Working Group on Access to Contraception: Discussion

During our first session this morning, the committee will consider the report of the Working Group on Access to Contraception. We are joined by Mr. Andrew Conlon, who is the chair of the working group; Ms Kate O'Flaherty, who is the head of health and well-being in the Department of Health; Ms Maeve O'Brien, who is the acting programme head of the HSE sexual health and crisis pregnancy programme; Dr. Caitriona Henchion, who is the medical director of the Irish Family Planning Association; and Dr. Mary Short, who is the director of women's health in the Irish College of General Practitioners and the president of the European Society of Contraception and Reproductive Health.

I would like to draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they 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 they continue to so do, they are entitled thereafter only to a 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. They 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 advise witnesses that any opening statements they make may be published on the committee's website after the 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 ask Mr. Conlon to make his opening statement.

Mr. Andrew Conlon

I thank the Chairman and members of the committee for the invitation to discuss the report of the Working Group on Access to Contraception. As the Chairman has noted, I am joined by Ms Kate O'Flaherty, who is head of health and well-being in the Department of Health; and Ms Maeve O'Brien, who is the acting programme head of the HSE sexual health and crisis pregnancy programme. I intend to outline briefly the background and context to the group's work before highlighting some of the key findings of the report and possible policy options the committee may wish to consider.

The Minister established the working group in April 2019 to consider the range of policy, regulatory and legislative issues that arise as he seeks to improve access to contraception. The establishment of the group was primarily a response to the ancillary recommendation of the Joint Committee on the Eighth Amendment of the Constitution that "a scheme for the provision of the most effective method of contraception, free of charge and having regard to personal circumstances, to all people who wish to avail of them within the State" should be introduced. It also reflected the commitment of the Minister and the Department to improving women’s experience of healthcare in Ireland. It should be seen in the wider context of the establishment of the women's health task force and the work the Department is currently undertaking.

The working group comprised officials from relevant policy areas within the Department, including the Office of the Chief Medical Officer and the community pharmacy, bioethics, research, health and well-being, eligibility and primary care units. I emphasise that this was not a closed departmental exercise. Consultation was an intrinsic part of the group's work. More than 5,000 responses were received in response to a public consultation exercise. Approximately 3,500 of these submissions were fully completed. The group directly met several key stakeholders, including the Irish College of General Practitioners and Irish Family Planning Association. I would like to take this opportunity to thank everyone who engaged with the work of the group, especially the stakeholders who met us or submitted detailed submissions to us, or both. They greatly informed the group's work and the report.

The first key finding of the report is that barriers to accessing contraception exist for some people. It identifies the most prevalent obstacles as lack of local access, cost, embarrassment, inconvenience and lack of knowledge. It is evident that contraception use in Ireland is high and stable and that difficulty accessing contraception is a challenge at the margins in overall population terms. The notion that there is a sizable affordability challenge across the population as people seek to access contraception remains unproven. A number of policy levers are available to the Government as it seeks to overcome the barriers that exist. There is considerable support among stakeholders for the introduction of a universal, State-funded scheme for contraception. The cost of introducing such a scheme is indicatively estimated at between €80 million and €100 million. This is a significant sum and leads naturally to the question of whether such investment would represent the best use of resources.

As the committee will appreciate, there is a substantial list of health service development proposals across the spectrum of prevention, primary and community care and the acute hospital system. Strong cases for additional investment can and have been made in respect of such proposals. In addition to this opportunity cost, there is a real risk that making contraception free to end users will simply displace or substitute for private expenditure. Equally, the view that free contraception will lead to a significant reduction in the number of crisis pregnancies may be over-optimistic.

Any policy initiative in this area should be seen as a behavioural intervention and must go beyond the question of cost to address issues of local accessibility, education and workforce capacity, all of which are considered in the report.

In terms of accessibility, the report examined in particular the potential role of community pharmacists in prescribing contraception, seeking to balance the need for easier access to services with the risk of contraindications and the positive health factors associated with continuity of care. The report recommended that oral contraceptives could be prescribed for a 12-month period to improve accessibility while maintaining patient safety, which would have the additional benefit of reducing costs to the State.

Education is highlighted as key to tackling lack of information, misinformation and embarrassment around contraception. The review of relationships and sexuality education, RSE, curriculum is under way and is welcome, but there will also be a need for wider public information campaigns, possibly under the Healthy Ireland banner. Positive steps are being taken in this area, for example, through the sexual well-being website, but it is important that we build on this work to ensure that we are reaching and informing as many people as possible. It also will be necessary to continue to build our workforce capacity to ensure that we have a sufficient number of trained healthcare providers to deliver safe and accessible contraception services.

The report concludes that there will always be some doubt as to whether a State-funded contraception scheme represents the optimal use of funds on a purely cost-benefit basis. However, it is clear that there are considerations beyond the economic that need to be taken into account when formulating policy in this area. These include: the human and women's rights dimension of contraceptive access; the policy context following the introduction of termination of pregnancy services; and the potential health benefits. It is these social or societal factors that led the group to suggest that further exploration of policy proposals to support contraception may be warranted and three possible options for further consideration are identified. These are a universal State-funded contraception scheme based on the current General Medical Services, GMS, scheme but including the copper coil; the expansion of the GMS scheme as it relates to long-acting reversible contraception, LARC, to all women; or a phased approach to the introduction of a free contraception scheme, beginning with younger women, possibly in the 17 to 24 years age range.

The order in which the options were presented does not imply a ranking of preference, and the group intended that they be viewed as possible directions of travel for further consideration rather than as fixed recommendations with set parameters. Clearly, the development of these or other proposals would require further detailed policy and legislative work, as well as consultation with service providers.

It is important to recognise that the issues discussed in the report relate to just one aspect of the wider strategy to support sexual and reproductive healthcare. The Department of Health and the HSE, in collaboration with stakeholders, are progressing work in a number of areas identified by the joint committee in respect of sexual health promotion and education. This includes the expansion of the free provision of condoms to at-risk groups, while the HSE will be repeating the in-depth general population survey on sexual health and crisis pregnancy to provide us with up-to-date information to support policy development and implementation. The development of the national sexual health strategy will also commence in 2020.

The Minister believes that this committee is in a position to make a valuable contribution in charting a path forward that responds to the challenges and cost implications outlined in the report, while seeking to ensure that we can facilitate access to contraception and strengthen sexual and reproductive healthcare in Ireland more generally. Hopefully, the discussion this morning can advance that aim.

I thank Mr. Conlon. I invite Dr. Henchion and Dr. Short to make their opening statements. I believe they are sharing time.

Dr. Caitriona Henchion

I thank the committee for the invitation to address it today. I am a medical doctor and have specialised in reproductive health for over 20 years. I have been the medical director of the Irish Family Planning Association, IFPA, since 2008. The IFPA is Ireland's leading sexual health charity. It promotes the right of all people to sexual and reproductive health information and to dedicated, confidential and affordable healthcare.

Access to a choice of contraceptive methods is critical to gender equality, to women’s ability to plan the number and spacing of any children they choose to have and to their participation in education, employment and public service, including voluntary work and politics. It is central to the achievement of the right to health and it is key to reducing the rate of unintended pregnancy and sexually transmitted infections.

The IFPA welcomes the working group report. The introduction of abortion care in January of this year has set a positive precedent for universal access to reproductive healthcare and policy on contraception should be consistent with this approach. We support universal access to all available methods of contraception without cost to the individual. This would enable people to choose the contraceptive most appropriate to their changing needs and preferences throughout their reproductive lives.

As a provider of abortion care and pregnancy counselling, we are acutely aware that many unintended pregnancies arise from poor or inadequate information and misinformation or because cost barriers force women who wish to avoid pregnancy to use unreliable methods or no method of contraception. In my daily practice, I have seen women present with unintended pregnancy who had chosen an effective LARC method but had deferred having it because of the cost involved. I have also seen women following a termination of pregnancy who are unable to afford their method of choice. This is completely unacceptable and I do not think this is what the public voted for in last year’s referendum.

Any contraceptive scheme must address the particular needs of young people. International research indicates that young people have higher rates of non-adherence and discontinuation of contraception than adults. We know from domestic research that adolescents identify cost as a barrier to access. Furthermore, the Irish Study of Sexual Health and Relationships identifies those who have sex before the age of 17 years as being significantly more likely to experience a crisis pregnancy. Given these risks and vulnerabilities, it would be unacceptable to exclude adolescents from a contraception scheme.

As the working group report acknowledges, the removal of the cost barrier alone is insufficient to ensure access to contraception for all who need it. Policy reform must address all barriers in a comprehensive and strategic approach. This includes legal restrictions, poor access to information about contraception, regional disparities in the quality and availability of services, gaps in provider training and capacity, stigma and lack of confidentiality.

The development of an implementation plan with clear goals and achievable actions will be key to the successful roll-out of a contraceptive scheme. This process must be undertaken in consultation with relevant stakeholders to ensure appropriate levels of planning and resourcing, as well as mechanisms for data collection, monitoring and evaluation. Specific measures must be introduced to address the contraceptive needs of vulnerable and underserved populations, namely, adolescents, refugees, asylum seekers and other vulnerable migrants, people with disabilities, homeless people, Travellers and other marginalised groups.

Members of the Oireachtas have a key role to play in supporting better access to contraception; political consensus and commitment on reproductive health policy will be crucial to full implementation, ensuring that these reforms can be progressed regardless of who is in government.

Dr. Mary Short

I thank the committee for affording me the opportunity to address it. I am a medical doctor, a general practitioner and the director of sexual and reproductive health at the Irish College of General Practitioners, ICGP. I am also president of the European Society of Contraception and Reproductive Health and chair of the Irish Society of Health Care Professionals.

In light of a free termination of pregnancy service, the ICGP fully supports the principle of free contraception that is appropriate, available, accessible and free to those who wish to avail of it. Put simply, giving access to a free contraceptive service is the logical next step following the implementation of the community-provided medical abortion service.

The ICGP commends Mr. Conlon and his team on their comprehensive report but we cannot support the proposed phased roll-out of the service. His statement that contraception has potential health benefits that impact on people, and women in particular, when the opportunity to choose the most effective and suitable type of contraception based on their lifestyles, health needs and preferences is afforded to them is fully supported by the college. Reliable and appropriate use of contraception allows a couple to plan, space and limit their family size when they are ready and prepared for parenthood. In these different phases of a reproductive life, the choice of contraception will change depending on the needs of a couple. However, there are parts of the report that do not reflect the experience of GPs and I would welcome the opportunity to discuss this today.

Dr. Henchion and Mr. Conlon raised good points – lack of knowledge, fear of stigma and perceived lack of understanding from service providers may make contraception inaccessible. This raises the fundamental issues of information, education and knowledge, all of which impact on making the right choice at the right time. While Mr. Conlon makes a case for prioritising free contraception for the vulnerable and the marginalised, he also points out that these groups may for the most part have free contraception available to them through the GMS scheme.

The parts missing here are fundamental knowledge of reproduction, that is, sex education; information regarding the different methods of contraception; and empowerment to make informed choices appropriate to the particular need.

In addition, I make a case for those who have the educational knowledge but are at risk of making poor choices due to the initial cost outlay. A pack of condoms may seem an inexpensive option in the short term while a long-acting reversible method of contraception would be a better option. There is, again, a case for information and education for women in their mid to late 40s who erroneously believe that age, infrequent intercourse, etc., precludes them from a pregnancy. The ICGP, therefore, supports full and free contraception for all groups.

GPs are ideally placed to provide a full range of contraceptive services in the community. We are an education and training body and the college provides training in all methods of contraception and runs designated courses in the training of LARC. The college would like to expand the training and upskilling of our colleagues. The provision of LARC requires a specialised skill set of technical expertise. The training is time consuming and demands up to five sessions or two and a half days, although probably more in real time, to gain the necessary expertise, meaning GPs require funding and support for upskilling but, in economic terms, this is an upfront investment with long-term benefits.

I hope that we are all agreed that providing free abortion without contraception is not a healthy option. There is a strong case to be made for the normalising of attitudes to sexual and reproductive health, to rid ourselves of the stigma around our sexuality and to approach our reproductive lives through education and information appropriate to the age cohort. Free contraception on its own has not been shown to work, for which I gave the example of the UK but this has happened in other jurisdictions. Free contraception, acknowledgement of our sexual lives and needs over time, and a proper structural information and education programme will work to reduce the need for abortion, which is, I presume, the purpose of this exercise and would be a rewarding outcome for the provision of access to a free contraceptive service in the community.

I thank Dr. Short and Dr. Henchion. I call Deputy Stephen Donnelly.

I thank all the witnesses and their colleagues for coming here today, and for their work. Clearly, a lot of work has gone into this comprehensive report. It provides an excellent opportunity to debate the issues and various trade-offs.

There is a load of detail that I would love to get into with the witnesses. However, the question that people around Ireland and members of the public will have, and the question that I have been approached with by people who knew this session was coming up, is when will this happen. We have a good report, which and lays out the pros and cons, but it does not recommend a policy suite. There are some useful tensions between the various expert groups. People have different views but everyone is trying to achieve the same end and the debate is very useful. The fear is that while the debate continues in the meantime no money is allocated for budget 2020 and not enough happens.

Regarding implementation, is there an agreed timeline under which a package of interventions will be agreed? If so, when should the public start seeing a difference be it in the number of GPs with more training and knowledge, education in schools and for particular target groups, or free, partially free or more affordable contraception and so forth? When will the public, after whatever is decided, begin to see this happen for them? Is there an allocation in budget 2020 to pay for whatever is finally agreed?

Mr. Andrew Conlon

No money was allocated in budget 2020 for a free contraception scheme for two main reasons. First, it was a difficult budget in the context of a no-deal Brexit. Each Department and, indeed, the national finances were under pressure in that respect.

Second, the new money that was available for health has been prioritised towards mental health, community services and so on. There is also a practical element to that decision. As the report makes clear, there is an awful lot of detailed policy work and legislative work to be done to advance a scheme. In that sense, there would be little to be gained by allocating money in budget 2020 as the odds are it would sit there and not be utilised.

The mission for the Departments, in the 12 months ahead, is to do the detailed appraisal work. The report should be seen as a preliminary appraisal in public spending code terms, and now we move to consult with service providers to get more certainty on costs, examine our legislative position and finesse the parameters of the scheme that is advanced.

Having said that, what has come across so far in the report and statements is the work that has been done already, particularly in education. The HSE is working on that by developing a sexual well-being website and ensuring that there is a local distribution of materials and so on. We also have an ongoing review of the relationships and sexuality education, RSE, curriculum. There certainly has been progress. I accept that it might be a little under the surface at the moment and the public will not be able to see it but that is the direction of travel.

Has the Department a forecast date for when the public will see a difference?

Mr. Andrew Conlon

The Minister has indicated that he would like something in 2021. He is genuinely keen, as is the Department, and as am I as an official, to hear the views of this committee. By being here this morning we are progressing this issue. The Department is also very much engaged at this time of year in setting its priorities and allocating its own internal resources. The management board, the Secretary General and the Minister are having those discussions about the priorities for the Department over the next 12 months.

My following comment is not directed at Mr. Conlon, as he is not to blame, but what he has told us is very disappointing. Many committee members support the idea that if free abortion services are going to be provided, contraception must be provided free. It would be a perverse situation whereby women had to pay for contraception but not abortion in the case of a fatal foetal abnormality, crisis pregnancy or whatever. Introducing abortion services was not a simple thing to do, yet it was done but we are looking at several years after that before movements on contraception can be made. I am not a doctor but I imagine that steps such as training for GPs or reducing the cost of LARC, or rolling out education programmes for younger people and vulnerable groups are simpler to do than introducing abortion throughout the country.

My criticism is not aimed at anybody here but I am disappointed that people in will have to wait several years for action on this matter. I thank Mr. Conlon for the invite for us to give our views and input. My view and input is that things needs to start happening now. The service plan has not been signed off. I must confess that when I read Dr. Short's opening statement last night I was surprised at her call for further GP training. I would have thought that every GP understood contraception. Dr. Short is an expert who represents the ICGP. If what she is telling us is that GPs need more training, then let us give them more training. That is certainly not expensive to provide. Better intervention in schools, and better intervention with some vulnerable members of the population such as immigrant women, asylum seekers and various other groups, could be concocted and rolled out in a matter of weeks.

It is a small amount in the context of an €18 billion budget. We are all trying to empower women, and men, and especially younger women and women who are at higher risk. That kind of intervention can happen pretty quickly and at a low cost. We should get this up and running in the first quarter of next year. Let us get that into the service plan.

Dr. Short gave figures ranging between €80 million to €100 million, which will take most people by surprise. That is a chunk of cash. In the context of women's reproductive health, the Rotunda Hospital is screaming for investment just to make the hospital safe while they wait for God knows how long for a move out to the Connolly Hospital campus. The Rotunda needs some €20 million to make a significant difference in what is one of Europe's busiest maternity hospitals. They cannot get that, so €80 million to €100 million is a chunk of change. I bet the GPs could be trained up, education programmes could be run and targeted interventions could be used for a small amount. The report, and the opening statements, referred to the GMS scheme for medical cards, including some supports. It is by no means a perfect way, but it is one way of targeting supports to lower income people, and it is the entire point of the medical card scheme. It would be possible to identify the additional changes to that, or whatever bits are not currently included.

Let us get some responses.

That was my input. That was not my question. Mr. Conlon had looked for some input so that is my input.

Mr. Andrew Conlon

I thank the Deputy.

Ms Kate O'Flaherty

My colleague, Mr. Conlon, answered some queries on budget 2020 and the matters that his report looked at and I will add to that. I can confirm that increased funding has gone into the ancillary recommendations in respect of education and sexual health promotion. Additional money was allocated last year, broadly, for sexual health, which was a big focus for the Department and for the HSE, and included HIV prevention. While we are not discussing this matter specifically today, it is interrelated with regard to the education and broader sexual health promotion. Additional funding of €1.5 million has gone into a HSE sexual health programme for ancillary recommendations in respect of sexual health education and promotion, and the extension of the national condom distribution service, which we have started, and the committee may have seen the start of the roll-out in third level campuses. This is the start of the roll-out to other areas with at-risk groups. As Mr. Conlon referred to in his opening remarks, another comprehensive survey has been conducted of the population. It is almost a decade since we had the Irish Contraception and Crisis Pregnancy Study 2010. My colleague from the HSE will elaborate on any of those points for the committee if members wish. I confirm there is investment, and some of the other recommendations and actions the Deputy mentioned have started this year.

So something is happening.

Ms Kate O'Flaherty

Absolutely.

Dr. Mary Short

In response to the question on doctors needing training and upskilling, he ICGP has trained more than 1,000 doctors in the provision of LARC. The demand, however, has only been approximately 17%. We perceive that this will change when this becomes freely accessible to people. Obviously, this cohort of doctors - and more besides - will need to be upskilled and probably retrained. That is where this part of the equation comes in. We do have it but the further provision will probably require upskilling in certain areas.

I thank Dr. Short. I have three more questions.

Be very quick.

Should pharmacists be allowed to prescribe the pill? Given that we are in a world of finite resources, and considering affordability, what is the first action that should be taken? Is there a target group that, for a relatively affordable amount, should have certain contraception made available that we could do very quickly? Could we get to the highest need people quickly for a fraction of the €80 million to €100 million?

Mr. Andrew Conlon

With regard to reaching people, the report suggests a phased approach targeting young women first. It is affordable and the evidence suggests they are an at-risk group with most difficulty accessing contraception and the highest levels of crisis pregnancies. This is not to dismiss the comments that have been made about women in the older age groups. When we consider the statistics, young women are the group one would focus on first. It would help to overcome the budgetary challenge.

We wrestled with the issue of pharmacists prescribing. The recommendation expands the role of pharmacists in this area by extending the length of prescription for oral contraception. The group thought the issue and the role of pharmacists in healthcare, with pharmacists acting at the top of their licence and so on, went beyond the remit of the group as it was about more than contraception. We are all aware of Sláintecare and the reform of the health system. If there is to be a greater role for pharmacists and pharmacy prescribing by hospital and community pharmacists, it should be looked at as an issue on its own merits rather than being approached piecemeal through issues such as the prescription of contraception. The reference to that issue needs to be examined further.

Is that a "Yes", "No", or "Maybe"?

Mr. Andrew Conlon

The recommendation in the report is clear. It was also clear that we had conflicting views from different stakeholder groups on this issue. It was very difficult, if not impossible, for the group to make a decision within the timeframe and with the resources we had.

So it is a "Maybe". It is not a clear "Yes" or "No". Is that what Mr. Conlon is saying?

Mr. Andrew Conlon

The issue requires further exploration about the role of pharmacies across the health system rather than relating purely to contraception

I thank Deputy Donnelly and Mr. Conlon.

I welcome the witnesses and apologise in advance that I have a small cold, but I am making a massive deal out of it. It is big to me.

Mr. Andrew Conlon

Is it man flu?

It is pure man flu I have.

The working group put forward a number of possible directions: universal access, LARC, and a targeted scheme. I refer specifically to the front-line medical professionals in this regard. Do they have a view on whether it should be some or all, and what is the best way forward out of those choices? In an ideal world, what would they opt for?

Dr. Caitriona Henchion

Universal access is what one is going to be looking for. No matter how good any targeted intervention will be, people in need will always be left out. Having said that, it is worthwhile recognising the real world and recognising budgetary constraints, and that one has to do a good health economic analysis on this to try to figure out what the costs would be.

If it is going to be rolled out over time, one would try to see where phase one would start and see who are the most at-risk groups rather than just simply saying it is young people. The abortion statistics say the highest rate of abortion is in the 25 to 35 year age cohort and not necessarily only young people. Perhaps costs might be a more significant reason the younger people are not using contraception than it is for the older age group. It is a lot more complex than just looking at statistics.

There is a very easily recognisable group, for example, where somebody has had an unintended pregnancy. Whether they have an abortion or proceed to have a normal pregnancy to term, that person did not want to be pregnant and could be targeted with an intervention. Be it post-natal care, post-abortion care or specific age cohorts and so on, the important thing is that it would be a structured phased roll-out. I understand where Deputy Donnelly is coming from in wanting to do something, but I would be worried about doing something that is not part of a proper structure, so we can see where it is going, what stage is going to happen when, and where the end point is.

Would the best time to incorporate that education, which could be as subtle as a chat, be immediately post-natal or immediately post-abortion so the opportunity is there to talk to that targeted group in the first instance?

In that case, it would be a matter of having a chat with the person as to what suits her best and giving her the prescription. Money would not be a barrier in that case.

Dr. Caitriona Henchion

That is 100% right. In the case of somebody who is continuing with a pregnancy, there are several months in which to make the decision. In the circumstances we are discussing, the decision would be made very quickly rather than thinking about it only after the baby is born.

With an abortion, there is a very tight framework. Fertility returns within seven or eight days. Therefore, there is a need to use visits to start something and have a plan in order that, after two to three weeks and when in a position to confirm everything is complete, one is ready to go straight ahead. Unfortunately, it is sometimes purely down to money. I am not saying money is everything but it can definitely be a factor. It can be related to simple factors such as having to buy a lot of schoolbooks in September. It is not necessarily a question of poverty or poor families. The families could be doing fine generally. The cost might not be huge but it might not be possible to meet it at that exact moment because of conflicting costs.

Then the window of opportunity is lost. If the person does not have the money in her back pocket when having the conversation, the window of opportunity is lost. We are all agreed on the best time to have the chat. When the opportunity is lost, the woman is lost to the system because she may not be returning for any reason.

In Dr. Henchion's experience, is money an issue when having the conversation?

Dr. Caitriona Henchion

It definitely can be. I have seen people who went to the doctor to arrange to have a Mirena coil inserted and got a prescription but who are now pregnant because they could not afford to buy the device in the pharmacy. After an abortion, young people for whom cashflow might be an issue might decide they definitely want an implant but, because they cannot get the money from parents or others, are not in a position to go ahead with that. They make a responsible decision but are unable to act on it.

Dr. Mary Short

I concur with Dr. Henchion. It is very hard to single out one group of people who should be afforded free contraception. It is inappropriate. Providing only LARCs would afford no choice at all. It sends out the wrong message in that we are dictating a choice to a woman when, in fact, she should be able to avail of all options if she so chooses.

In his submission, Mr. Conlon mentioned a figure of €80 million to €100 million. Is that based on every woman of reproductive age having access deciding to avail? Is it based on the current number if there were no charge in the morning? Alternatively, is it based on a take-up rate of 100%?

Mr. Andrew Conlon

It is based on a cohort of women aged between 16 and 44, with an uptake rate of between 50% to 60%.

What is the current rate?

Mr. Andrew Conlon

For GMS patients, it is just over 50%.

Just over 50%. What is the figure for the general non-GMS population?

Mr. Andrew Conlon

We do not have those data, I am afraid.

With regard to providers outside the State, I understand the uptake rate, even where there is no charge, is around 35%. Am I wrong about that? One can read many studies but I do not have Mr. Conlon's expertise. I understand from what I read that the figure is around 35%.

Mr. Andrew Conlon

That is not a figure I have come across in research we looked at.

Where there is universal access, one would be contemplating rates of approximately 60% and that is what Mr. Conlon based those figures on.

Mr. Andrew Conlon

The rate is from 50% to 60%, which was based on the take-up of contraceptive services among the GMS population of women in the age group. That is the estimate. We hope to see an increase in the uptake of contraception with the education, the fact it is free and so on.

When Mr. Conlon was coming up with a figure, did he factor in a reduction in demand for termination-of-pregnancy services, which would inevitably-----

Mr. Andrew Conlon

It is not in the figure of €80 million to €100 million but it is acknowledged in the report that we would expect to see approximately €11 million in savings from a reduction in terminations, assuming an uptake in LARC usage.

Straight away, then, we are down to €69 million.

Mr. Andrew Conlon

Absolutely.

Did Mr Conlon try to estimate the wider savings that could be made in terms of the prevention of unplanned pregnancies or crisis pregnancies?

Mr. Andrew Conlon

Not within that figure. It is acknowledged in the report that further work would need to be done to nail down costs. The key element will be the clinical costs and the negotiation of consultation with service providers. A lot more clarity is needed. I stress the estimate is indicative.

We acknowledge it is tough to measure but the good news is that even after this chat, we could get the figure down to €69 million. We could make a very good value-for-money argument for the Minister and have our proposal implemented very quickly.

It is important when discussing this that we factor in the potential savings. We all know there will be benefits from this. What we need to do is ensure we consider positively what we can do and the best way to do so. We should consider not only the cost to the State but also what we do could in the long run to save the State a few bob.

Is there scope for an increased role for practice nurses or other healthcare professionals? I am being very helpful to the Government here because I am talking about a more inexpensive way to deliver care. What I propose would see an expansion, but not just in the number of practice nurses because other healthcare professionals might also have a role. They could expand their role and they would have a good part to play.

Mr. Andrew Conlon

Absolutely. I am not sure whether anyone else would like to contribute on that.

Dr. Mary Short

I believe we all agree on that.

Dr. Caitriona Henchion

Practice nurse roles have been expanding all the time. There are many skills that practice nurses bring to the job. They can bring immediacy. Obviously, the role of pharmacy could also be expanded. Without any major change, the lengthening of the prescription time is very simple. We are working against guidelines on this. We would be saying we should be able to give year-long prescriptions but we are not at present. Some small changes in this regard would be very quick to make. Obviously, we should consider other ways to provide-----

I mean no disrespect to the doctors in the room in saying it is a very good and slightly less expensive approach. We are already at €69 million and moving down. It is becoming very manageable.

Dr. Mary Short

I wish to add to that. I concur with my colleagues on practice nurses and the pharmacy aspect but as matters stand, practice nurses have no designated training. That will be another element we will have to address to have standardisation. Work is being done on a diploma in practice care nursing, which is very important.

That would be fantastic. Again, we are not talking about a massive amount of training but a relatively small amount, the benefits of which could be absolutely massive.

Dr. Mary Short

Absolutely.

Following on from the comments of Deputy O'Reilly, I note Mr. Conlon's comments on the expansion of the role of pharmacists throughout the health service but we are talking about contraception here today. While the idea of lengthening the prescription time is very welcome, I have never understood, as a pharmacist, why a prescription would not be for a year, especially where the long-term use of oral contraceptives is concerned. There obviously would be a saving for the patient in terms of both money and time.

What is the medical logic for not expanding the role of the pharmacists right now in the provision of oral contraceptive pills, especially in light of the success of the morning-after pill? The morning-after pill is a far more potent compound than standard oral contraception.

While I am largely out of doing community pharmacy work personally, in recent years there has been the advent of the online prescription in that one has an interface with a doctor who is often in another jurisdiction with no patient contact and no blood pressure monitoring. The blood pressure monitoring is the duty of the community pharmacist at the point of dispensing and the prescription comes in online. To my mind, that is moving away from immediate interaction with the patient and all the benefits that brings at doctor level and pharmacy level. It does not seem logical that on the one hand we say it is fine to go online, meet a doctor and get a prescription but on the other hand we say it is not fine to go into an experienced community pharmacist who has been dealing with issues such as this for many years, is well able to take blood pressure, is well able to have a chat with someone and has spent extensive time studying contraceptives at undergraduate and postgraduate level. I cannot understand why it is seen as better for the patient to interact with a doctor online rather than with a community pharmacist in person as there is generally one on every street in Ireland. Can Mr. Conlon expand on the logic behind that?

Mr. Andrew Conlon

I completely agree with that comparison between an online doctor and a pharmacist.

There is no arguing with it.

Mr. Andrew Conlon

We want a doctor and patient relationship. The group met representatives of the Irish Pharmacy Union, IPU, which sent in a forceful submission to the committee on the report. I assure members we heard equally forthright views from the GPs and their representatives.

I will stop Mr. Conlon there because we had this before about ten years ago with the use of the flu vaccination. There was massive pushback from the medical profession to the effect that pharmacists should not be injecting vaccines. When I was studying at undergraduate level 20 years ago, it was never assumed that would be part of a pharmacist's role but we managed it, we upskilled and we did it. There was all sorts of scaremongering that people would have anaphylactic reactions in pharmacies all over Ireland but none of that happened. It has been hailed as a huge success in patient satisfaction, in accessibility and in the ultimate goal of having a high uptake of the flu vaccine and convenience for patients. It has worked in a far more invasive and riskier setting in respect of the vaccine. We were heading towards a swine flu epidemic at the time and so there was an appetite to do it. Just because there is no major unwanted pregnancy epidemic in the country now does not mean we should pull back from this. That is why I cannot understand the logic because this shift happened before in administration and the same arguments that were used ten years ago are being used about the contraceptive pill.

Mr. Andrew Conlon

I want to cut to the chase. The arguments that persuaded the group to put forward the recommendations we did were the importance of the continuity of care. The doctor and patient relationship is key to integrated health. We have mentioned the women's healthcare context a lot this morning already. There is evidence that regular visits by women to a GP seem to promote better health outcomes. Therefore, we would be reluctant, as a group-----

Mr. Conlon said "seem to promote". What sort of quantitative analysis do we have of that? Is it just the view of the working group?

Mr. Andrew Conlon

No. The women's health task force that is working on that has suggested there is evidence there.

It has suggested it?

Mr. Andrew Conlon

It has suggested that to me in my capacity as a member of the working group. Fundamentally, the continuity of care piece, the doctor and patient relationship-----

We have loads of examples of continuity of care within the pharmacy sector. In the high tech scheme, for example, there is a patient care fee every month where the patient is assigned to a pharmacy at the point of prescription by a consultant and goes to that same pharmacy every month. There is a mechanism for people to engage on a continuous basis with their community pharmacist even if they are not having a dispensing of a particular item so there is a precedent there for the continuity of care. We have had many meetings in here where we have had GPs explain to us the huge pressures on their surgeries and tell us they are not able to cope with the demand. If we are moving into the implementation of Sláintecare, expanding the role of pharmacists and practice nurses and changing the role of GPs in the delivery of care, surely this is a logical first step. Mr. Conlon has not given me any logical reason to help me understand why this is not being rolled out in community pharmacy, other than referring to people's views. I am talking about oral contraceptive pills and barrier contraceptives.

Mr. Andrew Conlon

On this particular issue, the other consideration we had is there is too much of a focus on the idea that the dispensing of contraceptive pills would possibly run counter to our wish to encourage the use of LARC.

Yes, but as Dr. Short said, the choice element is fundamental to a woman's healthcare. While the evidence all suggests that the lower the user input, the more efficacious a product is and that we have far more success with long-acting reversible contraceptives, the fact is, as all the experts here know, at different stages in their lives women might choose an oral contraceptive pill at the start as there is a familiarity with it. I would like to see a point arrive where everybody is familiar with a long-acting reversible contraceptive but we are a while off that. There are psychological barriers to it and there might be issues where one might only need a contraceptive for a short time. It is far more complex, as the witnesses know, than just horsing a long-acting contraceptive into everybody. If we look at the dispensing data and if we leave cost out of it, a huge cohort of women in Ireland choose the oral contraceptive pill. That might be due to cost, familiarity or because of what is happening in their lives at that particular time. I cannot understand, when we consider the pressure that is on the health service, why we cannot look at this and try to help those women in a community pharmacy setting in order to take some pressure off the GP surgeries. We should move towards educating the next generation of younger girls in the field of long-acting contraceptives such as LARC, the bar in the arm and the Depo injections. I cannot see why there is resistance to that. It almost seems like a turf war in the health service again.

Mr. Andrew Conlon

If there is a turf war it does not involve officials.

I am not suggesting that.

Mr. Andrew Conlon

The IPU would not agree with this but the recommendation in the report about lengthening oral contraception was a move towards greater pharmacist involvement with the six-month consultation with the pharmacists.

It seems like the smallest step that could have been made; doubling the length of the prescription time.

Mr. Andrew Conlon

It was pragmatic and I accept it is conservative but-----

It was the least the working group could have done. Bearing in mind the discussions we had at the Committee on the Eighth Amendment of the Constitution to look at the roles of pharmacists internationally and the expansion, doubling the prescription time is about as little as could have possibly been done. Looking at the interesting statistics on the cohort of women who are more likely to have a termination, between 25 and 35 years of age, Dr. Henchion mentioned the cost element for younger girls. It is so complicated to try to determine who is most at need. That is clear in the report, which I have read a number of times. It is difficult to qualitatively analyse the report and determine where the money is best spent. Should it be given to the poorest person? Should it be give to the person who is most at risk? Why do we not just do our best with what we have at the minute? We have community pharmacists who are well trained in this area. Some pharmacists are particularly popular, if that is the word, for morning-after pills and access to contraception. I cannot understand, when we have such a large cohort of patients with such a large headline figure of €90 million to €100 million, why we do not work with what we have to start without trying to fix the whole thing on day one. We would tap into people within every age group within the community pharmacy.

Dr. Caitriona Henchion

To return to my point when I was responding to Deputy O'Reilly, I would not like the response to be determined by what can be done quickly. It has to be a proper, organised roll-out of a scheme. I am concerned that if a rushed step was taken, it could be the only step taken for a long time. It might incentivise one method over others, even though that method has been shown not to be perfect. While nothing will be perfect, the working group report outlined research that showed that 18.8% of oral contraceptive users had failed to get a prescription on time. We know from James Trussell's research in the US the difference between perfect use, that is, in laboratory conditions where the user is handed the pill every day and the failure rate is 0.3%, and typical use, where the failure rate is 9%. The solution is not to target one method and incentivise it through one scheme-----

I did not suggest that, as Dr. Henchion knows. I suggest that we already have-----

Dr. Caitriona Henchion

My concern is that if such a measure is taken in the short term, it may be the only measure taken for a long time. I have no problem with increasing that role-----

I am opposed to the idea that oral contraceptives from pharmacies would be the only measure we take. There is easier access in many other countries. There are now online doctor services, which is a total game changer. It is more advantageous for a patient's outcomes to interface with his or her experienced community pharmacy rather than interacting with a doctor online. The horse has bolted in respect of the way we dispense medicine and the way consultations happen. There should be a one-to-one consultation with a pharmacist. I do not understand why the consultation cannot involve a referral. If a woman who has been on the contraceptive pill for 18 months presents at a pharmacy and seeks a five-year or long-acting solution, why is a referral not part of the process? Community pharmacists are well used to such scenarios. An average of 90% of our work is referring people to doctors to be fixed up. I fail to understand why it cannot be part of the solution. I cannot understand the resistance to it, apart from the fact that there may to some extent be turf wars, like in the case of vaccines back in the day.

Dr. Caitriona Henchion

I do not see any problem with it being a part of the solution. My point is that I would like to know what the whole solution is before I jump into anything-----

Absolutely. It should be a part of it.

I welcome our guests to the meeting, thank them for the massive work they put in to the report and say, "Well done." While it has nothing to do with them, I am disappointed there was no allocation in the budget for contraception. Surely if the issue was to be taken seriously, there would have been an allocation in the 2020 health budget. I acknowledge it was a different type of budget from other years because of the looming potential costs arising from Brexit, but it would have been a vote of confidence in our guests' work if there had been a small allocation.

The report states education and information can help tackle issues relating to a lack of information, misinformation and embarrassment. Surely education could be provided at a lower cost than providing free contraception for everyone. What plans are there to tackle the lack of education?

Mr. Andrew Conlon

I might refer to my colleagues from the HSE, who are the experts on the education aspect.

Ms Maeve O'Brien

The sexual health and crisis pregnancy programme in the HSE works in the area of education and information. We worked with the NCCA on the recent review of RSE in post-primary schools and the review is currently with the council of the NCCA, which will address the school-space setting. Aside from that, we work with youth work settings and provide information to parents to support them in talking to their children about relationships, sexuality and growing up. We carried out a comprehensive qualitative study with parents in 2016 examining the barriers they experience and their concerns about talking to younger children aged between four and nine. On that basis, we developed a resource for parents to support them in the area.

We are also redeveloping our information for young people on a website. We have a website called b4udecide.ie, which was developed in 2007 to target 14 to 17 year olds, but it is outdated following recent changes. We are currently reworking the information with a view to relaunching it next year.

Is it all targeted at teenagers? What about the young men and women who might have left school when there was not a great deal of talk about sex education? I refer to those who might now be in their late 20s or early 30s. Does the HSE target that age group?

Ms Maeve O'Brien

Absolutely. We launched sexualwellbeing.ie in 2018, which contains comprehensive information on all the different types of contraception available. We also have a digital strategy that targets young adults via Facebook and Twitter to ensure that the information is digitally available, and work with the National Youth Council of Ireland and Foróige, the latter which delivers the REAL U training and workshops on the development of RSE policies, as well as providing training on pornography.

We work in three areas, namely, schools, youth work settings and parents, while information for the adult population is available on our website.

That is good. The estimated cost of €80 million to €100 million is a large sum, and there is a difference of €20 million. I accept that it is estimated but which of the two figures does the HSE expect it to be closer to? The sum of €20 million is a large difference.

Mr. Andrew Conlon

It is a large difference, which reflects the uptake, that is, whether it will be 50% or 60%. Deputy O'Reilly was correct that we will deduct a savings amount from there being fewer terminations and so on. There are issues with the cost, which is why I stress, on my own behalf in some ways, that there are many uncertainties and the figures are very much an estimate. In discussions with service providers, if we can come up with a scheme whereby the people who are currently part of the GMS scheme are retained therein and funded through capitation payments, the cost will reduce because the figures of between €80 million and €100 million represent the cost of targeting the entire population. It is the cost of doing exactly what it says on tin. The entire population is considered to be those between the ages of 16 and 44 and there is work to be done in that regard. The Department will aim to drive down the cost as much as possible.

On the mechanics of the report, Mr. Conlon stated 5,000 responses had been received in a public consultation exercise. Will he explain how that worked? Did the Department call or write to people? How did it choose whom to contact?

Mr. Andrew Conlon

It was an online survey for which one could use one's phone. There was also a press release and the Minister launched the online consultation. It was self-selecting and results were received by our research unit. While I received the information only yesterday, 3,500 of the 5,000 responses were completed submissions. The rest were ones where people dipped in and out and did not finish. I do not wish to mislead anyone in respect of the figure of 5,000, given that only 3,500 submissions were complete.

I welcome our guests and thank them for their information. I will approach the matter from the point of view of education, which is a fundamental part of access to contraception in respect of giving advice to women and girls well in advance in order that they will have some idea of the necessity to have options.

Is it intended to impart the information through schools, pharmacies or GPs? What is the best way to provide that information? During the hearings on the eighth amendment, we came across a number of cases where there was a serious dearth of information, particularly among teenagers.

Mr. Andrew Conlon

The simple answer to that question is that we need to use all those methods. We need the schools aspect, which is being worked on, but we also need to follow up with the people the Deputy mentioned who have left school or did not receive that education at school, through GPs, pharmacies, or primary care centres. Putting the information in those sorts of places strikes me as a sensible thing to do. However, I will refer the matter to the experts here.

Ms Kate O'Flaherty

That education information is provided in all those settings. It is already on the school curriculum. My colleague, Ms O'Brien, alluded to some of the resources available from the HSE, which provides evidence-based information for different age groups to parents and schools. Much more work must to be done in that area, pending the outcome of the review of the RSE curriculum. That will involve changes for every age group. The information is there. As Ms O'Brien noted, a great deal of work has been done in the past few years to build our content and resources and make it much more youth-friendly and accessible through online and social media channels. Young people would have been consulted in the development of all those materials.

Information on contraception is already there, to the extent that it is included in the HSE's resources and is provided as part of a normal consultation. I take the point that while the content and information may be there, people are not getting the knowledge and confidence they need to make those choices. That is something we can look at, in terms of how we work with partner organisations that interact with young people and women outside of school settings in particular. We need to broaden the base of the people using the one trusted set of resources. It has been important for us to have an evidence-based, factual information resource, which was developed by the HSE in partnership with young people, teachers and parents. It is helpful for young people that everybody is using the same resources and information, because they will not get confused if they have a good source of information.

Another important point to which Ms O'Brien alluded is that we now have a single foundation sexual training programme, which all adults who work with young people go through. That goes back to some of Dr. Short's points on the need for the adult population to be more open and comfortable in talking about sexuality and sexual and reproductive health. Much good work has been done in the past couple of years, and is still being done, to build those resources. We need to strengthen the partnerships we have with people, in order that the same information, evidence base and facts go out to everybody through that wider partnership.

Based on the witnesses' examination of the issue, have they identified areas that are deficient in getting the relevant information to the people at whom it is aimed? In general, what are the logistical snags?

Ms Kate O'Flaherty

Generally, with any health issue, one tries to produce the evidence base, facts and information in a friendly manner with simple language in order that people can understand it and get the knowledge. One of the trickier parts of any health intervention is helping someone to use that knowledge to support making decisions or choices. That is a more ongoing and in-depth issue. We work with the education system on well-being in a wider way to ensure young people have the skills to make those decisions. As part of our population survey or other surveys in developing future campaigns, we are always looking at whether people can understand the information and use it. That is key. Other factors sometimes affect how a person uses the information they get as well. They need to get it multiple times rather than just once. There is a benefit to the same fact-based independent information being available from multiple sources, because it helps increase people's understanding.

Dr. Mary Short

According to some of the reports published through the HSE, parents are more reluctant to talk to their young children about their sexuality. There is a case to be made for educating parents at the same time as schemes are rolled out for children in schools. Some parents do not have the language to have these conversations. If we normalise our sexuality as part of our developmental process and give parents the language to have those conversations, it will make for a better society in the long run. That is a fundamental and important thing to do for the future.

The next issue on which I require some assurance, from a health and safety point of view, is the choice of contraception types. Women currently access contraception by way of the Internet. Do the witnesses have a means of imparting knowledge on a health and safety basis? In some cases, a particular type of contraception may be unsuitable from a safety point of view. How do they interact with those potential cases?

Dr. Mary Short

First, we see women as individuals so every conversation we have with a woman is different. Women may come in with an idea of a type of contraception that may have been suggested to them by a friend or the Internet, and it is up to us as doctors to have that conversation, sort out what their needs are and decide whether that method of contraception is appropriate for them. They may, however, leave the consulting room with a less suitable method because the more suitable option is not affordable for them. This also relates to the matter of initial pharmacy prescribing, about which I have some reservations. Contraception is a medication to which contraindications and risks are attached. Women should consult a doctor, at least for the first visit, and if problems arise from the dispensing of contraception through pharmacies, they should be referred back to the doctor. Every individual case requires an individual consultation.

I agree entirely. The point I am trying to make is that, in the event of access to either information or contraception not being as good as it might be, women - younger women in particular - may still opt for the Internet. There will be no provision in the public arena for someone to discuss with the woman in question what is best for her, given her health profile. Situations will and do arise where, while particular prescribed methods may work for that woman, they may have other side effects as well. That is the point at which I am trying to get. We need to make contraception safe and available at a reasonable cost, without taking risks.

Dr. Caitriona Henchion

It is, again, about looking at everybody as an individual. While HSE websites, for example, provide lots of information about methods, in some cases a person might have two or three health issues, and while one of them alone might be fine, together they might not. No amount of public information will be able to educate people sufficiently to give them that level of knowledge. That is what healthcare professionals are for.

Taking the cost out of accessing contraception from a healthcare professional is the way to go about trying to prevent those sorts of public safety issues arising.

I call Deputy Alan Kelly.

I will pass the floor to Senator Kelleher. I was not here earlier.

I thank the witnesses for their presentations. To be blunt and honest, I am very disappointed. I made a contribution to the consultation during the summer and I am very disappointed with the report. It has moved away from the principle of women getting access to contraception. The debate is becoming more about cost, what we can afford and what we can tinker with and creating false alternatives. I am very disappointed about that. My questions are in concert with that and are directed particularly at Mr. Conlon. Does Mr. Conlon accept that contraception is fundamental to women exercising their health and reproductive rights and to preventing unwanted pregnancies throughout women's fertile lives?

Mr. Andrew Conlon

The report is very clear on that. It states that.

That is a "Yes", then.

Mr. Andrew Conlon

That is what the report states, absolutely, yes.

Does Mr. Conlon accept that contraception is a public as well as a private matter, that it is a matter of public policy and that it has a rightful call on the public purse? That is another yes-no question.

Mr. Andrew Conlon

Again, the report states that. I do not want to confuse any of my personal views with what the report states, which is why I am answering in this strange way, but absolutely, it is a policy issue.

It is not strange. I ask Mr. Conlon to bear with my line of questioning. Does he accept what the working group has been told in the consultation by the Start doctors, the Irish College of General Practitioners, the Irish Family Planning Association and others, that is, that in Ireland today there are very real barriers to women accessing the best and most effective contraceptives during their fertile and reproductive lives? In Mr. Conlon's opening statement he said the notion that there is a sizeable affordability challenge across the population in accessing contraception remains unproven. Who does he believe? Does he believe the IFPA, the doctors or the Irish College of General Practitioners, or does he have an alternative view?

Mr. Andrew Conlon

The answer is "both". The data in the report come from the Irish contraception and crisis pregnancy, ICCP, survey of 2010, which highlighted that, I think, 12% of people had difficulty accessing contraception and 3% of respondents identified costs. I will say straight away that the position is much more complex than that 3% figure suggests. There is a distinction, which the report tried to make, between a whole-of-population basis and particular cohorts of people, in particular individuals whom front-line practitioners see. It is not an either-or; it is a matter of trying to present that whole picture.

Does Mr. Conlon have any view about the unfairness of singling out contraceptives, which he agreed at the beginning were fundamental to women exercising their health and reproductive rights and preventing unwanted pregnancies? Does he think it is unfair that contraceptives should have to be bought or means-tested? For example, when a number of years ago I went to get my Mirena coil inserted, I had to pay for it and bring it with me. When people go into hospital to get stents or pacemakers put in, do they have to bring them with them in boxes? Why is contraception singled out in this way when it comes to women's health?

What is the rationale for using general arguments such as opportunity costs? There are opportunity costs with any form of public expenditure on anything. We will have an expenditure of €3 billion on the roll-out of broadband. There are huge opportunity costs as to where that €3 billion might otherwise be spent. I would have a few ideas, such as childcare, home care and a universal system of contraceptive care. Opportunity costs are an argument but one that does not apply particularly or solely in this instance. There are always opportunity costs. Again, why introduce this argument? It is a red herring and has introduced the kinds of debates we have had this morning about GPs versus pharmacists and older women versus younger women when, in fact, what we need to do is get on with the universal system of contraceptive care that was envisaged in the report of the Oireachtas Joint Committee on the Eighth Amendment of the Constitution. We are now talking about tinkering instead of getting the report right. That is why I am disappointed with it. I am also disappointed with the undue delay and the direction of the conversation. We need to get back to principles, including the principle that contraception is fundamental to women exercising their reproductive rights throughout their lives and fundamental for the prevention of unwanted pregnancies. I would like to hear from Mr. Conlon how we can shift away from the economic debate and move back to a more rights-based conversation. Why should I have to pay for my Mirena coil? Why should I have to bring it with me? Why does this apply uniquely to contraceptive care?

Mr. Andrew Conlon

To take the specific issue of the coil, I could not agree more. The report is explicit on the idea that having to buy the coil and then bring it back to the GP is an inconvenience, discourages people and so on. We need to change that. I think it only gets one line in the report but I had hoped that would be enough. From the group's point of view, that does not seem a sensible system to have, so I completely agree with the Senator. I am slightly disappointed with the Senator's disappointment, if I may put it that way. I had hoped this was one of the messages that would come through in the report. Again, it is explicitly stated in the report that it will spend a lot of time looking at economic and technical issues, but it acknowledges very early in the introduction the human rights and women's rights dimension in the context of the UN, the World Health Organization and so on. It is explicit about the gendered financial burden, in terms of both the cost of the products and the cost of crisis pregnancy in financial, emotional and health terms. The conclusion is explicit that, having gone through all the economic, technical and budgetary arguments, what we come back to is the rights issue, specifically the rights of women. This is associated with the consistency of policy and health benefits. I would have hoped women's rights would come through strongly in the report as a consideration but also, more than that, a driving force in looking at and changing policy in this area such that it is not about economics. The group - certainly I as the chair - did not want to advocate a particular course of action. That was not our role. Our role was to inform debates, provide evidence and identify policy options. I had hoped we had been successful in doing that. I take the point that the bulk of the report is about the technical side of budgets and budget management that reflects the practical concerns. I certainly would not want that to take away from that fundamental issue of rights. As a group of civil servants, however, we believe those questions of rights and so on are very much in the domain of political decisions for the Oireachtas, the Minister, the Government and so on. All we were trying to do was inform debate. What the report in some way suggests is a slight warning. Looking at this economically, as Deputy Donnelly has hinted at, it is hoped we can bring down the current figure, which stands at between €80 million and €100 million. It is multi-year and expensive.

That figure seems to be moving, even today, so I do not know if we can base anything concrete on those estimates because there is a big difference between €80 million and €100 million. There was also a figure of €70 million. That does not seem to be a firm figure on which we can hang our hats. As I said, this still takes us to the economic conversation. Any public expenditure has opportunity costs, and any movement from a means-tested or paid-for scheme will have displacement costs.

My concern is to place those at the centre of the argument. The centrality of the argument is that we get a universal, publicly funded scheme that is comprehensive and supports women throughout their fertile lives. The cost is important, but it is secondary to those principles. That is the point and feedback I wished to give to Mr. Conlon.

Mr. Andrew Conlon

I appreciate the feedback. I had hoped that is what the report had done. It is unfortunate if the drafting or writing has not emphasised that enough. I and the group do not disagree in any way with the fundamental importance of the women's health rights perspective on this issue.

Dr. Mary Short

I am no economist but I have read the report as well. On page 19, it states that the cost of rolling out a service is only 0.6% of the overall current health spend. That appears to be very little when there are 1 million women, which is approximately one fifth of the population, in their reproductive health years. The cost is very small. Also, on a gender equality basis, we provide free condoms to men who have sex with men and they get prophylaxis medication before they have sex and afterwards, yet we are fighting over a choice of contraceptive for women that can last five to ten years. It will lead to healthier women with options on when to have their children, when to space their families and when to limit their families. It bodes well for a society that can look after its future and its couples in their reproductive years.

I have some comments and questions. At the start of the meeting, Deputy Donnelly said it makes no sense to provide free abortion if one does not provide free contraception. This time last year we were in the middle of a very emotive and intense debate on the legislation that would underpin the repeal of the eighth amendment. At every opportunity the Minister emphasised the fact that not only was free abortion going to be introduced on 1 January, and there was a major push to have it done by 1 January, but also that there would be provision of free contraception. However, there appears to be a push back now. It is a year later and there has been no progress on introducing a scheme of free contraception for women. When will we see such a scheme being delivered in Ireland? The report mentions 2021. Is that realistic?

Mr. Andrew Conlon

That is the Minister's policy objective. As I mentioned previously, and I hate to repeat myself, detailed policy work, legislative work and nailing down the cost must be done. There must be a period of time to do the work and as that more detailed work is done, we become more informed on the cost, possible issues we have not foreseen and so forth. The Minister has been clear on his policy direction and objective and, hopefully, the working group has contributed to that. If we look at this as a preliminary appraisal in public spending code terms, plus a little more to do with consultation, that is probably the best way of looking at this report. Work is ongoing. I appreciate it appears to be under the surface, but a great deal of work is being done and it is represented in this report.

Cost appears to be one of the fundamental barriers to rolling out a scheme. There was no cost barrier to rolling out free access to termination of pregnancy, but there seems to be a cost barrier to rolling out free access to contraception. There is no argument in principle about the availability of free contraception. It seems to be about cost.

Mr. Andrew Conlon

The order of costs is different. The context of this issue is different as well. There is an issue with cost that we need to resolve. We must be practical about this. Unfortunately, it is not just a decision for officials or, indeed, the Minister. We would have to engage with the Department of Public Expenditure and Reform, the Cabinet and the Oireachtas. Cost is a factor and that is one of the benefits of this report. I am eager to add a caveat to that figure and the Department will try to reduce it, but giving us an estimate for the cost we might be facing is useful and helpful.

To return to the point, the Minister in his enthusiasm to deliver termination of pregnancy emphasised, on delivering it, that free contraception would be made available to the population. However, the Department is not delivering on that purely because of cost.

Mr. Andrew Conlon

I would not say we are not delivering because the work is being done and needed to be done. What this report has done is highlight cost as a barrier. The public consultation and evidence based analysis of the policy are reasonable and fairly standard steps we take when bringing a policy through. This report is moving the Minister's commitment forward.

I will turn to more practical matters. Deputy O'Reilly raised the issue of practice nurses being involved in the delivery of contraceptive services. Increasingly, practice nurses are playing an expanded role in general practice. It is often the practice nurse who would have a consultation with women about contraception, perhaps more than the general practitioner. If it is a male general practitioner, women are likely to engage with the practice nurse before they would engage with the GP. They have a huge role. Is the college running courses in respect of practice nurses being nurse prescribers for contraception?

Dr. Mary Short

The college is working with the practice nurses' organisation to set up a diploma course and all those things will be covered. At present, the relationship of the practice nurse is with the GP and the service the practice nurse provides is through the general practitioner. The insurance costs are through the general practitioner as well.

With regard to nurses having a nurse prescriber role, is that through the college or through other agencies?

Dr. Mary Short

I am sorry, but I cannot answer that question as I do not know the answer.

In my experience with contraception and prescribing the pill to young women, the reasons they do not take it are fear of putting on weight, mood alteration and not remembering to take it, which is a common issue. How does one address that with regard to education? Obviously, they would be offered alternative methods of contraception and long-acting contraception if they cannot manage to take or tolerate oral contraception. It is one of the main reasons young women discontinue taking it.

Dr. Caitriona Henchion

On the first part of your question, we, as health professionals, and the HSE have a role in actively dispelling many of the myths about contraception. People will tell one that absolutely everything that has happened to them since the day they started taking the pill is related to the pill. We must actively say it is not from the pill, that it does not happen and give them the real information. There are other issues. One can meet somebody who never forgot her pill. Then she had a planned pregnancy and now that she has a toddler the pill must be put in the press with the door closed and she forgets to take it. It is recognising different things that occur in people's lives at different times. There are people who do a great deal of travelling for work. The pill is not ideal for them and one must talk to them about that. It is about having a holistic conversation at the start.

Also, when somebody comes for a check-up it is not just about the person's blood pressure and weight. One must ask, "Do you ever forget your pills?" or "Do you find it easy to remember to take it?" If she replies that she would never forget it or it happens once in a blue moon, that is fine, but she could reply that probably most months she will have at least a scare where she thinks she has forgotten it.

That is the time to have a conversation about whether something else is more appropriate and when one wants the choice to be there to switch to the most appropriate thing at the time.

Dr. Mary Short

On compliance, we are looking at using pills continuously and using different regimes rather than the traditional 21 days on-seven days off which always has a failure rate attaching to it if the packet is not finished or another pack is started later. It improves compliance enormously if women can take the pills continuously. That is also part of the ongoing education about any medication.

Are there barriers to access to tubal ligation now? I understand that some gynaecologists no longer do tubal ligations for fear of the failure rate, that they may be open to litigation. There are other ethical considerations on its availability. What is the situation on this?

Dr. Caitriona Henchion

One of the biggest issues on tubal ligation is the gynaecology waiting list. There is such a long wait to see a gynaecologist and this is not an issue where it is possibly cancer, it is an elective procedure, therefore these people will never be high priority in a gynaecology waiting list. One might face a wait of over a year to see a gynaecologist to discuss having a tubal ligation and another year waiting for the procedure. When someone asks about it we would go through what is involved and if they are in the public system, how long they are likely to have to wait, that they will need some other contraception in the meantime. A Merina coil or Implanon is at least as effective, if not more so, than tubal ligation. Tubal ligation numbers have dropped since the use of long-acting reversible contraceptives. If a woman is paying for it, she will probably find a gynaecologist and have it done but on a public list, they will need to use a different method for quite a long time.

On education, and education in schools, are there any barriers to ethical objections to sex education in some schools? Is it difficult to introduce programmes to schools which may have an ethical objection?

Ms Kate O'Flaherty

I do not have the details to hand but the interim reports on the consultation of the very comprehensive review being undertaken by the National Council for Curriculum Assessment, NCCA, which was alluded to in the original recommendation of the joint committee, recognise that various factors must be taken into account regarding the views of parents and in line with school ethos, etc. The NCCA looks at how those issues can be resolved. It is an issue, although anecdotally, it may be a decreasing issue. It does not relate to a single religious outlook, but there may be other considerations. It also goes back to the point of educating adults and giving parents the language. People may often have reservations, for want of a better word, as to what is age appropriate for their children. On the resources being developed by the HSE in consultation and collaboration with education, teachers and young people, the most important thing is that we have clear, factual, evidence-based information which is available at an age-appropriate level. A key part of that is being able to work with teachers in schools to train teachers who teach SPHE and sex education in the confidence and skills to be able to talk to teenagers in particular around those issues. That is something that often comes up around the comfort and confidence that adults have in having those discussions and supporting the young people in their skills and so on. The Department of Health's policy perspective is that all young people would have access to factual information and supports and resources to help them make those informed decisions. We also have a commitment to support their parents, teachers and youth workers in their work to help the young people to take that knowledge on board, answer their questions and ensure that they can make informed choices as adults. It is very important that we have a consistent evidence-based approach among ourselves and other partners working together.

On sex education in schools, is it in-house provided by teachers from within the school or is provided by outside groups who come to the school?

Ms Kate O'Flaherty

Dr. Short might have some other detail, but I understand that it would be SHPE teachers. As part of their overall curriculum on health and wellbeing schools may invite people with expert knowledge in to add to the SPHE curriculum. The Department of Education and Skills provided particular instructions, supported by us, on the types of people that would come in and the type of information that would be given across other topics as well as sex education. It may be an issue examined by the NCCA review. The skills and confidence of teachers teaching SPHE and sex education in particular is something we need to support, no more than parents, in order to provide young people with a comfortable environment to be open, take up the knowledge, ask the questions that they have and get the factual information.

Does Deputy Kelly have any questions?

My questions have been covered. I share some concerns that Senator Kelleher eloquently outlined on what I expected from the report and what was actually in it. I encourage those present to bear in mind some of the comments from my colleagues but particular those of Senator Kelleher around those concerns. I had thought the report would focus in and be more proactive. Mr. Conlon might take the comments on board. He referred to some parts that he may have covered but which were understated in the report. That might be something that we need to change and dial-up in the future on implementation.

On behalf of the committee I thank Ms. O’Flaherty, Ms O'Brien, Mr. Conlon, Dr. Henchion, and Dr. Mary Short, for coming before the committee and for their evidence.

Sitting suspended at 11.17 a.m. and resumed at 11.40 a.m.