and give them access to something that will transform their lives. We want the Tánaiste and the Minister for Health to meet these parents and patients to understand how important this is and the transformative nature of this drug because the HSE clearly does not. I ask the Tánaiste to get the right information.

The Tánaiste

I will verify the information that I have. I have a date next to that reimbursement price that was proposed of 12 February, which I suspect may be accurate. Perhaps there has been a change since then in the price that is on offer. If there is, there is a structured mechanism for the company to engage.

Deputy Mattie McGrath

Do it again.

The Tánaiste

I ask the Deputy not to trivialise this important issue. We want to get it resolved. There is an absolute willingness on the part of the Government to do that. However, when we are talking about facilitating drugs for rare conditions, as we have been done this year, if we ignore price as part of the discussion, we could pay money that could go into other drugs.

Deputy Dara Calleary

There is €90 million in savings on the table.

The Tánaiste

Of course we want the best drugs to be available for rare conditions and other conditions. They are going through the assessment process. Cost must be a part of that discussion. The onus is on the company to come back with a proposal that I certainly hope the HSE will be able to consider favourably.

Deputy Caoimhghín Ó Caoláin

Today, in the audiovisual room, Deputies, Senators and support staff listened, many with tears in their eyes - I was facing them - and unashamed of the fact. They listened to the most heart-rending appeals of parents, children and adult survivors all contending with spinal muscular atrophy, SMA, in their lives. The stories of their lives and the lives of the many others who joined them afterwards at the gates of Leinster House need to be heard by every Deputy and Senator without exception. Along with colleagues from all parties and independent voices, I have been consistently raising the issue of approval of Spinraza for all SMA sufferers. I ask the Tánaiste to note that those who have turned 18 years of age and who have lived beyond childhood are equally entitled to this chance of not only improved life but life itself. This is world Rare Disease Day. It should have been a day of celebration for the 25 children and the 50 people aged over 18 who live with the cruel denial of the ability to live full and active lives. It should have been a day of celebration for their heartbroken parents, their extended families and all who care for them. It would have been if the HSE had approved Spinraza for reimbursement when its senior leadership team met two weeks ago on 14 February, St. Valentine's Day, but it did not. Despite the fact that Spinraza has been approved in 25 of the 28 member states of the European Union, and that its efficacy and effectiveness have been clinically established and demonstrated in a significant number of the cases of people who are accessing the drug, Ireland, with Estonia and the United Kingdom, remains unmoved. Scotland has acted unilaterally within the UK and has approved Spinraza for types 1, 2 and 3. With the UK exiting the European Union, Ireland and Estonia will stand alone as the only EU countries not to face up to their responsibilities to all their children and to those who have survived into adult life.

I am sick and tired of appealing to the Government and the Minister for Health, Deputy Harris, in respect of this issue and so many others. When the Minister and the Department fail to set the policy and fail to instruct the HSE to act in a responsible way on a given issue - and in this instance where the lives of very ill children are at stake - it galls and angers me. Against the almost daily statements of his and the Government's commitment to children's healthcare services and the new national children's hospital, the State is continuing to fail a small cohort of 25 children suffering from a devastating wasting disease. Will the Tánaiste undertake to act now as deputy leader of the Government, as an accountable public elected representative and as a parent?

The Tánaiste

I assure the Deputy that I, as deputy head of Government and as a parent, try to act every day in terms of the responsibility I have. I do not think we should be trying to paint the HSE as some kind of cold body that does not want to grant reimbursement for Spinraza. It does want to grant it. The HSE rare diseases technology review committee recommended that it should be approved. As it moves through the process cost must be part of the discussion and because the HSE does not believe the company involved is offering value for money there is a stalling in the process. This is why the HSE has written to Biogen to this effect. I certainly hope that what was suggested earlier by Deputy Calleary, that the cost proposal has changed, can be a factor in the response the company makes to the HSE's letter.

Make no mistake, the Government wants this issue to be resolved. We want our children and the families who love them to get the support of the State in respect of rare diseases and the drugs that are very expensive but that are absolutely justifiable in those cases. We also have to ensure the State gets value for money because if it does not, we will spend money that could otherwise fund other really valuable drugs that are also needed and other families and victims will not get the support they need. In the context of the dealings the State has with the pharmaceutical sector and drugs companies, we have to ensure that there is a fair pricing model and that we have a process that does not allow children and their trauma and stories to be used as a way of trying to get prices agreed.

I will speak to the Minister for Health and the Taoiseach on this directly but it is important that politicians are not the ones who make decisions on what is or is not value for money in terms of healthcare and that we have a system we can rely on to do this. Again, I encourage the company and the HSE to try to resolve the issue because I know how many people in the House understandably continue to take a very personal interest in it.

Deputy Caoimhghín Ó Caoláin

I hope that what the Tánaiste is saying is the case in terms of the Government's keenness in wanting to see this resolved. I charge that those who are representing the Government and us in terms of the engagement with Biogen are not demonstrating the same commitment. Make no mistake about it, the figures that Deputy Calleary has shared with the House are accurate. I have also met Biogen and I can state that an imaginative proposal that would leave the cost for those aged under 18 alone - just dealing with children - at approximately €9 million for two year's provision has been put forward. Figures have been bandied about and put out on the airwaves. The Government must take direct responsibility on this engagement because trusting and not exploring the full facts makes it complicit in the failure. If the Tánaiste was at the gates of the House but an hour ago to speak to those families and meet those children, he would not give the answers he is offering. He would instead make this matter his number one priority. I ask him to commit to doing exactly this from this moment forward.

The Tánaiste

This is a priority, just like it was a priority to get other rare disease drugs approved to date in 2019. There are families awaiting and needing decisions on reimbursement and the absence of those decisions has been going on for too long. In the case of Spinraza, it has been going on for too many months. We also have to ensure that we have in place a system which makes decisions on the basis of the facts in order to ensure that we get the drugs we need for the families and, in particular, the children who need them. We must also ensure we spend money in a way that guarantees we get value for all the money we spend throughout the healthcare expenditure profile, for rare diseases and other diseases. This is where we are at on this. We want this issue resolved for the families concerned. There needs to be a response from Biogen to the effect that persuades the HSE leadership that its proposal represents value for money and is comparable with the price of the drug in other countries. I will certainly speak to the Minister for Health about this issue. It is the responsibility of the Government to ensure that the figures are accurate but we must also ensure that experts make decisions in technical areas such as this. This is why we have in place the existing structure and systems.

Deputy Brendan Howlin

The remarks made by the Minister for Children and Youth Affairs, Deputy Zappone, yesterday in respect of Scouting Ireland have caused a great deal of anxiety and concern, particularly among scouting families. It is not clear whether she was informing us of a new problem or simply opening a window into a process of review and improvement within Scouting Ireland of which we are aware and which has been ongoing for many months.

Let us be clear that the first and foremost issue here is child protection. Since the scandals of child abuse in this country, the State has built up a range of invaluable safeguarding procedures and processes. Child abuse is a dreadful stain on our history. The State and all voluntary organisations must work together with parents and families to protect all our children.

However, we must also take great care in what we say, especially if it impacts on volunteers in any sector. From the responses of the Minister, Deputy Zappone, to date, it is still not clear to me what is new about the letter from Tusla to Scouting Ireland. Scouting Ireland and other major national organisations such as the GAA, the FAI and all the others have instituted detailed child protection policies in recent years. The Minister's comments yesterday suggested that parents need to be wary of sending their children to overnight scouting events, while some media commentary today suggested that scouting itself could be undermined. These are very serious matters. The letter from Tusla states, "we are concerned about the apparent lack of progress in reviewing the policies, procedures, training and culture which underpin the [Scouting Ireland] service, and we are of the view that these concerns should be escalated to you as CEO." Is this a new issue or is it simply a letter to the CEO asking him to accelerate an ongoing process?

The letter is dated 18 February. I understand that last Monday Tusla met the board of Scouting Ireland but none of the eight items in the letter were raised. Is this true? Has Tusla previously met the board? I understand that some of the actions being sought by Tusla have been ongoing for some time. In July 2017, Scouting Ireland commissioned a review of the handling of child protection cases. This review and the implementation of changes have been led by a safeguarding specialist who is beyond reproach on this issue. Scouting Ireland staff have engaged with Tusla and the Garda since then.

This House and the families involved need to know whether there is a new problem in Scouting Ireland. I ask the Tánaiste to provide a timeline of events and explain exactly what are the concerns of the Government or the Minister regarding Scouting Ireland that have come to light this week. We need to give assurances and support to the many parents and thousands of scouting volunteers who are deeply worried about what the Minister had to say yesterday.

The Tánaiste

I thank the Deputy for the opportunity to clarify a number of the issues he raised. Yesterday, the Department of Children and Youth Affairs received a copy of a letter dated 18 February written by Tusla to the CEO of Scouting Ireland, who raised serious issues regarding the handling of several recent child protection cases and criticised the apparent lack of progress in reviewing the policies, procedures, training and culture which underpin Scouting Ireland's service. The letter makes a number of recommendations to the organisation. These include the need to review the Scouting Ireland child safeguarding statement and procedures, an urgent review of the manner in which the organisation managed current child protection concerns and disclosures from children, an immediate review of the supervision of children involved in scouting and issues concerning the operation of a helpline. The letter also recommends that Scouting Ireland should consider the viability of continuing with overnight trips given the concerns outlined.

The Minister for Children and Youth Affairs is determined to ensure the safety of all children and young people participating in Scouting Ireland services. She is anxious that parents should be aware of the situation in order that they can make informed decisions and know that actions are under way to ensure that all reasonable steps are being taken by Tusla to assist in strengthening the child protections within Scouting Ireland. The Minister previously suspended funding to Scouting Ireland, but restored it on the basis of work done by the organisation and an independent report which she commissioned. In light of Tusla's recommendations to the Minister, following consultation with the chief social worker in her Department, she is now directing Scouting Ireland to co-operate with Tusla to define a robust framework for the safety of children and, in particular, the supervision of children involved in scouting activities. In the meantime, Tusla will establish a helpline with effect from Thursday 28 February for children and parents who wish to raise concerns. Scouting Ireland is due to provide a progress report to the Minister at the end of March which will deal with progress on governance issues and historic cases. The Minister will also receive regular progress reports on the implementation of the Tusla recommendations.

The direct answer to the Deputy's question is this is an ongoing relationship.

Deputy Brendan Howlin

There is nothing new.

The Tánaiste

The Deputy should not say there is nothing new.

Deputy Brendan Howlin

I was asking a question.

The Tánaiste

The Deputy just said there is nothing new.

Deputy Brendan Howlin

I asked, "Is there nothing new?"

The Tánaiste

The Minister made a decision to publish the letter so that this is dealt with in an open and transparent way. Concerns remain in regard to the need for Scouting Ireland to put procedures in place to ensure they are fully consistent with Tusla recommendations on child protection because we know there have been real concerns and cases of concern in the past. This is an ongoing process whereby Tusla will work directly with Scouting Ireland to make sure we can provide the necessary reassurance that many parents will demand.

Deputy Brendan Howlin

The Tánaiste will be aware that there are thousands of parents whose children will be going on camps, some of them this weekend. I seek clarity on the knowledge of the Government and the Minister for Children and Youth Affairs in regard to these matters. The Tánaiste stated that the Government is directing Scouting Ireland to co-operate with Tusla. Is he saying that it is not co-operating with Tusla?

The Tánaiste

That is not what I said.

Deputy Brendan Howlin

I have asked the question. The Tánaiste can answer it in due course. Did Tusla meet the board of Scouting Ireland last Monday - subsequent to the letter - but not raise any of the issues in the letter at that meeting? My understanding from an announcement on the 1 o'clock news is that Scouting Ireland is going ahead with its camps this weekend. Is it the view of the Department of Children and Youth Affairs that that should not be the case?

The Tánaiste

No. I am surprised at the defensive tone of the Deputy's questioning on this issue. The Minister is trying to act in a way that is transparent, open and responsible------

Deputy Brendan Howlin

She should be clear.

The Tánaiste

-----to prioritise first and foremost the safety of children. We know there have been cases of children who have been in totally inappropriate situations linked to Scouting Ireland in the past. Scouting Ireland is a very positive organisation and we want it to work, but we also need to ensure that Tusla brings its experience to bear on the necessary restructuring and procedures that need to be in place to give parents the reassurance they need.

Deputy Brendan Howlin

Is it?

The Tánaiste

That is why the Minister instructed that the CEO work with Tusla at the highest level of the organisation------

Deputy Brendan Howlin

I understand they have had 40 meetings.

The Tánaiste

-----to make sure that is the case. If she was not still concerned in regard to the need for that work to continue, she would not have said it. The letter states that parents should seek assurances that no overnight trips take place without adequate numbers of trained supervisors. Scouting Ireland must ensure that each of these supervisors knows the exact steps to take if a child comes to them with a concern or if something happens. Parents who seek these assurances and ask sensible questions are behaving in a reasonable and responsible manner. What the Minister is saying to parents is that they should ask the appropriate questions and get assurance from Scouting Ireland that appropriate numbers and supervision are in place before making an informed decision.

Deputy Seamus Healy

In the first case of its kind, the HSE pleaded guilty in Kilkenny District Court to two charges relating to the physical conditions in the department of psychiatry of St. Luke's General Hospital, Kilkenny and to two charges relating to not having a consultant psychiatrist sign patient seclusion orders within 24 hours of the seclusion taking place, as required by law. Judge Brian O'Shea fined the HSE and said:

For too long in this country, mental health issues have been ignored and stigmatised. The testimony of the inspectors and photographs [taken during the inspection] are the physical manifestation of that lack of care. What makes this worse is that the facilities here are those that house the most vulnerable people. Those people matter and the environment in which they are cared for matters.

The chairman of the Mental Health Commission, Mr. John Saunders, stated: "As a regulatory body, it is entirely unacceptable to find conditions that you would have expected to find in a Victorian workhouse in a mental health service in Ireland in 2019."

I will not go into detail on the issues raised in the court case: I would not have enough time to do so. The details are absolutely shocking. It is now quite clear that the unit is not fit for purpose. Most of those who know and have worked in the unit are satisfied that this is the case. Staff have been involved in industrial relations continually to rectify the problem.

The mental health services crisis at St. Luke's in Kilkenny and in south Tipperary has been ongoing since it developed in 2012, when the then Government and former Labour Party Minister of State, Kathleen Lynch, closed the 50-bed inpatient psychiatry unit, St. Michael's, in South Tipperary General Hospital, Clonmel. The closure of that unit was opposed by everybody, including nurses, doctors, patients and the public. All advised against it and warned about the difficulties and dangers that would ensue. Unfortunately, we were not listened to, and now the unit is not fit for purpose and continuously overcrowded. Patients are admitted to sleep on couches and mattresses on the floor. South Tipperary patients admitted to the unit are delayed on an ongoing basis and they suffer from inappropriate early discharge. There are also transport difficulties. I acknowledge the work of the Minister of State, Deputy Jim Daly, on this issue. He has accepted that the decision to close St. Michael's unit was wrong. We are working with him in the hope of having the unit reopened.

This is the straw that breaks the camel's back. We want to know sooner rather than later, and hopefully from the Tánaiste today, that the Government will agree to and support the reopening of inpatient psychiatric beds at St. Michael's, Clonmel.

The Tánaiste

On the Deputy's comments, it is true that the Mental Health Commission took a case against the HSE because of the poor conditions in St. Luke's Hospital, Kilkenny. I have read the background to this. The Deputy very helpfully agreed to let me know the issue he was going to raise this morning. As he said, it is pretty shocking. The HSE's mental health service accepts the serious concerns expressed by the Mental Health Commission and the findings from the legal proceedings. I am assured, however, that remedial works are already under way. The HSE has prioritised the psychiatry facility in Kilkenny for upgrade works valued at in excess of €1 million to bring it up to standard. The investment will address deficiencies identified during inspection processes and will include a comprehensive maintenance programme across the facility to ensure full compliance with regulations set by the Mental Health Commission in respect of privacy and premises. A household supervisor has been appointed and additional household personnel have been allocated to St. Luke's to address the cleaning deficits identified during the inspection of the premises. A training programme has commenced for staff and rules governing the use of seclusion.

Nobody is doubting that the concerns outlined and aired in a legal case by the Mental Health Commission are not serious and need to be addressed but €1 million has been committed to respond.

With regard to south Tipperary, I recognise the work the Minister of State, Deputy Jim Daly, is doing. There are plans to provide a new respite facility in Clonmel to replace Glenville House. A new modular 40-bed unit is being delivered at Clonmel hospital. The question of including psychiatric beds in a 50-bed unit planned for the hospital is also being raised by local public representatives. The Minister of State met Oireachtas Members and various local representatives to discuss current and future provision of mental health services in Tipperary, including a review of bed capacity. He also visited mental health facilities in South Tipperary. Arising from this discussions, he is expecting the HSE to submit a detailed report in the near future, and he will then consider the options available to improve acute capacity in Tipperary.

Deputy Seamus Healy

Any works to upgrade the unit in Kilkenny are welcome. There is a proposal for a crisis house in Clonmel but that is not the issue here. The issue is the availability of inpatient psychiatric beds in Tipperary and the fact that the current service is simply not fit for purpose. The court case is not the only issue. In fact, it is only the tip of the iceberg. The Mental Health Commission reports for 2015, 2016 and 2017, the most recent available, state that in all 21 areas covered, the Kilkenny unit is non-compliant. In many of the areas, such as staffing, premises, drugs and the transfer and admission of patients, the unit has not been compliant since 2015. The fact of the matter is that it is accepted by the HSE and the Minister of State, Deputy Jim Daly, that there are not enough psychiatric inpatient beds in the south east. It is 20 beds short. We want some of the beds back in Tipperary. We want the Government to reopen beds in Clonmel. This is the tip of the iceberg. We have been waiting for inpatient beds for far too long. They should never have been closed.

The Tánaiste

As the Deputy knows, the 44-bed department of psychiatry based in St. Luke's General Hospital, Kilkenny, is the designated approved centre for acute inpatient services for south Tipperary. Clearly, my previous answer recognises that there were significant problems in regard to that unit. They are being addressed, I am assured, and not before time. From reading the note on the context, I can see why some people would be very angry about this. It is being addressed now, I am assured.

The issue of capacity in south Tipperary and the potential need for further investment in acute beds for mental health services are being considered by the Minister of State, Deputy Jim Daly. He is expecting a report from the HSE in this regard so he will be in a position to make decisions. I will certainly ask him to respond directly to Deputy Healy as soon as he has a recommendation in that regard.