Clinical Guidelines for the Introduction of Abortion Services: Discussion

The issue for discussion this morning is the clinical guidelines for the introduction of abortion services and in our first session this morning we are meeting representatives from the Medical Council, the Irish College of General Practitioners, and the Institute of Obstetricians and Gynaecologists in this regard.

I welcome Dr. Suzanne Crowe and Mr. Bill Prasifka from the Medical Council. I also welcome Dr. John O’Brien, Dr. Mary Favier and Dr. Tony Cox representing the Irish College of General Practitioners. I welcome Dr. Peter Boylan and Dr. Clíona Murphy from the Institute of Obstetricians and Gynaecologists, who are also representing the Royal College of Physicians of Ireland, RCPI. I wish to draw attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I also wish to advise witnesses that their opening statements will be published on the committee's website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I invite Dr. Suzanne Crowe from the Medical Council to make her opening statement.

Dr. Suzanne Crowe

I thank the Chairperson and members for the opportunity to address the committee today. As the Chairperson said, I am a member of the Medical Council. I am also the chairperson of the working group which is reviewing the section relating to abortion in the Guide to Professional Conduct and Ethics for Registered Medical Practitioners. I am joined today by Mr. Bill Prasifka, CEO of the Medical Council. We are here to discuss the council’s role in regard to this important issue, so I will begin by giving a quick outline of the council’s responsibilities and functions which are particularly relevant in the context of the referendum result and pending legislative changes.

The Medical Council is the statutory body responsible for the regulation of doctors within the Republic of Ireland. Its purpose is to protect the public by promoting and ensuring the highest standards among doctors. The council works to ensure that medical education and training is always up-to-date and is benchmarked against the highest international standards. Standards for undergraduate and postgraduate training are set by the Medical Council. The council also requires doctors to maintain their professional competency through updating and maintaining their professional skills on an ongoing basis. The Medical Council is also where the public may make a complaint against a doctor.

The principal functions of the Medical Council relate to the control of standards of education and training at undergraduate and postgraduate levels, the registration of medical practitioners in accordance with their education and training, the determination of questions of professional misconduct or fitness to practise and the operation of EU directives relating to education and training in the practise of medicine. The Medical Council also provides guidance to doctors on matters relating to conduct and ethics through its Guide to Professional Conduct and Ethics for Registered Medical Practitioners. In summary, the key objective of the council is to protect the interests of the general public in their interactions with registered medical practitioners while also supporting doctors.

In terms of the Medical Council’s role following the referendum result and pending legislative changes, it should be noted that the Medical Practitioners Act 2007 requires the council to, among other things, provide appropriate guidance on all matters relating to professional conduct and ethics for registered medical practitioners. However, it is the role of the postgraduate training bodies to set clinical guidelines. The Medical Council sets out ethical guidelines for registered medical practitioners in its Guide to Professional Conduct and Ethics for Registered Medical Practitioners, the current or eighth edition of which was published in 2016. This guide is regularly reviewed and updated when there is a relevant change in legislation. Section 48 of the 2016 edition details guidance on doctor’s actions around abortion. However, the guidance currently relates to the situation prior to the referendum result and will need to be adjusted and updated in the context of upcoming changes in legislation. Section 49 of the current guide puts forward guidance for conscientious objection from a doctor. This section is also of a particular relevance to the changes in legislation and will also be reviewed and updated as appropriate. Sections 48 and 49 of the guide and a full copy of the guidance were provided to the committee as supplementary information in advance of this meeting.

The Medical Council term of 2018 to 2023 has recently begun and reviewing the ethical guide in light of the referendum results was a key item on the agenda for the first meeting. During this first meeting, the council came to the decision to establish a working group to review the guide as there are sections which will need to be updated or changed following the referendum result. The procedure for a section of the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners to be updated would normally be for a council committee or working group to review relevant information relating to the topic, be it research or new legislation, consult with key stakeholders and then draft guidance on the matter. Once the council is happy with the draft wording, further targeted consultation would normally take place and any feedback would then be taken into consideration. Final proposed guidance would then be brought to the full Medical Council meeting to be decided on. This ethical guidance from the Medical Council is for the use of doctors and should be followed in conjunction with the clinical guidelines set out by the postgraduate training bodies.

The Medical Council is happy to keep the members of the Joint Committee on Health updated throughout the process. I thank the Chairman and the committee for the invitation to address members today. We are happy to address any questions the committee may have.

I thank Dr. Crowe. I now ask Dr. Favier to make her opening statement.

Dr. Mary Favier

On behalf of the Irish College of General Practitioners, ICGP, I thank the Chairman and members of the committee for their invitation to discuss the matter of clinical guidance in the context of impending legislation for the termination of pregnancy in Ireland. The ICGP acknowledges that changes that will be required by the outcome of the May 2018 referendum on the repeal of the 8th amendment. As a result of the referendum outcome, a patient centred clinical care pathway for termination of pregnancy as part of a comprehensive reproductive and sexual health service that is appropriately resourced will be required in Ireland. The proposed legislation on this matter needs to be accompanied by measures and policies which aim to reduce the incidence of crisis pregnancy and provide support for those who experience it, including comprehensive contraceptive services and sexual health education programmes.

The result of this referendum has created a new reality. What has principally changed is that terminations of pregnancy which were previously undertaken in another jurisdiction will now be carried out in Ireland. How this is done, the standards and quality of care, the legal implications and the supports given to women at a difficult time is of concern to all of us. As healthcare professionals, it is imperative that we engage to ensure a safe and workable outcome. Our college needs to be part of designing the service and we would like to do so with our colleagues in the Institute of Obstetricians and Gynaecologists.

More detailed information is needed to inform legislators and to enable the Department of Health, together with the postgraduate training bodies and the representative bodies, to comprehensively draw up the detail and resourcing of services for those with unwanted pregnancies. Whichever model of care is developed, the patient must be front and centre in the required clinical care pathway. To ensure the delivery of safe, high quality and timely services to our patients, a series of critically interconnected elements will clearly need to be in place.

These will include the following: legislation; clinical guidelines and clinical care pathways; the licensing of appropriate medications; secondary care referral pathways clearly delineated and resourced; community-based opt-in provision; clarification regarding medical indemnity, if there is any; Medical Council guidelines; and a 24-hour helpline that includes a clear referral pathway to a known community provider, referral to in-person counselling, if required, expert advice to pre and post-termination expectations of care and complications and triage out-of-hours advice to address patient concerns and side effects, post-procedure, with onward referral to medical follow-up, if that were to be required.

This opening statement summarises the work, which may change as new evidence arises, required to address the pertinent concerns such as ultrasound and blood typing, and it summarises key elements of a clinical care pathway. Termination of pregnancy will be legalised for the first time in Ireland. Few clinicians are trained to deliver this clinical care pathway, unless they received training outside this jurisdiction. Naturally, this leads to concerns about patient safety in community-based provision of this new service. To address these concerns, and to generate solutions in the design of a termination of pregnancy service, the college undertook an electronic member engagement process, which does not close until the end of this week.

We have received some good and innovative suggestions for how a service might be offered. Clinical guidelines need to capture the full clinical care pathway from initial appointment to follow-up care post-termination. Clinical guidelines would map to the expected legislation and would undergo the usual best-practice rigorous review process in the college. GPs would prefer an opt-in mechanism by which they choose to provide this clinical care pathway. Clinical guidelines would be expected to address the totality of care provision, including appropriate means of confirming and dating a pregnancy, medical termination of pregnancy for those at up to nine weeks’ gestation, consideration of the additional complexities of providing medical termination of pregnancy at up to 12 weeks’ gestation, and secondary referral to hospital care where required in complex cases or cases where there is uncertainty about dates, known risk factors, etc. Following discussion of all the options available to her, the final decision about whether to undergo a medical or surgical termination of pregnancy should be the woman’s own choice and the appropriate informed consent obtained.

The evidence base on the need for administration of anti-D and the need for ultrasound scanning is becoming clearer and the guidelines would clarify these issues. If ultrasound is required, rapid access to this facility, including the expert provision and interpretation of sonographs, will be a critical element of the pathway. A 24-hour helpline, staffed by appropriately trained clinical staff will be required. This helpline will serve a dual purpose, namely, to provide immediate access to clinical information and care to those with a crisis pregnancy who are considering termination, and to provide post-termination assistance to answer specific questions and make onward referral for care as indicated. Whether GPs wish to provide this service, college members have expressed concerns regarding capacity and resourcing challenges such as staffing, facilities and training; the potential lack of appropriate specialist support; the possibility of medical complications for their patients; the public reaction for those who choose to provide and those who do not choose to provide this clinical care pathway; and a fear of litigation. They wish to see an acknowledgement of conscientious objection and how to accommodate this in the care pathway, and an acknowledgement of conscientious commitment and how to support this in the care pathway. There needs to be an integrated and resourced contraceptive service, provided to reduce the incidence of crisis pregnancies. They want clinical care pathways to keep the patient central to the service and be free at the point of care. They have concerns about the remuneration for service providers and desire a commitment from the Department of Health to a timeline within which a woman can expect to receive a service.

This is a significant juncture in medical care in Ireland. We have an opportunity to ensure the provision of a safe, best-practice, appropriately resourced, patient-centred termination of pregnancy clinical care pathway. The ICGP looks forward to playing a significant role in the development of this pathway.

Dr. Peter Boylan

We welcome the opportunity to address the committee and to discuss the matter of clinical guidelines being prepared in light of the impending introduction of abortion services in Ireland. The IOG is the national professional and training body for obstetrics and gynaecology in Ireland. Members of the institute are drawn from all 19 maternity hospitals and units throughout the country. In April this year, the IOG set up a number of working groups to establish principles to underpin the development of guidelines for legislation for abortion services in Ireland in the event of successful repeal of the eighth amendment. More than 50 members of the institute volunteered to participate in the development of guidelines. Members have visited units in Scotland, England and Norway where abortion care is integrated into the health system. Clearly, the legislative process is not yet complete, so the IOG working groups are drafting guidelines on the basis of what has been proposed to date by the Minister of Health. Guidelines will be completed when the final legislation is passed by the Houses of the Oireachtas.

The following workstreams have been established: early pregnancy; threat to life and health of the mother; fetal medicine; conscientious objection; and staff training. I will comment on the some of the general principles that we are following. To deliver fit-for-purpose services for termination of pregnancy in Ireland, the institute recommends that services should be free to all at the point of delivery and funding for the service, as with all women’s healthcare, should be appropriately resourced and ring-fenced. International experience, supported by data, is that following legalisation of abortion services, numbers decline with the passage of time for a variety of reasons, including the removal of barriers to access and when the service includes advice on, and provision of, contraception. The IOG, therefore, strongly supports the proposals of the Oireachtas Committee on the Eighth Amendment of the Constitution and the Minister for Health’s proposal that every effort should be made to reduce crisis pregnancies, including by the provision of free contraception.

Early pregnancy is defined as the first 12 weeks of pregnancy, that is 12 weeks after the woman’s last menstrual period and, on average, ten weeks post-conception. We have looked to the example of Scotland, a country with a similar population to Ireland, for data on termination services. In Scotland, approximately 75% of terminations are at less than nine weeks and 91% of these are medically induced. Approximately 10% require hospital attendance because of complications. We believe that Irish figures should be in line with those of Scotland.

In line with international best practice, it is proposed that early medical abortion, at less than nine weeks' pregnancy, takes place in the community. Although routine pre-termination ultrasound scanning is not recommended as mandatory in international guidelines, it is performed in most circumstances where it is readily available, and always if there are concerns about dates or ectopic pregnancy, or if the woman chooses. In Ireland, however, we are only too well aware of the well-documented infrastructural deficits in access to ultrasound in pregnancy. Introduction of a termination service without adequate scanning facilities is fraught with risk, and the IOG, therefore, recommends that appropriate and immediate investment in ultrasound is an integral element of termination services. After nine weeks, and before 12 completed weeks, it is recommended that medical termination takes place in the hospital setting due to the increased risk of complications such as bleeding. It is likely that a proportion of women will choose a surgical option for practical reasons. Risks and benefits of both methods will be explained.

The IOG recommends that a 24-7 helpline be established to help with appointments, provide reassurance, and provide information if a woman is concerned about any aspect of her care such as where to go in the case of a complication. The proposed three-day interval between the first consultation and initiating the termination is not supported by evidence; it may act as a barrier and it makes unwarranted assumptions about women’s ability to make their own decisions. There is evidence that those who request termination remain satisfied with their decision. A waiting time, if any, should be from the time of first contact with the service.

Contraceptive advice and services, including long-acting options, should be available at the time of the termination. Blood tests for anaemia, blood group and HCG, if appropriate, should be taken at the time of first consultation. It may also be appropriate to test for sexually transmitted infections in certain circumstances. On the threat to life or health of the pregnant woman, any woman whose life is at risk or where there is a serious risk to her health will be in hospital already. Since the introduction of the Protection of Life in Pregnancy Act in 2013, experience has been gained in the performance of termination in hospitals and, therefore, current practice need not alter.

Foetal medicine and termination for a lethal foetal abnormality will take place in hospitals. The medical procedures will be the same as for those performed for the risk to life or health. It is envisaged that medical management with Mifepristone and Misoprostol will treat the majority of cases.

Termination for foetal abnormality currently takes place outside the State. Diagnosis in Ireland is almost exclusively based on ultrasound. In the United States and Europe, magnetic resonance imaging, MRI, is the standard of care. It is useful in complex anomalies to confirm or exclude pathologies suggested by ultrasound. MRI results can change a diagnosis from fatal to life limiting and vice versa. The overall diagnostic accuracy of MRI is 93% compared to 68% for ultrasound. Thus, when MRI is used, further to initial ultrasound, additional information is provided in 50% of cases, the diagnosis is changed in 35% of cases, medical management is changed in 33% of cases and prognosis is changed in 20% of cases. MRI is currently only available in one maternity hospital in the country. The IOG recommends funding to expand access to foetal MRI.

The Medical Council has clear guidelines on conscientious objection. In section 49 of the current guide - I will not read it out - if a doctor has a conscientious objection to treatment then he or she has a duty to transfer care to another doctor. In an emergency there is no option but to give care. We see no reason to change these guidelines but we understand that the Medical Council is looking at them. Section 50 deals with current termination services in Ireland and will need to be updated once the legislative process relating to abortion is completed. We draw attention to the fact that the document on the professional refusal to provide abortion care on grounds of conscientious objection and European human rights jurisprudence on State obligations to guarantee women's access to legal reproductive healthcare has a human rights perspective. It states that, at a minimum, the State must ensure the adequate availability and dispersal of willing providers, prohibit institutional refusal of care, establish effective referral systems, disseminate information on legal entitlements to abortion care, impose clear limits on the legality of refusals and implement adequate monitoring oversight and enforcement mechanisms to ensure compliance with relevant regulations.

We want to be sure that the system is not set up to fail as we have seen already with other systems. On staff training, the institute has already begun organising courses for staff training on techniques not currently performed in Ireland and education on abortion care is being introduced into postgraduate training programmes for doctors. I understand that it will also be introduced into undergraduate programmes. A separate educational programme based on conscience and values is recommended for all whether directly involved in abortion care or not. Abortion care in Ireland will be a significant change for all healthcare professionals. In view of this, we recommend the establishment of an abortion provider's network to include nurses and midwives who will be integral to the delivery of woman centred care. I thank the committee and will be happy to answer questions.

I thank Dr. Boylan. To start, I would like to ask two questions. On the heads of the general scheme of the Bill, published in July of this year, which is the only document that we have to work on at the moment because we do not have the legislation yet, in head 7 in relation to early pregnancy, there is a requirement that the medical practitioner forms an opinion in good faith that the pregnancy concerned is not in excess of 12 weeks. Is Dr. Boylan making a distinction between nine weeks and 12 weeks in that after nine weeks it should occur in a hospital setting?

Dr. Peter Boylan

Yes, that is correct.

The second part of the question is on the three day period from initial consultation to confirming that the woman wants to proceed with her termination. Does Dr. Boylan feel that is not a necessary step? Is that correct?

Dr. Peter Boylan

Yes, it is. I will address head 7 on nine and 12 weeks first of all. Beyond nine weeks the rate of complication such as bleeding and perhaps a need for surgical completion increases and, therefore, it is not appropriate that should be carried out in the community. Most of the early terminations, in fact the vast majority, will take place in the woman's own home, in her own environment wherever she wishes to be. That is not appropriate if there is a high rate of complications from a patient safety point of view and so from nine to 12 weeks women will require hospital management. That raises the question of ultrasound as a dating mechanism. Figures vary but in Scotland, for example, about 30% of women will require a scan for uncertain dates and it will probably be something similar here. We have to be very careful in this country when introducing this service that there are no hiccups or adverse outcomes so we recommend that the majority of women would have access to an ultrasound scan if necessary or if the doctor feels that it is necessary. That will require a significant beefing up of ultrasound availability to doctors working in the community and to doctors in general.

In respect of the three day waiting period, there is not really any evidence that it is necessary. There are mixed opinions about it obviously and in some countries in Europe, the Netherlands for example, there is a waiting period between the time of first consultation and the actual termination of pregnancy. There is not, however, any evidence that it is necessary and it also makes presumptions about women's ability to make decisions about their own healthcare. We have heard much about paternalism and attitudes to women recently in light of the CervicalCheck problems so while there will be mixed views about it, many doctors feel that it is not in fact absolutely necessary and perhaps should be dropped. That is, however, a matter for the Houses of the Oireachtas.

I thank Dr. Boylan. Do any of the other groups want to make a comment on those questions in respect of nine weeks and 12 weeks?

Dr. Mary Favier

The expectation is that a service can be provided very safely in a community setting up to and including nine weeks. Between nine weeks and 12 weeks, as Dr. Boylan has said, complications become more problematic and there are more dating issues. We will need a very careful well elaborated pathway. When we talk about clinical care pathways we mean how to plot the journey a woman takes from the beginning through to the end of a service so that there is an expectation by the clinician providing the care of what that service will be. When we talk about guidance and clinical guidance we mean that we set up a section, a written education reference structure, so that clinicians can understand what they are doing. We will need careful clinical guidance, which we would develop with the institute, we will need very careful clinical care pathways and we will need significant resourcing. Before nine weeks we would expect to be in a community setting, between nine weeks and 12 weeks with the significant support of the hospitals or entirely hospital based and after 12 weeks it would be in the hospitals.

Will there have to be significant integration between the primary care and secondary care in respect of how the patient moves smoothly from one service to the other?

Dr. Mary Favier

Yes, that would be critical to success.

I thank Dr. Favier. I call our first contributor, Deputy Stephen Donnelly.

I thank all of the witnesses for coming in-----

Is the Chair calling spokespeople and then going around-----

What way is it being done? I will be chairing in a few minutes and I think it is committee members first and then-----

We will call spokespeople first-----

-----committee members and then other-----

I call Deputy Donnelly. I will then call Deputies O'Reilly and Kelly.

I thank the witnesses for coming in and for their time. The opening statements were very useful. I want to ask all three groups about timing. This a complex issue. It is the first time we have done this in Ireland and there is much complexity involved for all three organisations. The Medical Council needs to work through the ethical guidelines carefully. By my count there were about six steps in the process between stakeholder reviews, drafts, integrating feedback, coming back together and finally publishing. That is a comprehensive process. The steps outlined for GPs are wideranging. There is legislation, which we will all work on together, there are care pathways from primary to secondary, there is licensing of medications and availability of medications, there are 24-hour helplines, there is some way for people to opt in or out, whatever way it ends up, there is clarification on medical indemnity, which is obviously a hot topic at the moment, there are Medical Council guidelines and so on. There is an awful lot.

Some GPs and obstetricians I have spoken with recently are very worried about the amount of work to be done within the timetable that has been stated by the Government which is that this would be operational on the ground by January. The Medical Council is clearly putting a lot of time into making sure that this works for women in Ireland.

The Institute of Obstetricians and Gynaecologists has laid out various issues as well. The question I have for the institute is firstly the same question, namely how confident is it that things are progressing in such a way that this could be operational on the ground, to the standards required by January, which is the current goal. Second, specifically on the infrastructure required in hospital or community settings, the institute has made the point that additional diagnostics are required such as ultrasound and Magnetic Resonance Imaging, MRI. Does it have a sense yet of what we are talking about? Is it five new MRI scanners and doubling ultrasound capacity for example? I ask the institute and the ICGP what other capacity constraints are out there. Diagnostics have been mentioned. When this is up and running, do the witnesses foresee capacity constraints in terms of not having enough GPs? As we all know, GPs are under huge pressure at the moment. Do the witnesses foresee not having enough consultants, obstetricians, operating theatres, acute beds or post termination supports for the women? Could they talk about where the State needs to be quickly investing resources to make sure that there are not bottlenecks through all of this?

I remind members and witnesses to turn off their mobile phones because it interferes with the recording of the proceedings. Who did the Deputy wish to direct his questions to initially?

All three organisations. I do not mind who goes first.

I call Dr. O'Brien.

Dr. John O'Brien

I thank Deputy Donnelly. The first one he raised was the question of the timeline and we were all aware that the Minister has it in mind that the service would commence in the beginning of January. There are three work streams involved in this process. There is the legislation, which will be the responsibility of the Oireachtas. There are the structural implications, that is to say the provision of services either within secondary care or within primary care and the pathways that have been spoken about, where a woman needs a particular course of action to be taken - will that be there for that woman in an expeditious way? All of that needs to be worked out and to date we are not that far advanced in that side of things. On the ICGP, our role in this will involve the production of guidelines and the education of our members and we have done considerable work on our guidelines to date but they will intersect with the legislation and with the structural arrangements that will be put in place. In order for us to finalise that we need to have some knowledge of what else is happening in the three work streams.

Education will be another part. This is a new service being introduced which we have not had in Ireland before. We said in our statement that people will be unfamiliar and will need guidelines and educational input to reinforce that. We will probably do that in a web-based fashion but we also have an infrastructure of study groups around the country. Our continuing medical education, CME, group infrastructure which the committee might be aware of, where GPs gather together and discuss issues will probably be used. We will also probably be looking to roll out more regional presentations as well so all of this will be a rolling process. Whether we will have enough time for all of this between now and January is the question. I do not really have the answer to that because I do not know how far advanced people will be in the provision of the infrastructure and I do not know how far advanced the Dáil will be with regard to the legislation itself.

Specifically on that point, while I understand that the legislation and structures are the responsibility of other people, is it Dr. O'Brien's view that GPs will be ready to provide terminations and play their role in this system by January?

Dr. John O'Brien

On that, it relates to the Deputy's capacity question. There are three groups of GPs. There are those who are enthusiastically keen to provide this service within their own practices, there is the group who would be conscientious objectors who would not wish to be involved and then there is probably a larger group in the middle of people who are approving of the idea of the provision of this service, but because of capacity constraints within their own practices, will not feel that they are able to do it. The Deputy will be aware that 60% of practices are now closed to new patients. He will also be aware that there is a demographic cliff in general practice in that the National Doctors Training and Planning, NDTP, which is the HSE unit for planning, estimates that we will be down 700 GPs in seven years so there are major problems. GPs will also be looking quite critically at what the Deputy spoke about in terms of the infrastructure that surrounds them and the care pathways that will flow from general practice because they do not want to be in a position where they have embarked on a process with a woman and that they are not carrying that to an expeditious completion because of bottlenecks in the system, waiting times for ultrasound or waiting times for consultant provision. All the while the clock is ticking and there is the question of who would be legally responsible if the woman's pregnancy goes beyond 12 weeks and she is no longer eligible. There are a lot of concerns within general practice around this.

It would be fair to say that at this point that the ICGP is concerned about the ability of the GP system to provide a termination service in January.

Dr. John O'Brien

Yes I would be concerned. There may be other matters taking place within the HSE and the Department of Health of which I am not aware which might allay some of those concerns. If I return then to the specific responsibility of the ICGP, which is the creation of the guideline and the provision of education, we could probably meet our deadlines on those aspects but all of us would probably be concerned about the rest of it and the provision of infrastructure.

I ask the Institute of Obstetricians and Gynaecologists for its views.

Dr. Peter Boylan

The timeline is undoubtedly challenging but what needs to happen is for all of the relevant stakeholders, including the HSE, the Department of Health, the GP representative bodies, the family planning clinics, doctors who work in providing women's health care outside of those arenas and the institute and so on all need to sit down and work out the pathways of care that need to be implemented and get the patient journey clarified for doctors, both in hospital and in the community. That needs to happen soon so that we can get a clear picture of what the requirements are in infrastructural deficits that need to be addressed.

On the MRI, in reality it is only used in cases of foetal abnormality in order to clarify what the diagnosis is so it is only relevant in those particular circumstances. An MRI is not needed in every hospital. There is only one in a maternity unit at the moment, in the National Maternity Hospital but that is the consequence of a very generous grant from an individual.

Other scans or MRIs are done in Temple Street Children's University Hospital but that machine has effectively reached the end of its life and needs to be replaced.

There are challenges in that respect. The MRI machine in the National Maternity Hospital, with some jiggling around, could possibly be a national centre for referral to clarify the diagnosis for women and pregnancies where there are foetal abnormalities. The consequences of getting it wrong are serious. We could end up with a termination done for a condition that is not fatal or vice versa. It is not an issue at the moment because women have to travel abroad and in many circumstances, or most, when they go abroad, they will have an MRI before having a termination of pregnancy. That is something that has not been relevant in this country and it will not be until legislation is introduced and practice is changed. That would require some investment but it is not madly expensive. It just requires a jiggling around of consultant sessions, etc.

On ultrasound, there clearly are capacity constraints and we are all aware of those so that needs to be addressed. It may be better to let Dr. Murphy address the other capacity constraints as she is more on the front line than I am at the moment.

Before Dr. Murphy commences I must vacate the chair for a short while. Deputy O'Reilly will take the Chair in my absence.

Deputy Louise O'Reilly took the Chair.

Dr. Clíona Murphy

I thank Deputy Donnelly for the question. What he is asking about moves us on from clinical guidelines to integration and implementation. It is a continuum. We may well struggle to complete guidelines by January because most clinical guidelines can take longer than that. Implementation is a much larger process and, as Dr. Boylan said, up to now much work has been done in silos. Many stakeholders and I feel we would be better off sitting down together and contributing on the implementation process. From speaking to clinicians on the ground, different hospitals may have different capacity constraints. In particular, we are trying to anticipate what surgical capacity will be required in hospitals.

The narrative in the media up to now has been about the provision of services for the medical termination of pregnancy. A large proportion, however, certainly between nine and 12 weeks, may well be surgical. People may choose to have a surgical termination and there are also family reasons why they might do so, such as if they had children at home or workplace issues, etc. We need, therefore, to anticipate the provision of services in our hospitals. There is good evidence that provision of surgical terminations needs to be integrated into women's healthcare in hospitals. We are not looking for separate buildings or separate capacity but we have to be creative in looking at our current deficits.

On the capacity issue, is the institute aware of the HSE, the Department or any other bodies doing a mapping exercise to identify where the constraint issues are hospital by hospital?

Dr. Clíona Murphy

We have had two meetings with the Department of Health. There were supposed to be three. They were short meetings limited to guidelines. Any questioning on implementation was not expanded on. There has been some work, I believe, from the HSE perspective on guidelines and the sexual health strategy has been active. Again, however, we are not all aware of what is being done in different areas. I believe the HSE is starting an implementation group and we are happy to contribute, but I am not sure how much mapping has been done to date. Groups are certainly active but joining it up is the key.

There are also some areas in hospitals where capacity might be harder and there might be different issues. Maternity hospitals have the issue of trying to be respectful to women in a labour ward. In one hospital, for example, it is necessary to walk through the labour ward to get to the theatre. That may not be appropriate for women in this situation. In other hospitals, there can be difficulties for clinicians even in trying to have gynaecology emergencies performed in a general hospital and Senator Colm Burke may know a little bit about that but-----

Given Dr. Murphy's experience with care pathways and her knowledge of what is required for this pathway, has the institute concerns about meeting the January deadline as things stand?

Dr. Clíona Murphy

As things stand, we do not know the capacity we are trying to become ready for. There will be major public expectation for a rolled out service and that can lead to issues. We have seen how if things are not planned properly they can unravel. I certainly advise caution and perhaps we should consider some phasing in or a pilot - that is my own personal view - so that there would be some understanding among the public that it is a short timeframe to roll out a separate health strategy. If we were rolling out a vaccination programme, we would need longer than this to plan. While we are doing our best in all areas, there needs to be more integration into the whole planning.

I thank Dr. Murphy.

Out of interest for the people waiting, I am going to give the list of speakers. I am the next speaker, then Deputy Kelly, Senator Dolan, Senator Burke, Deputy O'Connell, Deputy Coppinger, Deputy Bríd Smith and Senator Kelleher in that order so that people have a sense of our time. I thank all the witnesses for coming in and I have some questions.

Dr. Suzanne Crowe

May we answer Deputy Donnelly's question?

Yes, I am sorry, my apologies.

Dr. Suzanne Crowe

I thank the Deputy for the question. His question reflects our own concerns in the Medical Council on this issue. At our first meeting of the Medical Council in July, we immediately identified this as a pressing need and the working group was established as a matter of urgency. We are about six weeks into that project and we are establishing terms of reference and ensuring that we have medical and non-medical representation on that group. The next phase will be going out to public consultation with a draft statement. We need to take a bit of time during that period to allow adequate consultation with public representatives, patient advocacy groups and professional representatives. All in all, it will be possible for us to deliver within that timeframe.

I thank Dr. Crowe and the Vice Chairman.

I thank Dr. Crowe and my apologies again. My first question is that 1 January is going to come quickly and the witnesses have all rehearsed some of the difficulties. We know that there are three pillars - legislation, guidelines and infrastructure and resources. Have all of the relevant stakeholders been in the same room together at any point to have that important conversation or are we only at the stage of drafting up the plan for where we might all get into a room together? On the roll-out of services for primary care, we hear much about that and that the preference is for primary and community care. Are we talking about family planning clinics, Well Woman centres and integrating all of the services that exist or is it only just GPs who have been involved in this up to this date? In respect of the 24-hour helpline, information line or whatever, have the witnesses given any consideration to who might staff that, who they would work for and how that would work? My sense is that could end up as a crisis line. A non-clinical person or a non-trained person could not be on that line because the purpose is to direct women towards a clinical pathway.

The ICGP made reference in its submission to specialist support that might be necessary. Can the witnesses give us a sense of that? We are talking about 1 January and we need to understand if that is realistic. We do not need to say in the middle of December that we mentioned specialist support and here is the list of what that looks like. This question is most likely for the IOG but perhaps others might have a view as well.

I am a bit mystified about where the three-day waiting period came from. It did not form a large part of our discussions at the eighth amendment committee. I understand it is the practice in some jurisdictions. I am interested in the views of all of the witnesses as to whether it is wholly necessary and, if it is deemed to be necessary, and we must be guided by clinicians on this, can the waiting period count from the first contact with the helpline or information line? Do the witnesses envisage that it would work like that? I will put my cards on the table and state I am not convinced that a three-day waiting period is necessary but it has been flagged.

My final question relates to the duty to transfer a patient where there is a conscientious objection. My understanding from the presentations is that such a duty to transfer exists already. I am interested if there are any plans to change that. If consideration is being given to that, the witnesses might enlighten us as to why or how it will work.

Dr. Tony Cox

I thank the Vice Chairman. Her first question was whether we had all met together, and we have. There is a close working relationship between the Irish College of General Practitioners and the institute. Of course we will meet the Medical Council. We will work on this pathway and-----

With the HSE as well?

Dr. Tony Cox

With the HSE as well. There have been several meetings with the HSE. I expect that once the legislation comes before Cabinet next week and goes before the Dáil in the first week of October, the meetings will step up and increase. There have been meetings between all stakeholders to date.

On the roll-out of services in the community, we envisage that it will be both GPs and other organisations such as the Irish Family Planning Association, IFPA.

Have they been involved in the discussions up to this point?

Dr. Tony Cox

They have been involved in the discussions but I am not sure whether they have been invited to present to a committee such as this to date. We envisage that they would be an important strand and part of the provision of services within the community, and that it would not only be GPs who will provide the service for the patient up to nine weeks.

Dr. Mary Favier

On the helpline, there are a number of models internationally. There is one in Bristol called One Call. It provides a first contact and is staffed by skilled individuals. We have a model in the Crisis Pregnancy Agency service. There is not much more to add to that. In its service, 75% of women who contact that service continue to have a termination of pregnancy but 25% do not. Those are the first type of discussions which are taking place. People are referred to in-person counselling if they wish but onto a provider if they wish, including appointments being made, if that is an appropriate thing to do.

There is no medical reason for the three-day waiting period; it is a legal or societal decision. The WHO guidelines specifically state they should be discouraged because they introduce delay and are not good for women's health. It is not a medical issue. We say that if we are to have that, the three days then should start from the very first point of contact, whether one rings the helpline or one's GP or a family planning clinic. As these are all electronic services nowadays, they can be timed. That is our suggestion.

Dr. Clíona Murphy

On stakeholders' meeting, there has been something of a Venn diagram with some stakeholders meeting together - we have certainly met the Irish College of General Practitioners, ICGP, several times - but the Department of Health has not necessarily been at all those meetings and nor has the HSE. We really need for the Department of Health, the HSE and clinical stakeholders to get together. That entire group has not sat down together for a significant period. The IFPA, which has a lot of experience in delivering crisis pregnancy services over and above hospital consultants, for example, have not been invited to as many meetings as it should have. We believe it should be involved more in the process.

I hear that clearly that there is a Venn diagram but that everybody needs to get into the circle.

Dr. Clíona Murphy

On the telephone helpline, the sexual health strand has engaged One Family for counselling. There is a possibility that this could also be expanded as a signposting service to help in setting it up. In other countries we have visited, Norway has a system where telephone contact is made with the clinical area. Their experience is that very few people change their minds. Those who are unsure make it clear on the phone that they are unsure and are exploring the option but people who call the line and feel they have their mind made up do not change their mind afterwards. It seems to be the international experience that people do their thinking before making the contact.

Dr. Peter Boylan

The duty of transfers is current Medical Council guidelines. We do not see any reason to change that. It is the duty of care to the patient.

Yes. I note that they are there already but I also note that they are under discussion.

Dr. Suzanne Crowe

On the drawing up of the working group, we are seeking representations from the groups that have been already listed, with the ICGP, and the Institute of Obstetricians and Gynaecologists. We have not sat down together as yet.

As the Vice Chairman correctly identified on conscientious objection, there is already a lot of detail in section 49 of the guideline. I think that the group will look to put more detail on conscientious objection in the next iteration in order that it is a very clear code of conduct for the doctor in stepping out or stepping aside but still keeping the patient front and centre and protecting the patient.

My question was very specific about the duty to transfer as it exists. Is it envisaged that this will continue?

Dr. Suzanne Crowe

It will continue. It is envisaged that it will continue but that we will provide some more detail on that also.

Okay. Our next speaker is Deputy Kelly.

I thank the witnesses for their statements. Today has helped to bring together the various components that must be put in place. It is a jigsaw that must be put together by January and then monitored continuously. We can all see that is going to be quite difficult but it must be done.

The presentations were very well put together on what needs to happen in the pre-nine weeks, nine to 12 weeks and post-12 weeks cases. While we can see the care pathways, there are issues in respect of interaction between GP services and primary care services and even geographical coverage, in south Kerry or north Donegal, for example. Issues will arise there. How can we ensure that provisional pathways are put in place to ensure that all those points are covered? What analysis is being done between the groups represented here working with the Department? I will return to those two meetings or non-meetings. What analysis is being done on this? No one can tell me that we have universal coverage or that there will be a universal coverage map based on the pathways as outlined. When I look around the country, I know that they do not exist and this will be even more the case in this regard. What work is being done? If no work has been done on it yet, the witnesses should be upfront and say so, because then we have a serious issue because we will have to solve it in the next 12 weeks. There is an interconnection between GPs, primary care setting and hospital settings and there are gaps there. How will we address that?

My second question is connected to that and relates to the meetings with the Department. I do not think that a lot happened at those meetings by the sounds of things. I do not want to put Dr. Murphy on the spot but the Department of Health needs to drive this but, with the best will in the world, it does not come across to me that it is doing so.

I do not want to overlap with the issues that have been outlined by previous speakers. Where are those issues in the discussions that have taken place? Where is the issue I have just raised? Is a plan being put in place? Have the witnesses seen evidence that a plan is being put in place? Maybe they can elaborate on what was discussed at the two meetings. How much progress has been made on foot of those meetings?

In moving on to my third question, I will not ask about the three-week rule and the infrastructure in hospitals. I respect what everyone has said about the Medical Council guidelines. In some scenarios, GPs deliberately act in a manner that does not involve referring people on, or camouflages the way in which that happens. We all know about the issues with clinicians that have arisen recently and have been considered by Dr. Scally. We will talk about them in the Dáil later. How are we going to make sure such issues do not happen? Where they do happen, how can we ensure they can be dealt with quickly? The issue of geographical coverage arises again in this context. When doctors behave in a certain manner, how can we deal with that clinically and quickly? That is my third question.

The fourth question I would like to raise is a quick one. I presume the witnesses support the concept of a 24-hour helpline. Various underlying supports, including infrastructure, are needed to kick that off while we do not know what coverage we have.

My fifth question relates to the role of public provision versus private provision. Concerns jump out to me regarding the latter. What are the thoughts of the witnesses on private provision? I have not fully worked out my thoughts on it. It seems that where there is private provision, there are concerns in respect of aftercare. There are also concerns about knowledge that is not being garnered or put into the public setting, and the gaps of information because of that. I suppose it is possible that some individuals will be targeted if they are just in a private setting. I have asked five questions, some of which overlap. I do not mind who answers them as long as they are answered.

Dr. Mary Favier

I will answer the Deputy's question about how we propose to address potential gaps in the nine-week provision. Our members have expressed concern in their online feedback about how this service will be provided in remote areas with small numbers of GPs who are under pressure and who are not taking new patients. We have not been in a position to do a mapping exercise on the numbers because we do not know what we are mapping against in terms of the legislation or the guidelines. Some innovative suggestions have been made. There is good international evidence that this problem can be solved in various ways, for example involving mobile provision. A service run by a family planning clinic or another GP could be provided in a local area once a month, for example. These are just suggestions. Someone who rings a helpline could be sent to a provider in another area. A person in a small town should be able to find a provider without having to run the gauntlet of trying to find somebody. One of the main ways of addressing this issue will have to involve the Department of Health giving a commitment to a timeline that creates an expectation relating to when care will be delivered. Women who have tried without success to access the service will have to be able to ring the helpline and ask for help in accessing it. We do not have answers because the process is just starting. There is a great deal of international evidence for ways of deal with this issue. Countries like Australia and Canada have expertise of service provision in remote areas. Some countries have better provision in the north than in the south. There are various ways of doing this.

Mr. William Prasifka

I will answer Deputy Kelly's question on the Medical Council guidelines, which was asked in light of what we are currently saying about conscientious objection. There is a duty on objecting physicians to ensure continuity of care, but some of them are falling short of that standard. As the ex post facto regulator in this area, the Medical Council is responsible for dealing with complaints that are made to it and for taking action when it becomes aware of cases in which people are falling short of the prevailing standards. The Act provides for the confidential process that must be followed when a complaint is made. It sets out a comprehensive procedure that must take place, and there has to be a full investigation. All procedural norms must be recognised. Due process and the constitutional rights of the practitioner have to be preserved. There must be a full process. The Medical Council is responsible for making a determination in the context of all the evidence that is presented. Each case is judged on its merits. As the regulator, we are in a difficult position. We do not want to prejudge any particular case. Every doctor is entitled to a full process and to an open procedure. The guidelines for conscientious objection and open disclosure specify that there is a strong duty to ensure continuity of care, to act in the best interests of patients and to provide full disclosure. If, having considered all the standards, we believe someone is falling short, the Medical Council can impose a list of sanctions, including advice, admonishment and censure and, in more severe cases, suspension and erasure, which means the doctor no longer has the right to practice. This is the role of the Medical Council as the ex post facto regulator. Ultimately, we have it within our jurisdiction, following full procedures and after confirmation by the High Court, to strike a doctor off the register.

Dr. Tony Cox

I will answer Deputy Kelly's third question, which related to the Medical Council guidelines, and his fourth question. We want to avoid the circumstances outlined by Mr. Prasifka. We want the guidelines to be absolutely and completely patient-centred. The patient must be at the centre. We do not want a patient in a crisis situation to present herself to a doctor who finds it difficult for any reason to provide the service required by the patient at that time. We feel that a 24-hour helpline, which was the subject of the Deputy's fourth question, is absolutely key. A 24-7 helpline that is staffed by well-trained medical nursing staff can ensure we avoid circumstances in which a patient in a crisis situation is confronted by a provider who finds it difficult to provide this service. We can ensure such a patient is directed to someone who is willing and able to provide the service and is available at that time. We would not want the circumstances outlined to come to pass.

They might have to travel from south-west Cork or south Kerry to Cork city. That is the crazy scenario.

Dr. Tony Cox

We do not know. We are engaging with our members. Perhaps that answers the Deputy's question about geographical coverage. We have not asked our members specifically whether they will be in a position to provide these services.

I would have thought that such a question needs to be asked quickly. Dr. Murphy might be able to answer some of my other questions.

Dr. Clíona Murphy

I will answer the questions about the provision and the mapping. We envisage that there will be a referral service similar to what occurs in other situations. It will be a hub-and-spoke sort of model. It is important for all designated hospitals to be involved in that. Abortion provision, especially between nine and 12 weeks, is not a highly technical procedure, even in cases of surgical abortion. It is important that such cases do not necessarily have to go to the largest hospital in the area. It should be acknowledged that all hospitals can play their part. There will be some training. The institute is fully geared up to provide training and support to providers in all areas of the country.

The Deputy also asked about our meetings with the Department of Health. We had cordial meetings with no problems. The guidelines were discussed, but it did not veer into implementation at all. I envisage that there will be ongoing engagement with the Department.

Has another meeting been scheduled?

Dr. Clíona Murphy

We do not have another meeting scheduled. Findings from other countries show that commitment from actors in the national health ministry or department was crucial in having a successful roll-out. We would like a bit more engagement.

On private provision and the private setting, we are keen that the service should continue to be integrated into the public health service. We have listened to our colleagues and we have close connections with the Royal College of Obstetricians and Gynaecologists, RCOG, in England. Their experience is much greater than ours and because of a difficulty providing the service in the public setting, outsourcing to private providers took place. Subsequent difficulties arose with a lack of training in the public setting and with variation in standards so we do not want to go down that route. Also, international evidence shows that data and monitoring are very important. If the service is spread between private and public, it will not lead to an improvement in standards. We envisage rolling out a service and there may be changes in how that is delivered over three or five years, as more information is obtained. It is much better if the service is integrated.

The other important area is targeting of abortion providers if they are in silo settings. I draw attention to a difference between private for-profit providers and non-profit providers. The Irish Family Planning Association, IFPA, for example, is different in that it is a not-for-profit organisation and there are strong links between our public provision and the IFPA.

I thank the witnesses for appearing and presenting their views. I start from a view that we need to trust women and have confidence in their decision making. At the same time, being pregnant, regardless of whether it is desired, is a life-changing moment. We need to keep in mind, therefore, that these decisions are not simple.

On conscientious commitment vis-à-vis conscientious objection, Dr. Favier will understand that there has been a major focus on the latter. That is to be absolutely respected. However, this is the first time that I have heard someone speak about conscientious commitment, which is the other side of the coin. I have not heard the issue of conscientious commitment being given parity of esteem in the public arena. That is something that should be considered. We are now seeking to provide a mandated public service and the people who feel a sense of duty to provide that service need to have support. I ask Dr. Favier or the other witnesses to comment on that.

The first workstream in Dr. Boylan's presentation, on early pregnancy, cites evidence from Scotland and states: "We believe that Irish figures should be in line with those of Scotland." That is a statement of belief. Does Dr. Boylan have evidence for this statement or is it based solely on Ireland and Scotland having similar size populations?

On foetal medicine, I was worried when Dr. Boylan said there was only one available MRI in a maternity hospital given that there are 19 maternity hospitals or units. He subsequently provided some clarity on the matter. Will this issue be addressed by the measures to which he referred when responding to Deputy Donnelly?

Dr. Peter Boylan

I will elaborate.

Dr. Boylan also spoke about the consequences of getting the diagnosis wrong.

Listening to Dr. John O'Brien I began to very much appreciate my family doctor. He indicated that some 60% of GPs have closed their lists and spoke of a "demographic cliff", which is an arresting phrase. He said, in response to Deputy Kelly, that he is concerned about GP services' capacity to deliver by 1 January. What is the knock-on effect if the GP side does not hold up on day one, which we all hope will not happen? What problem will land in our laps by the middle or the end of January?

The issues of the dispersal of population and living patterns in Ireland have been set out by others. Let us not forget that in cities and big conurbations there are people who are very isolated in their community. On the pattern of general practitioner services, there is an inverse relationship between critical need and the supply of services, with fewer general practitioners in poorer areas and more services in well-off areas.

The Senator's questions were directed primarily at the Institute of Obstetricians and Gynaecologists and the Irish College of General Practitioners but if the Medical Council wants to express a view, that is fine.

Dr. Mary Favier

I will answer the first question on conscientious commitment. Senator Dolan started from the very important premise of trusting women. As general practitioners, patient-centred care and keeping women and anybody who can become pregnant at the heart of that care are about trusting the patient and, in this scenario, trusting women. Starting from a premise of patient-centred care, we are left with trying to support women who face crisis and unwanted pregnancies no matter what decision they may make.

From a conscientious commitment point of view, that language has come into the literature to recognise that there is a moral judgment involved in the imperative to provide care in these scenarios when women face these crises. A significant majority of Irish people voted to change the legislation in the referendum and general practitioners and doctors are no different from the general population. If anything, they have a more informed position because they see women in these unwanted pregnancies and the extraordinary lengths they have gone to in order to raise money and leave the country. It was because it was unsafe that the position was changed and the Irish people voted for that change.

There has been a serious chilling effect in medicine because we have not been able to talk about abortion and it has been actively discouraged and criminalised. For those reasons, we have found it difficult to have these conversations. They are only starting and all of us are on a journey in the sense of clarifying and setting our values. We have a deadline of 1 January but it will take some time in Irish society, particularly in the medical fraternity, to explore these issues further. Conscientious commitment and conscientious objection are part of this and they both need to be respected and valued.

Dr. John O'Brien

The Senator's second question was on what happens if general practice does not hold up. This is also related to what he said about the distribution of the availability of general practice. As he will be aware, in rural lists the HSE is finding it very difficult to find any doctor to take up the GMS lists. The Senator is right that the distribution of doctors is more favourable in wealthier areas than in poorer areas and that is a very large problem. We are currently dealing with a specific area, namely, abortion, but general practice is comprehensive. It deals with all people and all problems so anything that is causing a failure of general practice will impinge on any discussion, including this one.

Currently, as a country we spend a little bit less than 4% of the national health spend on general practice, which is about half of what the UK provides, and we expect it to be the same. In terms of numbers of GPs per head of population, we have about half of what Australia and Canada have. They would be two popular destinations for GPs who are emigrating. While I am on that subject, we have research with regard to what is happening with our trained GPs, and it now appears that 20% of the GPs who are trained here go away and stay away. We spend a great deal as a country training those GPs and they are leaving for reasons including lifestyle, career progression and the capacity to do what they are trained to do.

I know members are sick of people coming in to say they do not have enough money, and to be honest, I am sick of saying it, but I still draw their attention to the base rate figures which are what percentage of the health spend goes on general practice and what they expect as a result of that. It is impinging upon the new service but it will impinge on every discussion. I have been before the committee for discussions on mental health and it impinges on it in exactly the same way. It is disappointing from our perspective because we feel passionately about the value the general practice provides to people in local communities and day-to-day lives.

To return to the Senator's original question on how it is going to impact and if we have a plan B, I think it is going to impact on the new service. I cannot quantify the impact but, inevitably, what is going on in general practice has to have an impact on the delivery and roll-out of the service.

Is there a plan B?

Dr. John O'Brien

I do not know if there is even a plan A.

Dr. Peter Boylan

With regard to MRI scans, as I explained to Deputy Donnelly, it really relates to foetal abnormalities and making sure the diagnosis is correct. With the numbers coming through it is likely that one or two MRIs would be perfectly sufficient to provide enough capacity. MRI is also very useful in other areas of women's health, especially in obstetric practice. There is an increasing number of placental problems involving the afterbirth invading the womb for women who have had several caesarean sections. That is becoming an increasing problem. Again, there needs to be one national centre for that sort of thing. In terms of the MRI scanner I talked about, my understanding is that with some alteration of consultant sessions and commitments as to who gets an MRI scan a national service could be established initially with one scanner and then another scanner should be introduced as well, somewhere, possibly in Cork because that is a large area.

What about the Scotland-Ireland thing?

Dr. Peter Boylan

I will let Dr. Murphy answer that.

Dr. Clíona Murphy

Our members have visited Scotland and a number of other countries. We are all working on estimates. If one takes Ireland, we estimate that approximately 4,000 women travel and perhaps another 1,000 have used medical methods, however, there is probably an unmet need, so from a geographic perspective 11,000 fits all right. A lot of people have the idea that we may be looking at 10,000 and the question is whether we will have 10,000 immediately or over a number of years. Anything next year is going to be an increase on what we have had before in this country so we have to understand that. There probably will be a plateauing and perhaps a decrease if we increase contraceptive methods and advice, as outlined by Dr. Boylan. With regard to the numbers then requiring, for example, hospital intervention, in Oslo in Norway, for example, they have 2,000 terminations per annum, 1,600 are medical and the rest are surgical so they would have 20% requiring hospital admissions. If we have 10,000 we have to think about 20% needing hospitals. We may not have 10,000, it could be 7,000 or 8,000 but they are all guesstimates to the best of our ability.

At least there is some pencil work being done behind the scenes.

A lot of the issues I wanted to raise have already been raised so I will be very brief. I thank the witnesses for their presentations and for the work they have done and are doing in this area. I know there is a deadline of sorts in terms of 1 January and that they are making every effort to meet it and have everything in place.

Dr. Boylan said one MRI scanner is sufficient. Has there been any engagement with Cork University Hospital, CUH? It does not have an MRI scanner in the maternity services but it has MRI facilities available in the hospital. Is it envisaged that we would go into one of the existing hospitals where MRI scanners are available within the hospital structure as regards providing that service there? Is that being considered?

The second issue relates to the various units around the country. One of the issues that will arise is that it is not only a case of there being conscientious objection by doctors but also conscientious objections by nursing staff. Has there been any discussion individually with maternity units around the country to make sure the services can be provided in each of the units where medical and hospital support is required?

The third issue is backup for general practitioners, in terms of whether there is going to be co-ordination of supports for GPs so that if they have an issue on which they need to get advice from a gynaecologist or obstetrician that a structure is in place for that. Has the issue been considered in terms of making sure the maximum level of support is available for people who will be dealing with patients on the front line?

Dr. Peter Boylan

With regard to the question on MRI services and Cork, it is important that a large hospital like Cork would have a ring-fenced budget that is solely devoted to women's healthcare and that they do not have to access services in a general hospital because that does not work. Women get bumped off waiting lists and they do not get equal access. It would be wonderful to have an MRI for women's healthcare in the southern region based in Cork, which is the largest unit. That would be a wonderful thing to happen and it should happen.

With regard to whether we have discussed conscientious objection with maternity units and the GP support mechanisms and community support mechanisms, that is why we need to get all the stakeholders around the one table to discuss the pathways of care, what is going to happen, who is going to do what and what funding is required to do the things that are required. Hopefully, we seem to be moving along a little bit, but we do need to sit around the table with everybody involved, namely, the Department of Health, the HSE, GP representatives, the institute, various hospitals and the primary care sector among others.

Who is Dr. Boylan suggesting should call that meeting at this stage?

Dr. Peter Boylan

Somebody has to lead it.

The question is who.

Dr. Peter Boylan

One must ask who is responsible and that is the Department of Health and perhaps the Minister who should perhaps organise something along those lines.

Deputy Michael Harty resumed the Chair.

Dr. Mary Favier

If I could come in at this point, there is very good international evidence that the most significant thing that influences implementation is the buy-in of the Department of Health. If it is committed and stays committed for a minimum of five years that is what determines whether implementation is successful or not.

The second thing that determines whether implementation is successful is that values clarification takes place. By that I mean that everybody works together to understand where they stand on this issue and not just with the doctors but all healthcare providers, including porters, cleaners, those who do the rostering and those who hold the budgets. All those people need to understand the service and why it is important, but most significantly it must be the Department of Health which co-ordinates and controls that and drives it.

Dr. Peter Boylan

That is a very clear message.

That worries me slightly because I have asked for a similar situation to be set up regarding elderly care where all the stakeholders would be brought together, from GPs, to geriatricians and private providers of elderly care and it has not happened.

I have asked the Department on numerous occasions that it would happen. I am concerned that there will be co-ordination on this by the Department but it did not happen in elderly care, which disappointed me.

I thank the witnesses for giving their time to come in to advise us in our important task regarding legislating to do what the people of Ireland asked us to do in May.

On the delivering service by January, I am concerned that this may not be possible. There is almost an assumption that these are new women who did not exist before, that the ten or 12 each day who will land out of the sky are additional and have never approached a GPs surgery. I remember evidence to the committee said that most of the women are already attending their GPs for contraception, cervical smears and so on, so they are pre-existing patients. That does not seem to have entered the conversation. I know it is a new service, but these women already exist.

There has been comment about the interaction between the GP and secondary care. However, maternity care is universal in this country. My understanding is that relationship between the GP and the secondary care provider is already established. There was a conversation earlier about how we would do this. Is communication between the two deficient? Will the GPs and the secondary care providers outline the problems we might encounter?

If we had 12 cases of anything else a day which had to go abroad or source illegal medication online, it would be a national scandal and a bundle of money would be liberated for it immediately. If the men of Ireland had to travel on a Ryanair flight they would be up in arms and out roaring and shouting outside the Dáil. This is something we have never provided in this country but it is not a novel provision. It is essential medicine. The committee heard that at length and we heart the World Health Organization's stance on it. Despite recent mutterings about overspends in health, I believe this is a separate bundle. It is long over due to the women of Ireland. I advise whoever writes the cheque to just do so.

The three-day wait was discussed at length at the committee. Some of those present here have a problem with it from the perspective of trusting women. I voted for it at committee but it is almost completely at odds with my belief that one would not trust a woman to make her discussion. Nevertheless, we have seen evidence that it does not have any negative effect.

It does actually, but please continue.

Perhaps one of the experts can tell us if there have been any negative effects as a result of a three day waiting period. The eighth amendment committee spent a lot of time making it very clear to the people of Ireland what we were putting before them. We put a three day cooling off period before them. Any change to that at this stage would have to be considered very deeply.

A mobile unit was mentioned. That reminds me of a library coming to my local town years ago. That was the image I had in my head.

It is not in any way a suitable way to provide women's healthcare. I have a vision of a big van. Maybe I am wrong but that is not the way forward. It cannot be how we look at it. Australia and Scotland have remote areas and they manage it. We should be able to manage it.

We discussed the ring-fencing of funding in a maternity strategy where the constant drag of women's health and gynaecological issues are just not a priority and women are expected to get over it and deal with their prolapsed whatever until a time comes when someone deems they can have an operation. I would be very supportive of this. It is a very time-sensitive matter. Going from eight to ten weeks totally changes someone's situation. Ring-fencing of budgets in contraception and the termination of pregnancy services is essential to ensure that women are not put at any undue risk. We heard evidence that the longer a pregnancy goes on and the later the termination, the greater the risk of complication. Doctors for Choice argued it should be as early as possible.

I refer to scanning. People are already taking abortion pills in this country without scanning. We had evidence of the complications. Will witnesses clarify if it was 20% of under-nine weeks where there were surgical complications or is it less than that? Is it not less than that? Will the witnesses clarify the complication rate for medical terminations under nine weeks. Do they have the evidence? How would any form of ultrasound or MRI in a GPs surgery, or whatever, possibly effect that? My memory of the evidence is that ultrasound intervention before nine weeks is neither here nor there except in the rare cases of ectopic pregnancy.

I refer to an abortion providers network. There appears to be agreement on the 24 hour helpline, certainly when a service starts, although I imagine that maybe in ten years time we will not need one. However, I am seriously concerned at the idea of an abortion providers network. Any list of providers of this service is ripe for targeting. I know there is a list of pharmacists who provide the morning after pill. Somehow I am not on it but my husband is and every so often, we receive a letter along with religious paraphernalia. There are lists of people who provide things that others object to. Such a list of providers seems to invite trouble.

The eighth amendment committee was very conscious of the service not being provided by a private operator in this country, but that it would be provided as part of the public health service on a universal basis. I do not know which contributor mentioned the emergence of private care. The most significant thing we heard this morning was the buy-in from the Department of Health. Can those who have engaged in this already tell us if their informed view is that a lead needs to be appointed in the Department of Health between now and next June, for example, for the roll out period of perhaps two years? Do we need a designated official? We have three Ministers of State in the Department of Health. Do they believe that someone must be appointed to drive this? They have clearly said that without leadership it will not happen.

I thank Deputy O'Connell and invite the witnesses to respond.

Dr. John O'Brien

I will begin with the Deputy's reference to 12 women a day. What I take this to mean is that with 5,000 people travelling to the UK currently, that works out mathematically as 12 people daily. That probably underestimates the number of women who are requiring abortion. My understanding is that it is somewhere between 5,000 and 10,000. In any case, the Deputy's point was that this does not represent an extra burden on practices as these women are already patients of the practice and this service can be fitted in. The nature of the work that will be involved in this will be time consuming. It is unlikely that it will fit in to the normal process of a standard GP consultation.

The work is likely to cluster. It is not likely to be dispersed equally across all GPs. Some 46% of GPs are female. I am a male doctor of a certain vintage and when I was a young doctor, I was involved in women's health. As the years have rolled on, I have seen less of it and almost no women's health issues have come under my remit in recent years.

With regard to the distribution of part-time work, many newer graduates work part-time hours. This is skewed a bit more towards female GPs who are graduating. It will not be a question of just 12 a day and it will not be evenly distributed across practices. As we discussed, there is the matter of provision of GPs. There are plenty of GPs in more affluent areas of Dublin and fewer GPs in poorer areas. That competes with all the other unmet need in those areas. It is not true to say it is just a little more work and to ask why we do not just slip it in. I do not think that will work.

I genuinely was not suggesting it was just a little bit but that it was not a huge burden on the system.

Dr. Mary Favier

I will address the complication rate issue. International evidence suggests that for nine weeks and under, one can expect that approximately 10% of women, one in ten, will need some sort of further support following a medical termination of pregnancy. That may be purely advice. This is again where the telephone service comes in. One might ask if there is too much bleeding and if one should do something, or there might be no bleeding at all and one might ask if that is significant, which it might be, since it might be a failed procedure and further input is needed. Of that 10%, approximately 10% will need to have further medical input and see a provider, either a doctor or a nurse. Of those, approximately 10% will need to go into secondary care to have something more done. That is how it roughly breaks down. The Deputy is correct that as one progresses through pregnancy, it becomes more common. Early is always best. With each week, there is a small percentage rise. We want to make sure that women are kept at the centre of it and that they get access to a procedure as early as possible, effectively as soon as they make contact, depending on the mandatory waiting period, so that we can keep the complication rate as low as possible. The further we go, the more the burden on secondary care and requirement of resources for it increases.

We generally try to avoid ultrasound scanning in post-termination scenarios in the very first early weeks because one cannot be sure what to do with the results. Access to it will be critical from a GP point of view where this service applies. In trying to keep the patient central, GPs would like to see a comprehensive contraception service provided and integrated. Our best goal is to reduce the rate of crisis pregnancies and we can only do that if we have universal access to contraception, not just universal access to termination of pregnancy.

Are there figures for the number of GPs who advertise and provide specific women's health services and have, in-house, their own ultrasound machines? There seems to have been an emergence of them in recent years for early dating of pregnancy.

Dr. Mary Favier

One can assume, for purposes of early dating of pregnancy, that there are no GPs who have ultrasound machines. Some GPs are taking on the role of ultrasound scanning but it is not in this area of early pregnancy but relates to whether one has gallstones, for example. Ultrasound machines are incredibly expensive. The cheapest second-hand one that can be bought is €15,000 and the sky is the limit on the high-tech ones that hospital services use. We do not see any scenario where GPs will be purchasing ultrasound machines out of their very constrained budgets. I work in an area of high urban deprivation. Under no circumstances, with all the cutbacks we have sustained, will we buy an ultrasound machine.

If a GP had one of these €15,000 ultrasound machines, are GPs already able to use them or does a course have to be done to use them, a refresher, or a continuing professional development, CPD, evening, or such?

Dr. Mary Favier

GPs would not have this set of skills and we as a college do not currently expect, though it may change, that they acquire that set of skills because it is quite a skilled procedure as our expert colleagues would attest to, and there are issues of indemnity which would need to be explored. Our best information is currently that there is not an indemnity issue relating to the early termination of pregnancy but there is with regard to ultrasound scanning, which indemnity organisations have raised a flag about.

Is it fair to say that GPs will not be looking for these ultrasound machines that cost approximately €15,000 to do the procedure in under nine weeks in their surgery?

Dr. Mary Favier

It would not be the best use of resources. The machines are much too expensive and require too much improvement to one's skill set to let them then sit there unused for most of the week.

Dr. Peter Boylan

I agree about the ring-fenced budget for women's healthcare. It is essential. We have seen too many times how women's healthcare has been problematic because of a lack of governance and budgetary constraints. The question about buy-in from the Department of Health really goes back to the question of governance of the whole process. From that point of view, it is important that the Department in some way leads out on co-ordination and getting everybody together around the table as we spoke of before. In the long term, this process should have a proper governance structure. We saw that a major issue with CervicalCheck was a lack of governance and overall supervision of the process.

I thank Dr. Boylan. We have some non-members who wish to contribute, Deputies Ruth Coppinger and Bríd Smith and Senator Colette Kelleher. Senator Mullen, who is a member of the committee, has just come in but he might like to settle himself first.

No hurry. That is fine.

Be conscious that we have another session after this with the Health Products Regulatory Authority relating to medication when asking questions.

I thank the witnesses for attending. I want to bring the conversation back to the women who are travelling, with over 1,000 having had to do that since we voted in May. We will never know the exact figure but from studies which have been done on telemedicine providers, up to five people a day in Ireland use abortion pills purchased online. These are the key people that we need to take into account. I agree and understand that GPs and doctors need training, infrastructure and resources, it is vital that unnecessary elements are not built in that will further delay women and those who are pregnant from getting the healthcare that they should get in this country. With that in mind, we should start with safety. Abortion is a very safe procedure as testified to in the evidence we heard in the Joint Committee on the Eighth Amendment of the Constitution.

On abortion pills, I have spent much time researching them because I was involved in helping to distribute them at a time when they were illegal. There are more deaths from wisdom tooth extraction than there are from using the abortion pill. People may have an impression that abortion is highly dangerous and has many requirements. It is safer than Viagra. It is probably safer than antibiotics with regard to reactions because people have reactions to antibiotics. I make these points because there seems to be a layer of bureaucracy that has been talked about being built in to the provision of abortion. Adverse outcomes are very rare. I respect the doctors and the studies that they have done but studies have been done on women in Ireland, who have used an abortion pill purchased online, by Women on Web, which is the biggest provider internationally.

Dr. Abigail Aiken testified that less than 3% required any medical follow-up, and this tended to be either antibiotics or a blood transfusion. A really extreme adverse outcome was rare. That was in the case of early use of the abortion pill and is in a study published in The Lancet.

I was very glad to hear Dr. Favier state early scans in a GP surgery would not be necessary because we can imagine how long that would take. I have read very recent studies from 2015 and 2016 that show they are not required for early pregnancy.

I want to speak about the 24-hour helpline. I would love 24-hour helplines for many issues. We do not even have 24-hour helplines for domestic violence because we do not have the money. Is this also something that is not really necessary? If the service will be provided, and I completely reject the idea of opting in, it should be a normal part of healthcare. It should not be abnormal that a doctor opts in. It goes against the grain of everything people voted for to introduce opting in and making the service abnormal. People should be able to go to their GP and have a discussion. This is what everyone spoke about in the referendum campaign.

The waiting period is another issue. I reread the committee report, and I stand to be corrected, but I do not see much, or any, reference to it. Absolutely, it was referred to during the committee's deliberations but there is no medical need for it. The doctors have just said this and it is what the WHO told the committee. We all know it was put in as a sop so Deputies could say there are restrictions on women. Let us be honest. The WHO told us it is dangerous because it inhibits access for people who are poor or victims of violence. A woman with other children would have to go for a second appointment. It looks like this is what will happen but it is not really required. One appointment should be enough. If we build in a waiting period, will a woman have to take the first pill in the doctor's surgery? This is not necessary. People are taking it with guidance online and they can take it with guidance from their GP. It would enforce barriers and would mean the most vulnerable women will have time added on. It is paternalistic. We do not have a waiting period for anything else. We do not have a mandatory waiting period for a vasectomy. It might be recommended to the person to go away and think about it but it is not written into law. It would be really dangerous for this to be enshrined in legislation rather than being left up to a doctor to tell someone she needs to think about it.

My next question is on health and I ask the doctors before the committee to comment. There is a difference between what the committee on the eighth amendment recommended and what is in the legislation and I am quite concerned about this. In the committee's report people were at pains to make sure, based on all of the evidence from doctors themselves, that what health was would not be nailed down in law. The general recommendation was to include reference to risk to health but what we actually have is reference to serious harm. There is a difference between these two things. This is a deviation from what we discussed in the committee and it should be opposed. There would be no consultation with the pregnant person at the centre of it, which is highly paternalistic. It is not even mentioned that the view of the pregnant person on what is the risk to her should be a factor in the final decision. It is completely up to two doctors. I respect doctors but they are not infallible. The person should have a say. If a doctor is in a situation where somebody is outside of the 12 week range we would still have criminalisation. This can have a chilling effect on doctors, as can reference to serious harm rather than reference to risk to health. Will the doctors comment on why these different responses are included?

Dr. Clíona Murphy

With regard to the safety issue, we are not trying to overdo the risks of early medical termination. What we are trying to emphasise is that we would like the service rolled out to be fit for purpose and that there would be no cost-cutting in this area so we would not be trying to do it in another area. We are fully on board with trying to deliver this service. Our members just want the appropriate backup and resourcing so we are able to cope with women who need to go to hospital. My apologies if it was interpreted as us overemphasising certain areas.

We see the 24-hour helpline as a signpost for people. There could be situations where a patient does not want to go to her local hospital or GP. A helpline may provide advice on other appropriate centres. There may be many advantages to such a helpline. We and the other clinical groups felt it might be helpful.

The Deputy's points on the waiting period are well taken. As far as I understand, it will lead to an extra visit and that could be difficult, particularly for someone travelling from one area to another, perhaps to another community practice. It would be a particular difficulty for somebody on the margins of the 12 week limit. If someone at 11 weeks and three days needed to wait three days that would be obstruction, and there is international evidence to state it forms obstruction. I will mention New Zealand, which has a waiting period and a very liberal interpretation of conscientious objection. This has led to weeks of waiting for women and we should try not to go in that direction.

With regard to the change from "risk to health" to "serious harm", the Deputy has highlighted that issues in medicine are not black and white. Certainly we have advocated publicly on the need for the patient's voice to be heard in complex medical decisions regarding her health and pregnancy. Good practice would involve a multidisciplinary team meeting the two practitioners but good practice would also take into account the woman's experience, her social circumstances and her other children. We do not legislate for this but certainly it would be good practice. We already do this in other areas of maternal medicine.

With regard to criminalisation, it is something that has been advocated against worldwide. This year, the Royal College of Obstetricians and Gynaecologists came out strongly against criminalisation of practitioners, particularly those acting in good faith for women. It is an issue that should be addressed.

Dr. Peter Boylan

I can only endorse what Dr. Murphy has said, particularly with regard to involving women in decisions about their own healthcare and discussing with them their interpretation of what a risk is to them, because everybody's circumstances are different. We cannot define serious risk or serious harm.

Many aspects of this are open to question but because this is a new service it is very important that we get it right from the beginning. We saw this with CervicalCheck. It was not got right from the beginning. It is important that lessons are learned from that experience and that we ensure this is right from the very beginning.

Dr. Tony Cox

The Deputy stated she does not feel a 24-hour helpline is entirely necessary, and Deputy O'Connell suggested it probably will not be necessary, but if we want a quality service centred on giving patients the best and safest quality care, avoiding the situation detailed in the Scally report where patients were let down by their doctors, we do not want a situation where they may be embarrassed about going to a particular provider who finds it difficult to address their concerns. A 24-hour helpline would certainly signpost them to somebody who will be available, willing and more than happy to help them with their crisis situation.

If doctors provided the service, it would not be necessary.

Dr. Tony Cox

It would not be necessary if every doctor provided the service, no.

Dr. Peter Boylan

The reality is that there will be people who are unwilling; that is the same all over the world. We will not be unique in that respect.

I thank Dr. Boylan. While Deputy Durkan was absent, I indicated to Senator Kelleher and Deputy Bríd Smith that they could come in. I will come back to Deputy Durkan afterwards if that is all right.

I cannot understand how the Chairman could do anything in my absence.

I will be brief because I know others want to come in. I thank the witnesses for their presentations. Dr. Boylan said the timeline is challenging. It certainly is challenging for women when they find out they are pregnant and the clock starts ticking in a very real way. It is challenging for the women who are taking the pill today, as Deputies Coppinger and O'Connell have described. It is estimated that 1,000 women will be travelling to the UK, which has been going on for years. We waited 35 years for what happened yesterday; the timeline is certainly challenging but some 66.4% voted for change. Given that time is of the essence for women, how can we as legislators work with colleagues in the colleges to make sure that there is no undue delay, for example in the drawing up of the guidelines that Dr. O'Brien mentioned? Do we need some formality on that?

Going back to the three-day interval, Dr. Boylan and Dr. Murphy clearly said in their paper that it is not supported by evidence, so surely there is a case that it should not be in the law. Would the doctors recommend we avoid putting it into the legislation? Would the witnesses be willing to write to the Minister for Health asking for an urgent meeting of all of the stakeholders, which should include women, the Irish Family Planning Association, the HSE and all of the various colleges and the doctors? Would they be willing to write to the Minister asking for that stakeholder leadership?

Dr. John O'Brien

The Senator is asking how the legislators can help with regard to the implementation of this service in as expeditious a way as possible. I think the members are all pretty well focused on that from their comments today. The areas that do need attention are those of the framework within which all this will operate. That is a planning issue to do with the HSE and the Department of Health. It will also be important that this is sufficiently resourced; ring-fencing of the resources has been mentioned already. There is also a whole question around capacity and actually providing the people, equipment, buildings and beds to deliver this service both in primary care and within the hospital system itself. The guidelines are moving along very nicely but once again the legislation is important in order that the guidelines map to the legislation. We need to know what this will look like so we can map the guidelines to what there is. It is an iterative process.

We spoke earlier about getting everybody in the room. That is something the members could possibly promote as well. Apart altogether from ourselves - we have been in the room - the people who have not been in the room are those in general practice, who will discuss terms. There is a need to discuss how that piece of it will work and to address funding going into general practice. General practitioners are outside of the normal HSE structure and they will have to be brought in as well.

Dr. Mary Favier

One of the most significant things that would give reassurance to the women of Ireland - our patients - would be a commitment, be it in legislation or in regulation, that there will be a timeline attached to when they can expect to receive a service. For instance, in Portugal, where they do not have any mandatory waiting period, it is written into their regulations that they must receive a service within five days. In Holland, where they do have a mandatory waiting time, that waiting time starts from the moment the women picks up the phone. It would give great reassurance to us as potential providers to know that the Department has our back and that there will be provision within a certain timeframe. It is not for us to suggest what that timeframe would be but this is a particularly timebound issue, unique in medicine. As the Senator said, the clock starts to tick for women, but unfortunately it is going to start to tick for providers, too. We are going to be faced with the additional burden and responsibility of how to shepherd women through these clinical care pathways. Who is responsible for them if the pathways fail? That question is exercising general practitioners and obstetricians as well as nurses and family planning clinics.

Dr. Peter Boylan

I think after today's hearings the Minister is probably fully aware of the urgency of getting everybody around the table at the same time. With regard to the three days, that is a matter for the Legislature. It is up to the Deputies and Senators. They know our feelings about it - that it is unnecessary and demeaning to women to suggest that they have to wait three days to make their minds up.

I will take that as a "yes".

Dr. Peter Boylan

The Senator may take that as a "yes" but it is the legislators who can fix it, not us.

I would add that I do not think a 72-hour waiting period was high in the mind of anyone who went out and voted in the referendum, although I have heard that argument being used.

I am sorry I missed most of the discussion and apologise if I am repeating things in my questions. I heard the presentations but not most of the discussion. Returning to the issue of the three days, I note from the presentations that there is nearly full agreement that this should be fundamentally a community-based service, that the vast majority of abortions are likely to be medical, that the abortion pill will be administered in over 70% of cases and that therefore it makes sense for it to be community based. However, if we take my community as an example, there is a very nice, modern health centre in Ballyfermot with several GP practices but it is very difficult to get an appointment. It is a very busy area. The last time I looked for an appointment, I was waiting for over a week to see a doctor even though I did not mind which doctor I saw. That is kind of typical and therefore I think we have a genuine problem in terms of what GPs can provide.

On the whole business of the waiting time, I am very pleased to note all the witnesses agree that it removes power from the woman, is demeaning and can be an obstruction to receiving an abortion. It is also a real problem to have that timing in there given the pressure on GP clinics I have just described. Even the waiting time was counted from the day the woman picks up the phone, it could be still five or seven days before she gets the appointment. I reiterate that it is a big part of it.

This is also linked with a question I have about the definition of "medical practitioner". If anybody has already asked this, I apologise for repeating it. The World Health Organisation safe abortion guidelines say that a medical practitioner is defined as a properly trained healthcare provider, including mid-level non-physician providers. Would the witnesses see that there should be an important role here for midwives, practicing nurses and indeed counsellors in the health service to help provide the service? If we are to go forward from January or whenever we can get this service in - sooner if possible - and if we are to rely totally on GPs when there is a crisis concerning the accessibility of GPs as it is, would it not make more sense for the Medical Council and everybody to recognise that nurses and midwives based in clinics could also provide the service, at least up to the point of providing the pill?

Taking in my second question on conscientious objection, along with the crisis in GP availability is the fact that some doctors may have a conscientious objection, which will add an extra burden onto the provision of the service. There is a real, important role for us to be very clear in the legislation on the question of conscientious objection.

There must be an imperative on doctors to refer onwards if they are going to deny women the abortion service. This must also be policed in order that we can see how conscientious objection is being applied and guarantee that the abortion service is provided. I would like the witnesses to comment on these points.

There has been considerable discussion on the issue of decriminalisation. Does the committee intend to examine it or would it be more appropriately sent on to the justice committee? If a 14-year sentence has a chill factor for medical practitioners, then it is unnecessary and unduly heavy-handed and should be removed. The issue should be examined in more detail by this or the justice committee. Will the Chairman explain how that can be done?

Dr. Peter Boylan

We covered the question of the waiting period. Generally, those of us present agree that it is not necessary. As the Deputy stated, it demeans women's autonomy.

Regarding the definition of "medical practitioner", there are plenty of instances in obstetric practice and general medical practice of advanced nurse practitioners dealing with complex medical conditions, for example, diabetes management. It is possible that advanced nurse practitioners could deliver the service. It is important that the service be got right from the beginning, though, and that there should be no hiccups. People will be watching it closely and waiting for something to go wrong, at which point the accusations will fly.

Decriminalisation is not a matter for us.

Dr. Peter Boylan

The Deputy made frequent reference to GPs, but "community care" is a better term for describing it. We envisage family planning clinics and so on also being able to provide the service and it not being restricted to GPs. That is an undue load and concentration on GPs, as there is more to this than just them.

Under family planning services, would midwives and nurses also be able to provide the service?

Dr. Peter Boylan

That is probably a matter for legislation. I am not sure about the restrictions on practice through the Nursing and Midwifery Board of Ireland, which is the equivalent of the Medical Council for midwives and nurses.

Dr. Mary Favier

My understanding of the legislation is that it will read "medical practitioner", which will restrict it to medical practitioners. Best practice internationally is moving towards mid-level providers in what is called "task shifting". In the UK, the services are almost entirely provided by nurses and midwives with doctors' supervision. Sometimes, the doctors' supervision is remote, that is, by telemedicine. In areas experiencing remote access issues or where not enough providers are giving mid-level training, nursing provision has been critical to allow for implementation. This matter would have to be carefully written into the legislation so that provision is appropriately structured. Individuals would have to be trained and involved in the process as well.

Dr. John O'Brien

It is probably worth saying that there are 3,600 GPs and 1,700 practice nurses in the country. For some time, the ICGP has been advocating for a 1:1 ratio. The Deputy's point seems a sensible avenue to explore, but there is not a ready supply of the people in question.

Regarding the Deputy's question to me, we have not seen the legislation yet. All we have is the general scheme. Head 18 reads: "It shall be an offence to intentionally end the life of a foetus otherwise than in accordance with the provisions of this Bill." The Deputy rightly identified the following:

(a) on summary conviction, to a class A fine or imprisonment for a term not exceeding 12 months, or to both, or

(b) on indictment to a fine or imprisonment for a term not exceeding 14 years, or to both.

This provision will be examined when the Bill reaches pre-legislative scrutiny stage at the committee.

This committee?

Dr. Suzanne Crowe

I might address the point about conscientious objection. The updated ethical guide will reflect the concerns that the Deputy is raising. Alongside public and professional consultation, we will seek to place the patient's voice front and centre in that conversation and the doctor's view on the issue very much in the background. There is an obligation in the guide to refer to another provider, but we will emphasise that it should also be timely.

I thank Dr. Crowe. Before calling Deputy Durkan and Senator Mullen, I will ask Dr. Crowe or Mr. Prasifka whether there is any situation in which the ethical guidelines of the Medical Council are in conflict with legislation and whether the same could arise in this case. We have not seen the legislation but, in light of the heads, could there be a conflict?

Mr. William Prasifka

I would not say "conflict", but it is important to note that there is a difference between what is legal and what may be good practice. It may be legal for a doctor to overprescribe a certain medication, but that does not mean that doing so is in the best interests of the patient. The legislation and the ethical guide have two separate sets of objectives, and it would be important to view them as complementary. They have two different missions, so they are not always the same.

I thank Mr. Prasifka. I invite Deputy Durkan to make his contribution.

My apologies, as I had to attend the Dáil for Question Time. I welcome our guests. I have four, or maybe five, questions for them.

Form the discussions that have taken place between the professional groups, the Department of Health and the HSE, has agreement been reached, and is everyone in accord, on the concept of doing everything possible to meet the January deadline?

Dr. Favier correctly referred to the suite of ancillary or supportive services, including family planning and sex education in schools, which was not mentioned, that would provide information to men and women, boys and girls, in such a way as to improve their knowledge of the situation as life opens up before them, for example, how to deal with the kinds of situation that can arise in emergencies and their respective responsibilities in that regard. How have these issues been examined in the professional exchanges since the referendum?

I do not agree with the now-emerging notion that a three-day waiting period is not necessary. It was discussed at great length during the committee's hearings. Reference has been made to other jurisdictions in which three-day or four-day waiting periods are applied. A good number of European countries are counted. In some cases, the Netherlands and Germany have longer waiting periods than is envisaged here. Importantly, the committee discussed this matter at great length. We agreed or disagreed, but we proceeded on that basis and the referendum followed. According to the submission made by the medical professionals from the Netherlands, the women involved sometimes changed their minds, as was their right. That right should be accommodated and I stand over that statement. If there is a compelling reason for a woman or girl to seek a termination, she has a right to have counselling and some time. That time should not be of such an extent to endanger her life or whatever the case may be, only to allow her to make a decision based on the best evidence available and what action is most appropriate for her in her particular circumstances.

That is why we come back to the GPs as the first point of counselling. The GP must be in a position to advise a pregnant woman in such circumstances on what is best for her. It is not within our remit to change what we have done because the people made the decision on the basis of the Citizens' Assembly hearings, the hearings in this committee room and the submissions made by various people in different, and in some cases appalling, circumstances. It is important to try to remember that.

Based on the discussions between professional groups and the HSE and the Minister, are the witnesses all of one opinion on the feasibility of putting together the package of services deemed to be required?

I accept the right to conscientious objections. Based on the witnesses' discussions with their own professional groups and also with the HSE and the Department of Health, do they believe the services will have the ability to provide a universal service reasonably evenly across the country without areas that will require no services or sparse services? Will the same constitutional benefits extend to all people throughout the country no matter where they live, without exception?

My last question is on the medical and surgical issue. The most important thing is to address the health and safety issue, to make the service available and to make sure it is of the highest quality in order that nothing prevents a woman who may have a crisis pregnancy, whatever the case may be, from gaining access to the clinical advice and services required to address the issues she may have at any particular time. For instance, I can see the three-day waiting period readily being accommodated within the system as it stands if there is a will to do so. It is important that nothing shall impede the availability of the kind of service that a particular pregnant woman needs at a particular time. I emphasise that because in the past there have been instances where in the aftermath people have said if something else had been done earlier, there might have been a different outcome. We need to get away from that. It is long since passed the time when women will allow a situation to prevail whereby anything less than the best and highest quality first response is available to them at all times. That is what they spoke about and that is what the people who voted in the referendum spoke about and voted on. We have to stick to it.

Dr. Clíona Murphy

I will answer some of those questions. With regard to whether we are in agreement on the January timeline, we are in agreement that it is a tight timeline. We are in agreement that lots of different measures need to be taken before then and a lot of integration needs to be done. We do not say it is impossible but that it will be difficult. That needs to be acknowledged and a great deal of work needs to be done between now and then to get a service up and running. The only thing the IOG has been tasked with so far is the development of guidelines. There is much more to do on the development of guidelines. We can say what doses of medication are required at a different gestation point but there are many other pieces of the mix that need to be put in place and that requires talking to all stakeholders. The committee is hearing that message today.

With regard to the three-day wait, it is ultimately a legislative issue. Our point is not to put additional barriers in front of women and to acknowledge that internationally only 10% of women who are offered counselling go for it. Most have done a lot of decision-making before making first contact. We must be conscious of the time it could take if there is a three-day wait and an additional visit. Ultimately, it is a legislative issue.

With regard to the feasibility issue, similar to the January timeline issue, we are not all of the same opinion. There are conflicting opinions even among our members and among various GPs. Within the ICGP, there is lots of discussion still being had. We are not all of the same opinion on every issue. There are some issues we are still considering and on which we need consultation with other medical practitioners, for example, regarding the administration of anti-D to rhesus negative women and whether it would be given at eight weeks or only over nine weeks. Issues such as that on their own still require consultation. If we add up all the issues in a complex roll-out, there is lots to be discussed in various fora. We totally concur with the Deputy's remarks on accessibility and with other speakers that women have to be the focus of this and not necessarily the practitioners. We must all be focused as multidisciplinary teams on dealing with the development of the best services for women.

Dr. Tony Cox

Deputy Durkan asked if we had reached agreement with all the stakeholders. There has not been a meeting where the HSE, Department of Health, ICGP, IOG, Medical Council and other providers such as-----

Who has been missing most consistently?

Dr. Tony Cox

Pardon.

Who has been missing most consistently?

Dr. Tony Cox

I am sure everybody can work that one out for themselves. It has not happened yet.

What is the big secret? Why can we not-----

Dr. Tony Cox

I am just stating that-----

Does Dr. Cox have the answer to the question Deputy Durkan asked and, if so, will he answer it?

Dr. Tony Cox

Who is the missing person?

The question I asked was who is most likely to be missing from the meetings and interactions that have taken place over the past few months. Who was most often the absent partner?

Dr. John O'Brien

The meetings that took place were initially meetings in the Department of Health with the medical officer in the Department. They were exploratory meetings fleshing out what I said earlier about the three streams of work - legislation, guidelines and the provision of a workable framework. There were three meetings hot on the heels of each other at that particular juncture but there were no meetings in the latter end of the summer. We had a meeting with the HSE more recently. It is not about who has been missing; it is just that it has not been happening.

Everybody takes holidays some time in August, expect perhaps me. The point is it is important for us to know if any particular group is foot-dragging, for want of a better description.

Dr. John O'Brien

Dr. Cox's point is we do not want to point fingers at people. It is not particularly helpful. What is particularly helpful is to get us all into the room together to work collaboratively to move whatever needs to be moved forward. The Deputy's point about the number of women who have had to avail of abortion services outside of the country so far this year is worth bearing in mind and repeating. We just need to do it.

The witnesses are getting it right.

Dr. John O'Brien

I will tell the Deputy that afterwards.

I want to emphasise the question. We should make no mistake that there are many things we need to get right in the health services in general. It is no reflection on anybody in the room but if we do not get something right soon, our credibility as a nation among the family of nations will be seriously at risk. We all need to put our shoulders to the wheel, whether we are administrators, politicians or medical professionals. We need to be clear on where we are going and we need to provide the services that are required. They should be of the highest quality and have the highest degree of availability.

We have been living for years with the nonsense of having to wait for services but in the case of a pregnancy, there is not much sense in telling somebody to come back next year or the year after. We cannot have waiting lists for this service. If we have a slow down in the process, it will damage the entire structure of the service.

To rephrase the question-----

Chairman, I wish to correct the record. There is no mention of a 72-hour waiting period in the report of the Committee on the Eighth Amendment of the Constitution. That is important because it was stated that we all voted for it. Any time that issue was raised, it was shot down by experts.

Deputy Durkan was very vocal on the issue. Deputy Durkan should not be making out that we discussed it.

Deputy Coppinger-----

For the benefit of the Deputy-----

Deputy Durkan, just for a moment-----

I am just correcting the record.

I am correcting the record as well Mr. Chairman. I want to set the record straight.

The record is there.

It is quite clear that there are precedents set in other countries and they are still working and seem to be working well. They are there for a reason. We had a discussion, at length, in the committee and we arrived at decisions and voted on them.

We did not vote on it. I am just correcting the Deputy, who is factually wrong.

I am sorry. If the Deputy would please stop interrupting I might finish what I have to say.

Deputy Durkan constantly interrupts.

We can clarify the situation. Let us not have a dispute across the floor of this committee. It was a different committee that dealt with this.

I did not raise this question. This question was raised with me and I was corrected. I am now correcting the corrector, if that is possible. I want to proceed without interruption. Chairman, I waited until the very end because I had to leave the room, and I did not object to anybody else going ahead of me, including Members who are not members of the committee. I rest my case.

My final question is to ask the extent to which all the professional groups, independently and collectively are satisfied and committed to the quality of service that is required.

Dr. Tony Cox

We are committed to a quality service. That is what the Irish College of General Practitioners, ICGP and the Institute of Obstetricians and Gynaecologists, IOG, do. We cannot accept a second standard level of service for our patients. The patient is front and centre in this whole process. That is what we are about. The ICGP has been working on the feasibility of introducing the services. We have a framework for a clinical care pathway. We have been waiting for the legislation, which is key and we welcome the announcement that it will be coming very soon. We will be able to map the framework of our clinical care pathways to the legislation that is coming very soon. We have been working away. We are absolutely dedicated to quality and to the safety of the patient at the centre of the process.

To rephrase the question, are the witnesses satisfied that the ICGP and the IOG are getting sufficient support from Government agencies and from the Department of Health in drawing up their guidelines?

Dr. John O'Brien

I think it is evident that there has been a slowdown during the summer months. We are anticipating that minds will be more concentrated from this point and we anticipate that we will be getting invitations from the Department of Health and the HSE and that there will be a collaborative discussion involving all the key parties.

Dr. Clíona Murphy

Let me add that the IOG did get very good support with regard to organising site visits to other countries and with regard to the support we might avail of on administrative issues and in organising courses. There was obvious backup in that regard. The issue is to have that engagement going forward.

My questions relate to where an abortion is requested by a woman and is not being proposed by doctors in the context of a necessary health treatment, that is, effectively on the 12-week grounds. I do not think any of my questions have been dealt with at any stage during the hearings this morning.

Much was said about conscientious objection this morning. I would be grateful for some assistance. When we talk about what healthcare professionals may or may not be required to do, are we talking about criminal sanctions that might face people as a result of how they exercise their conscientious objection? Are we talking about potential civil sanctions or litigation or are we talking about professional regulatory sanctions, employment consequences or protecting people from employment consequences? I would be grateful if that issue could be teased out. Are there examples of general practitioners, whether for conscience or capacity reasons - by conscience reasons, I mean anything such as religious or philosophical objection or their best judgment about authentic healthcare - who do not offer particular elective medical services but do not have a duty to transfer? I do not say that everything hinges on the answer to that question but I would like to know the answer to it. This is an unique issue, a life and death issue. This is an issue where there is a serious difference of opinion between healthcare professionals who regard abortion as a part of healthcare or alternatively as a human right versus a group of people who in good faith believe this is an unethical, harmful and possibly doubly harmful elective procedure. Are there existing examples of cases where people do not have a duty to transfer, notwithstanding that they are not offering elective medical services? Is there a difference in the view of the expert witnesses in the protection that should be afforded to nurses, midwives, other healthcare staff or professionals, including administrative staff, and people involved in teaching medical procedures compared with the protection afforded to doctors, who may have a conscientious objection? Do they stand in the same relation? Ought they stand in the same relation?

Turning to the question of the three-day waiting period, to be frank I note the ICGP and IOG representatives are clearly dumping on the idea of a three-day waiting period, yet they are telling us that not all of the people they represent are of the same opinion on issues relating to this. To what extent have the bodies consulted with members about the three-day waiting period? What is the state of opinion among the ordinary membership of their respective bodies and can the witnesses enlighten us as to the statistics on how people think about this issue? It is noticeable how sharply opposed to the three-day waiting period both bodies have been, yet they say at a different moment in the presentation that people have widely varying views. When the witnesses say that it is not "necessary" - this is a word that was used - may I ask what they mean about it not being necessary? Is there evidence that it facilitates some women in not choosing abortion in some cases? I have heard it suggested it does not often happen but can the witnesses be more precise in their information? Why is that condition provided in the Netherlands and in other places? Are they saying that it is their view that the same number of abortions will take regardless of whether there is a three-day waiting period?

In saying that the IOG and ICGP representatives have a clear opposition to it, I have not heard, and perhaps I should have been listening more carefully, what the Medical Council has to say on that, if anything. On the one hand, the Medical Council is saying that in its forthcoming guidelines, the doctor's view will be backgrounded and the patient's view will be to the foreground. Mr. Prasifka, on the other hand, draws a distinction between what the law might permit and what the Medical Council considers to be ethical at the same time. Is it conceivable that the Medical Council might take a view that there is an ethical dimension to the three-day waiting period?

Is it conceivable, for example, that even if the law does not effectively treat the unborn child as a patient where abortion is sought, the Medical Council might say that ethics require consideration of the unborn child as a patient be given? Might that touch on decisions, reviews or recommendations of the council in respect of the three-day period?

Does a waiting period ever apply in the provision of other kinds of elective medical services? Again, I am not saying the question of whether there ought to be one here hinges on the answer to that. Is it the case that with most serious medical services, it simply does not happen on demand and on the day anyway? The example was raised of a vasectomy. I do not know how that works. Is it rare for anything serious to happen on the spot or are there are examples of where waiting periods apply and are effectively prescribed, either by law or by regulation, such that people may not have immediate access to certain elective medical procedures? Is it the view of our guests that the removal of a three-day waiting period could, or would, cause an influx of women from Northern Ireland seeking abortions in our jurisdiction? Is it something any of the witnesses have discussed, or have there been submissions to that effect?

I will move to the third phase of my questions. There has been much talk this morning about preventing crisis pregnancies but no talk about preventing abortion when crisis pregnancy arises. I ask why that is the case. I accept the Constitution no longer protects the lives of unborn children as a fundamental right, but it gives full power to the Oireachtas to regulate this area in whatever way we, as legislators, see fit, including, I presume, that we might choose to encourage women not to choose abortion as a matter of good public policy, public health, ethics and welfare of the unborn child and so on. Why is there no talk of trying to prevent abortion in the context of a crisis pregnancy having arisen? I presume a three-day waiting period is partly about that with respect to the welfare of the mother and the unborn baby. I also presume it is one way of trying to keep the unborn child in focus as a patient deserving care, notwithstanding that abortion is permitted. Is that the understanding of the witnesses as to why a three-day waiting period is in play?

Are there other examples of how the Legislature might keep the welfare of the unborn child in view in the context of an abortion regime applying? Has any thought been given to how a woman requesting abortion might be engaged with? I stress this should happen respectfully and never with deception or coercion? For example, could there be a requirement for a woman to be offered an ultrasound and sight of the ultrasound to strike a balance? Has that been discussed within the organisations represented here?

Dr. Peter Boylan has said the number of abortions here is likely to mirror that of Scotland due to our similar populations. There were 12,100 abortions in Scotland last year. Accepting it is difficult to quantify the number of abortions taking place while also accepting that the best information we have from British and international statistics indicates a much lower figure, do the witnesses accept we are looking at a significant increase in our current rate of abortion on the balance of probabilities? In light of Dr. Boylan's expectation of 10% of cases resulting in admission, is it reasonable to speculate that we are talking about 1,200 additional hospital admissions in a year? Given that we have an admissions crisis in hospitals with trolley numbers recently hitting an all-time high, is it reasonable to speculate how the system will cope with this?

It was mentioned that once abortion is introduced, rates fall over time. I am open to correction but I understand that Scotland's rate has been increasing over the past three years, even as its birth rate has fallen steadily over the past ten years. In a sense, that lends some kind of urgency to my question about the impact on the health service.

There are ten questions to be answered.

Dr. Suzanne Crowe

I will take the conscientious objection issue. The Medical Council was established very much to protect the interests of the public in its interaction with registered medical practitioners. That is what I mean by the patient's voice coming first and the doctor's voice second. The current provision as regards conscientious objection in the ethical guide covers all lawful treatments in this State and it is not specific to abortion provision. It covers any treatment that a doctor holds ethical or moral concerns about and does not want to be involved with providing. For example, this might include any services relating to reproduction such as vasectomy, which was raised earlier. It also includes assisted reproduction and other lawful treatments. It is not anticipated that this will change and it is important that it remains in the ethical guide to cover a multitude of treatments available in the country. If there is an issue with how the conscientious objection is being delivered or interpreted by individual practitioners and that concern comes before the Medical Council, it will be managed in the usual way that any complaint is managed in front of the council. That will be of a confidential and individual nature.

The Senator raised the matter of allied professionals working in hospitals such as nurses, physiotherapists, pharmacists, etc. Other professionals have their own professional bodies and I imagine they will also produce ethical guidance.

Dr. John O'Brien

There were a number of questions but perhaps I will take one or two of them. The Senator mentioned the three-day waiting period but it is not fair to say we are advocating the dumping of the three-day period and we are sharply opposed to it. We are saying that we do not have evidence to support it, which is quite separate. Of course, the guideline we produce will be evidence-based and that is where we will go.

The Senator asked what doctors want. This is not about what doctors want but about what patients need. It is important that it is framed in that way. He asked if we consulted members, specifically those who hold opposing views and views of conscientious objection with regard to the provision of abortion services. We have done so and an extensive process is under way currently. It is a qualitative process and we have created an outline document for our members. We have invited their contributions online and we are still in the process of doing that. We are not at the end of the process and it will be the end of the week before it is finalised.

The Senator asked about waiting periods for other issues. In general practice, I cannot think of another instance.

He asked about an influx of women from Northern Ireland and it is not unreasonable to expect, certainly in Border counties, that some women would avail of the services. I do not know how Brexit will affect all of this or where any of that might go.

The Senator asked most specifically about the prevention of abortion when the woman presents. That kind of goes back a little bit to Deputy Durkan's comment that the GP would advise what was the best thing for her. I have never advised anyone what is the best thing for them. I have entered into a dialogue with them as to what might be. I might present them with evidence, one way or another, but I have wanted it to be something that they owned so that it was their decision-making more than my decision-making. In terms of the prevention of abortion, it is more a question of allowing the woman to articulate what it is that has led her to the predicament that she is in and maybe explore with her what are her options in the face of that. She may very well have made up her mind as to what those options are, and so be it, or it may be that in the process of the dialogue that there may be an alternative course of action that she then chooses to follow. This goes back to the amount of time that will be available to GPs to have a discussion with patients. Every woman will come with her own unique set of circumstances and context and her wishes and her needs will need to be front and centre of all of this. The counselling services will have a bearing on that.

I am not sure, and the Senator raised the prospect of giving women sight of an ultrasound-----

Dr. John O'Brien

If a woman wanted something then I would certainly try to facilitate what the woman wanted. To my mind, that would be quite a difficult piece of the conversation to have in that I would not wish to try to lead the woman down a particular road, or another road, so I might have difficult with that.

I shall pass on the question on the increased rate of abortion to others.

As these are involved issues, can I seek further clarity before we move on to other responders?

I thank Dr. O'Brien for his response and I thank the Chairman for facilitating me.

Dr. O'Brien said there was no evidence to support a three-day wait. What does he mean by no evidence? What would the evidence look like? Is he thinking about evidence that people might not choose abortion? Is he thinking of evidence that people are happy that they had to wait? I would like him to be more specific.

Let me outline what I asked. I did not ask whether people had been asked about their conscientious objection. I asked whether people had been asked specifically about the three-day waiting period and whether they had a view on that.

On the question of advice, it is clear from Dr. O'Brien's answer that he does not want to influence the decision that might be made. Has he never advised a person to give up smoking for the good of his or her health, for example?

Dr. John O'Brien

I would invite somebody to give up smoking. I would never tell somebody to give up smoking. That is a side issue.

Not necessarily.

I ask the Senator to give Dr. O'Brien a chance to respond.

Dr. John O'Brien

Apropos the business of the evidence, in so far as we can establish, there may be some instances of harm from a three-day wait. The Senator's point about evidence was well made. In terms of what we accept as evidence, much of the evidence that we might look at is not pertinent to the facts on the ground straight in front of a person. All that I can tell the Senator is that we have not found compelling evidence of benefit. We just have not found it. We have engaged with our members, most specifically, to ask them to also provide us with evidence that we have not found. That has been part of the dialogue.

The Senator asked whether we asked a specific question on a three-day wait. We did not ask a specific question on that aspect but we have allowed space within the consultation process for people to bring forward, in a non-directive way, issues that are pertinent and of concern to them. Did the Senator ask something else?

No. I thank Dr. O'Brien.

I ask Dr. Boylan to comment on three-day wait and the evidence on same. Another question was asked on the level of elective or emergency admissions that one might expect for terminations.

Dr. Peter Boylan

In terms of the three-day waiting period, we have stated guidelines in our submission, which is what we were invited to do. We say that the three-day waiting period "is not supported by evidence". We also made the comment that, "It makes unwarranted assumptions about women’s ability to make their own decisions" about their own healthcare. That, basically, is the position. It is a comment rather than anything else.

An influx of women from the North of Ireland was mentioned. That is not a matter for us in respect of guidelines. What we are tasked to do in the institute is to write guidelines, in consultation with other bodies that we have heard a lot about today, and also to involve ourselves in the training of practitioners who are going to be delivering the service.

Regarding the numbers in Scotland, in our submission we noted that in Scotland 75% of terminations are less than nine weeks and 91% of these are medically induced, while approximately 10% require hospital attendance because of complications possibly not requiring admission. We made no comment about actual numbers; we were talking about proportions.

I am not aware of any condition in medicine that requires a three-day or any waiting period. Waiting periods are a consequence of access and availability of beds, operating theatres, etc.

Does Dr. Boylan have a view on the level of additional care that will be required once termination of pregnancy is introduced, in terms of hospital admissions?

Dr. Peter Boylan

There will be, inevitably, some increase in hospital admissions. Maternity hospitals and maternity units are incredibly flexible by their nature because they have to be. For example, the number of deliveries in the large maternity hospitals has increased from approximately 5,000 15 to 20 years ago to 9,000 now without any increase in infrastructure. A proportion of women present with spontaneous miscarriage at all hours of the day during the week, on weekends and so on. They are dealt with as they turn up and the same thing will happen in these circumstances. There will be an increase in workload but we do not anticipate that it will be overwhelming.

Deputies Kate O'Connell and Louise O'Reilly wish to ask supplementary questions. I remind them that we have another group waiting to come in. We are just a little over time and I ask them to confine themselves to asking simple straight questions so we can get answers.

As the witnesses have referenced, there is little evidence to support a three-day wait. Recently, Dr. O'Brien said that there might be some instances of harm. I ask him or his colleagues to elaborate on the matter now or even after the meeting as it is important.

Dr. Mary Favier

The WHO guidelines on safe abortion have quite a considerable section on the matter. I suggest that members access those guidelines. In terms of harm, the WHO argues that the biggest issue is that the wait delays gestations or delays when a woman receives a service, and then there are more medical harms associated with that.

That brings us back to our initial discussion with Dr. Favier.

Dr. Mary Favier

Exactly. The wait introduces significant barriers. As the provision would appear to introduce a mandatory two visits or interactions then, by definition, if one lives in more remote areas, or faces financial, childcare or disability issues, there are barriers.

One of our biggest concerns is that mandatory waiting periods may push women with those risk factors back into illegal services and accessing abortion pills over the Internet. Although abortion medication is very safe, we have concerns regarding its usage in unsafe environments. A three-day mandatory waiting period may contribute to such usage. The number of women who continue to access such services over the Internet is a marker of potential failure on this issue. We will know whether we have been successful in provision when we look at those numbers. Women will continue to do so for many reasons but it should not be because we have placed barriers in their way. From a medical rather than a legislative perspective, a mandatory three-day waiting period appears to be one such barrier.

We invited the witnesses here to give their professional opinions. Do our general practitioner witnesses and those representing the Irish College of General Practitioners believe it fair to say that the three-day waiting period could be dealt with through guidelines or left to the discretion of doctors depending on the individual circumstances of each case and that to impose legislative constraints may have negative and unintended consequences?

Dr. Peter Boylan

Yes.

Dr. Tony Cox

I think so.

As the Chairman is aware, I have spent a lot of time attending meetings of this committee and the Joint Committee on the Eighth Amendment of the Constitution. I ask that the clerk compile a graph illustrating Senator Mullen's attendance when issues-----

No, that is not an issue-----

-----of a gynaecological nature are under discussion. His attendance at the health committee when such issues are being discussed seems to be far more frequent than for any other issue.

That has no relevance for the committee.

I refer to the repeated use of the term "elective services" by a member of the committee in reference to abortion. Elective services are those which are scheduled in advance because they do not involve a medical emergency. To class women seeking an abortion as attempting to access elective services is to try to diminish women. I believe that member has failed in his pathetic attempt to do so today. I wish to put that-----

That is not in issue. We are here to take evidence from witnesses who have attended to give their expert opinion. We are not here to adjudicate on a row between members.

The Chairman is a medical doctor and did not pull the member up on that usage of the phrase "elective services".

I call Deputy O'Reilly.

It is totally disrespectful to women.

I am happy to allow-----

I ask Deputy O'Reilly to, please, continue.

I echo the remarks made by Deputy O'Connell. Anyone who pays attention to the committee proceedings knows which members only attend meetings of the committee at which women's healthcare is discussed.

The issue of the provision of services for women from the North was raised. As the witnesses are aware, the Minister for Health, Deputy Harris, announced that such services will be available. My question is a fairly simple one and relates to two areas. The meetings which it is thought have been taking place were discussed. It would be of concern if they have not been taking place. At such meetings, have the witnesses discussed the provision of services to make good on that commitment given by the Minister for Health and also, possibly, the Taoiseach? Has the provision of services for women from the North been discussed? Brexit was mentioned. Any discussion of the issue will have to be Brexit-proofed, although what form Brexit will take remains to be seen.

I have a concern regarding the collection of data. Dr. Boylan and Dr. Murphy made reference to discussions that took place with their counterparts in Scotland. I presume that when the witnesses went to Scotland their counterparts had access to information and could give the witnesses the profile of women accessing services there, which they can track over time. Very little data will be collected under the current proposals. What is the view of the witnesses on how we should go about the collection of data and whether we should try to gather more information? Such data might inform considerations of the care and services that will be needed in the future and whether there may be a need for improved access to contraception or other services in certain areas. The current proposals do not seem to prioritise the collection of such data. I believe it important that they be collected. I ask the witnesses for their views in that regard.

Dr. Peter Boylan

Audit is part of running any service. It is very important that that information is collected in order to inform how the service is working and what improvements need to be made. Audit is critical in the running of any aspect of the health service. We have been tasked with providing information regarding guidelines around the content of the proposed legislation. Implementation of the service is a matter for the HSE and the Department of Health and that is where women from the North of Ireland fit in. Our job is not to arrange the provision of the service. Rather, that is a responsibility of the State. From now until the end of the year is the time for the interested groups to come together to discuss the issue because we have a very good idea of our guidelines and now need to know about the provision on the ground, which is where the Department of Health and the HSE come in.

Dr. Mary Favier

For the information of Deputy O'Reilly, there is a significant amount of international evidence to show that the better the collection and monitoring of data, the better the provision will be. We are in a difficult circumstance in Ireland in that we are beginning with almost no such data. We must very carefully extrapolate from the data from other countries. The World Health Organization, WHO, has very good guidance on what type of data should be collected. Patient and doctor confidentiality and the new GDPR recommendations must be considered. For instance, every doctor's Medical Council number must currently be attached under the Protection of Life During Pregnancy Act. Many such requirements must be teased out in terms of whether they are necessary and why they are there. No data which could identify a woman can be collected but that leaves much to explore. Good data will be of great importance in terms of implementation and planning.

Has that formed part of the witnesses' discussions? My understanding is that it is currently proposed to collect very simple anonymous data which do not indicate the age or demographic profile of women accessing the services. If that issue has not formed part of the discussions, I ask that the witnesses ensure it is put on the agenda. The committee will do what it can on the issue. If the draft legislation is progressed in its current format in terms of the amount of information that will be collected, we could be sitting here in five years' time unable to have any meaningful discussion on how to develop a service due to a lack of data. I appeal to the witnesses that when they attend the meetings and, it is hoped, everyone is in the middle in the Venn diagram, the collection of data forms part of the guidelines in regard to the proposed legislation because we will not be able to plan without such information.

Dr. Mary Favier

Portugal, the European country which most recently changed its legislation following a referendum 12 years ago, put a particular focus on the collection of data. It has very good data which it uses every year to interrogate its provision of and access to services, particularly in rural areas, as well as the issue of prevention. The WHO provides that data set and makes recommendations on what should be collected and how services might best be planned. I do not think it will take much reinvention to collect such data here. As GPs, we do not want onerous burdens placed on doctors to collect data which do not have a medical purpose or potentially form the basis for a change in healthcare. As we stated, GPs are exceptionally busy and, unfortunately, anything that adds another layer of work often does not get done. Patchy data is nearly as bad as no data.

I call Senator Burke.

In view of what has been said here today, I propose that the committee formally write to the Department of Health to ask it to convene a meeting of all parties involved in this matter. It is important that everyone sits around a table at a very early stage. The Department may claim it is waiting for the legislation to be published. However, if it called a meeting today, it would be two weeks before such a meeting would be held, by which stage the legislation would be published. The committee should write to the Department in that regard today.

Members should be kept up to date on the progress being made by all the agencies involved.

I support that. It is a very reasonable suggestion. Time is of the essence in this matter. There was a fairly decisive result in the May referendum which behoves us to act upon it. Subject to the view of the Chairman, the committee will do what it can to assist and to ensure the legislation is progressed on time.

Senator Mullen asked a question of the Medical Council. Does the Medical Council have a view on a three-day waiting period, or would that come under its remit?

Sorry, that was not my question. The question, if I may, and if the Chairman is seeking to facilitate me, was whether the Medical Council could theoretically depart from the approach being taken by the Legislature and, as a matter of ethics, consider what was due to the unborn child, including but not confined to the question of a three-day waiting period. As a matter of fairness, I do not intend to respond in kind to what was said but I have participated in this forum in debates on orphan drugs and the controversial use of cannabis in medicine, and I do not know whether Deputy O'Connell was here when I asked particularly pertinent questions, which no one else here had asked, of the Minister for Health about the treatment of cervical cancer. I do not think I owe Deputy O'Connell or anyone else here any defence of my priorities. When it comes to life-and-death issues, however, I strongly defend my right to pay very close attention to matters that I believe could be particularly harmful. As for my use of the word "elective", again I believe I am on solid ground. I do not think I am being in any way disrespectful when one considers that one of the proposed heads of the legislation provides for abortion in circumstances where there is no reference to it being medically indicated. I do not understand how in ordinary parlance people could regard that as anything other than elective. Again, attacking me for simply trying to bring clarity to the discussion is, sadly, not without precedent here but inappropriate.

I thank Senator Mullen. It only remains for me to thank the witnesses for appearing before the committee. Sorry, did Mr. Prasifka wish to comment?

Mr. William Prasifka

I will try to be brief. The Medical Council has a direct statutory responsibility to develop guidelines on ethics and professional practice. This is in section 7 of the Act. It is a very wide remit. It is not necessarily limited to saying everything that is legal is ethical and is consistent with professionalism. The example I gave was that it may be legal for a doctor to prescribe a certain drug in a certain dose but it may not be professional or ethical. The fact of the matter is that the three-day waiting period is not a matter on which the Medical Council has any record. It is not part of the current guide to professional conduct and ethics. For us, it is really a matter for the Legislature. Our primary goal, which is very important, is to come up with the ethical guide in light of the revised legislation, but we would tell the Oireachtas that the matter of the three-day waiting period at this point is firmly within its remit and is a matter of law.

I thank our witnesses: Dr.-----

Will the Chairman take one last question, which arises from the discussion, or would that upset him? General practitioners advise; they do not force anyone in one direction or another. It goes a little beyond this, however. There may be a pre-existing condition which would require advice and a clinical decision as to what route a woman should go. I refer to a number of conditions one might have. I think I remember someone saying during the hearings that sepsis was a very rare condition nowadays. It is not, of course, as we now know. On that point, are the witnesses satisfied, from general discussion among themselves as a body, that they can, in all these circumstances, advise a woman or girl presenting with what could potentially be a crisis pregnancy in her best interest at that time?

Dr. Peter Boylan

Yes.

Dr. Tony Cox

Yes, we are satisfied. The counselling we give is non-directive, as we have reiterated a number of times. Obviously, however, one weighs up the patient's medical circumstances and situation, and if some particular treatment is contraindicated or dangerous, one will highlight that to her, and the patient, the woman, makes her choice. Yes, it is non-directive counselling, but the medical history, the medical risk, all these things are weighed up as well, absolutely.

I thank Deputy Durkan for his concluding remarks. For their time and their expert input I thank Dr. O'Brien, Dr. Favier and Dr. Cox from the Irish College of General Practitioners; Dr. Boylan and Dr. Murphy from the Institute of Obstetricians and Gynaecologists; and Dr. Suzanne Crowe and Mr. Bill Prasifka from the Medical Council. I think their input will inform the legislation, which has not yet been published. This is a very important matter and we will come back to it. We will have greater clarity once the legislation has been published.

I will suspend the sitting briefly because we have been here for four hours and we need to give staff a break. I hope the representatives of the Health Products Regulatory Authority, HPRA, can accommodate the suspension.

Sitting suspended at 1.06 p.m. and resumed at 1.38 p.m.