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Dáil Éireann debate -
Thursday, 12 May 2022

Vol. 1022 No. 1

National Maternity Hospital: Statements

I might be sharing time with the Minister of State, Deputy Rabbitte.

The proposed new building for the National Maternity Hospital is probably the most important investment in women's healthcare in a generation. It is widely agreed that the midwives, nurses and doctors in Holles Street provide great care and that they are leaders in advancing women's healthcare. After repeal, Holles Street was one of the first hospitals to provide termination services. It was one of the first sites for the new specialist menopause clinics. It has been involved in many of the new services rolled out around Ireland last year and this year. It is involved in the advances in midwifery-led maternity care, gynaecology, genetics, endometriosis, fertility, mental health and much more.

It is also widely agreed that the building in Holles Street is no longer fit for purpose. The vision of the national maternity strategy is one in which women are treated with dignity and respect in an appropriate modern environment. The facilities at Holles Street simply cannot provide that environment. Women occupy Nightingale-style accommodation, sharing wards with up to 13 other women and with only a thin curtain separating the beds and inadequate shower and toilet facilities. It increases the risk of infection and compromises the privacy and dignity of patients, who are forced to queue in public corridors to use bathroom and shower facilities.

The new building will meet the needs of these women. It is about having enough beds, theatres, diagnostic facilities and day-care facilities. It is about having appropriate bereavement supports. While the new building will meet these needs, it will do much more. Every woman will have her own en suite room and there will be many more maternity beds. There will be separate and appropriate space in the tragic cases of bereavement. Instead of 11 delivery rooms, there will be 24 modern delivery rooms. Instead of 18 gynaecology beds, there will be 31 beds. Instead of 35 neonatal intensive care cots in shared spaces, there will be 50 individual-room neonatal intensive care cots. The new neonatal intensive care unit has been designed in a way associated with reducing the stay for neonates. All parents want and need to be by their baby's side day and night, especially when the baby is critically ill. Parents will be able to room in with their sick or premature babies. This enhances mother–baby bonding and breastfeeding rates. This new building means the teams in Holles Street will be able to expand services for women, to make sure there is rapid access when it is needed, and to do it all in a modern hospital.

It is also widely agreed that co-location is important. Every year, hundreds of pregnant women need to be transferred to St. Vincent's University Hospital, as inpatients or outpatients, for treatment they cannot get at Holles Street. Every year, a number of critically ill women are transferred to St. Vincent's, often for life-saving interventions and intensive care. The midwives and doctors are telling us that, as maternity care becomes more complex, the need for access to the services in a large adult hospital is continuing to grow.

It is widely agreed — indeed, it is demanded — that all healthcare services must, under law, be provided at the new hospital. This demand is absolutely correct and appropriate and must be met. The new hospital is being set up to do exactly that. The new hospital's constitution guarantees its clinical and operational independence in the provision of any maternity, gynaecology, obstetrics or neonatal service that is lawful in the State. However, we have gone much further than that. Not only is independence guaranteed to provide all services but the hospital will be required to provide all services. This includes terminations, tubal ligations, gender affirmation and everything else permitted under law. Added to that, if for some reason the hospital were not to provide all services, the State, via the Minister for Health, would have the power to intervene directly to direct it to provide all services.

It is also being demanded, quite rightly, that there be no religious influence in this new hospital. Ireland has a dark history when it comes to the church and women's reproductive health. I fully understand and fully acknowledge the deep sense of mistrust of many people in Ireland on this issue. I fully agree with the demand for a fully secular hospital. The new national maternity hospital will be fully and completely secular. There will be no religious influence; there can be no religious influence. The hospital's constitution explicitly states the services must be provided "without religious ethos or ethnic or other distinction". This is stated six times in the hospital's constitution. As with the provision of all services, the State, via the Minister for Health, can directly intervene to ensure there is no religious ethos in the provision of any services.

St. Vincent's is also a secular, voluntary, not-for-profit healthcare provider. Dr. Rhona Mahony, a member of St. Vincent's board, has pointed out that the board has been working for years to create a secular healthcare provider.

Citizens with very understandable concerns were outside the Dáil yesterday with signs that demanded that the National Maternity Hospital not be handed over to the nuns. That is what was written on the signs. Several colleagues here were outside with the concerned citizens. I want to be absolutely clear: the nuns are gone. They stopped their active involvement five year ago and in the past few weeks transferred all their shares to St. Vincent's. In fact, I waited until that share transfer was completed before bringing any proposals to the Cabinet or the Oireachtas for consideration. There is no mechanism for any religious involvement, now or in the future, in St. Vincent's or the new national maternity hospital. I would never propose a new maternity hospital that had or could have any religious influence. Dr. Rhona Mahony, Professor Mary Higgins, Ms Mary Brosnan, who is the director of midwifery, and the midwives, nurses and doctors in Holles Street, who are begging for us to listen to them, would never agree to anything other than a fully secular hospital. These clinicians are the women and men providing all services in Holles Street today. They will be providing all services in the new hospital.

The nuns are gone, and we are not handing over our National Maternity Hospital. We are not gifting it to anyone else either. This is a partnership between the State, St. Vincent's and the National Maternity Hospital. The National Maternity Hospital will provide the staff and run the new hospital. The State will fund and own the new hospital building. St. Vincent's will provide the land for 300 years. This gives the State leasehold ownership in the same way as people own the apartments they buy. Each party — the State, St. Vincent’s and the National Maternity Hospital — will appoint three of the nine directors to the board of the new national maternity hospital. The National Maternity Hospital will in turn appoint directors to the board of St. Vincent's.

The two hospitals will be physically connected to ensure seamless and rapid access for patients, particularly critically ill patients.

Both hospitals will provided shared services to be used across the healthcare campus. Many clinicians will work in both hospitals.

A structure was agreed in the 2016 Mulvey agreement whereby the shares in the national maternity hospital charitable company will be owned by St. Vincent's Healthcare Group charitable company. This provides St. Vincent’s Healthcare Group administrative rights, for example, for accepting annual accounts at general meetings and approving the appointment of auditors.

The new national maternity hospital will be fully clinically, operationally and financially independent. It will have its own constitution and its own operating licence with the HSE.

It is worth comparing the National Maternity Hospital today and the new national maternity hospital that is being proposed. Today, the land under Holles Street, the freehold ownership, is with the Earl of Pembroke. The State owns neither the land nor the building. There are two priests on the board of the National Maternity Hospital today, including the Chair, who is, and has always been under its articles of association, the Catholic Archbishop of Dublin. In the new national maternity hospital, the State will own the building and it will own the land under leasehold ownership for the next 300 years. The State appoints three of the directors. The Minister for Health will have broad powers to intervene and direct the hospital. All services must be provided, there can never be any religious influence and, of course, healthcare services for women and infants will be modernised and greatly expanded.

While more and more people who are partaking in this discussion about the new hospital are concluding based on all of this that there will be no religious influence - indeed, there can be no religious influence - and that all services not only can but must be provided, some are demanding that the State's ownership of the land should be in the form of a freehold ownership rather than a 300-year leasehold ownership. St. Vincent’s has been clear from day one that freehold would not be considered. Regardless of what any of us may think, that has been its position. The reason it gave us for this is the ongoing management of the healthcare campus. It points out that there needs to be one owner to ensure it is managed for the multiple services on site. This includes St. Vincent’s University Hospital, the private hospital, the new national maternity hospital, screening services, GP day care, research facilities, the UCD education centre and, quite likely, more in the coming years. It points out that the shared services on this site are provided via single integrated systems, including heat, power and essential piped gases vital for patient areas. It points out that the service corridors for the entire campus run through the new national maternity hospital building and that the new development includes facilities for shared services for the overall campus. I was in Texas recently, at the biggest healthcare campus in the world. It is a not-for-profit healthcare campus and it has many providers. It is huge. There is the world's leading cancer centre and many other providers. However, the entire site is owned and managed by one company, the Texas Medical Centre.

Some do not accept this. They do not accept the position being put by St. Vincent's. They do not accept that 300-year leasehold ownership is enough and they are demanding freehold ownership. To this end, many have accepted that St. Vincent's will not do that voluntarily and are saying, therefore, we must engage in a compulsory purchase order, CPO. What if we engage in a CPO? It might well collapse the partnership, which would end co-operation on co-location. The courts may well rule against the State and I would imagine could point out that we already have lease ownership of 300 years. A CPO could take years, due in part to the complexities involved given that what we are looking for here is a site in the middle of a larger health campus. Imagine the complexities involved in a CPO if the State were to look to CPO land in the middle of Intel’s manufacturing plant in Leixlip. The new hospital building, which has been agreed and which we have planning for, would be compromised as the current design includes space that currently St. Vincent's is on and some of St. Vincent's current university hospital has to be knocked down and provided for the new building. The building works, under a CPO, could also take years longer, as it would inevitably be more difficult for two separate site owners to work through the highly complex areas, such as shared services. Future clinical care could become higher risk as separate owners of lands would need to participate, for example, in the upgrading and fixing of services that are on each other's parcels of land. There would, of course, be a much higher cost to the State, including legal costs, a purchase cost - would that parcel of land be worth €50 million, €100 million or €150 million - and there would very likely be additional costs due to ongoing delays in the building works. It is not reasonable to put a project as important as this at such risk, to delay it potentially for many years or derail it entirely, in order to move from a leasehold ownership to a freehold ownership.

Women’s healthcare has never been sufficiently funded. It has never been sufficiently prioritised in Ireland. We are changing that. This year a new national network of services is being put in place. Contraception is becoming free, starting with women aged 17 to 25. Next year I hope to secure funding to start publicly-funded in vitro fertilization, IVF. More HSE hospitals this year are beginning to provide termination services. The new national maternity hospital is an essential part of the change, improvement, modernisation and investment in women's healthcare. We have been talking about this hospital for nine years. It is time to act.

I am afraid Deputy Carroll MacNeill has less time.

I have significantly less time.

I am sorry. I beg the Deputy's pardon. I thought the Minister of State, Deputy Rabbitte, was coming in. I am so sorry.

I was supposed to have six minutes.

I have been a patient of the National Maternity Hospital. My constituency includes the National Maternity Hospital. My son has been a long-term critically-ill patient of the neo-natal care unit. I am one who knows well exactly how deficient the National Maternity Hospital can be and has been.

I thank the Minister for his engagement with me over the past year. It is particularly in relation to the public interest directors and increasing their number from one to three. It has been necessary because the current structure, as I have said in this House, is not open enough to those who raise complaints and concerns.

I would very much like to see this hospital go ahead. Obviously, like many other people and like the Minister, I would like to see public ownership of it but that has not been possible. Can I get to 95% happy?

The questions around religious influence were answered in large part for me by speaking to one of the doctors this week about the provision of HIV services in the HIV clinic in St. Vincent's that is operating daily, giving out free condoms and providing PrEP medication for gay men, in particular, 40 or 50 times a day, with absolutely no religious influence. I spoke to a doctor on the ethics committee who assures me that there has been no religious influence in his work over the past number of years. I accept that and the need for the hospital is clear.

I also accept the position in relation to freehold versus leasehold. Obviously, good legal title to any property in this country is either freehold or leasehold with 70 years left to run. Anybody who has bought a house or an apartment will have gone through that process. If I were to buy an apartment and there was a leasehold title with more than 100 years left to run, that is perfectly good title equivalent to freehold. This is a leasehold title with 299 years and I accept that as being appropriately good title.

Perhaps in part because of the constraints while the Minister is in negotiations, the communication of these issues has been only in the past two weeks. I can understand why that may be so but it has impacted upon trust. Women are already distrustful of some of the maternity hospitals. They are already distrustful, for very good reasons, of religious institutions. Their recent experience of the differential treatment in different hospitals of maternity services during Covid has amplified that distrust. An inability to access equally abortion services across the country in HSE hospitals has impacted upon that trust. Not only women, people across Ireland want to know and they want to get answers. This pause in this period has been useful.

I will be going back to my constituents - I had planned to do it today - to answer the different question.

I will be going back to my constituents with the answers I have to their questions about, for example, compulsory purchase orders, CPOs, leasehold and freehold, and the term "clinically appropriate and legally permissible".

Without being able to go into it, I want to acknowledge that it has been possible to provide better and better answers. As somebody who was waiting to see the constitutional document of the new national maternity hospital, I do believe more can be done. I appreciate the Minister does not want to reopen negotiations but he could get agreement to an addendum to the constitutional document specifying a non-exhaustive list of those services that shall be provided in the hospital. He could also advance funding for a centre for reproductive excellence at the site to be a leader in this area and so that people could see our commitment. He could also find ways to roster out the conscientious objection problem that can limit access to services not just in the new national maternity hospital but across HSE services more generally. There is also capacity within the Government decision for the Minister to come back to the Dáil when the hospital is built to update the House on the services that are being provided in the national maternity hospital every year. It is about ensuring trust. I have a little more research to do but I am at 95% on this. The hospital is needed.

I thank the Minister for agreeing to take statements. To clarify, this is a session of questions and answers. I believe that is what was agreed so we can go over and back with the Minister. Is that correct?

It is statements and questions and answers. It is up to the Deputy how he proceeds.

I will go over and back with the Minister. I thank the Minister for agreeing to this format today. For how long has the State been involved in negotiations with the St. Vincent's Healthcare Group?

My understanding is the State has been involved since the then Minister, James Reilly, first announced there was to be co-location at the St. Vincent's site in 2013.

It was 2013. How many Ministers have been involved in talks? It will have been James Reilly, the Minister, Deputy Harris, and Deputy Donnelly himself. Was it three Ministers?

The Minister, Deputy Varadkar, has also been involved.

We should not forget Deputy Varadkar. There have been four Ministers for Health involved in the negotiations at various times. Last year, some controversy again arose in respect of this issue. The Taoiseach and the Tánaiste responded to concerns from Members of the Oireachtas. At that time, the Tánaiste put on the record his concerns regarding governance, ownership and so on. I would imagine that sparked a fresh round of negotiations the Minister will have been involved in. How intense were those negotiations over recent months, whether it was three months, six months or a year? How involved was the Minister? Who was involved on the other side?

The engagement was very intense. The parties involved were the HSE, the Department of Health, St. Vincent's Healthcare Group and the National Maternity Hospital.

Over what time period were the negotiations conducted?

They spanned most of time I have been in office.

There were very intense negotiations at the very highest level involving a lot of time and effort from the Minister. Why all of these negotiations?

When I came into office, the constitution of the new hospital had not been written. The offer of leasehold ownership was for 99 years with an option to extend this by 50 years to 149 years.

Why is there a need for a constitution, a new company and all of these protracted negotiations involving four Ministers over nine years or longer? Why has all of that been necessary?

The partnership being proposed is complex. I believe we all accept that. It is a clinical partnership between two voluntary hospitals but the State has a role, generally through the HSE. The negotiations were very complex. There were many rounds of talks and when I-----

What is behind the complexity? That is what I am trying to get at. We know it was complex. That is one of the arguments we are making. All of this is very complex. I imagine co-location is part of the reason for that complexity. The lease arrangement is also a complex aspect. Why is the lease arrangement complicated?

It is a very large partnership. If any of us were to look at a proposed partnership involving assets potentially worth several billion euro, we would find that lawyers had pored over all the documents and, in many cases, the level of complexity-----

Let me make it easier for the Minister.

I will just finish on this. In such cases, the level of complexity at a corporate level would be far in excess of what we see in the number of documents we have now.

Let me make it easier. If we were building the hospital on public land, there would not be that complexity. There would be no lease so there would not have been those complex issues to deal with.

If we were building on public land, by definition, there would be no lease.

I just wanted to clarify that. When the Minister became involved in the talks having come into office, did he state it was his preference for the land to be brought into full public ownership or make a formal request that be done? Is that something he asked for?

It was for the same reason we all wanted that. Look at the debate we are having. People have very understandable concerns. None of us is expected to walk around knowing the difference between rent, leasehold ownership and freehold ownership. People are not expected to know that apartments are typically bought under leasehold ownership whereas houses tend to be bought under freehold ownership.

We accept all of that. I will get to what St. Vincent's Healthcare Group may want later. I am just establishing facts here. The Minister came into office and made it clearly known to St. Vincent's Healthcare Group that it was his preference for the land to be transferred into public ownership. That was his preference and he has just explained the reason. However, over recent days, particularly in the meeting of the Joint Committee on Health yesterday, the Minister and many others were telling me and others who have concerns about the ownership that it does not matter. They were asking us why we were raising these issues, what our concerns were and telling us it was dealt with. Despite this, the Minister is also telling us he went into the process and asked the question that should be obvious to everyone in the House should be asked, which is why the site is not brought into public ownership. That is also what I would have done. My point is the Minister cannot have it both ways. He cannot say this was his stated objective and what he sees as the best outcome but that we have not got the best outcome.

It is a fair question but I disagree with the Deputy's characterisation. I am open to correction if the record shows otherwise but I believe my position, which I have stated very freely on many occasions, has always been that I would prefer public ownership and to own the freehold. The Minister, Deputy Harris, and I both asked for that.

Why would the Minister prefer public ownership? This goes to the heart of the matter.

If I may finish, I am open to correction but I do not believe that I ever asked why the Deputy was asking his questions. We have been having a very open debate. The Deputy and many of our colleagues here are asking the exact same questions I asked. I acknowledge the questions he is asking are absolutely legitimate.

I am asking the Minister why he made those arguments for all of those years. I will not go back and quote what he and others said because that would just waste everybody's time. It is accepted. Why did he have that position before he himself was involved in talks? Why did he initially carry that position into the talks and request public ownership? What was the reason?

This probably goes back to something we were discussing at the committee meeting yesterday. For historical reasons, there is a very understandable and deep mistrust in our country. Any complexity in a proposal such as this can therefore add to the concerns people have. We want this to be as clear and as clean as possible. For the reasons we have all been debating for the past two weeks, having the site in leasehold ownership requires additional engagement beyond that required for freehold ownership.

We will get to how clear and clean it is in a few minutes because that gets to the substance of my concerns. I will move on to the issue of potential ambiguity in respect of phrases in the text of the lease and the constitution. I refer to the term "clinically appropriate". We have been through this an awful lot. Yesterday, the Minister offered to write a letter of comfort and express his interpretation of that phrase. He made that offer yesterday. Does he accept that such a letter would have no legal standing, however?

I am not a lawyer. The advice I have received previously is that Oireachtas debate does have some legal standing and that, when the courts are seeking to interpret things, people can refer back to the Oireachtas debate.

I am not a lawyer, so I would prefer not to make a definitive statement on this.

The Minister would in principle accept that interpretation of law will not happen on the floor of the Chamber and interpretation of law does not happen in an operating theatre; interpretation of law happens in a courtroom by judges. That is why it is important that we get this right. There are concerns. Whether the Minister agrees with those concerns or not, given there are concerns about phrases, and we will hear in the health committee today from a number of legal people, is the Minister open to any changes of the text in regard to the lease, the constitution or any of the other elements of the legal framework in terms of that phrase or any other phrase?

As we discussed yesterday, first, what we can take as a given is that it has been clearly established through Oireachtas debate that the term “clinically appropriate” will absolutely not apply to healthcare services being withheld from women, and I think that is the genuine concern people have. Second, I do not know if the health committee accepts it, but I am absolutely willing to write to the health committee-----

I have only five minutes left. That is not the question I asked.

I am answering it. Third, as per yesterday, I am not ruling anything out. I really want to listen to and be involved in the entire debate and to reflect on that.

The Minister will forgive me for wanting a bit more than that. The Minister says he is not ruling anything out but, equally, that is not ruling anything in. Let us have a little of the facts here and let us be a bit more up-front. Either the Minister is open to changes to the text of the legal framework or he is not. The other related question is if the St. Vincent's Healthcare Group is open to any changes of the text.

I do not speak for it, obviously, only for myself. It is clear. When any of us say we are not ruling anything out, I think that is-----

The Minister is telling us today on the floor of the Dáil that it is possible, before next week, before anything goes to Cabinet, that we will see the Minister in fresh talks with St. Vincent's Healthcare Group potentially to change the text of the legal framework. That is a live possibility.

We are not foreseeing any major changes in terms of documents that would-----

I did not ask about major changes. I am asking if it is possible-----

Can I answer the question, please? We are not foreseeing any major changes but, at this point, and including, as the Deputy said, the constitution, I would not rule anything out. However, the debate has not finished. We are still in the middle of it, so we are still very much in listening mode and then we need to reflect on the totality of it.

I think the Minister understands what I am saying to him. If he is open to change, he has to go back and have conversations. He cannot unilaterally change it as it would have to be accepted. Is that correct?

Is that going to happen?

At this point, I cannot say either way. We are still in the middle of these debates.

Not really, because a clock is ticking very quickly. On Tuesday, we are told, the Cabinet will make a decision. The Minister has said this is going on for nine years and he is sitting here telling us there could be changes to an agreement that took nine years to get this point, but when? Is it maybe over the weekend or on Monday?

The debate is going on.

It is, but the clock is ticking.

I do not know about the Deputy but I found the health committee genuinely very useful yesterday so-----

Is the Minister seriously telling me there is the potential for talks between him and the St. Vincent's Healthcare Group between now and next Tuesday?

What I am saying is that I think it is highly unlikely there would be talks requiring substantive change to the legal documents but, at this point, we are still listening to the debate and I am not ruling anything out.

Obviously, people will make up their own mind as to what to take from the Minister's response.

To go back to what we talked about over the last few minutes, the Minister had exactly the same position that I had from the get-go on this. We have a very complicated healthcare system in this State, which we agree on, I imagine. It is a two-tier system with a mix of public and private, which is not ideal. We have voluntary hospitals, independent hospitals and HSE hospitals. We have section 38 organisations and section 39 organisations. It is very complicated. We had Sláintecare, which we all agreed was about a single-tier health service in a public system. This is the first hospital that is being built or signed off on since Sláintecare yet it will be a private company that will be established.

It is a private company that is being established. The National Maternity Hospital at Elm Park DAC is a company.

It is a charitable company.

It is still a company.

It is a not-for-profit charitable company, and that is what matters.

I will phrase it differently. It is not a HSE hospital.

It is not. It is a voluntary hospital.

Exactly. Rather than what we all should have in place, which is a public hospital.

If I can interrupt, for the purposes of people who are listening, it is important that we are very clear that we have HSE public hospitals, we have voluntary public hospitals, like Holles Street today, and then we have the private hospitals.

That is my point. It is all very complicated. We are writing a cheque, or the HSE will write the cheque on our behalf, as taxpayers, for up to €1 billion. This is why I am concerned. It is the reason we are in the position we are in. The Minister himself used the words “complex” and “complexities”. We are establishing this company, which is a charity, yes, but it is still a company, the National Maternity Hospital at Elm Park DAC. That will have directors coming from three different sources - from the State, from the St. Vincent's Healthcare Group and from the existing National Maternity Hospital. That company is a subsidiary of St. Vincent's Healthcare Group, which will own the land and will be the landlord. There is the lease arrangement between St. Vincent's Healthcare Group and the HSE. St. Vincent's Healthcare Group has its own constitution and its own board. That, in itself, is a subsidiary of St. Vincent's Holdings CLG, which has its own constitution and its own board. We then have a licence, a lease and all of these constitutions. This ambiguity is being raised, not by me, but by some who are legal experts. All of that would be absolutely avoided if we had a public hospital on public land in public ownership. For the life of me, I do not understand today why we are not getting that.

The Labour Party leader, Deputy Bacik, made clear again on Leaders’ Questions today our position on this, particularly in regard to CPO, which is an area I would like to focus on at the start of my contribution. Since this project was announced in 2013, we have had four separate Ministers for Health and three separate Attorneys General. What I would like to know is how many of those Ministers sought advice from how many of those Attorneys General, given there is overlap between the various roles, with regard to submitting a CPO for that land? Was there one ask or two asks? Did the Minister, Deputy Donnelly, ask? Did the Minister, Deputy Harris, ask? How many advices came back?

I cannot speak for my predecessors but I can tell the Deputy that I did seek the Attorney General's advice on a CPO for the reason Deputy Cullinane and I were just discussing. I asked exactly the very reasonable and correct questions that Deputy Smith is asking.

Does Deputy Donnelly feel he was the first Minister to ask for the advice of the Attorney General on this in all the nine years?

I would be very surprised if I was.

Did the Minister ask about, or did any of his officials discuss, any previous advices from Attorneys General and how they may have been similar or different?

I will check with the Department. I can certainly confirm that I did seek such advice.

I understand that the Minister did but I would be interested to see if previous Ministers did and if the advice that those Ministers received differed in any way from the advice he received, which is an important point.

In his response to Deputy Bacik today, the Tánaiste said very plainly, very clearly and in a determined manner that he expects this decision to go through Cabinet next week. He just plainly set it out straight. Our sense that anything is going to change, be subject to change or have the scope for change diminishes almost by the hour and, for me anyway, it diminished further when the Tánaiste said that.

I want to ask the Minister about the role of the St. Vincent's Healthcare Group. It became clear over the course of recent months, particularly over the course of engagement in the last couple of weeks, that the level of clinical engagement between Holles Street and St. Vincent's Hospital is very strong, with the same clinicians working in both hospitals - I know there are clinical reasons for this and all the rest. As part of a process, it meant that this was not so much a selection of a site based on separate and different criteria, but it was more like an arranged marriage and they were so interlinked at this stage that a decision had to be made and there was no other choice. That has been made clear through the various committees and the various engagements that have taken place.

Would the Minister accept that this is not a great starting point when selecting a site for any new piece of State hospital infrastructure?

What is not a good starting point?

That the two sites are already so interlinked clinically is not a great starting point to have an independent assessment of what may be the best site for various different reasons. It is not perhaps the best starting point and this was more a fait accompli in terms of it going to St. Vincent's rather than an objective study of what may be the best site.

It is certainly relevant. For example, there is very close co-operation between the Rotunda Hospital and the Mater Misericordiae University Hospital and between the Coombe Women and Infant University Hospital and St. James's Hospital and, potentially, Tallaght University Hospital as well. It is quite regular for there to be co-operation between major adult teaching hospitals and maternity hospitals.

In terms of this being put forward to the public as the Government having looked for the best site and that it was St. Vincent's, it was always going to be St. Vincent's. There was no way it would be anything but St. Vincent's. Does the Minister accept that this was always going to be case?

No, I think cases could be made. For example, the Rotunda Hospital has a very close working relationship with the Mater Hospital and, in the same way that critically ill women are moved from Holles Street to Elm Park, critically ill women are moved under blue light from the Rotunda Hospital to the Mater Hospital, yet the proposal that has been in place for many years for the Rotunda Hospital is to move it out to Blanchardstown and co-locate it with Connolly Hospital.

The Minister mentioned that if we were to pursue a CPO the partnership and all the goodwill with St. Vincent's Hospital would collapse. Does the Minister think that he and the State have used their leverage enough with St. Vincent's Hospital? At the end of the day, the taxpayer pays the wages of all the senior staff in St. Vincent's Hospital. St. Vincent's Hospital seems to have dictated almost everything in this regard.

My time is running out. The Minister has acknowledged there is very understandable concern about ethos and the role of the religious bodies in this.

There is no need for him to repeat his answers on that as we have heard them very clearly. I have doubts that this golden share model is an example of a model we will ever see used again. The Minister said it is a model he would not mind seeing used. Would he acknowledge that the golden share model, by definition, enshrines that concern forever? The women of Ireland will always have that concern because the Minister had to put in this golden share model just in case these services were not delivered. That is part of the PR that has been put forward on this golden share model. I know it is an ownership model as well, but part of what the Minister said is that if the hospital is not providing the full spectrum of legal services the Minister can tell it that it has to provide these services, whatever the case may be. Does he accept that this model by definition means that the concern and worry that exist now will remain in perpetuity because of that model?

No, I would not. It is a very sensible extra layer of protection.

It would be if it is a pro-life Minister.

The constitution explicitly obliges the new hospital to provide all services and to do so without any religious ethos. In the context of our country's history regarding women's reproductive health, having an extra layer where the State, via the Minister for Health, has this very broad power to intervene and compel the hospital to do what it is meant to do is a good thing. In fact, I would like to see it in other voluntary hospitals, to be honest.

I am grateful to have an opportunity to contribute to today’s discussion on what is a very important matter. I have listened intently to the debate, the language, the concerns and the pros and cons. I have been in the House for the last two weeks listening to every debate I can and, between meetings, I watched the proceedings of the Oireachtas committee yesterday. I thank the Minister, Deputy Stephen Donnelly, for his speech on the issue, which I believe sets out clearly the reasons for, and the benefits of, the chosen course of action.

What do we all agree on? We all agree that the clinicians in the National Maternity Hospital provide excellent care to women and infants. They have been leaders in modernising women's healthcare. A new modern hospital building is needed urgently for the National Maternity Hospital. The new hospital should be built beside a major adult hospital to ensure women have access to the widest possible range of healthcare. The new hospital must be fully clinically independent and there must be no religious influence now or into the future. The new hospital must provide all services and procedures that are legally permissible. The State's investment must be protected. The Government's plans for the new hospital meet all these goals. The new national maternity hospital will be clinically, operationally and financially fully independent. All procedures that are currently carried out in the National Maternity Hospital in Holles Street will be provided in the new national maternity hospital. This includes terminations, tubal ligations and gender-affirming procedures. The new hospital will provide all maternity, gynaecology, obstetric and neonatal services that are legally permissible. My understanding from what I have listened to is that there is agreement there.

However, the most important and relevant fact in this debate is how vital this development is to bring Irish maternity care into the 21st century and beyond. It is recognised as a piece of critical infrastructure for the continued development of maternity and women’s health services, and it will help to cement the momentum and achievements we have seen in women’s healthcare over the last few years. We are building a once-in-a generation, world-class national maternity hospital, ensuring world-class facilities for women, girls and babies for generations to come. We are already aware of the importance and benefits of co-locating maternity services with adult services. The National Maternity Hospital and St. Vincent's Hospital have worked together for decades, and approximately 40% of consultant staff at the National Maternity Hospital are employed by, and work between, the two hospitals, creating the ideal platform to achieve the clinical ideals of co-location.

Both yesterday at the meeting of the Joint Committee on Health and again here today, the Minister has comprehensively addressed the concerns raised. He has given very clear explanations on the legal agreement and the significant work that has been done to ensure the full range of services will be available.

The referendum in 2018 was very clear. People in Ireland voted overwhelmingly for abortion to be legal. Abortion is permitted in Ireland during the first 12 weeks of pregnancy, and later in cases where the pregnant woman's life or health is at risk or in cases of fatal foetal abnormality. I am just stating the facts. The figures show that approximately 21,000 abortions have taken place over the last three years since the legislation changed. The facts speak for themselves. Abortions happen every day of the week, every week of the month and every month of the year. My question is: why are there concerns that all services permissible under law will not be carried out in the new national maternity hospital? They are already happening in the current, not-fit-for-purpose hospital. It is not fit for purpose from a condition and infrastructure point of view, not in respect of the staff and the care. The religious orders have left the scene. They no longer provide healthcare. They have not interfered in the last three years when 21,000 abortions were recorded. This is fact; this is reality. It is muddying the waters.

All procedures that are currently provided in the National Maternity Hospital under Irish law will be provided in Elm Park. I will state again that they include termination, provision of contraception services, tubal ligation, fertility services and gender-reassigning procedures. It cannot be clearer. Clinical services will not be provided according to any religious ethos, but according to the best national and international clinical practice. All lawfully permissible services that should be provided in a maternity hospital will be available here.

Over the last few days the very clinicians who provide such care have come out in strong support of the project. I do not believe any Member of the Dáil or the Seanad, apart from the Tánaiste, has worked in Holles Street, although I am open to correction on that. We have to believe the clinicians. Clinicians at the National Maternity Hospital have spoken passionately about the project and have urged us to press ahead. What they clearly recognise is that there is now a range of legal stipulations to guarantee that all procedures will take place. These are the clinicians who annually see several hundred pregnant women transferred to St. Vincent's Hospital as inpatients or outpatients for treatment that is not available in Holles Street.

These are the clinicians who every year see a number of critically ill women transferred to receive intensive care that is not available onsite at Holles Street. The physical transfer of such high-risk clinical cases between two separate sites is not in keeping with best practice, but Members should not take my word for it, they should please read the correspondence and listen to the likes of Dr. Rhona Mahony, Professor Mary Higgins and many others. They, along with many clinicians across maternity services, have expressed their confidence in the agreements that have been brokered between the relevant parties. It is my belief that their confidence is well founded.

The Minister, Deputy Stephen Donnelly, has made himself available to answer questions. He has made the necessary documentation available for openness and transparency. We have debated for far too long. While we debate here in the Dáil, it is business as usual in Holles Street where there is a 14-bed Nightingale ward, and where women are queuing to go to the bathroom.

It is not a Nightingale ward.

I appeal to the Minister to please be the Minister for Health who delivers a state-of-the-art national maternity hospital. The women of Ireland do not deserve to wait any longer.

I thank the Minister for his comprehensive statement on this matter today. I fully support the view that the project should go ahead. I am extremely astonished at the interpretation by some members of the legal profession of what a leasehold title is. As someone who has practised and been involved in the purchase and sale of leasehold title for more than 25 years, it is clear that there is misinterpretation being given to what a 299-year lease is. A 299-year lease gives absolute power to the lessee to manage and run the facility in the best way they want.

It is important that the lease sets out six covenants on which the lessee is answerable to the landlord. The first relates to the primary responsibility for the funding of public hospitals and the provision of public healthcare facilities. The second is that the tenant cannot assign without the consent of the landlord. The third is that the lessee cannot change the permitted use. The fourth is that the premises is actively used throughout for the provision of public health services. The fifth is not to abandon the use of the premises. The sixth and final covenant is about the freehold title issue. Here is a lease for 299 years, which is about providing where a new hospital can be built to provide up-to-date care for maternity services and related healthcare for women in this country.

It is important to note what is clearly set out under clause 6.1 of the lease, which relates to "quiet enjoyment":

The Landlord hereby covenants with the Tenant that so long as the Tenant pays the rents and observes and performs the covenants and the conditions of this Lease the Tenant may hold and enjoy the Premises and the rights hereby granted peaceably during the Term without any unlawful interruption by the Landlord or any person lawfully claiming under or in trust for the Landlord.

It is clear that the lessee, which in this case is the new national maternity company, will in fact have total freedom in the management. There is misinterpretation on whether it is freehold or leasehold title. It is interesting how the current National Maternity Hospital is held under a lease; it is not freehold title.

Then we go on to the issue relating to compulsory purchase. People are being quoted extensively in the media saying there should be a compulsory purchase order. Let us look at one of the opinions provided by a legal counsel and quoted extensively in the media. It states on page 62 of the opinion:

Insofar as the State proposes to compulsory acquire the lands, the appropriate legislation is under the Health Act 1947 which confers on the HSE the power to compulsorily acquire lands. However, significant issues relate to whether the procedure under Health Act 1947 is constitutional in affording sufficient independence in the process for confirming a CPO.

On the one hand we have the person being quoted extensively in the media to the effect that we should compulsorily acquire the site, yet on page 62 of the opinion he clearly flags that there may be difficulties if the State goes down that road. The Minister clearly outlined that this is a partnership between the new national maternity hospital and St. Vincent's Hospital Group. We are delivering a comprehensive health service on the one site, which is extremely important.

I remarked to a pal of mine as I was coming over here that, as a middle-aged Irish woman, I rather think I would have learned to enjoy being gaslit by men in suits, but somehow I just cannot manage it.

I must inform the Minister of State, Deputy Butler, that a Nightingale ward has 24 to 34 beds in it, not 14. There is one 14-bed ward in the National Maternity Hospital.

I know there is, because I was in it after I gave birth to my child. It is not a Nightingale ward. The Minister of State is in the Department of Health. At the very least, she should please get the absolute basics right. When issues and questions arise, it is thrown out that, for example, the religious have left the scene, or there are loads of Nightingale wards, but there are none. The Minister of State should withdraw that statement and correct the record, because there are not any Nightingale wards in the National Maternity Hospital. There is one inappropriately large ward. Nobody is disputing that we need a new national maternity hospital. I have never worked in the National Maternity Hospital. I have represented workers who have worked in it, I have given birth in it, and my grandson was born in it, so I have an association with the hospital. I am an Irish woman, the same as the Minister of State, Deputy Butler, and I have an interest in ensuring the new national maternity hospital is built on land that is controlled by the State. That is why people have concerns.

Five years ago, the Dáil passed a Sinn Féin motion unanimously, with the support of everybody. The motion stated very clearly that we must ensure that the new national maternity hospital is built on the St. Vincent's Hospital campus as quickly as possible; remains entirely in public ownership; and is legally guaranteed independence from all non-medical influence in its clinical operations within the laws of the State. The Minister of State supported it, as did the Minister, Deputy Stephen Donnelly. There was cross-party support. There were concerns over religious influence at the time, which is why we proposed the motion. There were concerns that the hospital and the clinicians would not be able to operate freely and provide all legally permissible services. Those concerns have continued. We would not be here having this debate if those concerns had gone away. We simply would not be using our time to have this debate if all of those concerns had been allayed. Does the Minister acknowledge that concerns remain? Does he acknowledge that people have genuine, heartfelt concerns about the building and location of this hospital? We all want the hospital built. Nobody is disputing that. Everybody wants to see it. The hospital was not fit for purpose in 1995 when I gave birth to my daughter in it. We all want to see the new hospital built, but we need to get it right. It will cost €1 billion. Given the Government that we have, we will probably be looking at €1 billion in the rear-view mirror at some point. It is a lot of money. There is a huge amount riding on this. People have genuine concerns.

I do not want to let this opportunity go without mentioning Sheila Hodgers. I think of her often. She died in a hospital. She was not killed by a nun, by the way. There were no nuns running around. That is not what people are afraid of. She was killed by an ideology, by an ethos. She died and her baby died. For her and for all of those women who are put into the National Maternity Hospital as it stands now, we have to get this right.

In June 2021, the Taoiseach said that when the State is making a significant investment, it should own it "lock, stock and barrel". I rarely agree with the Taoiseach, but I agree with him on that. We will not own it. Could the Minister outline what he will do between now and Tuesday? Who will he be talking to in terms of the genuine concerns he has acknowledged have been raised? Who will he be meeting and how will he ensure those concerns are addressed? Is it his plan to meet the St. Vincent's Hospital Group?

If so, what will be on the agenda and when will he inform us of the outcome of that meeting?

The Deputy has made a lot of accusations. She and I have worked together on the Joint Committee on Health for many years and I hold her in high esteem. Just for clarity, can I ask if her comments about being "gaslit by men in suits" pertain to me?

There are a lot of men and a lot of suits talking about this, and the Minister well knows it. They are saying to people who have concerns that their concerns have been comprehensively addressed, but they have not been. I am asking if the Minister accepts that those concerns are legitimate and genuinely held by me and others.

Not only do I acknowledge it, but I acknowledged it clearly in my opening statement, in many interviews I have given and at the health committee yesterday. I ask the Deputy to accept that in good faith.

We are out of time. We will return to the formalities of the Dáil whereby speakers stand. I am speaking to both sides of the debate. We must keep some formality in the debate.

I apologise, a Leas-Cheann Comhairle.

That is okay. I am talking about every side. I call Deputy Shortall.

I want to go back to the term “clinically appropriate” and the reason there is no definition of it. That is particularly baffling given that there are six pages of definitions in the lease agreement. Across all of the other legal documents that have been released, there are pages and pages of definitions. Why is there no definition of the term “clinically appropriate” given the confusion that seems to exist around it?

That is a very fair question, and one that is being asked repeatedly. The advice I have from the legal team, to which I posed exactly the same question, is that for lawyers and clinicians, the phrase “clinically appropriate” is a normal phrase used all the time. It is used in every hospital, on every ward and by every clinician. The legal team told me that in the same way that it would not define "obstetrics", "gynaecology" or "neonatal", for example, “clinically appropriate” was in that category. However, if I may say so, the Deputy’s question is very fair and reasonable. Clearly, for non-lawyers or non-clinicians, the phrase does not sit in the same place as the term "gynaecology" or "obstetrics", for example.

As per the conversation we had yesterday, at a minimum, the issue has been described and discussed at great length in the Oireachtas. I can yet again give an unambiguous assurance regarding the concern that people have that it could in some way be used to give a clinician some right to withhold services from women. That is not the case. I will finish on this point because I want to respect the Deputy’s time. I will write to the health committee and make that very clear. I also want to reflect on the totality of the debate as well on this point.

That is the very point. It is baffling that the Minister is not prepared to provide a definition. I put it to him that there is no equivalence between the phrase “clinically appropriate” and names of different branches of medicine. That is a completely different thing. The term “clinically appropriate” is open to ambiguity. Even those who are in favour of this project are interpreting it in different ways. For example, the obstetrician, Professor Mary Higgins, says that it means future-proofing. However, that is not the case. We know that we can provide a list and we can future-proof that by simply saying, “but not limited to”.

The Minister and the Taoiseach have both said that the meaning of that phrase is to be very clear that it is only maternity-related services that are to be provided. Yet, we discovered just in the last few days that dermatology is to be provided in that building. Who knows what other services will be provided and who knows whether they are public or private and what that is all about? We also know that Professor Shane Higgins believes that the term means that this is to be clear about the services that will be performed at the new hospital. Clearly, therefore, there is a lot of confusion and whole series of different interpretations of that phrase. The Minister has committed to providing a note to the health committee to explain his understanding of that. If he is prepared to do that, why would he not be prepared to provide a definition in the legal documents?

I just want to clarify this point. The Deputy said I am not prepared to provide a definition. I am, through debate and also very clearly in writing to the health committee.

A definition in the legal document is needed.

I accept that point and Deputy Shortall asked a reasonable question. I want to listen carefully to the contributions of the Deputy and all colleagues. I will then reflect on those. I agree with the Deputy and other colleagues. Deputy Cullinane and others have said it and Deputy Duncan Smith may have said it as well. For people watching this debate who are coming from a baseline of mistrust for real and legitimate reasons, we need to address those concerns. As I said, I am not ruling anything out. I want to listen to this debate very respectfully and then reflect on what is needed.

The Minister’s agreeability is welcome, but the reality is that all of the indications are that the Cabinet will sign off on this project or deal next Tuesday. The Minister has accepted that we have a point, that there is confusion and there are problems associated with this phrase. He is saying he is prepared to provide a definition of that to the committee and he will send us a note on it. Why then would he not include a definition in the legal documents? That could be done in a matter of minutes. Would he regard that as a substantial change to the legal documents?

I am not a lawyer but I would not regard that as a substantial change.

I do not believe adding a definition would be a substantial change at all.

On the Deputy’s first question as to why I could commit now and yesterday to write to the health committee, it is because that is immediately within my gift. However, any changes to legal documents that have multiple parties involved would require consultation and other conversation. I am not in a position to commit to that. However, I certainly can commit to providing a definition directly to the health committee and indeed to all colleagues.

The Minister seems to be indicating that he agrees with Deputies on this side of the House that there are problems and ambiguity with that phrase. He is prepared to provide a definition of that to the committee. In that case, I cannot understand why he is not prepared to include a definition of that in the legal documents, especially given that there are pages and pages of definitions. He says he does not believe that would substantially change the deal.

I do not, but there may be lawyers who do.

Will he now give the matter consideration? Rather than just being pleasant about it, can he give some kind of commitment that he will take steps to include a definition of that phrase in the legal documents? That would solve this problem to a large extent.

He has the solution here in his hands. Is he prepared to do that?

Do I have time to respond?

Yes, quickly. The Minister has one minute.

I am not only seeking to be pleasant. I absolutely accept the validity of the concerns that are being raised.

The Minister accepts them.

What I have said is that I cannot commit to changes to legal documents here. I know the Deputy appreciates that. What I can commit to is reflecting on exactly this and seeing if there is more to be done, including exactly what the Deputy has laid out. I am, of course, already reflecting on this, what was said at the health committee yesterday-----

We need more than a reflection.

----and on the wider public debate.

We need a commitment.

It is not just a reflection. I am just saying, and I know the Deputy appreciates this, that I cannot commit to any specific changes-----

-----to the legal documents here.

Will the Minister pursue changes to the legal document?

Deputy, please. We have another Deputy who wishes to speak. I thank Deputy Shortall.

This is a critical point.

We could be here all day. The Deputy's time is up.

Will the Minister pursue changes?

I call Deputy Neasa Hourigan.

Otherwise what he is saying is meaningless.

Deputies, please be fair to everyone.

I will touch on that issue again, so the Minister may have a chance to come back to it.

Those of us who have been on the health committee and who have looked at these documents at length and considered the matter yesterday and again today have had the time this incredibly complex agreement requires. I hope we will have a little more time because one of the things I want to do is talk to a legal or governance expert from St. Vincent's Hospital to ask why it would not consider giving the land to the State. Considering the way other sites in the State work, I am not sure I accept the current explanation.

I have many other questions around this deal. I would have liked more time to consider the business case and why it has been returned for review. I would have liked more time to think about why it came to Cabinet when the business case had not been signed off because this is a major project. Why have we managed to get to that €1 billion figure we talked about yesterday when, I am sorry to say, the construction costs just do not indicate it would cost €1 billion? Why do we have an empty hospital, block 1 in Elm Park, sitting empty for ten years, which the National Maternity Hospital, NMH, agreed in 2012 was suitable for its needs? Why is that empty and sitting there? What does this hospital mean for Sláintecare contracts? I would have liked time to consider all of that, but we do not have time for that today.

We all want the maternity hospital built and we all want it to proceed, no one more than me who has small children. I was very glad to hear the Minister talk about and recognise the dark history of women's health in this country. If we are to recognise that, we have to address the lack of faith, not dismiss it and call it a red herring, but actually recognise it. I have suggestions for how we could recognise it so that extra time would be helpful. We also need to release all legal documents relating to the share transfer and take up the Irish Family Planning Association, IFPA, suggestion of encouraging the NMH to have a professorship of abortion care because our maternity hospital must be a centre of excellence. It is not just that it should allow abortion and sterilisation. It must be a centre of excellence for that care.

As Deputy Shortall spoke about at length, the term "clinically appropriate" should be removed, clarified or added to, either in the documents or as an addendum or memorandum of understanding. There is a lack of faith and trust from the public in Irish institutions. We can solve that in a number of hours and days. It worth doing that. I point out that many of the parties in this Chamber found themselves massively out of step in 2018. Not just the Government but those in the Opposition were out of step with the public mood in 2018 when it came to abortion. Let us not go there again and let us not contextualise this debate as Government versus Opposition because I do not think it is that.

Yesterday, we talked about listening to doctors and I said "No". That is not what I walk the streets for. I walk the streets to listen to women. The women of this country care about this and my voters care about this. I suspect those who are actually giving their votes to the Minister and the Minister of State care. Make no mistake, I do not want to see this Government and the institutions of this State continue what we have done in the past, which is to assume we know better when we do not. We should listen and clarify before we sign off. The people involved in this discussion are not just the Minister - I thank him for this time - but also the three leaders of the coalition parties and the master of NMH. If we are truly listening to women, I ask and implore those five men to act.

I greatly appreciate the opportunity to contribute to this very important, very sensitive and very emotive debate for everyone in the House, including the Minister. I appreciate the decision taken by the Government to pause for two weeks in order to address many of the very understandable concerns and suspicions held not just by members of this House but the vast majority of people in this country and, most importantly, the women who have been betrayed institutionally by this country for so long up to this point. We hold a very clear responsibility to be their voice in this Chamber and to ensure they are not betrayed again.

The concerns I referred to have been raised by others this afternoon. I make the point that, like everyone, I want to see this hospital built urgently. It has taken nine years to get to this point, plus another two weeks. If it has to take another two weeks for the Cabinet to reflect, as the Minister rightly said, on the mood not just in this Chamber but in the Seanad and the health committee, it is worth waiting to assuage those fears that can be assuaged. I appreciate that for some people this deal will never be perfect. That will lace their opposition to it, which is understandable and a perfectly just opinion to hold. However, I want to make sure the best possible deal can be secured, not for me or the Minister but for the very many women we represent, be they in Wicklow or Dublin Rathdown.

I will return to the points raised by Deputies Hourigan and Shortall relating to the phrase "clinically appropriate". I was very grateful for the briefing the Minister and his officials gave to my parliamentary party the other evening and I look forward to the press conference to be held tomorrow by officials. I will repeat the concern I expressed at the briefing that there should be an addendum, or a rolling update from the Minister of the day, to ensure that every single service the women of Ireland are legally entitled to and allowed to have is guaranteed. We cannot go back to the ridiculously dark days where, on a whim based on the ethical opinion of the person who was there, using the State's laws and supposed public opinion as a defence, women in this State were absolutely robbed of the best possible maternity healthcare.

I put that very sincerely to the Minister. He has asked for and wants reflection and to listen to us. As a Government backbencher, I am saying to him we need to have that clarity of definition. It is not for me. We need to have that reassurance for the dozens and dozens of women and their husbands, brothers, children and parents who are flooding my office. They are not the usual suspects. They are not the campaigners. They are people I know personally and are my friends on Instagram. They have genuine, heartfelt, understandable concerns. Those concerns do not need to be assuaged to satisfy the 160 Members but, more important, the people of Ireland who will foot not just the financial bill of the establishment of this new hospital, but the moral and social bill. That is a very grave responsibility and I very much hope that is resolved.

I fundamentally accept the basis that there is no religious influence on this hospital. I accept that. It has been made very clear. As the Minister will understand, however, the history of this State means there is understandable concern over what religious influence can be. I spoke with a former Church of Ireland chaplain to the National Maternity Hospital. He is a very progressive and understanding man who knows this issue in and out. He came up against a system, when dealing with patients of a minority faith background, like me, who were not allowed access care because of the religious ethos of the hospital they were going to for supposed best care. Many people in the State have no religious ethos. He said he went up against this for decades as a chaplain to the National Maternity Hospital and he wants to know the detail, not just on his behalf but on behalf of the very many women he was able to talk to, many of whom he had to counsel and ensure could be accompanied to the United Kingdom to receive the level of care they were entitled to. He wants to know where the detail is. What is in the letter from the Vatican to the Sisters of Charity? What are all the legal documents allowing for this transfer? It may be a very simple matter for that clarity and confirmation to be given to those people. If it is, I implore the Minister to lay it all out on table to make sure there is not any suspicion because, sadly, too many people in this State have died, suffered and been robbed of very basic decent human rights due to the suspicious and malevolent actions of this State over its centenary history when it comes to the care of our women.

I thank the Deputy. We have made up the time already.

This State and the religious orders have a shameful track record in their treatment of women and children. It is written into our Constitution, the foundational document of the State, that a woman's place is in the home. Until 1957, a married women became the legal property of her husband. Until the 1970s, a marriage bar forced women to resign from work upon getting married. Marital rape was not made a criminal offence until 1990.

We have all heard the apologies from previous Governments over the years. Only a year ago, the Taoiseach apologised in this House. On that occasion, he apologised for the institutional abuse suffered in mother and baby homes. As the Taoiseach said, "The State failed you", and we need to recognise a profound failure of empathy, understanding and basic humanity over a very lengthy period. We need to have that empathy and understanding at the core. Two years before that apology, the Tánaiste also stood in this House and apologised on behalf of the State.

That time it was to people who were sexually abused in day schools and for the delay afterwards and acknowledging its responsibility to protect them. In that very same year, he gave another State apology. That time it was for the CervicalCheck screening programme. He said "we vow to make sure that it never happens to anyone else ever again”. The Irish Times reported at the weekend, the HSE is continuing to outsource cervical samples.

Before that the Tánaiste’s predecessor, former Deputy Enda Kenny, also stood up in the Dáil and he issued a State apology. He issued a State apology for the Church-run Magdalen laundries. No sooner had he issued this apology, than the HSE had to issue its own apology to Praveen Halappanavar, the husband of the late Savita Halappanavar, who died needlessly in my local hospital, Galway University Hospital. She died because religious ethos took primacy over that poor woman's right to life. Galwegians like myself and all those who marched for women's rights to choose remember the pictures of Savita which were present at every single march; her smiling face watching down over us, driving us to ensure that it would be a case of “never again”. We have heard the apologies. We have heard the “never again” and the “lessons have been learned” lines yet here we are. I am not going to rehash the legal arguments around the leasing arrangement with St. Vincent holding company or the separation of religious orders from their stakeholders. Many legal experts and people far more qualified to speak about this than me have raised serious concerns. I think these concerns compounded by the appalling track record of the treatment of women in this State lead me to fear that we will at some point hear more apologies in this House.

I will conclude by telling a story about a good friend of mine. She is living proof of what happens when a religious order does have a share in the hospital. In 2018, she was allowed sign for a hysterectomy when her life was in immediate danger. Thankfully her surgeon was skilled enough to remove an ovary, tube and growth without the clinical necessity of a hysterectomy. A year later, it became clear that she required a radical hysterectomy to have any quality of life. Her condition was life limiting but not life threatening. While a hysterectomy was clinically appropriate it was not deemed necessary and hence permissible. As a result, other treatments were prescribed: months-long cocktails of Pethidine injections, morphine patches, Oxycodone and Fentanyl were prescribed destroying her quality of life. Because she was 26 and had no living children, the hospital's religious ethos deemed a surgery that would improve and eventually save her life to be inappropriate. In fact, she later discovered that her medical team could not mention the possible need of a hysterectomy with her at that point due to that ethos. That was despite her uterus slowly perforating. Eventually she had to travel to England for this operation. Another Irish woman forced to cross the sea to seek the medical services denied to her in her own State.

We must have, as so many women have said in the past weeks, months and years, a public hospital on public land to ensure that women get the healthcare that they need and that they have full confidence within it. We can see from the last number of weeks how important that is to women.

I only had five minutes and I have used all of my time. Maybe in his own summing up, the Minister will address some of the concerns that were raised.

Today the Tánaiste said the two weeks that we were given to consider the deal around the new national maternity hospital were given to look at what additional safeguards could be added. That question remains. What additional safeguards can be added? I am standing here because I am sore sitting. We have been sitting at long meetings about this issue all week. I will sit at more of them next week and the week after if necessary. But we have to make progress. The progress we have to make has to be based on a certain amount of honesty and openness and more honesty and openness than we have had so far.

Yesterday, it was very interesting to hear the consultants and the clinicians who deliver the services to women. They are very anxious to get this hospital built as are all decent-minded people in the country. They have fought long and hard to get that hospital built. They outlined to us very clearly why the current facilities are inadequate. However, I am still unconvinced that there is not something deeply wrong about this deal that has not been addressed or resolved and that the information that we have been provided with has simply highlighted and crystalised that concern for us, despite assertions from the Government and the Minister that this new state-funded facility to be built by the State in the coming years will be truly State owned and solely State controlled. That, as I pointed out to the Minister yesterday, is refuted by St. Vincent's Healthcare Group. Its fact sheet says the opposite to what the Minister is putting across as the case. Yesterday was interesting because we were once again drip-fed information that had not yet been put on the table. For example, there will be facilities that do not pertain to maternity or reproductive care located in the new national maternity hospital because other areas of the existing hospital will have been discommoded. The facilities for dermatology will be there although it is not clear whether those are to be public or private dermatology wards, departments, suites or consultant rooms. That flies in the face of the excuse that is given to us consistently around why we need the words "clinically appropriate" in the deal and why they need to be repeated six times all over the deal alongside "legally permissible". The reason we were given was because the consultants and the obstetricians need to know that the new maternity hospital is only for the purposes of reproductive health and maternity purposes. Yet here we have dermatological clinics, suites or whatever sharing the space of the new maternity hospital. That does not stack up. I am extremely worried that that wording will be left in. Again, I ask the Minister to remove that wording and give a guarantee to the women of Ireland that "clinically appropriate" does not mean that some clinician or a team of clinicians makes decisions over women's lives but that women have control themselves over decisions that need to be made. We have just heard testimony of one very stark case of why that needs to be done.

I am also very concerned because during questioning on this here the other day the Taoiseach told us that we had inherited a health and maternity system that is overwhelmingly private and voluntary and has a history of religious and mostly Catholic influence. He told us that it was not ideally where we would start from but it is where we are. We are where we are. It seems that the health service that we have is just an artifact of our history like the natural landscape. It is there and there is nothing we can do about it. We have a dysfunctional and broken system for a reason. It is because political choices were made over the last 100 years by parties, some of which are still in this House and others which are not, that they would hand over chunks of vital public services to be run by the religious orders, namely health and education. That was not an accident. It did not happen like the mountains appeared in Kerry. It was politically and ideologically motivated. This deal commits to the continuation of that broken system of private, often religious, interests in the care of women's health with the control to some extent over the choices that women want to make not being in their own ambit.

My opposition to this deal has hardened over the last week. It hardened further when the Minister said yesterday that even if we fully owned the hospital we could not guarantee that all services would be delivered. Other HSE hospitals, eight according to the Minister, are not delivering reproductive care that should be available to women, namely abortion. I asked the Minister in the corridor for the names of the hospitals. He could not remember them but he said that he would send them to me. So far, I have not received them. He then told me that the main reason they are not delivering the service is funding. Funding has been an issue for most of those hospitals. That is not the impression he gave Joe Public or the committee yesterday. The impression he gave was that there was an ideological issue that was crippling the HSE-run hospitals from delivering abortion care. He has to square that circle. We need more time, more discussion and more answers. There is a Byzantine complex structure with guarantees, golden shares and balances in board membership. There is the exit of the sisters and the promise of an evolving secular group. All this is necessitated by the determination and utter insistence of St. Vincent's Healthcare Group to hold onto the land and to refuse to gift it to the State.

At least the nuns were willing to do that. They want to retain dominance, influence and control over the new national maternity hospital. I know the Minister does not want that. He probably thinks the way the Taoiseach does in that we are where we are and we cannot aspire to a fully State-owned and run hospital, although that is what he would like. If that is what the Minister would like, he should join us on the protest on Saturday at 2 p.m. outside the Dáil, where women in this country will be saying to the Government that we have to move on and that we have to move away from an old and failed model with a suspicion and mistrust of the way business was done written all over it. We need to control and own that land in its entirety.

I am so glad and it is so welcome to me that we are having this debate. Taking a pause over the past ten days was the right thing to do because people have questions and it is up to all of us who have questions, including public representatives, men, women and today's children who may someday be using the new national maternity hospital, to get those answers. I thank the Minister for already answering some of my questions today and in the briefing he provided to Fine Gael Deputies, Senators and women's network members during the week. I am glad we had that opportunity to talk this through with the Minister because it is such a complex issue. It is also an extremely important issue when it comes to the future of women's healthcare. We should acknowledge that even by having this discussion we are showing how far society has come because as a nation we are seeking assurances there will be no role whatsoever for the church when it comes to the provision of healthcare in Ireland. Not so long ago we would have accepted religious influence in so many areas of our lives with no questions asked but that time has well and truly passed.

As a young woman in my 30s, I do not want the church next or near my reproductive rights. I stood outside the gates of this House demanding that women who were going through maternity care would have their partners with them. I marched with these women, I campaigned on the repeal of the eighth amendment and I campaigned for the legislation for terminations in Ireland. It is because of the murky past and the blurred lines between State and church that I am glad the nuns are gone from our healthcare system. I am glad the Vatican has no role whatsoever in healthcare or maternity care in Ireland because religious influence in healthcare would be as inappropriate as me asking the parish priest to say something in his sermon at Mass. It is Irish law and not canon law that determines our laws and values as a nation.

It is the detailed legal advice and political assurances that terminations, sterilisations like tubal ligation and gender-affirming surgeries will all be carried out in our maternity hospital that I trust in. We need to have the highest standards in healthcare when it comes to our new maternity hospital. We heard so much discussion of the term "clinically appropriate", which has caused confusion and we need to clear that up. If that means, as my colleague, Deputy Carroll MacNeill, has said, providing a non-exhaustive and non-exclusive list of procedures and treatments that will take place in the hospital, then that is what we have to do. We have to spell it out in black and white so there can be no confusion whatsoever that all legally permissible procedures are to be carried out in the new national maternity hospital. I ask the Minister to provide people with that piece of mind because that is the most important reassurance women need. We need to know the hospital is legally obliged to provide terminations, sterilisations and gender-affirming surgery. I know this is the case. I would not vote for a hospital if I did not believe that, but people watching at home have not had the opportunity to pore over all the legal documents and they need that assurance. The Minister needs to listen to that request and respond to it.

From the briefing this week, I understand the Religious Sisters of Charity was sent a one-page document approving its request to divest its interests in healthcare to a secular organisation that we know as St. Vincent’s Holdings CLG. Just knowing that cleared up so many questions I had, but the public still have those questions. Will the Minister seek a copy of that formal approval from the Vatican to transfer the Religious Sisters of Charity's shareholding in the group to the new charitable company, thus fully divesting it of any influence over healthcare? If we had that document and if it could be published, that would alleviate people’s concerns. It would prove the nuns are gone and that they are out of the picture. There is a narrative out there that they are still involved which we need to clear up, and furnishing a copy of that document would help.

It is so important we completely alleviate the concerns of the public on this matter because we desperately need the new national maternity hospital. I want a hospital that is state of the art. I want a hospital that is co-located so that it is integrated into the existing hospital. The new hospital will have corridors and not ambulance rides to bridge the physical distance between maternity care and intensive care to provide the best possible care for women and their children. I cringed when I heard Professor Shane Higgins, Master of the National Maternity Hospital, Holles Street, tell us that, right now, surgeons are packing up surgical tools, putting them in the boots of their cars or in taxis and battling traffic across the city to deliver critical care to women who need it. In 2022, that is unbelievable. It is also unbelievable to think our current national maternity hospital, which we are so happy with in so many ways, has two religious appointees on its board and is chaired by the Archbishop of Dublin. What some might find totally unbelievable is that it still carries out terminations. Thankfully, our new national maternity hospital will not have any religious ethos, religious representation on the board or religious interference, and it too will carry out terminations. We need this investment in women’s healthcare, we need this state-of-the-art hospital and we need it now rather than later, or as soon as is possible. We hear from our clinicians and from the people who deliver this care day in, day out. In them we need to trust.

I thank the Minister again for being here for these statements, as he was a number of weeks ago when time was made available to discuss this issue of the national maternity hospital. On that occasion I said I did not believe any Member of this House wanted the national maternity hospital run by a religious order and that is still the case. Not only is it the case but, following the publication of the documents, it is clear the Government’s strategy has been to ensure all legal protections are put in place to make sure there is no religious interference with or limitation on the services that will be provided in the national maternity hospital.

I echo the points a number of other speakers have made. I appreciate the time that has been put in during recent weeks to read the documents and for the Minister to do exactly what he promised he would do a number of weeks ago in the House, that he would give time for us to do that. That has been beneficial and it has allowed us to answer and ask many of the questions because other speakers are correct that we have a long, dark, unhappy and unpleasant history on this issue. Sometimes answering concerns, even if legal experts believe they are unfounded, is appropriate and it is useful in a public debate on the national maternity hospital. That is not to undermine the necessity to deliver this project but these two weeks will not significantly delay it and I welcome that.

I am no expert in any of these areas but I have taken the time to read these documents, particularly the lease because the issue of ownership of the public land seems to be of particular concern. I can find no legal mechanism in the lease which allows the landlord to interfere with or limit the services in the national maternity hospital. If there are Members who believe there are ways for the landlord to do that and that therefore freehold is important, I ask them to plot that out. How do the Pope, the cardinals or the heads of the religious order practically limit the services? I invite them to show me the conditions in the lease that allow them to do that. They are not there and, therefore, that issue of public ownership of the land is not one we need to surmount to protect the legally permissible services that will be provided there. If Members believe we need to surmount this issue, I would like to see the reasons for that, but I cannot find any mechanism in the lease which would enable the landlord to interfere. Then you move to the issue of the ownership and management of St. Vincent’s University Hospital, of the clinically independent national maternity hospital and of the combined campus. In the operating licence and in all the other documents, I cannot find a way where that would happen.

In all the times I have talked to the Minister about this, I have never mentioned the following.

Deputies might be surprised to hear - I was certainly surprised - that I am a former governor of the National Maternity Hospital. I was very surprised because when I was elected Lord Mayor of Dublin, I was made a governor of the National Maternity Hospital. The reason I was there was because when the Archbishop of Dublin, who is the chairperson of the National Maternity Hospital, was not able to chair the meetings, I had the responsibility of chairing the meetings.

My two children were born in the National Maternity Hospital. There is much debate about the building being outdated, but the governance model of the current National Maternity Hospital is completely outdated because the Archbishop of Dublin and the Lord Mayor of Dublin chair the board. I remind people who believe the current model is appropriate or that it allows all legally permissible services that the Archbishop of Dublin is the current chairperson of the National Maternity Hospital. Based on my assessment as a layperson, I believe the current legally permissible services are available.

I welcome the Minister's comments that he will look at that issue of the term "clinically appropriate". He has done everything to reassure people to this point and I hope he will continue to do that.

I stress to people that we need this hospital. If the current National Maternity Hospital, which is chaired by the Archbishop of Dublin and whose freehold is owned by the Earl of Pembroke, can provide legally permissible terminations and if St Vincent's hospital, which is now a secular hospital, can provide terminations at the moment, then in a hospital which has far greater secularisation - in fact, not only do we have one secular hospital, we now have two secular hospitals as a result of this process - and with all the guarantees I have seen, I can see no reason or method whereby those services could be limited.

The Minister has asked for a two-minute suspension or he will be as quick as he can.

Cuireadh an Dáil ar fionraí ar 3.32 p.m. agus cuireadh tús leis arís ar 3.34 p.m.
Sitting suspended at 3.32 p.m. and resumed at 3.34 p.m.

It is amazing what a mess can be created by certain governments attempting to build hospitals. Fine Gael helped by Fianna Fáil has already made a fine mess of the financing of the national children's hospital. Now we have the current debacle with the new national maternity hospital. The main problem with the national maternity hospital is ambiguity. We all know the dangers of ambiguity and what can happen when what are understood to be long-standing agreements or principles break down. Let us consider Roe v. Wade in the United States. Established law from the early 1970s protecting women's rights to healthcare may be overturned on ideological grounds 50 years later.

We need to introduce safeguards against any kind of ambiguity or uncertainty. The best way to do that is to build a public hospital on public land. This is the very best way to guarantee all services required will be offered to women attending the hospital and it is the best way to protect the State's investment. I do not understand why the State cannot just own the land. As it is obviously not a financial issue, what is it? Why does St. Vincent's Healthcare Group want to keep control over the site?

I am a member of the Committee of Public Accounts and we have seen countless times the consequences of major capital projects going over budget and over schedule. We have seen the consequences of the State being beholden to private enterprises. The Government, for once, needs to learn from its many mistakes in the past and try to do this properly. One of the major stumbling blocks has been the "clinically appropriate" clause in the contract. The rent will be €10 per annum if six terms are complied with, including that there can be no change to permitted use without the consent of St. Vincent's Healthcare Group. Permitted use is subject to the clinically appropriate text which is undefined. Clinically appropriate can mean different things to different people in different times. What might be clear and obvious to the current Minister might not be so to a future anti-choice Minister in 50 years' time.

The safeguard of the golden share might not be worth a grain of salt in this case. We need stronger safeguards and Sinn Féin along with others here feel that a public hospital on public land is the best way to achieve that. The Government has not given any good reason we cannot do this. Of course, I understand about the need to avoid delays but I do not think we should proceed as things stand. There are simply too many unknowns.

I appreciate that clinicians in the field feel that things can proceed as they are, but our job is to ensure the State gets best value for money and that the rights and the healthcare needs of women in Ireland are protected. It is not just the Opposition and interest groups who can see this. Some Ministers and Government Deputies clearly have the same concerns we have, but it has taken some convincing to get them on board. For the umpteenth time we need a public hospital on public land. That was the original plan and that is the plan we need. For once we hope the Minister will listen this time and try to get things right from the get-go.

I will ask the Minister a few questions and give him time to respond at the end. This debate, sadly, relates to the issue of trust. In the week we are debating the ownership structure of the national maternity hospital, on Tuesday, during the introduction of the Birth and Information Tracing Bill to rectify the issue of illegal birth registrations, the Minister for Children, Equality, Disability, Integration and Youth, Deputy O'Gorman, offered a formal apology on behalf of the State for the deep hurt and anguish experienced by people whose births were illegally registered. The Minister said "nothing in these measures can undo the past and fully right the wrongs that these people have experienced".

Herein lies the problem before us. Many people feel that any link between the new hospital and the church, albeit through a private company, is a grave insult to the many victims of the church with particular emphasis on those impacted by the Magdalen laundries and the mother and baby homes. In reality, the nuns have passed the ownership to a company established by the church. This company will have three representatives on the board of the national maternity hospital and people believe this is a very strong link between the nuns and the ownership and governance of the national maternity hospital. Members of the HSE board expressed the concern that boards can influence the culture, values and ethics.

To address this, we have a proposed golden share to be held by the Minister. The golden share allows the Minister to direct the board to allow relevant lawfully permissible services without religious ethos or other distinction. The difficulty is that the country has a very poor history with the operation and use of golden shares.

The Sugar Act 1991 provided for a golden share in Greencore. That golden share was not worth the paper it was written on when it came to the abolition of the sugar quota. The golden, class B shares that are held in Aer Lingus to protect connectivity between Ireland and Heathrow will expire in September. Why will this particular golden share be different? How will it be enforced when we have such a poor record of enforcement?

I asked the Library and Research Service to look at this issue of the golden share for me. It has provided me with a paper that states that the EU position on golden shares and foreign direct investment has changed as a result of Covid-19 and member states can, in some cases, have rights that would enable the State to block or set limits on certain types of investments in companies. The paper goes on to say that while the guidance is directed at foreign direct investment, the general principle of the right or duty of an EU member state to safeguard essential assets, such as healthcare assets, could be read far more broadly. That is the case in terms of assets, but we are not talking about assets in this case.

I asked the Library and Research Service if it could find an example anywhere in Europe where a golden share applies to the provision of healthcare services, as is being proposed here. The Library and Research Service could not find any example of that. Will the Minister give me an example of where such a legal provision around a golden share is in operation anywhere else and where it has been enforced?

The concern in much of this debate relates to the phrase "clinically appropriate". It is referenced twice in the constitution of the new company. It is also in the operating licence that will be issued. However, it is not included in the clause relating to the golden share. We might replace the phrase "clinically appropriate" with a separate phrase that is in the clause relating to the golden share to the effect that any maternity, gynaecological, obstetrical and-or neonatal service which is lawfully available shall be available in the new national maternity hospital. The use of that phrase would overcome many of the concerns we have. If "clinically appropriate" does not include that broad range of maternity services, why is it written in the clause relating to the golden share and why is there a contradiction in terms between what is provided for in the golden share and what is being provided for in the constitution of the company and in the operating licence? The Minister might address that point for me.

The reality is we need a new national maternity hospital as quickly as possible. The current facilities are completely unacceptable for women. However, we need to see a review to address the genuine concerns that have been raised. With small changes, particularly to address the issues around "clinically appropriate", we can provide the clarity and reassurance that is needed.

I thank the Deputy for his contribution and questions. The golden share is a name attaching to ministerial powers. The golden share from many years ago was a name attaching to different powers. They just happen to have been called the same thing. What matters to us is what the ministerial powers here are. There are two very significant powers. The first is that the reserved powers of the new hospital, which are essentially the things the new hospitals does, can only be changed with the unanimous agreement of the board and that of the Minister for Health. It is those reserved powers that are so important because they are the powers around providing all services and doing so without any religious ethos. It is important no such change can be made without the unanimous agreement of the board and the agreement of the Minister for Health.

The second power is a power around being able to intervene directly. That is an important power that resides in clause 9.1.1 of the articles of association. It refers to the duties of the directors, one of which is to carry out any direction of the Minister, including in writing, at his or her sole direction, including to ensure, and this goes to the heart of the debate, any maternity, gynaecological, obstetrical or neonatal service which is lawfully permissible in the State shall be available. That is important. It does not state those services may be available; they shall be available in the hospital without religious ethos, ethnic or other distinction. It goes on to say, for the avoidance of doubt, that the directors shall be obliged to comply with any such direction.

The ministerial power here is important. Even if the board of directors were to agree unanimously, it does not have the ability to change the purpose of the hospital and the obligations on it. If somehow the board of directors fails in its duties or all of these amazing clinicians in Holles Street stop providing services, the Minister can directly intervene and instruct the hospital to provide all services and to do so without any religious ethos.

It is important we are having this debate today. Regardless of one's views, the development of a new national maternity hospital is a major milestone in the delivery of women's healthcare in Ireland. The women of Ireland deserve better, and we are finally getting it.

I have not spoken on this topic too much to date. I have previously stated my concerns around how this project was developing and the need for the State to own the land and site. I have also flagged the potential need for a compulsory purchase order. However, having listened to the Minister, numerous clinicians and legal experts, my view has changed. I believe the current proposal is the best way forward to deliver this project for future generations.

We all agree a maternity hospital is needed and I hear the concerns being raised by the Opposition and stakeholders. However, I feel some of the information being shared on this issue is misdirecting the key objective, which is to get this hospital built.

On the central issue of leasing the site, it is important to note that many primary care centres around Ireland are in buildings and on land owned by, and leased from, third parties. Nobody would reasonably suggest these landowners dictate what services GPs or other clinicians do or do not offer. As the Minister said earlier, the State does not own the current national maternity hospital or leading hospitals, such as the Rotunda, the Coombe, the Mater, Cappagh, the eye and ear hospital or the Mercy hospital. They are public, voluntary hospitals funded by the HSE for their day-to-day operations. The HSE also invests in their buildings and equipment to ensure the delivery of much-needed public health services. The national maternity hospital will be the same.

I, too, had concerns about the potential for certain procedures being curtailed, but again I believe that issue has been cleared up sufficiently. I am confident the documents published last week clearly show that all procedures under the law that are currently provided at the National Maternity Hospital will be provided in the new maternity hospital in Elm Park. As already mentioned, that includes termination of pregnancy, provision of contraception services, including tubal ligation, fertility services and gender-affirmation procedures. The legal framework provides assurances that all clinical services permissible will be provided in clinical practice and will not be subject to any Catholic ethos, or indeed any other religious beliefs, but only according to the best national and international clinical guidelines. This is made clear in the lease, operating licence and constitution of the new national maternity hospital that were published last week.

We are finally on the cusp of getting a world-class facility where women and babies will have the best possible care in a secular hospital, free from religious ethos, where all legally permissible services are provided. The Government's proposal, the contracts and legal framework ensure this is protected, along with the public good, in this proposal. I recognise and hear the concerns being raised but I also hear the resounding endorsement of clinicians at the existing National Maternity Hospital for the new hospital, as outlined by the Minister. Like many others in this House today and those watching this debate, I agree that the existing hospital is not fit for purpose. The women of Ireland deserve better.

I know a woman who is currently attending the National Maternity Hospital having suffered multiple miscarriages. This woman has to walk corridors filled with expectant mothers, pass rooms of pregnant women waiting for scans and walk by doors bearing end-of-life symbols indicating that the woman inside the room is in the process of loss. She goes on this journey to get to the mental health unit so that a psychologist can help her to process her difficult miscarriage. The Victorian layout of the hospital at Holles Street is retraumatising women. The women of Ireland deserve better. We are on the cusp of better and it is time to move forward.

I am grateful for the opportunity to participate in this debate and I thank the Minister for the time he is giving to help us to understand this.

I think it was Shakespeare, in King Lear, who wrote, "Striving to better, oft we mar what's well." More of us might say that the best is the enemy of the good. There is no doubt that this is not a perfect arrangement. If we were given a blank sheet of paper and were starting to design our health service from scratch, this is not how we would design it. However, in Dublin the only adult hospitals with the specialisms we would need to have to give a world-class maternity service are both voluntary hospitals, namely St. Vincent's and the Mater. That is the reality. I respect those who say that it would be better if that were not the reality, but it is. Best care is only going to be provided in the new national maternity hospital if we have that integration. The new national maternity hospital will give women dramatically better care, with single rooms, double the number of theatres and delivery rooms and massively increased access to new specialisms.

What must be said though, in recognition of the many concerns articulated by the Opposition and by some Government backbenchers, is that it is very understandable that if one puts the Catholic Church and women's health into the same sentence, a red mist descends for an awful lot of people. They remember the very painful history and that is extremely understandable. I can understand why this debate generates so much feeling among many people and that feeling is very genuine. However, our job is to look in detail at the partnership that is to be forged between an adult specialist hospital with a huge range of specialisms and the new national maternity hospital. That is what we are trying to do in this process. The first thing to say is that the church will have absolutely no role. A lot of people outside the House do not appreciate that this is the case - that the nuns have given over all of their interest. What remaining interest in the land that they held has now been transferred to a secular trust, operated under Irish charity law and with no role whatsoever in relation to the running of the hospital.

The second thing that strikes me is that the new hospital is going to be obliged to deliver all lawful abortions, sterilisations and other interventions, not only by its constitution which we have seen published, but also by the licence it operates under from the HSE, by the public interest directors who make up its board and by the golden share operated by the Minister. This is not just a triple lock, which we know of in other circumstances, but a quadruple lock that is being provided. It is far, far more than is the case with the current National Maternity Hospital, it has to be said.

I would have been among those who would have liked to see outright ownership, but ownership under a 300-year lease is ownership. Anyone who buys an apartment in this State knows that and that is the reality. We may question why St. Vincent's Hospital Group wants to retain a lease and not surrender full ownership. It has said that is an absolute requirement of its partnership in this project. The reasons it is offering are understandable at one level. These hospitals will have shared corridors and shared staff and are going to be wholly integrated on a site that has many other operations. One can see from St. Vincent's point of view why it would want to protect its wider operations on the site by having a lease arrangement and not outright ownership. To be fair, under pressure from Ministers, the group has come a long way in terms of the way the lease has been drawn up.

It must be borne in mind that the idea of a CPO, involving going to the courts, would be very hostile to any partnership arrangement. Also, it is very difficult to CPO something that is not going to be a detached hospital on its own grounds. This is going to be an integrated hospital, with shared corridors and so on. It would be very difficult to procure this by CPO. The outcome would be uncertain and it would certainly wreck the concept of partnership that is at the heart of this project.

I have listened to Deputies and to Deputy Bríd Smith in particular, whose views I might not agree with but I always respect the sincerity with which she expresses them. Her position is that we should not start out from here. I do not want to be putting words into her mouth but there are many who hold the view that there should be no private medicine in the Irish public health service, that there should be no non-State ownership and no voluntary trusts of this nature, but that is not the health service that we are trying to adapt to provide care for women who need it urgently and who are currently being treated in unsafe arrangements. It is really important that we start from what is possible, not from what is the ideal. As I said at the outset, the best is the enemy of the good.

I would like to ask the Minister to clarify a couple of things, the first being why it is necessary for the national maternity hospital to be a subsidiary of St. Vincent's Hospital Group. It is not clear to me why that condition is there. Like others, I would like the phrase "clinically appropriate" to be clarified. Reference has been made to the fact that there are limited specialisms going to be available in this particular hospital, which is understandable, that services evolve over time and that we want to protect the maternity and neonatal service but I agree with other Deputies that some clarifying statement around that phrase would be useful. There is a recognition that the Minister's words, when these arrangements were put in place, would carry considerable weight when anyone is looking at this subsequently, in a legal context.

I am speaking on behalf of Deputy Mattie McGrath, who sends his apologies. He cannot be here today because he is having a surgical procedure carried out.

The plan to move the National Maternity Hospital from Holles Street in central Dublin to the St. Vincent's campus has been in train since 2013, but the project has been mired in controversy for many years. The Religious Sisters of Charity have even transferred the ownership of the lands at St. Vincent's to an independent entity which is to lease the new maternity hospital site to the State for 299 years. Unfortunately, critics with fanatical agendas are claiming that a Catholic religious ethos would live on, possibly compromising the hospital's power to carry out different procedures on women. These claims are false and completely inaccurate as the new hospital will have operational and clinical independence to deliver all services that are permitted in the State.

In order to progress the delivery of a new national maternity hospital through the leasing of the site, a final sign off at Government level is now required. Reports indicate that under the proposed lease agreement, the HSE will own the building on a ground lease of 299 years and there will be a change to the board composition. The ongoing delays and foot-dragging by the Government mean that the construction costs for the new hospital have skyrocketed. The project will be funded with public moneys. Conservative estimates put the cost at €1 billion to build and fit out the hospital. Only incompetent public procurement practices would allow a project that started out with an estimated cost of around €200 million to climb fivefold in just a few years.

In all, everyone should satisfy themselves that a number of factors are fully addressed, including several factual positions. Will the State own the hospital? The answer to this question is a clear "Yes". The hospital will be the national State-owned hospital, built and funded by the State. The State will own it on a leasehold basis for the next 299 years. Will the State own the land on which it is built? No. There will, however, be a 299-year lease at a rent of €10 per year. That rent can only be increased if the HSE tries to use the site for purposes other than healthcare. Who will actually run the hospital? The hospital will be run by a charity regulated under charities law and it will be managed by board of trustees. No one will have a controlling interest and nobody will have a beneficial interest, except the Minister for Health who will have a golden share to protect the core values of the hospital. What role will religion play? None whatsoever. The Sisters of Charity have left healthcare in Ireland. Their shareholding in St. Vincent's has been transferred to another charity, not a private company as some allege. It is a charity regulated by law. The constitution of that charity makes no reference whatsoever to religious ethos. Furthermore, at the moment in Holles Street all of the obstetric, neonatal and general gynaecological care permissible within Irish law is available. Will all of that continue under the new hospital? The answer to that question is "Yes". With these questions clearly addressed and answered, it is clear that the project must proceed on from the decision in the publicised minutes. We must respect the views of those who are dissenting but not allow this to derail the building of the maternity hospital. We must accept that the best protections for a truly national maternity hospital are in place.

Members of this House and some commentators have wrongly attacked the Religious Sisters of Charity and have made all kinds of unfounded accusations against the order. A letter published in the Irish Examiner in November last, from Sr. Patricia Lenihan, the superior general with the Religious Sisters of Charity, outlined in the clearest possible terms the role, or otherwise, played by the order. Another letter published in The Irish Times on 4 May written by the chair of St. Vincent's University Healthcare Group, Mr. James Menton, addressed the outrageous misinformation and disinformation circulating about the St. Vincent's Healthcare Group. The letter also addressed the Religious Sisters of Charity issue. It confirmed that they have left the group and have no further involvement in it. The group is an absolutely secular institution. The contents of these letters paint a very different picture from those being painted by the people who wish to bash the Catholic Church on this issue. That bashing is all about political point-scoring and is nothing more than trying to use the situation for political gain.

It is also worth stating that the Religious Sisters of Charity have consistently called on the Minister for Health to speed up the transfer of the St. Vincent's Healthcare Group to facilitate it as soon as possible. The congregation has continuously insisted that it will have no role in the new national maternity hospital to be constructed on the site. The congregation withdrew its sisters from the board of St. Vincent's Healthcare Group in 2007. In 2020, they gifted 29 acres of land of the site of St. Vincent's Hospital to the State, and 3.2 acres of land to St. Michael's Hospital in Dún Laoghaire. In fact, the sisters have done everything in their power to expedite the transfer to the new independent charity which is St. Vincent's Hospital Holdings, so that the new hospital could progress. The delays to this project are completely due to the other parties involved, including the Minister, failing to take all actions necessary to facilitate the completion of the transfer as soon as possible. The ownership of the St. Vincent's Healthcare Group, which owns the lands, will be transferred to the new independent charity, St. Vincent's Holdings. The Religious Sisters of Charity have said that they now own only one building on the St. Vincent's Hospital site, which is and will continue to be leased to the healthcare group, in order to provide income for their continuing work and for the care of their elderly sisters.

Unfortunately, nuns in Ireland have been stereotyped in Irish public debate to the extent that they have been reduced to the role of villains. Perhaps then it is no coincidence that when the news first emerged that the new national maternity hospital is to be built on a site on the south side of Dublin that is owned by the St. Vincent's Healthcare Group, and for it to be owned by that trust, all hell broke loose simply because the Sisters of Charity own the trust. That trust has a 14-person board and two elderly sisters sit on it. The new maternity hospital will replace the current hospital on Holles Street, which is no longer considered fit for purpose. After tortuous negotiations between Holles Street and the trust, it was agreed that the new maternity hospital would have full independence although the trust, and therefore the sisters, would own it. I cannot understand. We should actually be debating the new children's hospital, including when it will be finished and why it ran over budget, but instead we have spent so much time on something that is quite simply and easily sorted. I put it to the Minister that we must get on with it and go ahead with it. The debating is over. The Sisters of Charity have basically gifted it to the country and we should make use of it.

Yesterday and today the Minister confirmed that there is a lack of trust around the issue of the church. This is not just confined to the past: it is here and now. There was a reference to "red mist" in an earlier contribution. This is a red mist that many thousands of women in the State have experienced.

To my mind there are very serious issues relating to trust in the context of the establishment of St. Vincent's Holdings. I want to refer to the so-called "fact sheet" issued last week by the St. Vincent's Healthcare Group. On the question of whether St. Vincent's Holdings CLG is an offshore company, it says "No" and suggests that the services of PwC were used to form St. Vincent's Holdings. They confirm that St. Vincent's Holdings is an Irish incorporated company, that no offshore companies were used in its incorporation, and that St. Vincent's Healthcare Group comprises only Irish incorporated and resident companies. This is factually incorrect. Two offshore companies, Porema Limited and Stembridge Limited, were instructed by PwC to set up St. Vincent's Holdings. The reasons for using offshore companies generally by companies is to mask the real instructions given in setting up a company. Only those involved in the setting up of St. Vincent's Holdings know what instructions they were given and who gave the instructions.

We do not know the exact nature of the St. Vincent's Holdings. Is there a public juridic person under Canon Law, as are the Sisters of Charity as a religious order? We cannot know the actual facts because we do not have access to the full application made by the sisters to the Vatican. We do not have access to all correspondence to and from the Vatican, and no access to the shareholder agreement between the Religious Sisters of Charity and the directors and owners of St. Vincent's Holdings. We do not know what conditions were attached to the transfer of the assets of the Religious Sisters of Charity in the St. Vincent's Healthcare Group to the St. Vincent's Holdings. These assets, including three hospitals, are estimated at above €500 million. It is inconceivable that the Vatican, having consulted with the archbishop of Dublin, Diarmuid Martin, and the president of the Irish Episcopal Conference and the apostolic nuncio to Ireland, Eamon Martin, would have agreed to transfer such assets to a charitable company without strenuous conditions being attached. The idea that the Government is prepared to do a deal without knowing who or what they are dealing with is simply wrong.

The St. Vincent's Healthcare Group's so-called "fact sheet" is a seven-page document and manages not once to mention or refer to the issue of termination of pregnancy. We need clarification on the issue of what is appropriate medical care. Everybody has said that we need clarification on that. It needs to be stated quite simply, in a legal document, that tubal ligation, sterilisation, gender affirmation, abortion and contraception will be part of the services in the national maternity hospital.

I have three and half minutes and I could make a lot of comments but I will try to be focused. I have read and struggled through the documents as best I can and what I see before me is that an unholy mess has been created. I have with me just some of the documents we have tried to download on the computer. That unholy mess completely suits the entity that is St. Vincent's Holdings, under the St. Vincent's Healthcare Group, and under that the new maternity hospital DAC, each of which is a complete subsidiary of the other. We cannot get away from the trinity. We have the male trinity at the top and we have the male trinity here. We simply cannot get away from it, it would seem.

We are here today because of the outrage, the upset and the lack of trust by the majority of women and men in Ireland on this. I disagree with the Minister of State, Deputy Butler. I have the greatest of respect for the Minister of State but there has been little or no debate on this other than what was forced by the Opposition repeatedly. We used three Private Members' motions, and Sinn Féin also used time, to force the debate. There are committed people on the ground who have been demonised for daring to ask a question. I will now go around in a circle and we will start in 2013, although it all started before that with the accountants report. In 2013 the male Minister for Health tells us that co-location is wonderful and that we all agree. I was not in the Dáil at the time but I will take the experts' advice that co-location is the way to go.

Fast-forward four Ministers later and there is no co-location anymore but complete integration into the trinity of ownership of private companies - the Minister shook his head earlier - albeit with charity status. Let us make English mean something here - they are private companies. The changes that have happened from the Mulvey agreement, which I welcome, are simply that we are now appointing three directors to the new company, which is a welcome change, and there is also a golden share. I have no idea what that means other than what I have read, but it does not reassure me in any way in this sense. I do not know how that is going to operate. What is the process around that? If somebody is at a disadvantage in the hospital because it is not being run the way it should, will that woman, man or anybody in that family be able to appeal to the Minister? Does the Minister understand that? We need guidelines around when and how that lovely golden share will be used.

We have a situation where St. Vincent's or whatever it was named absolutely refused to give over ownership. This Government and previous Governments never come back and said, look, it is not giving us ownership, therefore, we are going for a completely different model. The Minister never told us when the nuns gifted their share to the new entity and on what basis. Was Revenue involved in that? What was the value of it? I understand that at some point, it was a €600 million value. What value was it? What conditions were attached to it, if any? The Minister might clarify that. It has never been clarified. Has anyone seen the correspondence under which they were allowed to divest that very valuable asset to a new entity? Where is all the correspondence around that?

The phrase "clinically appropriate" has meant so many things to different people to whom I have listened. Sometimes it means all legally permitted procedures, and we are supposed to be reassured by that. Then, we hear from other experts that it means we are not going to have brain surgery. Can you imagine? We are not going to have other services here because it is a maternity hospital.

I have no idea really why we cannot have a public hospital on a public site. I say to Deputy Michael Collins that it is not ownership.

The Deputy's time is up.

I will finish up. Leasehold is not ownership; it is leasehold of the land. We do not even own the hospital. The Minister might say it is technical but there is no ownership here whatsoever. We finish up by going around in a circle and blame those who dare to ask a question. Does the Minister know when I despaired the most? It was when the deputy chair of the National Maternity Hospital went on the national airwaves to reassure us. I have to say, quite honestly and openly, a Cheann Comhairle, that I thought, sweet Jesus, what have we done as women to allow somebody like this speak in our name and attempt to reassure us that we own this hospital? We go through this labyrinthine document for what?

I thank the Deputy.

It is to serve the interests of St. Vincent's Healthcare Group, which is owned by St. Vincent's Holdings CLG. I thank the Ceann Comhairle for his tolerance.

I thank the Deputy for her contribution. I am sure she does not intend to cast any aspersions on the vice chairman of the hospital board.

I absolutely intend to take issue with his reassurance.

The Deputy is quite entitled to do that but we are not casting any aspersions on the individual.

I am sure he is a lovely man. I do not know him.

I do not know him either. I thank the Deputy very much for that. That concludes our statements on the National Maternity Hospital.