Dáil Éireann debate -
Thursday, 4 Apr 2019

Vol. 981 No. 5

Ceisteanna ó Cheannairí - Leaders' Questions

Deputy Dara Calleary

We saw another press release from the Government announcing a new national oral health policy called Smile agus Sláinte. Only Fine Gael could try to make dental treatment sound fluffy. The new policy implements one of the recommendations of the Sláintecare report. All children will receive eight oral healthcare packages while medical card holders who are over 16 years will also receive packages. However, there is no mention in the fluffy press release of the 18,000 children who are currently on the orthodontic waiting list or the 24,000 children waiting for dental treatment in general, including many in my constituency. I have been lobbying the Government hard on this matter. As we speak, up to 9,000 children with moderate to severe malpositioned teeth and jaw problems have been waiting for more than two years for access to an orthodontist. Those who can afford treatment will pay in excess of €3,000. All of that was glossed over.

The proposals are welcome but as with every press release and announcement from Government Buildings, also know as spin central, this one comes with a health warning. While the president of the Irish Dental Association, Dr. Kieran O'Connor, welcomed the publication of the document, he pointed out that his members were not involved in or consulted in detail regarding its formulation. We have a new dental strategy that has been formulated without talking to dentists. One could not begin to make it up.

I remind the Tánaiste of the conversation I had with him on Tuesday regarding an article by Paul Cullen published in The Irish Times and followed up by Aoife Hegarty in "RTÉ Investigates" on Tuesday evening. The programme, which was compiled following whistleblower allegations, reported on an audit of orthodontic treatment affecting 7,500 people in the greater Dublin and Leinster area in the period between 1999 and 2002. The report was finalised in 2015 and still has not been published. We need to know the details of that report. Why is it taking so long so deal with the findings? Have the people affected been contacted? Since Tuesday, what has been the Government's response to Paul Cullen's article in The Irish Times and the "RTÉ Investigates" report? What action is being taken to contact people whose orthodontic treatment has been compromised by the difficulties within the service?

The Tánaiste

I am still not quite sure whether the Deputy welcomes the new approach to orthodontic care.

Deputy Dara Calleary

I am sceptical.

The Tánaiste

It is certainly a very positive new policy, with eight new packages of care for children up to the age of 16, and an attempt by the Government to be proactive. For what it is worth, there was extensive consultation before the new approach was launched.

On the second issue raised by the Deputy, in 2015, the HSE received a review report it had commissioned following receipt of a statement of concern from two consultant orthodontists relating to an orthodontic service serving the greater Dublin area between 1999 and 2002. The statement of concern was initiated by the consultants who claimed that some children suffered damage as a result of interrupted orthodontic treatment at the time of the dispute between the consultants and the HSE relating to the model of care for delivery of orthodontic services. The original review report of 2015 was, in effect, a scoping report commissioned to advise the HSE on what actions should be taken to determine if there was a risk of harm to patients during that period. The report did not include a review of any patient records for the period and so, understandably, reliable conclusions could not be drawn at the time regarding definitive patient harm.

Since receipt of the 2015 report, the HSE has initiated a comprehensive audit of more than 7,500 patient files available from that period. Dedicated funding and personnel have been allocated by the HSE for this work. Due to the scale of the audit of the files and the requirements for dedicated personnel and resources, the timeline has been protracted. However, this work is nearing completion. While the Minister and the HSE regret that the work has taken a long time to progress, the priority for the HSE at all times has been for a robust audit on which to base further action. The HSE has informed the Minister that it cannot, as a matter of course, commit to the publication or otherwise of the report prior to the completion of the audit process. The benefits of publication must be balanced with the requirement for patient confidentiality and its obligations to afford natural justice to all other parties concerned. I assure the House that once the audit of patient files from the period is complete, a HSE serious incident management team will consider the results to determine if a recall of any patient is required and to co-ordinate open disclosure, as necessary.

Deputy Dara Calleary

I welcome the proposals relating to the dental strategy generally. I am just quoting from the press release issued by the Irish Dental Association, which represents the people who will deliver the proposals. It stated that nothing short of a complete reversal of Government policy would be required if the policy was to be rolled out successfully. The Government does not do reversals very well. Therefore, while I welcome the approach, I am sceptical.

Regarding the report into orthodontic services, have the 7,500 people affected been contacted? Have they been advised by the HSE review team that their files are being examined and they may have to undergo treatment? What is the level of contact with them? Are the individuals involved in the treatment still in the service of the HSE? Are they still working for it? The Tánaiste spoke about natural justice and I accept that but what is the timeline for the completion of this review? The HSE has had the report since 2015. Four years later, surely there should be an end in sight for the completion of the review and publication of the lessons learned.

The Tánaiste

It is important to remember that these files go back to the period from 1999 to 2002 so they relate to quite a long time ago and there are many patients are involved - 7,500. My understanding is that this audit is likely to be completed in the next couple of weeks. That is the indication I have from the Minister.

Deputy Dara Calleary

What about contact with the patients?

The Tánaiste

I do not have a direct answer to that question but I presume the patients will not be contacted until the audit has been confirmed and we understand what we are dealing with and they can be informed properly. I can confirm the position for the Deputy later. The priority is to finalise the audit to understand the number of patients involved and the detail of each of those patients so that we can contact them and fulfil the obligations under the open disclosure requirements that are now in place.

Deputy Pearse Doherty

On Tuesday, my party leader, Deputy McDonald, raised the issue of hospital overcrowding with the Tánaiste. I raise it with him again this morning because, in the past number of days, the problem has gone from bad to worse.

Early in the week, there were serious problems at Cork University Hospital. There are still significant problems there, with 43 people on trolleys today, according to the Irish Nurses and Midwives Organisation, INMO. To top it all off, there was utter chaos yesterday at University Hospital Limerick, where the number of patients on trolleys reached a level never before seen in any hospital in the history of this State. The INMO recorded 81 people on hospital trolleys yesterday morning. By midday, the number had reached 92. Today, there are 76 people on trolleys in that hospital, while there are 531 people on trolleys in hospitals across the State. This is absolutely scandalous. We are reaching record numbers of people on trolleys and hospitals are in situations of utter chaos. The pictures on the front page of today's Irish Examiner are akin to the scenes in a hospital after a major natural disaster, but there is no natural disaster. These scenes of overcrowded hospitals and patients lying on trolleys in our corridors are becoming all too common. There are patients in University Hospital Limerick who have been waiting for days to get a bed, and all the while, right beside them, ward 1A is closed, padlocked and chained. The Government has put 17 beds in that ward out of commission and that makes absolutely no sense. My colleague, Teachta Quinlivan, has called for the immediate reopening of the ward, and I echo that. The Minister and the HSE should do this without delay.

There are, however, bigger problems at University Hospital Limerick. I have seen correspondence provided to the health committee on behalf of the staff of the hospital. It makes for disturbing reading. The correspondence in question states that University Hospital Limerick continuously fails to adhere to national emergency department escalation policy and remains constantly in full capacity protocol. It states that the additional winter funding provided by the HSE has had no impact on overcrowding. It states that the consequence of all this is that nurses are struggling to provide safe care and cannot adequately monitor or assess patients to the level required. The staff go on to state that this is due to inadequate staffing and the extra trolleys on wards and in the accident and emergency department. This amounts to one thing: an unsafe hospital for patients. It is impacting on patients and putting them at risk and it is affecting the health and safety of staff. Both of these impacts are incredibly worrying. However, this is no longer just a winter problem; it is a problem all year round.

What is going to happen to the patients in University Hospital Limerick on foot of the escalation over the past 48 hours? More generally, what is the Minister's plan to respond in a meaningful way to the capacity crisis right across our hospital network? Whatever he is doing is just not working. Not only is it not working; it is completely and utterly failing. We need serious action from Government.

The Tánaiste

I will deal with the specific issues relating to Limerick in a minute, but it is important to give a broader picture nationally of what is happening with regard to trolley figures. The trolley numbers for the first quarter of this year are the best for five years, so it is important we deal with the numbers and the facts. I know there are some hospitals under severe pressure and staff under pressure, and no one wants to minimise or belittle that strain. It is there. It was there earlier this week in Cork and yesterday in Limerick and Galway, which are under pressure. The hospitals are responding to this, but the overall trolley numbers are down and are lower than at any point in the past five years. It is important to recognise progress. This reduction in the numbers is due to our investing in more capacity. We are trying to streamline management systems in hospitals in order to ensure that we can deal, in particular, with capacity at this pressurised time of year as we come through the winter and see outbreaks of influenza and so on and in the aftermath of a strike action, which also caused some pressures. I am not apportioning any blame in this regard; I am just outlining the reality. That said, there are and have been particular issues in the past 24 hours in Limerick.

The Deputy specifically mentioned ward 1A. The HSE has informed me that the closure of a 17-bed medical short-stay unit, ward 1A, at University Hospital Limerick will facilitate the completion of works on a new fracture unit there. The closure is in accordance with the plans to redesignate the space occupied by the old emergency department at the hospital. University Limerick hospital group has advised that staff were fully involved in this process, with the various teams presenting business cases on optional use of the old emergency department. The hospital group has advised that the new fracture clinic will have a specific benefit for patients in reducing waiting times and improving patient experience. We are trying to invest in new facilities at the same time as trying to manage current pressures, and we must do both. We cannot simply abandon plans to invest in increasing capacity and improved efficiency in an effort to try to deal with the immediacy of what is a very pressurised situation at University Hospital Limerick. The hospital group advises that the closure of these 17 beds has been offset by the opening of 22 beds elsewhere in the hospital in recent weeks, including a 12-bed surgical short-stay unit and three additional cardiology beds. It is widely agreed, however, that a key part of the solution for Limerick is additional beds. The capital allocation for 2019 of €2 million has been granted in recent weeks to facilitate the completion of enabling works for the 60-bed modular ward, to which I also referred on Tuesday.

Deputy Pearse Doherty

No matter what way the Tánaiste wants to spin it, we were sent pictures yesterday from individuals who were in University Hospital Limerick as 92 patients were lying on trolleys in corridors, wards and the accident and emergency department. The pictures are of ward 1A with padlocks and a chain around the gate. There are 17 beds behind those doors that could be accommodating these patients. However, Limerick is not the only hospital that has wards that are closed. In my local hospital in Letterkenny, there is a 20-bed ward in respect of which the Government has given sanction to open only ten of the beds, despite the fact that every day, every week, we see patients on trolleys. While the Tánaiste tries to claim that the Government is doing so much better, the reality is that there are 531 patients on trolleys today, hospitals are being deemed unsafe and his own local hospital in Cork had to invoke status black, which means it is unsafe to admit a patient into the hospital regardless of the circumstances. There is complete and utter chaos in our health service. This is not just about the discomfort of not having a hospital bed; it is about the treatment and the health outcomes. Those on the front line are telling us-----

An Ceann Comhairle

The Deputy is way over time.

Deputy Pearse Doherty

-----that people are dying as a result of this crisis, and the Government is failing to address it after eight years in office.

The Tánaiste

The Government is addressing this but it is taking time. Let us look at Cork University Hospital. This morning, according to the HSE count, the number of patients waiting on trolleys in Cork was 25, down 31 from yesterday and 55 from Tuesday morning.

Deputy Pearse Doherty

According to the INMO, it is 43.

The Tánaiste

The hospital has got on top of what was an unacceptable situation at the start of the week. Let us look at what the Government is doing in the medium term in order to increase capacity. What is required is a combination of increased capacity and improved efficiency and management systems. Increased capacity is a priority for the Government, as we have stated. An additional 241 beds were opened under the winter initiative of 2017-2018, and the national service plan for 2019 provides for a comprehensive capacity programme. Elements of this programme include 75 acute beds and 70 community beds scheduled to come on stream in early 2019 as part of the winter plan. The HSE has confirmed that 46 acute beds have been opened to date. I could go on and list a series of other capital expenditure programmes that are being invested in, including in Limerick, which is a major focus in terms of extra bed capacity. One of the issues-----

An Ceann Comhairle

The time is up.

The Tánaiste

-----to which I referred earlier involves upgrading of the Limerick facilities in order that we will have more efficiency in the not-too-distant future, when we get through the pressures we face today.

Deputy Clare Daly

In December 2017, I raised with the Tánaiste the case of Anthony Cole, the first person to bring an action concerning Lariam. That action had just been settled after the State sparing no expense in assembling a major legal team, with ten days of hearings over five months, before the Government threw in the towel.

The second Lariam case, of Mr. Patrick Fedigan, was settled two weeks ago, again on the steps of the court and after enormous cost and delay. What on earth is going on here? Not only is the Government not dealing with the existing cases of Defence Forces personnel who have experienced devastating health consequences as a result of taking Lariam but it is actually potentially adding to their number by continuing to force soldiers to take Lariam. That is despite their wishes and a motion passed by this House.

As a result, we have almost 300 loyal but damaged men and women who served this State proudly, and whose papers have been lodged with the courts, facing a lengthy and costly application process before the State will eventually have to settle, as it will. There is not one word about redress and compensation to end this madness. It is a crazy situation. When these cases get to the courts they are, of course, then likely to encounter the 83 cases which have been also been lodged before the courts in respect of Pandemrix. Those cases are mainly the result of children who developed narcolepsy after receiving the swine flu vaccine. Those suffering families have had to fight this State for discovery for years. When I raised this with the Taoiseach last year, he said he would instruct the Minister for Health, Deputy Harris, to bring forward the commitment in A Programme for a Partnership Government to introduce a no-fault vaccine scheme to respond to the needs of people with disabilities arising from vaccination. He also stated the commitment would be implemented by last year. Where is it? The programme for Government is three years old. This scheme was recommended as early as 2001 and these families have been suffering since 2010. We would be forgiven for thinking that the State is engaged in some clandestine plot to enrich the legal profession at the expense of the public and to the detriment of those whose health has been seriously and negatively impacted upon as a result of State actions. There is no justice and accountability for those people. That is appalling.

While everybody moved on to the latest scandal some weeks ago - I think John Delaney was the flavour of the month this time - Dr. Scally produced his latest report. He outlined in that report the problems with the open disclosure approach which, he stated, remains in place despite being judged to be deeply flawed. It is not good enough for the Tánaiste to state the Government is working on it. It has been foostering around with these issues for more than 11 years. We had succeeded in having mandatory open disclosure before this Government removed it two years ago. When will the Government stop talking about doing things and actually start to do them? I was about to say talk is cheap but it is not cheap for the victims or the State. It is about time the Government started delivering on some of the things it tells us it is dealing with.

The Tánaiste

The Deputy had many questions. I will deal with the Lariam issue first. It is important to emphasise that malaria is a serious disease that has killed hundreds of thousands people. We need to protect our troops when they are in malaria zones in different parts of the world. Let me be very clear with the House, however, that the health and welfare of the men and women of the Defence Forces is the utmost priority for both the Government and the military authorities. I am advised there are three anti-malaria drugs. I remember looking at this issue when I was in the Department of Defence and speaking to many of the families with concerns regarding the use of Lariam in the past.

The choice of medication for deployment overseas for both officers and enlisted personnel, including the use of Lariam and other drugs, is a medical decision made by medical officers in the Defence Forces, having regard to the specific circumstances of the mission and the individual member of the Defence Forces. In other words, it depends on how long members of the Defence Forces will be in a region and what the medical advice is regarding the appropriate use of drugs in respect of frequency, etc. A working group reviewed the Defence Forces approach regarding these drugs to ensure procedures continue to be appropriate and in accordance with international best practice. I also remember reading a number of reports from other countries relating to the use of Lariam or other drugs.

A further case has been listed for hearing in the High Court on 7 May. It would be inappropriate for me to comment on individual cases given litigation is pending. This has, however, been an ongoing debate for many years, with which I and other Ministers have been confronted. The approach of the Government and the current Minister is to try to ensure we are acting on the best advice of doctors and medical personnel, inside and outside the Defence Forces, regarding working groups and protecting the health of our soldiers. That is the only motivation we have on any policy regarding the use of Lariam or other drugs to combat the dangers of malaria.

Deputy Clare Daly

I have a lot of time for the Tánaiste but I am very disappointed with his response, which is indicative of the reason we are in this mess. I state that because what he has given me is Civil Service speak. The working group on Lariam actually recommended that a medical advisory group be set up to look into these issues. That was in 2017. I recently found out from a freedom of information, FOI, request that the group has never met, not once. Best medical practise would tell us that other defence forces are not using Lariam. The Tánaiste's answer is, therefore, patently wrong.

The Tánaiste did not deal with all of the fundamental questions I put to him. The State's denial has led to a continued over-reliance on litigation and failure to address the serious concerns of those people whose health has been impacted by State actions. The Government is causing those people enormous hardship while enriching the legal profession and failing to make our health service safe. The type of answer the Tánaiste gave me is the same reason we do not have a mandatory open disclosure policy that would make our hospitals safer. He is listening to civil servants and not his instincts. The Government is not addressing the issues it has stated it will address. It is incredibly disappointing and citizens deserve much more.

The Tánaiste

We are introducing a patient safety Bill that will require open disclosure.

Deputy Clare Daly

That was said last year.

The Tánaiste

It is being brought through the system. The Government has committed to that Bill and we will fully follow through on it. Deputy Clare Daly and I have spoken before about the broader issue of the approach to Lariam. She knows this is not a straightforward issue to deal with. Families have made certain accusations and they need to be tested. Those families have chosen a legal route to seek compensation and the truth and they are perfectly entitled to do that. The State also has a perspective on this.

The core issue is whether Lariam is suitable for use. Different countries take different approaches. It is not true to state that all countries are moving away from the use of Lariam. Some countries have and others have not. Some use it in certain circumstances and in certain locations and others do not. I have not been involved with this file for a while because I am outside of that Department. I will follow up on the expert medical group and respond directly to the Deputy on that. On the broader issue, however, is not as simple to deal with as Deputy Clare Daly sometimes maintains.

Deputy Eamon Ryan

We have been very sensitive on this side of the House when discussing any arrangements that may be required in the event of a no-deal Brexit for fear of inadvertently influencing the UK debate. That debate is now moving on, however. Red lines have been crossed that could not have been crossed previously. That may, hopefully, lead to some sort of collective sense and some idea of where the UK is going. In the interim, however, this House cannot just state we have no plan in response to those seeking clarity regarding what we would do in a no-deal scenario.

I refer in particular to the Taoiseach who answered questions yesterday regarding the sanitary and phytosanitary, SPS, checks we may have to do. That issue is becoming very real. If anybody in Westminster wants to quote anyone in this House stating there is no problem, we can respond by stating we will have to irradiate our wooden pallets. The idea that there is a maximum facilitation, max fac, solution is complete nonsense.

If anything, the closer we get to a no-deal Brexit and the more we prepare for it, the more obvious the case for the backstop becomes. Today the German Chancellor, Angela Merkel, and the Taoiseach debate how to protect the Single Market in Farmleigh House, including specifics such as the management of sanitary and phytosanitary checks. We must start to give the Irish public and farmers some understanding of what that might mean. There was talk yesterday of farm gate animal checks being different because we will have to involve vets. We better try to provide some clarity so that we will not be totally unprepared for what we will have to do if the British Prime Minister, Theresa May, and the leader of the Labour Party, Jeremy Corbyn, are unable to reach some sort of agreement and the UK inadvertently crashes out of the European Union. The Taoiseach indicated yesterday that it may be possible to apply some of these checks on an all-island basis, although he said that would require the co-operation of the UK Government. I presume it would also require the co-operation of the EU. He also suggested that issues in respect of chlorinated chicken or steroid-treated beef may be managed with checks at Dublin Port and Rosslare Europort.

Can the Tánaiste provide clarity on the matter of animal checks, which seems to be one of the most difficult issues we will have to manage if a no-deal Brexit occurs? Irish agrifood companies have set out their concerns about what needs to be done in today's newspapers. This is a public debate. This House needs and deserves some details of the plans for that specific area because it is the thorniest and most difficult challenge we will face in a no-deal scenario.

The Tánaiste

I thank the Deputy for raising this issue. It is no secret to this House that, while an extraordinary amount of detailed work on how Ireland and the EU collectively would respond in a no-deal scenario has been completed and published, the most difficult issue to put a contingency plan in place for was always going to be how we would manage an all-island economy in the context of a no-deal Brexit. Those who maintain the argument that this could work easily with some alternative arrangements and without the use of the backstop or the principles behind it, which involve regulatory alignment, are making false arguments and have been doing so for months. There is no easy fix.

The British Government has produced a paper in which it says that it will not implement checks or apply tariffs in respect of goods travelling from the Republic of Ireland to Northern Ireland in the context of a no-deal Brexit, but that would be a temporary arrangement until a solution was negotiated between the British and Irish Governments and the European Commission. There is no way the EU can provide the same assurance in respect of goods travelling from North to South because we cannot ignore the obligations and responsibilities that would be on the EU if Northern Ireland, as part of the United Kingdom, were to leave the European Union and therefore be outside of the Single Market and customs union. I am confident that the EU would have to apply the rules it applies to any third country outside of the EU to Northern Ireland, which would pose real difficulties on this island. That is why this week we have intensified our engagement with the European Commission on how we can work together to fulfil the dual obligations we have, first, to protect peace and relationships on this island and to prevent physical border infrastructure and, second, our obligation to protect the integrity of the EU Single Market. There is no alternative arrangement or magic solution that does the same job as the backstop, which it to keep the all-island economy functioning as it does today. Instead, we will be looking at mechanisms that will allow us to collect tariffs and which will provide reassurance to other EU member states that Ireland will not be dragged out of the Single Market by the UK crashing out of the EU. We cannot allow that to happen. We cannot protect the normal functioning of an all-island economy, which is what the backstop does, but we can certainly prevent the security issues caused by physical border checks from arising. We intend to avoid such checks.

We are working closely with the European Commission on this issue. I suspect that some of the conversation with Chancellor Merkel today will focus on this issue. I assure the Deputy that EU leaders, from Chancellor Merkel to President Macron, want to assist Ireland is solving this problem, recognising that there is a dual obligation that is very complicated and difficult to solve.

Deputy Eamon Ryan

It is difficult, which is why I agree fully with the Tánaiste that what has been said in Westminster - that there is some easy mechanism to deal with this - is complete nonsense. We need to progress preparations and prepare our people properly. My concern is that there is still no clarity on some very specific issues. Glanbia has said today that it brings 130 million l of milk from Northern Ireland to the South every year. It would be useful for farmers on both sides of the Border to know what will happen with that milk, rather than everyone rushing to find a plan to manage the issue the day after Brexit. What happens in the case that we suspect there is chlorinated chicken in the UK market, a scenario the Taoiseach cited yesterday? How would we manage that? Would it be managed at Dublin Port, at the factory or at the Port of Larne? We should not be scrambling to answer that question on Brexit day plus one. We all agree that we want to avoid infrastructure at the Border, but if we will have to have vets carrying out checks in respect of animal movements, when will the vets be told what those checks will be and where they will take place? Leaving it until after a crash-out would not be doing a service to our people. We need some sort of internal discussion on the issue so that we will know exactly what might be ahead of us, as difficult as that might be.

The Tánaiste

An internal discussion is taking place, but it is important that the options are weighed up and that we agree on something before we start informing the public. Otherwise, anything we say will be twisted by some in Westminster to get a political message across that is not accurate. That has happened over and over again with regard to alternatives to the backstop. People stand up in Parliament in Westminster and misrepresent the reality. They will continue to do that and it does not make much sense for us to continue to make comments that allow them to do that.

Having said that, the Deputy is right. We need to be ready for Brexit day plus one, as the Deputy has called it, in a no-deal scenario. We need clarity both with the European Commission and with businesses. We are working towards providing that clarity. Some of what we can and cannot do is now pretty clear but there are awkward issues that need to be dealt with arising from our obligations to avoid any infrastructure on or near the Border and, at the same time, to protect the Single Market. Unfortunately, we cannot and do not control any decisions in Northern Ireland and so checks in Larne are not in our gift. Ultimately, any protection for an all-island economy now or in the future can only be delivered with the co-operation of the British Government. I remind the House that in December 2017, long before the withdrawal agreement had been drafted or agreed, in return for the process moving on to the next stage, the British Government gave a very clear commitment to Ireland that the default position in the absence of agreement in other areas would be regulatory alignment on this island to prevent border infrastructure. We should continue to request that commitment be honoured by the British Government. It was not contingent on a withdrawal agreement being agreed.

Protecting an all-island economy now and into the future can only be done by taking a regulatory alignment approach to the problem. Anything else would be disruptive to trade. We must ensure that, in that context, we do everything we can to protect the peace process.