Health Insurance (Amendment) Bill 2024: Instruction to Committee

Minister for Health (Deputy Stephen Donnelly)

I move:

That, pursuant to Standing Order 233(2), Standing Order 187 is modified to provide that it be an instruction to the Committee on the Health Insurance (Amendment) Bill 2024, that it has the power to make amendments to the Bill which are outside the scope of the existing subject matter of the Bill, in relation to:

the Health Act 1970, to provide that HSE Guidelines on "ordinarily resident in the State" apply to certain women who receive menopause products;

the Health Act 1970, to provide for the making available for supply to women, without charge, of certain products used to alleviate the symptoms of menopause and for the provision of a regulation-making power for the Minister for Health in this regard; and

the Health (Pricing and Supply of Medical Goods) Act 2013, to provide for the HSE's conditional supply and reimbursement of listed menopause products, meaning hormone replacement therapy drugs, medicines and surgical and medical appliances, used to alleviate the symptoms of menopause and which are on the Reimbursement List as administered by the HSE;

and to make other consequential amendments required to take account of the changes above.

The purpose of this motion is to instruct the Dáil, in committee, that Standing Order 187 is modified in accordance with Standing Order 233(2) to provide that the committee has the power to make amendments to the Health Insurance (Amendment) Bill 2024 that are outside the existing subject matter of the Bill.

I am pleased to say that Government approval was recently received to bring amendments to the Health Insurance (Amendment) Bill 2024 to provide the legal basis for the introduction of free HRT, or State-funded hormone replacement therapy, and the moving of these amendments on Committee Stage. The proposed amendments will provide a legal basis for the provision of HRT to women experiencing the symptoms of menopause. This will mean that where a woman has been prescribed HRT by her healthcare provider to alleviate the symptoms associated with all stages of menopause, the cost of these medications and products will be met by the State.

A new section 67F is proposed to be included in the Health Act 1970 to provide for free menopause medicines and products to women who have been prescribed menopause medicines by their healthcare provider to alleviate the symptoms of menopause. Section 47A of the Health Act 1970 will be also amended to provide that existing guidelines on “ordinarily resident in the State” will apply to the women who receive free menopause products under this measure.

Section 20 of the Health (Pricing and Supply of Medical Goods) Act 2013 is to be amended to provide for the HSE’s continual supply or reimbursement of menopause products on the HSE reimbursement list, while section 23 of the Act is to be amended to provide for the HSE’s discretion for the supply of menopause products that are not on the reimbursement list.

Since I became Minister for Health in 2020, progressing and helping to bring about a revolution in women’s healthcare has been a top priority for me and this Government. The Government made a strong commitment to promoting women’s health in the programme for Government. I am proud to say that since then, the Government has allocated approximately €180 million to be targeted at new developments in women’s healthcare. We have heard from many women that they often feel dismissed in their experience with menopause, that the cost of menopause care is a burden, and that some women have even considered giving up their jobs due to the severity of their symptoms. This legislation, when enacted, will mean that where a woman has been prescribed HRT by her healthcare provider to alleviate the symptoms associated with all stages of menopause, the cost of those medications and products will be met by the State. This will relieve some of the cost burden we have heard about.

In line with established policy, HRT medications and products covered will be those that are included on the HSE reimbursement list. In order to progress this work to lower the cost of menopause, I have allocated €20 million to implement this new measure in 2025. The measure does not cover the cost of consultations with healthcare providers, costs for pharmacists, or costs for the insertion or removal of a coil. These matters can and should be considered as matters of policy in future expansion of the scheme.

We have made important progress in menopause care in recent years. This includes the establishment of specialist clinics for the treatment of complex menopause cases. We have increased awareness among our clinicians through the development of training and a quick reference guide for GPs and practice nurses to upskill in identifying and treating symptoms of menopause. In budget 2023, we began the process of relieving the short-term costs of menopause on women with the removal of VAT from HRT products. This new measure today represents the next step in this process.

Hormone replacement therapy is the most commonly used treatment for managing menopausal symptoms and has been shown to be the most effective intervention for management of these symptoms. Many women will spend a good portion of their lifetime going through the various stages of menopause. This measure aims to make this transitional period a little easier by making HRT more accessible to everybody who needs it and providing it for free, or State-funded.

I ask for the support of Members of the House for the motion to enable these important amendments to be tabled.

Deputy David Cullinane

I will absolutely support these amendments. This is something for which we have collectively called for some time. I will make a broader point that there have been very significant developments over the past number of years in supporting women in menopause, including the establishment of menopause clinics. A whole range of other measures were put in place. The Minister outlined other areas where we can advance further over the course of the next number of years. I assume that will fall to the next government.

I will ask a question. We are obviously legislating for free HRT for women - not all women but for women who need it. I will put two issues to the Minister. When will that come into effect? Will it be free from day one, or is it something that will be incrementally brought in? The Minister referenced €20 million, but it is not exactly clear when this will go live, to use that expression, or come into effect. Is it something that will be free from day one or will it be at reduced cost and will ultimately be free over time? The other issue I have been asked to raise by younger women with endometriosis, and other women who have the symptoms of menopause at a much younger age, is whether they will be also included. Will it be women of only a certain age? The Minister might be able to come back with some of the details on that. These are issues I have been asked about.

I support the amendments. This is important progress. I welcome the funding that has been announced.

Deputy Róisín Shortall

I very much welcome this motion to allow for amendments outside the scope of the original health insurance Bill. The amendments brought forward by the Minister will, if passed, provide the statutory basis for free HRT, as we have been told.

It is true to say that for too long women's healthcare has been sidelined but, thankfully, that is changing. There are still numerous examples of paternalism in our health service, especially in reproductive health, but the shroud of shame that reinforced that culture is certainly beginning to lift. The Minister should be commended on the particular interest he has in the area of women's health and the progress that has been made to date. Although there are many more important actions that still need to be taken, which I will return to later, it is important to acknowledge the initiative he has taken here. Notwithstanding this, the introduction of free HRT from January will have a significantly positive impact on many women's lives. That is very much to be welcomed.

For too many, the cost of HRT has been prohibitive. Most women who avail of HRT take it for two to five years and face prescription costs of between €30 and €70 per month, if they do not have a medical card. This new scheme should save those women up to €840 a year. That is very much welcome, but HRT comes in many forms and prescribing vastly varies based on hormonal profiles. That is why it is important that key stakeholders are engaged in the planning of this roll-out. Women and their representative groups must be also consulted to ensure the scheme is effective and tailored to their needs. Maybe that is happening already but it is very important. I am not aware of there being that consultation. Another matter that must be addressed is the shortage of HRT. I appreciate that this is a global issue and that the Minister has taken legislative steps to address medicine shortages. However, greater engagement with the relevant stakeholders is required to bridge this gap, in particular, with the Irish Pharmacy Union.

I will take this opportunity to speak more broadly on the women's health action plan and its implementation to date. An updated action plan for 2024-25 was published in April but it was not accompanied by a new implementation plan. Publishing a plan is well and good but delivery is obviously the key thing. I acknowledge that significant progress has been made on free contraceptives, menopause care and IVF, but I am very concerned about perinatal mental health. The new women's health action plan makes no mention of the long-promised mother and baby unit in St. Vincent's hospital. This was promised in the 2022-23 action plan. Some of us have noticed that it seems to have been dropped. What has happened to that? It is very badly needed. This new unit was supposed to have been delivered by 2023 but in a recent parliamentary question reply from the HSE, I was told that St. Vincent's does not have the space for it. This means that mothers who require admission to a psychiatric unit in the postnatal period will continue to be separated from their babies. That is unacceptable, as I am sure the Minister will agree. Given all the well-documented adverse effects associated with this practice, there should be no question of that happening. It is now seven years since this facility was first recommended in the model of care for specialist perinatal mental health services. Why has it taken this long to realise that St. Vincent's cannot facilitate it? What are the alternative arrangements?

Of course, one unit was not a very ambitious target to begin with, yet it is still being missed.

There are more than 20 of these units in Britain, for example, yet we do not seem to be able to provide even one for the entire country. The Minister needs to provide a new timeline for delivery of this vital perinatal mental health facility.

I also add my voice to the National Women's Council's call for a more targeted approach to women's health. The action plan needs a clearer focus on how the inequalities experienced by marginalised women can be addressed. This must include the social determinants of health. In some cases, we are talking about basic social determinants such as poverty, educational disadvantage, housing inequality and low incomes. They need to be addressed because they are a huge factor in terms of women, and indeed men in other cases, in being able to access care. We are also conscious of the commercial determinants of health, which, very often, work against well-being and good health status. The issue of the social determinants of health was dealt with extensively in the 2017 Sláintecare report, but it has not received the kind of attention that it deserves. While removing cost barriers is an important part of the solution, tackling the social determinants of health requires a cross-departmental and cross-government response, which was why the implementation office for Sláintecare was supposed to be in the Taoiseach's office, because most Ministers have a role to play in terms of tackling the social determinants of health.

I am also very concerned about the lack of progress on the legislative recommendations in the O'Shea review of termination services. The health committee published its report on this last December. Almost a year later, it is still only being considered by the Cabinet committee on health. Clearly there is no appetite to act on the health committee's recommendations to give effect to the O'Shea report without delay. The delay certainly has been very undue. At this stage in the Dáil term, with an election looming, it is hard to see that there will be any chance of these issues being addressed in advance of the election, and that is very regrettable. These ongoing deficits in women's healthcare will need to be the priority for the next Minister for Health. We certainly need to keep them on the agenda.

Insofar as this proposal goes in respect of HRT and making it available free of charge, it is a good initiative. There is a slight concern among some people who would say there is already quite a high prescribing rate for HRT. We need to make sure the Bill does not increase that rate. There are ways other than HRT through which women deal with menopause. That is absolutely fine. There is a lot of different thinking on that. It is important that it does not influence the approach the medical profession and women themselves take to menopause. It is a very welcome development, however.

Deputy Richard Boyd Barrett

Never let it be said, but I am happy to support this positive development. It is an important step forward for women's healthcare. Making products that help alleviate the symptoms of menopause, such as HRT, free to women is a very welcome development. It points in the direction we want to go, which is that all healthcare should be free for all who need it. I refer not only to women's healthcare, but all healthcare, based on a person's needs and not what a person can afford or what a Government is willing or unwilling to put into these vital services. I am happy to support the Bill.

I will comment briefly on the earlier discussion. There is absolutely no question but that our health workers make our health service function and are responsible for the huge achievements of our health service in terms of looking after sick and vulnerable people in this country. Do not let anything that is said in this discussion imply that I am making any criticism of health workers. I doubt anybody is making any criticism of health workers - far from it. The points that were raised were brought to me by health workers, however. That is why I brought them up. I did not make them up. I did not develop them for a pre-election narrative to have a go at the Minister for the sake of it but, rather, because health workers, many of them women, contacted me, demoralised.

Notably, the Minister did not respond on the substantial issues I raised with him regarding St. Michael's Hospital because they are facts beyond dispute. They are not misinformation; they are responses to parliamentary questions from the Minister's Department and from the HSE, stating that maternity leave is not covered. The jobs of women workers are not covered, leaving the rest of the staff, often women, very stressed and demoralised because of the Government's employment and financial control framework. That is what they said. That is not misinformation; it is a fact. The Government does not want to admit it, but it is a fact. The Minister should not try to characterise others as misrepresenting or bringing in misinformation when those are facts and they are coming from health workers. The Minister is entitled to put out his narrative and his propaganda all he wants but, equally, he should acknowledge when real issues are raised about the problems the Government's policies are causing. The Minister sort of guffawed about the CT scanner in St. Michael's Hospital that I mentioned earlier, as if to say they only asked for it in 2023 and it is now the end of October 2024. Does it really take a year for somebody to assess whether a CT scanner is needed in St. Michael's Hospital? Do we need to bring consultants in to assess the business case? The Minister can tell me if I am wrong or missing something, but it does not bode well if that is the case. It does not bode well if the nurses are balloting for industrial action or if they are protesting. It does not bode if well if huge numbers of posts in the health service are not being filled. It does not bode well if huge numbers of people feel compelled to pay large amounts of money in private health insurance because of their fear of waiting lists, sitting on trolleys or the lack of proper resourcing and staffing and so on in the health service. There is no misrepresentation in any of that. I admire the Minister's combative response. For the Minister to fail to acknowledge the problems the pay and numbers strategy is causing in terms of the morale and the capacity of our health service is to misrepresent the real situation in our health service.

Deputy Michael Healy-Rae

I warmly welcome the Government's proactive approach to this issue because it is something I have dealt with in my work in recent years. One thing I was very grateful for were the specialist clinics for treatment of complex cases. Unfortunately, the law of averages pertains to all issues in life, and the whole issue of menopause can have varying degrees of complex cases. I acknowledge the work that has already been done and I appreciate what is going to happen going forward regarding State-funded HRT treatments. It is welcome. It is only right that we do anything we can to assist ladies in these types of difficulties. I thank the Minister and the Government for doing that.

I do not like shouting at the Minister at all. It is the exact opposite, in fact. There is a reason, however, that everybody is getting heated here today.

I want to say this in a very cool and proper fashion, with respect to the Ceann Comhairle. Today, for example, many people marched outside University Hospital Kerry in Tralee. These are workers who are working for us. When I say that, I mean they are working for the State. If we need help and to go to hospital or if our parents, grandparents or other family members have to go to hospital, we have to rely on those people. Those people are not coming out and protesting outside the gates of the hospital for the fun of it or because they are happy with you. I do not like personalising anything. When I say "you", I mean the Minister for Health. It could be Deputy Donnelly or the person before or after him. It is whoever holds the position of Minister for Health. If they were happy, they would not be protesting. They would not be coming out and saying they need this, that or the other. The reason people like me are standing up now or earlier today and being angry about that is that we are their voice. Being a Teachta Dála means nothing more than one is a messenger of the people. We have to come up here. Earlier this morning, I wanted to go to Kerry because I wanted to be with those people outside the gate to show them that a person who is elected for them was listening to them. I did not go because I decided my place was to be here, to speak and be a voice for them here. I am saying this respectfully. I am not shouting across the floor at the Minister and one thing I am definitely not doing, because I do not agree with it, is personalising it and saying the Minister did this or that. It is the office of the Minister. Of course, we would like to see issues like cataracts being dealt with. I will send a bus up to the North next week. We should not have to be doing that. We should have a proper ophthalmology unit in University Hospital Kerry, Tralee. If something happens to the eye of a person working on a lever crane or in a farm yard, such as a bit of steel flying into it - it could be the simplest thing in the world - that person will not be able to get that taken care of in Kerry. The person would have to head to Cork. That is wrong. We should have better services.

Do I acknowledge that services have improved in certain areas? I do, but I am working very closely with people who work in our community hospitals and they are under severe pressure. I know of people going in at 4 a.m. and 5 a.m. on their days off to do paperwork just because they are diligent. They are not paid any extra for doing that, not one euro, but they are doing it on their day off because they want to keep their day off as their day off but at the same time they do not want to be clogged down with paperwork. They are not saying anything about it to anybody. I personally know of people going in at 4 a.m. or 5 a.m. and doing paperwork and then going away and calling that their day off. They are not making any song and dance about it. That is why we are angry when we are speaking for those people. If everything was right, we would not be standing up here and criticising the Minister. I heard the robust answer the Minister gave to Deputy Boyd Barrett. Deputy Boyd Barrett is passionate when he is speaking, as are the rest of us. Why is that so? It is because we are diligently doing our jobs and fighting for people. We are not sent in here to be silent or to be mummies. We have to hold the Minister and his Department to task.

It is not as though the Minister is not armed with money. My God, you could wallpaper the walls with the money that the Department of Health is getting. The amount of money the HSE is spending every year is astronomical. If you put it on a graph, Warren Buffet could hardly keep account of it because the amount of money we are putting into health is going straight up to the stars. It is really astronomical. It is frightening. At the same time, the delivery on the ground is not there. Why are nurses collapsing under the pressure of work? Why are they complaining? These people are not complainers. Every one of the fine nurses, doctors and catering staff are diligent people. They are not groundlessly complaining that they are overworked and underpaid. They are proud of their work. They want to be there but they want to feel appreciated. They do not want to be run ragged. I know the Minister will appreciate this but what every one of us here today should be focusing on is the patient, that is, the person lying in a bed. It could be a stroke victim who needs an extra bit of attention to be helped up and put sitting on a chair. Can the Minister imagine how bad he would feel if he was a nurse and knew that Mr. A or Mrs. B should be taken out three times a day but, in his heart and soul, he knew he could only do it once a day because of time constraints? He would be upset in the evening when he was going home and he would feel that he did not get around his ward. It is not the fault of the nurses in these situations. They can only do so much. That is why they relay it to us and we come up here. That is why we are angry.

The Minister should not take it as though it is a personal attack or anything. To be blunt, it is us doing our job properly. If we were not on our feet and getting cross, we should not be here at all. The Minister should not blame us for being factual or tough. All we are trying to do is stand up for vulnerable people and, ultimately, the patient. We are shouting on behalf of the person lying on a bed who needs extra physio. The Minister should not blame us for shouting up for people.

Question put and agreed to.

Dáil Éireann debate - Wednesday, 23 Oct 2024