Traveller Health: Discussion

I welcome members and viewers who may be watching this meeting on Oireachtas TV to the meeting of the Joint Committee on Key Issues affecting the Traveller Community. I also welcome our visitors in the Gallery. The purpose of today's meeting is to begin our deliberations on the topic of Traveller health. We will meet representatives from Pavee Point, the National Traveller Women's Forum, Mincéir Whiden, the Kilmallock Traveller Women’s Group and the Traveller Primary Health Care Project, and officials from the Department of Health. I welcome Ms Brigid Quirke, Pavee Point; Ms Maria Joyce, National Traveller Women's Forum; Ms Kathleen Sherlock, Mincéir Whidden; Ms Nora Mooney, Kilmallock Traveller Women’s Group; Ms Missie Collins, Traveller Primary Health Care Project; and Mr. Jim Walsh, principal officer, and Ms. Dairearca Ní Néill, assistant principal officer, from the drugs policy and social inclusion unit of the Department of Health.

We will hear of the gross and stark health inequalities that affect Travellers' health. The figures for life expectancy are mentioned in so many submissions, with a life expectancy of 66 years for Traveller men, which is 15 years less than the average, and 12 years less than average for Traveller women. Traveller babies are 3.6 times more likely to die in infancy than among the mainstream population and Traveller mortality in general is 3.5 times higher. In recent weeks, we have had the stark figures on suicide rates, which, of course, are part of health. Today, we are focusing on health more generally and we will move now to hear the submissions. As there are many witnesses, we will be strict about the five-minute rule because if some take seven minutes, the person at the end gets squeezed, which is not particularly fair. The clerk will remind us at the four-minute mark that the speaker has one minute left. It is very important that members have a chance to put questions to the witnesses and have a proper discussion and debate about this very important and stark set of health inequalities and disparities around Traveller health.

In accordance with procedures, I am required 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 the committee. 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 or her identifiable. Members are reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside of these Houses, or an official either by name or in such a way as to make him or her identifiable.f

I remind members and witnesses to turn off their mobile phones or switch them to flight mode as they interfere with the sound system. I also wish to advise that any submissions or opening statements that witnesses have made to the joint committee will be published on the committee's website. After the presentation there will be questions from members of the committee.

I call Ms Kathleen Sherlock to make her opening remarks.

Ms Kathleen Sherlock

On behalf of Mincéir Whiden, cant for "Travellers talking", Ireland's only all-Traveller forum, I thank the special joint committee for the opportunity to make a presentation on Travellers' health. We must start the submission, as we always do, by stating the obvious: the Traveller community is in crisis. The evidence is there for everyone to see. The Traveller community is at the top of every negative statistic and the bottom of every positive outcome in Irish society, whether education, employment, health, life expectancy, mental health, addiction and now the escalating suicide rates. The fact is that we are haemorrhaging people through chronic illness, ill health, addiction and now suicide. The underlying causes are poverty and poor living conditions, social isolation and exclusion. We in the Travelling community are losing our ability to cope and to endure. We are dealing with layers upon layers of grief. For decades the Traveller community has experienced unrelenting anti-Traveller bias and racism. We are the most disadvantaged, discriminated against and marginalised community within Irish society. Urgent action is needed to turn these challenges around.

The Irish Traveller population is currently fewer than 40,000. Today we are talking about the inequalities in Traveller health and mental health and the actions needed to address these inequalities. In doing so we cannot leave out the factors that contribute to the crisis in Traveller health and mental health. This is a crisis in Traveller accommodation, poor educational attainment among the Traveller community and high levels of unemployment, social exclusion and anti-Traveller bias and racism. These issues are interlinked and negatively impact Traveller health and well-being. To resolve the crisis and the destruction we are witnessing within the Travelling community, we must understand their interconnectivity and take a holistic approach in addressing each of these issues. These are not insurmountable issues to fix. With commitment and resolution they can be fixed, and we will be a better people and a better country for it. The neglect and inequality the Traveller community and pockets of deprived, long-term disadvantaged communities throughout Ireland have experienced and endured are a stain on the character of the nation and must be put right. Ireland is only a small country but we stand proud with the nations around the world for the contributions our country has made on the world stage. We must, however, address the internal challenges and support the people our nation has left behind for far too long. Successive Governments have failed to put in place decisive actions to resolve the inequalities which exist within our country and which have allowed so many of our people to be left behind, doing the best they can and trying to survive in conditions and with challenges that in many cases are hard to imagine in a first-world country such as Ireland. Sadly, too often the contributions made by individuals from the Traveller community and disadvantaged communities throughout Ireland that have made our nation what it is have been forgotten or underappreciated.

As a nation we cannot continue to blame people and communities for the marginalised, disadvantaged and deprived situations they were born into and are trying to survive in. It is time to reach out and pull up the citizens of our nation that have been left behind. We are not a problem people. We are not problem communities. We are people and communities with problems that are the direct result of generational poverty and exclusion. We need help and support to overcome the challenges our communities are facing, decisive Government actions and the implementation of equality-based policies to address these inequalities and challenges.

I will outline some statistics relating to the Travelling community. Life expectancy for Traveller men is 15 years younger than in wider society, for Traveller women 11 years younger. Our infant mortality rate is 3.7% higher than that of the general population. Suicide among Travelling men is just under seven times higher and now accounts for the deaths of 11% of Travellers annually. We currently have no statistics on the suicide rate among Travelling women, but this has become a very worrying trend in recent years.

A number of young Travellers, boys and girls, have also committed suicide.

I will outline some of our key recommendations. A national Traveller action plan should be published and implemented urgently. This should include the establishment of an institutional mechanism, within the HSE and the Department of Health, to drive delivery and implementation. This must be inclusive of clear targets, indicators and outcomes, timeframes and budgets. Sláintecare also recommends access to universal free general practitioner, GP, healthcare within the next five years. We recommend that Travellers be prioritised and fast-tracked in this process. We further recommend, with immediate effect, that all Traveller employment and primary healthcare projects are entitled to medical care similar to disability, community services programmes and community employment schemes. This would involve in the region of 300 medical cards.

Traveller-specific infrastructure, including Traveller health and primary healthcare projects, should be protected and receive increased resources for their expansion and development in line with the national Traveller and Roma inclusion strategy. It is important that health reforms do not undermine the work in progress of the Traveller health units, THUs, given their institutional knowledge and impact on the ground. It must also be ensured that clear budgets are allocated and protected to address Traveller health and inequalities.

Finally, a national Traveller suicide intervention and prevention strategy needs to be implemented urgently. Some of the statistics that we do not have-----

Ms Sherlock has reached the end of her allotted time.

Ms Kathleen Sherlock

I will finish there. I will just add that we have no facts or figures on the number of Traveller people attempting suicide and the number of families on suicide prevention watch. That is also having a major impact on families. I thank the members of the committee for their time.

I thank Ms Sherlock and I now call Ms Quirke from Pavee Point to make her submission.

Ms Brigid Quirke

Pavee Point is delighted to have the opportunity to be here and we welcome this focus on Traveller health inequalities. We have provided a comprehensive submission, which will serve as a reference document, and we are also available if the members of the committee require any further information. We will give a quick overview of the issues involved and leave time for discussion at the end, as we feel that is the best use of time. We would like to highlight the key issues in the area of Traveller health, including the poor health status of Travellers, the impact of broader social determinants, to which Ms Sherlock referred, the positive developments that have occurred and the need for investment in a strategic and co-ordinated response to address these Traveller health issues.

I will now contextualise Traveller health within the broader social determinants. There is a need to recognise the causal pathways, which include discrimination, education, employment and accommodation. If we are to realistically address Traveller health inequalities, we need a whole-of-Government approach in addressing these determinants. We commend the work of the committee to date in exploring these issues and recommend that other thematic sessions should include questions on their impact on Travellers' health.

Next year will mark a decade since the publication of the comprehensive all-Ireland Traveller health study. That took three and a half years to complete, cost taxpayers €1.3 million and involved a concerted effort between Traveller organisations, Traveller peer researchers from primary healthcare projects and researchers in UCD. The study yielded an unprecedented participation rate of 80%, an exceptional response. The evidence of the study, which we keep highlighting, showed that Travellers have the lowest life expectancy of any group in Ireland. Overall life expectancy for Travellers is 66, with Traveller men living some 15 years less and Traveller women some 11 years less than their counterparts.

In addition to those statistics on infant mortality and overall mortality, it is important to note that the study suggested that institutional discrimination does exist within the health services. Less than half of all Travellers had complete trust in health professionals compared with trust levels in the general population, according to a study. More than half of Travellers were concerned about the quality of care they receive when they engage with the service. Some 40% of Travellers reported discrimination in accessing health services. This was supported by almost 70% of the service providers, who agreed that their services discriminated against Travellers. Services providers were also interviewed in the study to determine what they felt were the issues.

We know from the study that Travellers are dying from the same causes as the general population. They are not dying of any exotic illnesses particular to Travellers, they are dying of heart disease, cancer, respiratory disease and suicide. They are, however, dying in far greater numbers across all ages. If this was any other group in Irish society, it would be seen as a national crisis.

However, as our colleagues have pointed out, the findings of the study have been largely ignored. When they were published in 2010, we were told no action could be taken as there were no resources available due to the recession. Despite the recovery, we still have no action and Traveller health continues to deteriorate. We believe it is not prioritised within the Department, or within Government, and we require leadership and urgent action.

It would be remiss not to acknowledge that some very positive developments have occurred in the past 20 years, in particular the development of a strong Traveller health infrastructure at national, regional and local level. I refer also to the establishment of the National Traveller Health Advisory Committee. That was a structure within the Department of Health that represented Travellers, the HSE and the Department. It was responsible for the development of Traveller health policy and it had oversight of the Traveller health budget. Its achievements include the publication of the Traveller health strategy in 2002, the piloting of the ethnic identifier, which has now been rolled out, and the groundbreaking All-Ireland Traveller Health Study.

We acknowledge that the committee heard last week that the National Traveller Health Advisory Committee was reviewed and that a recommendation was made to disband the group. However, that was not the case and, in its absence, there are no representative mechanisms to drive a response to the detailed findings. As we said, we have a lot of evidence and many strategies; we need an implementation plan.

We are awaiting the establishment of an essential structure to monitor Traveller health policy and mainstream Traveller health across the Department in line with the commitments in the national Traveller and Roma inclusion strategy, NTRIS.

At regional level, we have the Traveller health units, which are partnership structures between HSE and local Traveller groups coterminous with the original health boards, through which Traveller health issues are highlighted and mainstreamed into regional health service provision.

In addition to national and regional structures, the Primary Health Care for Travellers projects at local level, which have been acknowledged as the cornerstone on which health services are delivered effectively to Travellers, were clearly reflected in the All Ireland Traveller Health Study, with 83% of Travellers receiving health information from the primary healthcare projects. There is also a higher uptake of cervical screening and breast cancer screening in areas where the projects exist.

Unfortunately, this Traveller health infrastructure has weakened due to lack of investment in the past ten years, leading to the closure of a number of these essential projects.

There has been disproportionate disinvestment in Traveller health which pre-dated austerity. This was when the budget was transferred from the Department to the local health structure. This was identified in 2009 to the Joint Committee on Health and Children in which we highlighted that in 2007, €1 million was allocated for Traveller health developments, of which €100,000 was allocated towards the All Ireland Traveller Health Study, with the remainder put towards balancing the HSE budget.

Similarly, in 2008, a further €1 million was allocated to Traveller health developments. The HSE introduced a stipulation that one could only spend in 2008 what one spent in 2007, therefore, once again, €900,000 of the Traveller health budget went to balancing the HSE budget. Of a potential €2 million for Traveller health development funding, given Traveller health status, the All Ireland Traveller Health Study and the significant needs, €1.8 million was used to balance the HSE books. We believe this reflects a lack of prioritisation of Traveller health and a disregard for Traveller health inequalities. Traveller health has not received any new development funding from the Department of Health. There has been once-off funding and money given towards the employment of mental health workers locally.

We welcome the commitment in Action 73 of the NTRIS to develop a detailed action plan with clear targets, indicators, timeframes and resources. A robust consultation process produced the first draft of the action plan, which totally ignored some of the recommendations from the consultation process. While we would like to acknowledge the HSE's commitment to revise the plan, there is a need to ensure that the revised plan includes the establishment of a new institutional mechanism under the aegis of the Department of Health and the HSE to drive the implementation of the plan.

Our recommendations are the same as those of my colleagues from Mincéir Whiden. The need for ethnic equality monitoring is the last one. We need to roll out the ethnic identifier across all health and social care administrative systems. We require that to monitor access, participation and outcomes in terms of all services for Travellers. This will provide an evidence base to inform Traveller health policy and service utilisation in the future. It would also help to target and ensure more effectiveness and efficiency in the health service. It will also ensure that under section 42 of the Irish Human Rights and Equality Act 2014 there will be a statutory requirement on public health bodies which are mandated to take proactive steps to assess equality and eliminate discrimination.

I thank Ms Quirke. I call Ms Joyce from the National Traveller Women's Forum to make her submission.

Ms Maria Joyce

We welcome the opportunity to speak to the committee on Traveller health, but we also have to recognise that it is the latest in a long line of spaces, policies or others in which Travellers and Traveller organisations, like the National Traveller Women's Forum, have engaged in attempting to bring about equal outcomes in terms of health for Travellers. This is not new information and it should definitely not be this difficult to have our community's issues heard and acted upon.

In our written submission we have raised many issues and put forward recommendations, but for today I just want to emphasise one issue, namely, that the current national health structures and very limited policy implementation that has taken place for the advancement of Traveller and Traveller women's health have failed to have any meaningful long-term impact overall. Achievements have been made locally and regionally by Travellers and Traveller organisations, including primary healthcare projects, but we should also recognise the contributions made by individual healthcare and HSE professionals. However, while the Department of Health continues to behave like an absentee landlord, ignoring the need for structural and institutional changes in the health service's thinking and practice, we will progress no further.

As our submission points out, the studies and research have been done, and the findings, as the committee has heard from Kathleen and Brigid, are stark and shocking, yet there has been no targeted strategy or action plan put in place to address the health inequalities for Travellers since Traveller Health: A National Strategy 2002-2005 and the national intercultural strategy over a five-year period, which ended in 2012. Health issues for Travellers have been excluded entirely from all mainstream health related strategies, including the current Healthy Ireland framework. I suggest that members google the document. There are two references to other strategies within it with regard to Travellers. The only direction that the Department of Health appears to want to go down is to pigeonhole all matters concerning Traveller health into social inclusion. This is not the answer, and again the question has to be asked how long more we have to wait for the Department of Health to meet its own policy commitments to Travellers. We need implementation.

Nine years after the launch of the all-Ireland Traveller health study in 2010, as Brigid has said, there is still no Department lead and there are no personnel with a brief on Traveller policy within the Department of Health. It has been more than two years since a commitment was made to develop and implement a detailed national Traveller action plan based on the findings of this study using a social determinant approach. Yet as has been said, Travellers continue to die from cancer, heart disease and other preventable conditions, including death by suicide, in greater numbers than the majority population. Of course we cannot demonstrate that with hard data because there is still no desegregated data collection across all of the health systems in Ireland, and I will say that that suits the Department in that regard.

Regional Traveller health units are under-resourced and their funding has not been ring-fenced for Traveller health. Despite underspends in some Traveller health budgets, the HSE in some regions made cuts to key services for Travellers under cost-saving measures, reducing the hours of Traveller community health workers and other supports. In one region the Traveller health unit has not met, despite efforts by Traveller groups in the area to make it happen. There also needs to be more accountability and transparency within the health system in relation to Traveller health budgets. In addition to this, the national Traveller health advisory committee, which was the driver behind the all-Ireland Traveller health study, has not been convened since 2012, despite repeated calls by Traveller organisations. Members will have heard Brigid say at a previous meeting that it was a recommendation that it would not continue to meet. That was misleading to this committee. That was not the case

In 2017, we saw the launch of the national Traveller health-Roma inclusion strategy, with a range of actions on health. We are still awaiting the long-promised national Traveller action plan from the Department of Health. Another commitment was also made by the Department to review and improve existing arrangements for engagement between Traveller organisations, the HSE and the Department of Health. In May 2018, the Department, the HSE and organisations participated in a workshop where our views and position were made very clear around a number of issues, including the effect of monitoring and implementation of Traveller policy, the need for institutional mechanisms representative of all stakeholders to drive the implementation, and dedicated resources - financial and personnel. These issues and other issues are being raised continually by all stakeholders with little response from the Department of Health. A draft of the national Traveller health action plan was circulated for feedback in March 2019.

The draft document was inadequate and demonstrated the lack of attention and commitment the Department of Health has given to addressing the health inequalities of Travellers. The repeated request is that the Department of Health urgently address the issues we have raised here today by finalising and, more importantly, implementing a holistic and gender responsive national Traveller health action plan which will deliver, hopefully, real change in health outcomes for Travellers. An independent implementation body must be established and much have ring-fenced budgets in order to drive delivery and implementation. There are more recommendations in our submission but I will not go through them now.

The issue is implementation. The studies, statistics and evidence are available. Travellers are dying in greater numbers and at earlier ages than is the case in the majority population. How much more of that evidence is required before there is action?

Ms Nora Mooney

I am a Traveller from Kilmallock in east County Limerick. I am married with two children, one in secondary school and one in preschool. I represent Travellers in east Limerick on the HSE Traveller health unit and I am chairperson of the Kilmallock Traveller Women's Group, which was formed in April 2017. It is a lively, vibrant group that is ready to stand up and be counted. We are committed to working towards changing outcomes for Travellers. It is a mixed age group made up of grandmothers, mothers and young single women. In the short period since it was established, the group has also set up Kilmallock Traveller Men's Group. Ours is a voluntary group with no staff. We are dependent on volunteers. We are supported by Ballyhoura Development and receive funding from the HSE Traveller health unit for our group activities. We appreciate the opportunity to attend this meeting so members can hear about the situation in which we find ourselves in east Limerick.

Recently, an assessment examining the health needs of Travellers in east Limerick was carried out by Ballyhoura Development. I was the Traveller representative on the steering group for the project. This was the first meaningful engagement with the Traveller community in east Limerick. The methodology used to conduct the research was peer-led, which meant that members of the Traveller community were employed directly to carry out the survey. I am proud of the work the team of peer researchers completed. The outcomes from the report are not just findings, but our real life health issues which are not being addressed in a way that supports change for us. In this day and age and in this country, can one believe that only 29 out of 424 Traveller individuals in east Limerick are over 50 years of age? Worse, only three are over 65 years of age. One of them is my father. It frightens me to think that I might not see 50 years of age and that I am much less likely to reach the age of 65 years. For how long do the members of the committee expect to live? I am due to retire in 23 years' time. Our recent assessment demonstrates that I will more than likely not be around for this. It appears there will be no need for the old age pension or the fair deal scheme for me.

I wondered how I might get the committee to understand where we are coming from and how our health issues impact on our lives and those of our children. Now that we have completed the assessment we realise its seriousness and the time limits in which we must achieve change. The stereotype of Travellers has led to discrimination in all sectors, including education. My experience of education was not positive at the start. When I was in primary school, I was automatically segregated into a remedial class, without reason or assessment but simply because I am a Traveller. I often spent hours in the playground singing instead of being in class learning, which I was well capable of. It is no wonder that we are such good singers today, or is that another stereotype?

It was only when I was old enough to realise that I was being treated differently and told my mother that the situation changed. It was because of my mother's belief in my ability and her perseverance that I was eventually integrated back into the regular class. Since then I have completed secondary and third level education. I am forever grateful for my mother's intuition, but 30 years later I find myself doing the same thing for my children. What has improved? I know from the personal experience of my immediate family that the low expectation of Travellers to perform well in education continues, along with segregation and discrimination. If we cannot change this discrimination in primary school, where can we change it?

Do members realise that 48% of my community in east Limerick live in mobile homes or trailers? While I am lucky to have my house, and the mortgage to go with it, some of my family have been on a council housing waiting list for more than 16 years. That is 16 years of living in damp, mouldy, overcrowded conditions. Is it any wonder that our life expectancy is so low?

Some 80% of Travellers are unemployed compared to 5% of the general population.

We need meaningful employment opportunities for Travellers. I want to be able to ask my children what they would like to be when they grow up and to know there are no barriers preventing them from realising their dreams.

I cannot leave today without mentioning mental health and how the conditions and situations in which we find ourselves are impacting on our mental health. Every day, I see how mental health issues affect the people I love and care for. How many family and friends do members think I have lost? How long could they hold the weight of these factors on their shoulders? None of these issues is standalone. They are all interlinked and contribute to the multiple layers of disadvantage continuously experienced by my community. What can we do about it? Where is the innovation and the new ways of thinking, for example, Traveller-led methodologies across all sectors, including housing, education and health? This means that models similar to primary healthcare projects are applied across other sectors, specifically education and housing. We know this way of working achieves great results. For example, the assessment carried out in east Limerick identified 113% more Travellers than the census in 2016 identified. Ours is one of the best educated countries in the world. Why are we continuously using one-trick pony solutions when it comes to Traveller welfare? In east Limerick we are already on the brink of losing our oldest generation. We need support and resources to bring about change for our community. The first step for east Limerick is the establishment of a Traveller health primary healthcare team. While we have received a commitment in principle from the HSE, time is running out. Do I not deserve to be around to see my grandchildren grow up? We see ourselves as advocates for our community and we already bear the weight of our community on our shoulders. It is up to us to find the solutions, be the listeners, make the connections and find the words to help but we cannot do this without the support of this committee. I thank members for listening.

I thank Ms Mooney for what was a very personal account. As we all know, the personal is political and all private problems are public issues. She has linked that very powerfully for us today. It cannot have been easy to talk about these matters and I welcome her candour.

Ms Nora Mooney

It is an insight into how we feel and what is happening.

I now call on Ms Missie Collins from the primary healthcare for Travellers project.

Ms Missie Collins

I thank the committee for inviting me this morning. It is a great honour. I must start at the very beginning, when the primary healthcare project started. I was one of the people who approached the health board back in the 1990s. It was 1992, I believe. There were about 14 people sitting at the table. When I said that we needed primary healthcare for Travellers, I was told that it would not work. When I asked why, I was told that it would mean Travellers going out, talking to Travellers and moreover, Travellers are not educated, cannot drive and cannot do this, that and the other. I said that our need was greater than ever. We did not win that day but when I was coming away from the table, I said that I would be back. Back I went to a member of staff. He said, "You're not giving up Missie, are you?" and I said no, that I was not giving up. He agreed to a pilot for nine months. I asked if he could do a little more than that and he asked me what I meant. I asked him to come to the steering group meetings so that he would know how the project was going and he did.

In the beginning we visited 85 families. Now we are visiting 300 families. We devised our own questionnaire, went through it with them and found out all of their needs. Then we took that back to Pavee Point and to the health providers and services there. At that time, three needs came out of the process, namely, a well woman clinic for our women, a hearing test for the children and a dental service. One of the aims of the project is to try to close the gaps in the health service. That went on and we got all of the answers there and it went very well.

We were able to take some of our women over to the Well Woman where some of them with breast cancer were caught in time. We saved the lives of some of our women. Some of them are living in the programme today.

As part of the programme, we mapped out the provisions for children out on the sites, who would then go for their hearing and other tests. Those of us involved in this programme attended meetings with the top officials in the Department of Health and Children. I thought it was great for me to be able to sit at meetings with the higher up bodies who need to give the Travellers support. We lobbied for a health strategy for Travellers and it took many hours over a nine year period of sitting round the table at meetings in the Department of Health and Children. There were 27 recommendations in the health strategy for Travellers, one of which was for an All Ireland Traveller Health Study to be carried out by Travellers for Travellers from one end of Ireland to the other. I have to say that is the greatest piece of work we did. We got all the information, and one thing that we counted as a good outcome, is when the health providers and services were upfront and stated that they did discriminate against Travellers. The former Minister for Health and Children, Ms Mary Harney, was the then Minister when I launched the All Ireland Traveller Health Study. I held that report over my head and I was proud to do so. I believed that the recommendations of that report would be implemented but I was very disappointed that it did not happen. I always say to myself: "Where is that All Ireland Traveller Health Study report now? What shelf is it on in the Department of Health?"

The report compiled the statistics on the life expectancy of Travellers, and I know at first hand about life expectancy because I lost my husband when he was a young man. I have lost brothers and sisters when they were young people. There is nobody who can tell me about life expectancy better than what I know from my experience. Things will have to change. Travellers' health is at crisis point. We want a commitment on services for Travellers. Since 1994 I have been chasing Ministers for Health and I have met them. I gave a former Minister, Mary Harney a fright when I followed her out. The Minister, Deputy Simon Harris is a very nice man and he promised me that the Traveller Accommodation Programme, TAP, meetings would come under the Department of Health. Who is blocking this happening? Is it the Department of Health that is blocking it? I get angry and I have to say what is on my mind. I want that meeting to happen again. We should be sitting at that table.

The Traveller primary care workers only work for 12 hours a week, yet some of our women have lost their medical cards because their income was a couple of euros above the limit. Seeing that Travellers have very poor health, all Travellers should be entitled to hold their medical cards. If there are full-time jobs for younger Traveller women, they should get them because the primary health care projects are the greatest thing that ever happened for Travellers.

I do not think there is much more for me to say because others have said it, but I repeat that I would like medical cards to be issued to young Travellers. Let me add that the Minister of State is accompanied by officials from many agencies, who all have a role to play in improving Travellers' health.

There is a broader picture to it. The determinants of health are discrimination, bad living conditions, unemployment and education. These are the four that come up. I know that from visiting the sites, seeing young mothers and old people. We only have a fistful of old people – seven - over the age of 80. I live in group housing and seven young men out of the 50 houses have died. We have hardly any men left. It has to change for us and change fast. When I meet a Minister or someone from one of the bodies, there is no use in him promising me to try to change it. It has to happen for us.

(Interruptions).

Thank you, Missie.

Ms Missie Collins

It is all right.

That definitely deserved a round of applause. I think we can break the rules today. We need to do better, however, than to break rules. Ms Collins outlined a history of struggle and resistance, yet the facts have not been acted upon. It is the responsibility of all of us. I thank Ms Collins for bringing us to this place.

I call on Mr. Jim Walsh and Ms Dairearca Ní Néill from the Department of Health.

Mr. Jim Walsh

I am the principal officer in the Department of Health with responsibility for co-ordinating policy on health services for Travellers. I am accompanied by my colleague, Ms Dairearca Ní Néill, who is the assistant principal officer with specific responsibility for Traveller health matters.

I am relatively new to the post but I come with much understanding of Traveller and inequality issues, having worked with the Combat Poverty Agency and the social inclusion division of the Department of Employment Affairs and Social Protection. I have much understanding of the issues and concerns raised by the previous speakers this morning.

The all-Ireland Traveller health study was an initiative of the Department of Health, which also funded it. It reflected a concern about the health status of Travellers. We have heard many of the figures. Travellers have more illnesses and die younger. They are at greater risk of substance misuse and mental health problems. The all-Ireland Traveller health study highlighted that these health inequalities are rooted in the social determinants of health which encompass accommodation, education, employment and discrimination. There is great acceptance of this, at least in the Department of Health.

The Department of Health provides funding of €10 million a year to the HSE for initiatives specifically targeting the improvement of health outcomes for the Traveller community. Other funding is provided by other sources, including the mental health budget from the social inclusion programme. A further €500,000 funding is provided through the Dormant Accounts Fund. As the HSE will attend the committee at a later stage, I will not go into the detail as to how these resources are spent in supporting primary healthcare initiatives. We must acknowledge, however, that the model of work developed through those primary healthcare initiatives highlighted here. This model of peer working and engagement with Travellers should be used across our public services. Much credit is due to those who have been pioneering those initiatives. It is part of our delivery of health services.

I want to focus on some examples of health policy at national level which support the Traveller community and illustrate the challenges in meeting the health needs of Travellers.

The first is the national positive ageing strategy. As we have heard, ageing is a key issue for Traveller health. The most recent figures we have are for 2018 and indicate that 3% of Travellers were aged over 65, compared with 13% of the general population. It is clear that Travellers die younger. A particular issue in addressing positive ageing for Travellers in the strategy is the lack of disaggregated data on ethic status, which are required to monitor and address their health needs. That issue has been highlighted at the committee. To address this deficit, the healthy and positive ageing initiative developed a bespoke set of 14 indicators of positive ageing for Travellers which was published in May following extensive consultation with members of the Traveller community. There are two interesting elements to the indicators developed. First, the threshold for positive ageing was reduced from 50 years to 40 years, reflecting the fact that Travellers die up to ten years younger than the general population. Second, they took on board very specific issues regarding Traveller accommodation which may not affect the rest of the population. We drew up customised indicators to monitor positive ageing for the Traveller population. This reflects a commitment in the national positive ageing strategy to change mindsets, promote social inclusion and pay particular attention to the needs of marginalised groups.

The second example to which I wish to refer is the national drugs strategy, an area for which I am responsible within the Department. The use and misuse of drugs and alcohol is an important concern for the Traveller population. More than 300 Travellers were treated for problem drug use in 2017, which represents 3.7% of all those attending for treatment and indicates that Travellers are five times more likely to receive such treatment compared with the general population. One of the actions of the national drugs strategy, Reducing Harm, Supporting Recovery, is to improve access to addiction services for people from the Traveller community who use drugs. There are particular challenges in engaging Travellers in drug services and these arise from the stigma associated with drug use among the Traveller community, especially among males. My written submission outlines some initiatives by task forces in particular to try to engage in a culturally appropriate way with Travellers facing addiction issues.

Mr. Walsh has had five minutes. I ask him to conclude.

Mr. Jim Walsh

I wish to flag the national Traveller and Roma strategy which is a whole-of-Government response to addressing health and other needs of Travellers and contains more than 30 health-related actions across four themes. One of the main actions in the strategy is to develop and implement a detailed action plan to address specific health needs of Travellers using a social determinants approach. A draft is in circulation. The Minister for Health, Deputy Harris, and the Minister of State, Deputy Catherine Byrne, are very engaged on the issue and supportive of the health action plan. I strongly agree with the earlier comments that we need implementation, a monitored action plan and clear outcomes from it.

The Department is committed to ongoing engagement with Traveller organisations on Traveller health issues. In 2018, my unit convened a workshop on Traveller health which brought together relevant units of the Department, the HSE and Traveller organisations to take stock of where we are in terms of Traveller health issues. There are many examples within the Department of health structures with Traveller representation and I make reference to these in my written submission. In line with action 74 of the national Traveller and Roma integration strategy, the Department and the HSE will review arrangements for engagement with Traveller organisations to support the Traveller health action plan. We are committed to hosting a seminar in the Department with key officials to look at the health action plan when it is finalised and to participate in any new structures proposed under the plan. The Department is committed to improving the health status of Travellers. However, many of the levers to achieve this objective lie outside the remit of the Department of Health. The Department will continue to engage with the steering committee of the national Traveller and Roma inclusion strategy and with Traveller organisations to improve health services for Travellers and to address the social determinants of health.

First of all I must say thank you to Missie. Sometimes I fear that I am becoming desensitised to trauma, pain and struggle. I definitely had this challenged in me just there. I was definitely re-energised in listening, supporting and continuing that fight she has long been fighting. Hopefully we can play a part and see through all of the work the witnesses have been doing for all of these years.

Because we keep having the intersection between education, accommodation and so on, and given the role Jim is in now, would it not make sense to remove all criteria for everything when there is a health crisis and a crisis of the Travelling community? This would mean removing the criteria for housing and for medical cards and for literally every barrier that exists until it is corrected and until Travellers are living longer. One cannot positively age in a caravan that is full of mould and cannot be adapted, where there cannot be a shower chair or all of the things our older population needs to positively age at home.

When I first started to engage with Pavee Point around education and addiction back in 2010, the number of Travellers was at 52,000. Drug use was not a feature 15 years ago when I first started working in the drug sector. A very small number of Travellers were using, or in chaotic substance abuse, at that stage. At the time a woman from Pavee Point told me that because of the age discrepancy in life expectancy Travellers would never usually enter the nursing home or home help system. How can we support Travellers to be able to care for their loved ones within their communities when they are facing illnesses?

In nursing homes, doctors are paid a higher amount to visit the elderly in nursing homes - I can be corrected on this and the Minister of State might know - than they are in the homeless sector where there is also an ageing population, as with the Traveller population, that is ageing at 45 and 50 years of age due to life conditions. Do we need to look at the pension packages provided when someone enters a nursing home and make these packages accessible across the board to people living in the homeless sector and to people in the Traveller community who would not usually end up there? Perhaps I am wrong about the numbers of Travellers who end up in nursing homes but I know that the woman said they generally tend to care for those people at home. Because a Traveller's life expectancy is much shorter the length of that care is probably much shorter. Could we look at nursing home types of care and how it could be implemented into the Traveller community in the context of the benefits of nursing home care along with the pension packages and the pension ages, and recognise that a pensioner exists at a much earlier stage among the Traveller community? What kinds of supports would this bring if it was an official recognition?

My main point is the question around mobile health units. Those who need healthcare the most are often the least likely to receive it. There are mobile health units used by the homeless sector and the Roma community in rural parts of Ireland where it is harder to get access to healthcare. Is there a benefit to mobile healthcare units being Traveller specific and where we could make sure that healthcare and primary healthcare gets directly into Traveller communities?

On the implementation of everything we have spoken of at this committee, would it make sense to have a Traveller-led taskforce within the Department of Health to make sure the implementation happens so that Travellers are leading that change and that charge rather than just being consulted in an ad hoc way? How quickly could we get things done if the groups and organisations we see coming in to this committee were actually part of a taskforce within the Department?

How can we remove the criteria and barriers? I am talking about education and the leaving certificate points systems with regard to removing every single criteria there is for Travellers, and removing application forms and prescriptions. I propose removing all of that until Travellers are in a position where they can live full lives and reach their full potential.

Life expectancy for Travellers has decreased dramatically. It is policy that has killed the Traveller community, rather than bad health outcomes or education. We need to remove the policy implications so that Travellers can access all the things they need to access.

The question calls for urgent radical action to remove all barriers and incentivise getting health to people where it is most needed, in the form of mobile health units, and for a Traveller-led task force.

Mr. Jim Walsh

They are very good points. We should look to ensure there are no barriers to services. Whether that is done through universal access or not is difficult to say, given the different living standards across the Traveller population. In the context of home-care services, the fact that they have lowered the age threshold from 50 to 40 in the analysis of healthy ageing for Travellers is an acknowledgement of premature ageing among Travellers. This could also be applied in policy with access to home-care services and I will inquire about this when I go back. I am not sure if nursing home care is the right model of care and other people will be better qualified to answer that than I. It may be that home-care packages are right because there is such a strong community focus. I will inquire about that and take advice on it.

I was not encouraging Travellers to go to nursing homes but that whatever incentives doctors have to visit nursing homes should exist within communities that have similar ageing issues.

Mr. Jim Walsh

We should just change the threshold.

Ms Missie Collins

On accommodation, not many Travellers like to go into homes. No accommodation is being built for Travellers but mobile homes with electricity and toilets, like chalets, would enable our people to go into them in a wheelchair and have a walk-in shower but these homes do not exist. It is like the Third World.

Ms Kathleen Sherlock

We have all known Travellers who were taken care of by their families in trailers or at the side of the road. Some of them had prolonged cancer, which are very challenging circumstances, but they had no supports. Like Missie said, they had no toilets, no showers and no dignity or privacy.

Ms Maria Joyce

We need to be careful not to allow Departments to shirk their responsibility. There are appalling standards in Traveller accommodation and poor educational attainment outcomes in education. Fundamental issues underlie everything in Traveller policy, such as racism and discrimination. These issues have to be addressed but that does not take away from the responsibilities of the Department of Health to Travellers' health. They did the study, which came out of nine years of lobbying by the Traveller health advisory committee, which was almost disbanded as the study was being rolled out. We engaged in a review process in good faith but the disbandment of the committee was based on the fact that key stakeholders, in health and other areas, did not engage with it to the necessary level. We were blindsided, however, by what followed and we did not even receive the review until 2018, despite the fact that it had started in 2012. There has been a study but the Department of Health still does not have an action plan or an implementation plan.

Some work has been done on a plan, but it is inadequate. More work needs to be done in this regard.

Mr. Walsh spoke about an upcoming space, workshop or seminar within the Department of Health in respect of the action plan and where it stands. I would like to think that key stakeholders such as Travellers will be engaged in that process. When we gave our feedback on the initial draft, we said we felt it was inadequate. I do not want to keep repeating myself when I say that the Department of Health has responsibilities in this regard. There is evidence from various studies. We need more desegregated data. The Department needs to implement the findings of its studies.

Mr. Jim Walsh

I would take guidance on the mobile health units from the Traveller representatives. I think we have a really good model of Traveller-centred and Traveller-driven primary healthcare. I think we should put more resources into that area, rather than having mobile doctors. There can be a gap between where Travellers are and where doctors are. I think we should put the resources into primary care units and build up from the bottom. Other people would be better placed than me to comment further on this matter.

A question was asked about the Traveller task force. The key gap is the lack of a Traveller health action plan. We are working towards filling this massive gap. This is being driven by the HSE, which is in charge of health services. The Department of Health is a very small organisation. Almost €17 billion in resources are with the HSE. That is where the engine is. That is where all the resources are. That is where the personnel are. We need to see the action plan. We are frustrated that we have not seen it. When we see it, we want to be part of it. We want to bring it into the Department. We want to involve Travellers in the discussion on the policy issues. We want to ensure everyone is aware of the direction that is being taken. We need to ensure a clear awareness of Traveller issues is built into new policies when they are being pursued in the Department. That is part of our responsibility. We need to focus on the action plan because that is where the deliverables are. We are committed to being part of that structure. There is no point having a structure in the Department of Health when all the action is somewhere else. The action is in the HSE. We are happy to be part of that with Traveller organisations.

Ms Brigid Quirke

When we had a mobile clinic in the past, it was a very negative experience for Travellers. It led to their being isolated and segregated. It was like a segregated service. We believe that targeted mainstream services are needed in the interests of equality. The mobile clinics were a targeted service, but they were not a mainstream service. Concepts like the positive duty and the ethnic identifier need to be considered as part of a targeted primary healthcare project. At the same time, we need to work with mainstream services to make them more user-friendly for Travellers while ensuring there is monitoring and training. In the longer term, that is more sustainable than isolating Travellers, which would have been the experience in the past.

I am concerned that the issue of the budget has not been addressed in the Department. I appreciate that Mr. Walsh thinks primary healthcare projects are a great model. While we are delighted to hear that, we are conscious that such projects are dying on their feet, unfortunately, because they have had no investment. Perhaps we could get the base budget back. It is fine to speak about €10 million, but no new moneys are being made available. We have not had a budget. If Mr. Walsh thinks primary healthcare projects are good, he needs to ensure that there is investment in them. In the last ten years, we have lost at least 50% of our projects because they have closed. The women from east Limerick who are here today are not getting funding. They are trying to get something off the ground, but nobody is supporting them. The issue of the budget has to be addressed. The Department is responsible for policy. The HSE is responsible for implementation. Mr. Walsh and his colleagues in the Department have more clout than they are giving themselves credit for. If we want to make things happen, that is the way we have to go forward.

I think Ms Quirke is calling for leadership.

Ms Brigid Quirke

Absolutely.

A sum of €10 million might sound like a lot, but if it is not enough-----

Ms Brigid Quirke

It is very little.

-----it is not enough.

I thank everybody for coming to this meeting to make their contributions. I will not go over the old ground. The research has been done. The studies have been done. The findings are there. The witnesses have put their real-life experience on the public record for us all to hear. I think it is powerful. We should leverage and use it in a way that can move things on. I do not want to patronise anyone and I do not want to make any promises to anyone. We need to identify where the barriers and the blockages lie. We all have responsibilities. We are policymakers and legislators and the witnesses are stakeholders. From what I have gathered here today, a great deal of work has been done to establish the facts.

It is evident from the mortality rates for infants and elderly people in the Traveller community that there is a lack of action. The witnesses have also identified a lack of funding.

I will focus on the silo system in Irish public life, that is, the Department of Health versus other Departments. Mr. Walsh has said that the Department has certain responsibilities, but it cannot reach into other Departments. That is partly our problem. How can we cross-cut Departments in order for them to come together to provide a package that improves healthcare for the Traveller community? I would like the committee to focus on that issue and I ask the Chairman to note it for future meetings. We must tackle that silo mentality. Even in the Department of Health itself, there are silos within silos. We have identified a specific cohort of a community with unacceptable levels of mortality. Some provision is made in the general populace provision, the national drug strategy, or through care of the aged. This specific cohort needs specific attention and additional resources. The findings and studies are there, and we need a clear action plan to address them. I understand that the Department only has so much funding with which to work, but if there is a lack of funding, we need to specifically prioritise that funding and use it where it can have the greatest impact, whether that is addressing suicide among the Traveller community, drug abuse, care of the elderly, or resources. Let us make a start and provide the additional resources somewhere. I would be interested to hear from Ms Collins, who mentioned that she started lobbying for primary healthcare back in 1992. That project started out with 85 families, and is now up to nearly 400. Where is that initiative now? Has it been expanded? Is it nationwide or mainstream?

Ms Missie Collins

There are nine projects around the Dublin region, and more throughout the country. There is not one in Limerick, but there is in Galway.

It is ad hoc, then.

Ms Missie Collins

Yes.

That is my point. That is a successful project which Ms Collins initiated.

Ms Missie Collins

Yes. We were the role models. I was talking to this girl, who I only met for the first time today. One of my aims all along was to give support for a primary healthcare project where there was none. If I can ever help her, I will do the same thing.

That project has worked in some areas but is not available everywhere. Why are we not expanding the successful projects? That would be a start, even if it is just to send a message that we are trying to do something about this, rather than letting the thing roll on with the same budget and mortality rates every year. If that is not changing, we are doing something wrong.

Ms Missie Collins

We have not gotten a new budget or extra money for a long time.

That is my point.

Ms Missie Collins

I could be doing much more, and Pavee Point could also be doing more around mental health. It is unbelievable. Mental health cannot be tackled with fresh air. I do not want to be too cheeky here, but it cannot be done. The funding has to be there.

That is my point. There are silos in the system when the Estimates are being prepared for each Department. Mr. Walsh has to battle his corner. He is responsible for the Traveller community's health, as well as the national drugs strategy. There are pressures across the health system, as we all know. However, findings clearly show that mortality rates among this community are far higher than the general populace, and that needs an extraordinary response. Politicians need to step up, and the Department must prioritise this. Let us hear where we should make a start. Not everything can be funded, and I do not expect that on day one, but even if there was an incremental approach, starting next year, we could increase the funding for primary care for Travellers. That alone would send the message that we are making progress. However, if we do not get additional resources, we have a long way to go. Those are some of my observations from this morning, but the committee will also be coming back to more of this with our own recommendations on possible improvements.

Senator Coffey hit on the barriers, the silo and making a priority start on key areas for additional funding. What is there is clearly nowhere near enough to even make a start.

Ms Maria Joyce

I will make a couple of points on that. There have been significant cuts to the overall Traveller health budget since 2008, with the onset of the recession.

This meant that meant Travellers experienced a double impact in the specific cuts to the Traveller health budget and the overall cuts in the area. It is good to hear Mr. Walsh refer to the primary healthcare programmes but they have been significantly affected by cuts in recent years. Even though there were some areas under the regions where there was underspending in Traveller health budgets, cuts were still made to services, including Traveller primary healthcare programmes, as a cost-saving measure. As Traveller health budgets were not ring-fenced, they were sucked into the bigger black hole with regard to overall health budgets. One useful thing this committee could do would be to look at those budgets from the Department of Health to the HSE to determine how much is ring-fenced and how much is not spent on what is intended initially in respect of Traveller health.

There is an absolute need for targeted initiatives, not outside of the mainstream and not segregated provision. Primary healthcare is one model of that but there are other pieces of work that must be done. However, no new moneys are coming into Traveller health and that is where things get stuck. This is not just about money. While money is, of course, significant and important, that leadership which was referred to where we have a shift in positive policy is not there. We still have the ingrained negative policy superimposed here. The reality is that change is not coming as swiftly as needed.

Ireland should be ashamed of itself. I cannot put it strongly enough. Ireland should be ashamed that, notwithstanding the statistics that have been set out here today and included in all of the submissions, there is still no real action on the change needed to ensure we do not continue to have these same conversations in ten or 20 years' time and that our grandchildren and great grandchildren will not have to deal with the same kinds of health issues and shortened lifespans heard about across the board today. Ireland should be ashamed of itself when it comes to Traveller health. While the wider determinants are there, it is always something else that is the reason we cannot implement what we have. A number of Departments, whether it relates to accommodation, health or education, are not accepting responsibility for the fact that they need to put the resources in and implement the policies and strategies they have. They need to roll out concrete work, including on disaggregated data, to monitor effectively and ensure there are real outcomes for Travellers.

I have a quick follow-up question on the action plan. Am I right to say it is the HSE's responsibility to produce that? Mr. Walsh has mentioned it and is frustrated himself that it has yet to appear. Is there any timeframe for when we will see this action plan? What progress has been made on the plan to date?

Mr. Jim Walsh

The update we have from the HSE is that it will be ready by the end of the year. A draft was done but there was a change in personnel. The leader in the social inclusion office has just retired and there was a bit of a transition. The HSE will probably say more about that next week. The work is now being led by the chief officer of CHO 6. That senior person is now pulling the plan together with Traveller input and we hope to see it by the end of the year.

I agree completely on the silo system. I refer to the national Traveller and Roma inclusion strategy led by the Minister of State at the Department of Justice and Equality, Deputy Stanton. The strategy is important because it involves a whole-of-Government approach and brings all the actors together, including Departments and Travellers. Within that, we have over 30 actions, including actions to reduce the health inequalities experienced by Travellers and Roma. There is a very good plan of action there and we could get more traction on that, especially with regard to the social determinants of health. In the context of silos within silos, however, we need to be careful.

If we look at the €10 million - the pot of money we have - we can see that more than €17 billion is going into the health system, so Travellers' needs need to be prioritised across the system.

Something in my paper that I did not get a chance to talk about is the idea of proportionate univeralism. Mental health, which has €1 billion, is a very good example. They need to prioritise and I think they are doing so. That is where there are lot of resources. We can look at other examples across the system as well. The €10 million we have is focused on primary care, particularly initiatives with Travellers. That is really important and we need to grow it and reverse the cuts that took place. The action plan will provide a clear mandate as to what is required. The Department and the Minister are committed to giving leadership to implement and fund that plan. We need a roadmap. Then the Department can be challenged about what it is doing to support that.

Our committee is there to help with that leadership. I am anxious to hear from the three members who wish to ask questions.

I thank the witnesses for their presentations. It seems that one of the major problems is getting people to avail of services. One of the major challenges I see all the time is the bureaucratic barriers to accessing services. Applying for a medical card for anybody is a very difficult task because the amount of paperwork needed for even the simplest application is incredible, so think of the barrier for somebody who finds reading and writing difficult. We need to cut to the chase and say that there are significant barriers to accessing mainstream services and we need to simplify that. I listened with interest to what my Senator colleague said. I do not know whether it is as simple as ensuring everything is accessed through an ethnic identifier but something must happen to make access easier. I would be interested in hearing the witnesses' views on that.

Is there a committee within the Department that monitors the €10 million and do Travellers sit on that committee? The reason I ask this question is because, especially in times of financial pressure, people in organisations are geniuses at manipulating money. One concern I have is that some of that €10 million is being used as replacement money. It is being spent on Travellers but in a way that replaces money that should be have been spent on Travellers as members of society anyway. In other words, is it truly additional or did the Department, during the bad times, start using it to replace other moneys and services, counting it as Traveller services because a Traveller availed of a mainstream service he or she should have received anyway? I have seen this happen. There is need for close monitoring of that.

If the witnesses from the Department think I am being suspicious, I have seen a lot of things happen in times of pressure. The argument will be made. I will give a concrete example. I introduced CLÁR, which was a scheme for very specific geographic areas. The next thing that happened was that all sorts of services, including hospitals, that were way outside these areas were telling me that they provided services to the people within the areas and were asking for some of that money. Therefore, we need a monitoring committee that would include the people receiving the service to make sure the €10 million is really an extra €10 million on top of the normal services all of us as citizens are invited to avail of. I would be interested in finding out what structures have been put place by the Department to monitor that spend. I trust everybody and I trust nobody. I think everybody needs to be monitored. Will the witnesses give us the 2008 budget compared with what is available - the €10 million mentioned here?

There is another issue that I am concerned about. In one way, I laud that they are trying to help the Travellers at 40 because they are aged ten years beyond a person of 50 in the settled community but a more fundamental issue that we must keep coming back to is, why are they ten years older at 40 than the settled population at 50. It comes back to what all the statistics tell us. All the statistics show that people who are unemployed, in bad housing, etc. go to doctors more, go to hospitals more, get ill more often and die much younger, and that most of our health outcomes as a society are not a reflection on the health service in the first place. The biggest determinant of outcomes is not the health service in the first place. Many in the so-called middle classes go to the doctor less, take less medicine and live much longer. The reason is a thing called "lifestyle". What determines lifestyle? One hundred and fifty years ago, the biggest killers were water-borne diseases. Thankfully, we eliminated those more or less in the western world. That is lifestyle rather than pure medicine. We are still bad at housing. We are still bad at unemployment. There is good data in the Department of Employment Affairs and Social Protection on the effect of unemployment.

I am anxious to hear from the other two.

Point taken. I have a question. For example, we know that cigarette smoking is more prevalent among those who are unemployed for the obvious reason they have nothing to do all day. Has any study been done as to whether Travellers with good education, good housing and jobs live as long as the settled? In that way, we can measure the forced lifestyle situation and its effect on people's health. I think one would find shocking the effect of housing, unemployment and all those lifestyle issues, including non-engagement in sport. Travellers do not engage in sport because they are not invited to engage in sport.

There are many issues. We need to deal with the immediate health issues - that is what we are here for today - but we can never leave the spectre in the room out of this particular debate, that lifestyle is having a significant effect. Unless we co-ordinate all these matters, we will deal only with the symptoms, not with the underlying cause of all this.

Who would like to respond to those points?

Ms Kathleen Sherlock

Deputy Ó Cuív is spot on. We all agree with that. We know that we cannot separate the living conditions from opportunities. There are the living conditions, the social exclusion and the lack of employment. These all impact upon health. We all know we cannot separate that.

At present, to answer Deputy Ó Cuív's question on the study, it is too soon yet to be able to do a study because the vast majority of Travellers who are getting educated now were getting educated and having opportunities within the past 20 years. I grew up with three grandparents. We all know many children who are growing up without any grandparent at all, and some of them are growing up without a father.

I want to come back a little, if I can, to mental health and addiction. Much of the time, we talk about addiction and suicide as if it is something that is endemic within the Traveller community. The reality is these are new phenomena. They are environmental factors. Travellers are not becoming addicted or having health issues for the most part because they are predisposed to that. They are managing situations or unable to manage situations. When we look at how to address it, I must come at it from where we are when we are meeting Travellers. My friends here are better at the statistics on it than I am.

We are meeting Travellers who are crying out for help, perhaps for someone in their family who has a mental health issue and is threatening suicide. When they look for help or support it is not there. Therefore, one thing we have recommended is a national mental health strategy. We must look at delivering very quickly on an action plan or plans which reduce Traveller deaths. I do not know how many Travellers have died since we first looked for a national action plan on Traveller health. I am not sure how many Travellers will die before we get an action plan. The people we are losing are not statistics; they are our fathers, mothers, brothers, sisters, cousins and children, and this has an impact.

We need a national strategy that will deliver services when Travellers are crying out looking for supports around mental health. We know of families who have looked for supports and found they were not there because it was out of hours, and the family member died within a few hours or days. If a Traveller presents in a suicidal situation, he or she needs to be fast-tracked. We cannot leave them out until the services are available next week; it must be dealt with immediately as an emergency service.

I will call Ms Maria Joyce, Ms Brigid Quirke and Mr. Walsh before we take more questions.

Ms Maria Joyce

We really welcome the examination of the budgets, including what is there and what is new. Interpretations of how money is being used is also important. We would also welcome a Traveller role in that, which is important from the perspective of the recipients. A holistic approach involving all the key determinants is obviously very important. One does not stand alone from the others. Mr. Walsh made a comment as he concluded. It is not just a case of emphasising the Department of Health's approach to this but that of other Departments too. If everyone was doing what they ought to be then the Department of Health can do what is needed.

But then if they do not -----

Ms Maria Joyce

The problem with that is that it is always someone else's responsibility. The Department of Health has responsibilities here and it has resources. It is not only about what the HSE should be doing on this and us handing over to it; there are responsibilities. Health is not a tiny Department. It is important to acknowledge that it has responsibilities. This was a point made by Ms Sherlock.

We must also be careful that we are not blaming Travellers for the state of their health. I am not saying that is what Deputy Ó Cuív is doing but it is really important that we do not do this. Yes, there are problems with substance abuse, but that does not define who Travellers are. There is an effort to tackle those issues and deal with them where they impact particularly, such as among younger sections of the population. We have struggled with getting the recognition of Traveller ethnicity and its impact on identity. There is the question of Travellers having to hide who they are when seeking employment. These are all factors. We need to bring this back to the specific responsibilities of the Department sitting before the committee today and how those responsibilities are not being met, based on its own policies, strategies and recommendations. These are not being adequately resourced or matters are being funnelled one way instead of a holistic approach to the remit being taken.

I hear what the Deputy has said to a degree around comparing Travellers who are educated and those who are not but we need to be very careful around the thinking.

Sorry, if I may just explain. People love collecting statistics. I do not think that a study is necessary. I would bet any amount of money on the following.

My bet is that if one creates the same circumstances in housing, education, jobs, access to recreation, non-discrimination and so on, the lifestyle would be the same. That is, there is nothing inherent among Travellers that creates a shorter lifespan except that which is imposed. I wish to make it absolutely clear: the housing is imposed.

I think the Deputy has made his point very well and clearly and it is an important one.

I do not want anyone to have any misunderstanding about what I am saying.

I wish to bring in Ms Quirke. I am anxious to bring in two other members who have not asked questions.

Ms Brigid Quirke

The data was all compared with Survey on Lifestyle and Attitude to Nutrition, SLÁN, data, so it picked the most marginalised in the State, namely, people with medical cards or in receipt of GMS services. We did not compare Traveller data with the whole national level data but with the population in receipt of GMS services. It still shows that Travellers are well below the level of even the poorest in society.

This is important. Let us frame it slightly differently. If Travellers are compared with the rest of people in receipt of GMS services, which is what was done, and then a comparison is done on housing, education and so on, it would probably be found that that also matched.

Ms Brigid Quirke

Sorry, that was only one point. I welcome Deputy Ó Cuív's point about more monitoring around the budget. Looking back historically, as Ms Collins has done, the Traveller health advisory committee had a role overseeing the Traveller budget. There was a structure. We monitored the Traveller budget, there was accountability, and we could call the health boards to come before us to explain what had been spent and how they had spent their money. Since that committee was disbanded, we have had no input into the Traveller health budget. That is why we want to bring back the structure.

Senator Coffey has gone but I wish to clarify a couple of things. Ms Collins spoke on the Traveller primary healthcare project. A Traveller heath strategy between 2000 and 2005 was produced by the Traveller health advisory committee. Primary healthcare was seen as an excellent model and was piloted by Pavee Point. That was regarded as a cornerstone which would be rolled out. They rolled out 40 primary healthcare projects, there were eight Traveller health units, a Traveller health advisory committee and we had a Traveller health strategy. We were in a very good place, things were very positive and Travellers were included at all levels. We were told that there were no clear targets in the strategy because we had no data, so we lobbied to be able to collect the data. We were promised that after the data had been produced, we would get a new Traveller health strategy with clear actions from the Department of Health and a defined and protected budget. A study was done in 2010. As Mr. Walsh said, the Department co-funded it with the HSE and the Department of Health in the North, as it was an all-Ireland body.

That was nine years ago.

Ms Brigid Quirke

Yes, we got the funding to do it in 2007, but it took from the 2002 strategy to 2007 to get the study done. People did engage and there was great buy-in to the study because, as Ms Collins said, we explained that once we had the data, we would get a clear strategy and deal with Traveller health issues. When we got it, it was put on a shelf. Now the push is for the action plan. The Department was committed to producing a Traveller health strategy but it has not done so. It is wrong to suggest that it is waiting for the action plan. The only reason we are getting an action plan is the national Traveller and Roma inclusion strategy, which is a European initiative, not a national initiative. Europe told Ireland it must produce a strategy for Travellers and Roma, and within that we got the action plan. There is still an issue with commitment.

This is a good moment to bring in Mr. Walsh to respond to the points.

Mr. Jim Walsh

There are many good points there on barriers to access of services. I completely accept that. This is why the primary healthcare projects are so good. They try to get over those barriers to identify and address those. The €10 million budget was raised. To be clear, that budget lies with the HSE. That is the difference when people mention the Traveller health advisory committee, THAC. There was a budget there and that is now with the HSE, which has oversight of it.

Does anyone have oversight of the HSE's oversight of the budget? Are there Travellers on a committee within the HSE overseeing the budget? If not, we know the games that go on.

The HSE will come to the next module, so that would be a good question to put to it.

Mr. Jim Walsh

I support the call for better and clearer monitoring and clearer reporting of the budget and how well we are using it.

That is a very fair issue.

The Deputy made the point about social issues of health and lifestyle. One of the points I had made earlier was that Healthy Ireland is very important because it is trying to make initiatives to address some of the lifestyle issues and to develop and fund projects that encourage Travellers to be involved in sports activities and other physical and social activities to address some of those lifestyle issues. We can push that with the Department of Health but other Departments are also involved.

To be fair, given that the crisis in health is so great and so fundamental, talking about things such as the Healthy Ireland type initiatives is like talking to people with cancer about getting fit. It is useful but it is not really where we are at. I do not think we should be talking about health in that way.

I apologise that I had to step out and I am sorry if I cover ground that has already been covered. There are substance abuse issues across all of our marginalised groups and minority groups. Decriminalising that space will go a very long way in helping us to engage openly and honestly about those issues without fear.

Some of the witnesses have called for ethnic identifiers. It is something I have also looked at to measure LGBT homelessness and LGBT youth homelessness. Given the discrimination that exists in our society and in the structures of the State, are the witnesses confident that ethnic identifiers are the best policy in measuring good data?

Ms Brigid Quirke

We were involved in piloting the ethnic identifier. It is a good question. Other countries in Europe have had State-imposed ethnic identifiers, but in our case it was Traveller groups lobbying the State to get an ethnic identifier. We need to be very clear that there needs to be good practice and codes of practice developed, and proper training. We have been doing work with different Departments; we have it in the national drug treatment service and in some of the hospitals. We go in and train people and a code of practice is developed. When we piloted the first question in Tallaght hospital people felt that nobody would engage but once we explained to Travellers that it is for their benefit and that the data are disaggregated and de-identified - and therefore anonymised - and once we explain that it is really to monitor where exactly the blocks are in access, participation and outcomes for services, we actually and surprisingly had 100% response. It was important. In the past people have asked Traveller-specific questions, which is much more likely to discriminate. If, however, one asks the question in the context of everybody having to identify their ethnicity - and it is important that it comes with a code of practice and clear guidelines on how it is used to inform policy - the data can be disaggregated and given back to front-line workers to encourage people. It is a bit like how the information is used in the census and how we now know how many are going to school and taking part in education, and Travellers can see the benefit of that. Women in east Limerick found that there were more than 100% of the Travellers there that they knew of, which meant that the need for public services was being underestimated. Initially in 2006 the census said there were 24,000. In the study we found 40,000. If one wants to plan appropriate service then the data are needed, once it is filled in with the correct protections and codes of practice.

That is a good way of doing an ethnic identifier.

Ms Brigid Quirke

Absolutely. Part of it is positivity duty.

Ms Maria Joyce

On the ethnic identifier, it is important that it is operated under a human rights framework. It is not about targeting people or creating situations. It is about getting the data needed to ensure the responses that are put in place, or that those that are needed are monitored. The human rights framework is very important.

Senator Warfield asked about decriminalisation. Ireland has an issue with substance abuse for some sectors of the community, especially where there are fewer opportunities and outcomes for education and employment, as young Travellers have in Ireland. We know that more than 80% of Travellers are unemployed, and we also know there is huge inequality in attainment and access to participation in and outcomes from education. Where those opportunities are not available then these will be issues for young people.

Protecting the people is central to this, where they are impacted upon by those abuses, not anyone else within that.

The important thing is the human rights protection framework for the use of ethnic identifiers, and it is important in making sure there is a proper recognition of the numbers of people who have identified as Travellers because there can be an underestimation.

Mr. Jim Walsh will speak next and then Deputy Collins, who is very patient.

Mr. Jim Walsh

Drugs policy is another part of my remit so I fully take the Senator's point that we need to have a health-led approach to the possession of drugs. More of a focus from the health point of view would address some of the stigma issues that we spoke of earlier. The Ministers, Deputies Harris and Flanagan, along with Minister of State, Deputy Catherine Byrne, have announced a health diversion programme, which the Department is now preparing to roll out, where people caught in possession of drugs will be referred to the health services and taken out of the criminal justice system.

To clarify that, this would happen just once, where a person is caught once.

Mr. Jim Walsh

The Senator has a big interest in that measure, and I fully acknowledge that point.

Many of us around the table have a big interest in that, but particularly Senator Ruane.

I will be very brief. I have an observation. I have never seen a section of society that has been the subject of so many studies, strategies and recommendations than Travellers, and they are still in a situation where the Traveller community is now at a huge crisis point in their health. My question for Jim is in the context of the committee's recommendations. Are Traveller communities saying that the Traveller health advisory committee should be re-established?

The €10 million is for Traveller health specifically. Will the money for the Traveller health action plan come from a separate source or is part of the €10 million to be used?

On the implementation body, from listening to any speaker representing their community from the Traveller community I always get the message that it should be "nothing about us without us". They have to be included. I made this point last week also. Perhaps Mr. Walsh could take this message on board with regard to whatever plans are implemented and the Traveller community being represented. Community representatives are not asking, they are demanding, that this be addressed. This is why I have been so impressed with Missie. All of the witnesses here today have been involved with their communities but she has been pushing on Traveller health for so long. That is not to disrespect anybody else who has spoken here today.

When we asked a representative from the HSE last week about the ethnic identifier we were told that it would be a long process and the HSE is working with its European counterparts. This is another area we will have to look at. Brigid said there are examples out there and a scheme-----

That was with regard to the coroner and deaths rather than the ethnic identifiers.

Yes. I will leave it at that.

Ms Maria Joyce

An implementation body is needed to drive the overall Traveller health budget. It needs to have teeth, with oversight and ring-fencing of budgets so it can deliver. A structure is needed but it will need to actually deliver on the implementation, with the teeth to be able to do that.

That is something the representatives would like the committee to recommend.

Ms Maria Joyce

Yes.

Mr. Jim Walsh

On the issue of funding, I presume that with the action plan will come a requirement for more resources. We do need more resources. I imagine that will be the next stage and that is where the Department of Health will show leadership. We would then have to go back for those resources to fund the action plan. It will have to be-----

Will that be on top of the €10 million?

Mr. Jim Walsh

Yes. It would either be on top of the €10 million or we would need to look at where the resources are being spent across the Department in other policy areas to see if we can ensure resources within the main health budgets are being targeted at Traveller health initiative resources across other budgets, which goes back to the idea of proportional universalism.

Are resources across other budgets being targeted? To me, €10 million is a specific budget, but we also need to be looking at the bigger picture. We definitely need more resources. I fully accept that. The involvement of Travellers is a fundamental principle.

It goes beyond involvement. People are talking about more than that.

Mr. Jim Walsh

Yes. We could also say participation.

We could also say control and direction.

Mr. Jim Walsh

Yes. One of the first decisions I made when I took on the job last year related to our advisory group, a standing sub-committee, on drugs strategy. We included a Traveller representative in that structure because there had not been one before. It is a big issue. We asked a representative, who said they would definitely like to be involved. Where opportunity arises, Traveller representatives should be involved. Driving on the action plan will be very important. We need a structure in that regard. The Department of Health is happy to be part of that structure, which will ensure that the objectives and actions in the strategy, and the resources being applied to the action plan, are actually delivered. We are very committed to being part of that.

Ms Missie Collins

Can I haul Mr. Walsh on that? That did not happen in respect of the all-Ireland Traveller health study, which cost a lot of money. Actions arising from that study should have been implemented. If I am alive for it, I want to see a better future for my grandchildren and great-grandchildren arising from this action plan. What is on that piece of paper, and I will only call it a piece of paper, has to be done for Travellers' health. Our people are dying at very young ages every day of the week. There are crises with regard to our children and mental health.

I will ask some very specific questions. Mr. Walsh said he hopes to get the plan by Christmas. A question ran through my mind: which Christmas? When large bodies such as the HSE set out to draw up a plan, they go around all the different sections. The slowest section holds up the other 99%. Will Mr. Walsh ensure that whatever is drawn up by 23 December will be given to the Department? If necessary, will the Department release the plan with blank pages, explaining that it is because some sections did not come up with their plans? Will it go ahead with the rest, shaming the sections in question to get it done quickly? In other sectors, I have seen years spent trying to get plans together and further years spent trying to get them implemented. It is better to have a plan, even if it is not 100% complete on the first day, and to start implementing it immediately. There can then be an improved second plan. We can call this the first interim action plan. Can we get this on the desk by 1 January 2020? We need it urgently.

Mr. Jim Walsh

We are frustrated. We want the plan. Perhaps when the HSE is before the committee members can ask about it more specifically. We have been told it will be ready in the fourth quarter. That quarter has already started, so from our point of view the clock is ticking and we want to get the plan so we can move forward with regard to actions and resources. Perhaps the committee can ask the HSE about this in a few weeks. Like I have said, we want to be part of driving and implementing the plan. It is an action in the National Traveller and Roma Inclusion Strategy 2017-2021. We included this action. It was not imposed by Europe. The Department of Health and the HSE included that action in the strategy because it is our responsibility to address Traveller health issues as a priority. The plan is there. It is our responsibility to deliver on it.

Ms Maria Joyce

It was actually Traveller organisations that lobbied for the inclusion of health as a key piece in the national Traveller and Roma inclusion strategy because of the failed implementation of the previous strategy. We lobbied for an implementation plan in one shape or another to be included in that strategy. The Travellers who participated in the process lobbied incredibly hard for that. The European dimension of the national Traveller and Roma inclusion strategy has brought a bit more pressure to bear so that there is at least a draft on the table. There is a long way to go in this regard but it is misleading to say that this is not the context in which it is happening.

Ms Joyce has made her clarification.

Ms Brigid Quirke

People were asking about the differential in regard to mortality. I have a rough estimate. When we did the study we found there were 134 excess deaths, which means 134 more than would be expected if people had the same standard of living as the general population. That is 134 years so over approximately nine years that would be 1,200 excess deaths among Travellers because nothing has happened. The gap is widening, so that is likely to be an underestimation.

That relates to a lifestyle that is mainly induced or living conditions that are imposed.

Ms Brigid Quirke

Yes, it is the number over and above what would be expected if they had the same standard of living as the rest of the population.

Ms Kathleen Sherlock

We have seen a spike in deaths among Travellers this year. We know of 30 Travellers who died through suicide. We have no idea how many people have died as a result of addiction. A significant number of young Traveller women have died as a result of cancer. We are talking about women in their 40s. We do not have figures that reflect the number of Travellers who are dying. I do not think anyone has the exact figures, but it is probably even higher than we think.

That is why we will be returning to this topic on 5 November. We will have the HSE in and will be asking some hard questions of it. I will ask the committee members if we can invite a Traveller health co-ordinator, Ms Deirdre O'Reilly, whose submission arrived late, to participate. I presume that is okay.

It is impossible to sum up this issue. It is about people's lives, including those of our witnesses' families and loved ones. There is a sense that the crisis in health, including mental health, has been captured but largely ignored. Mr. Thomas McCann mentioned a sense of difference. An inadequate response was mentioned, as were inertia, inaction and a need for implementation to be evidenced. I was shocked to hear that there are underspends in the area of Traveller health in addition to the underspends in Traveller accommodation. I was not aware of that, but it seems to reflect a wider lack of urgency. Where we need an extraordinary response, as Senator Coffey said, we are getting an inert response. The word "shame" was used. I certainly share that sentiment. We will return to this topic again. Ms Collins said that the Minister for Health made her some promises in respect of the re-establishment of structures. We will look at that in our report. There needs to be real and meaningful structures in the Department of Health, but also in the HSE because that is where the money is. Questions need to be answered about the adequacy of the budget and about where the budget goes. Perhaps additional resources are needed for targeted initiatives. Tackling social determinants will solve health issues in the long run but we have a crisis here and now and it needs to be addressed.

I will bring today's meeting to a close. I thank committee members, the people who are watching from outside, those in the Gallery, and, above all, those who yet again shared painful stories and the officials for being here throughout the proceedings. On behalf of the committee, I thank them all very much.

The joint committee adjourned at 1.05 p.m. until 11 a.m. on Tuesday, 5 November 2019.