Commencement Matters

Free Travel Scheme Eligibility

I was recently contacted by a lady who is receiving treatment for cancer. She applied for disability allowance in April this year but was told she is not likely to receive a decision on her application until mid-July.

In the interim, she has been travelling to and from Dublin every day from Westmeath to receive treatment. She does not have her own transport and there is no alternative for her to get to Dublin from where she lives but to take public transport. Every day, she and a companion, who travels with her to support her, take the bus to Dublin and back in order that she can receive radium treatment. The cost of this travel is almost €40 per day. A cancer diagnosis does not mean everything else suddenly stops. Bills still need to be paid and food put on the table. Life has to go on, but for already stretched families an extra travel bill of €40 per day is often too much to bear.

If this lady's application for disability allowance is approved, and we expect it will be given her circumstances, she would be eligible for free travel and would not have to incur these costs. However, as I understand it, it is not possible to claim back travel costs already incurred once disability allowance is finally granted. This means people who are extremely ill and would ordinarily be entitled to this benefit are incurring very high costs for transport due to the long processing delays in the Department.

On a separate issue related to delays, I have also been contacted by a lady who has applied for carer's allowance but must wait 18 weeks before her application will be reviewed. These long waiting times are simply inexcusable and unacceptable and something must be done to address them.

Specifically in the case of those who have been diagnosed with life-threatening illnesses, such as cancer, and who are receiving regular treatment that requires travel over long distances, it would be appropriate to automatically grant them free travel from day one. This would relieve the extraordinary financial stress that some find themselves under at a time when they are already extremely vulnerable and need all of the support they can get. Lest we forget, these people are fighting illness and we should do all we can to help them.

I understand that disability allowance, or any other benefit, cannot simply be handed out without a proper assessment as to entitlement, but where we know that somebody has a serious and potentially terminal illness and has to travel for treatment, free public transport should be offered from the outset and without any further review.

It is likely that a large number of people will make their own transport arrangements and not need to take public transport. This measure should make a huge difference to those who need public transport and its introduction would be reasonable and justifiable. Most importantly, it would be the caring and compassionate thing to do for those affected. Therefore, I ask the Minister to consider amending the system to make this benefit available in circumstances such as those I have outlined.

I thank the Senator for tabling this Commencement matter, to which I am responding on behalf of the Minister for Employment Affairs and Social Protection, Deputy Regina Doherty, who apologises for being unable to come to the Chamber.

The Department of Employment Affairs and Social Protection provides a free travel scheme as a secondary benefit for older people and certain people with disabilities who are customers of the Department. The scheme provides free travel on the main public and private transport services for people who are eligible under it. There are approximately 914,000 customers in receipt of free travel. A person who regularly travels significant distances for hospital treatment for the illnesses described by the Senator will already have this entitlement if he or she is in receipt of invalidity pension or disability allowance. Therefore, any extension would have to involve others who have no such entitlement.

The objective of the free travel scheme is to ensure older people and people with disabilities remain active within their communities. Any extension of eligibility under the scheme to include people who are not customers of the Department would change this objective and radically alter the nature of the scheme. Any such scheme would require a more significant operation than that which administers the Department’s free travel scheme because, potentially, it would have to grant and withdraw a significant number of passes each year from people who are not customers of the Department. It would have to do this using information which would ultimately be provided by doctors or hospitals. All free travel passes issued by the Department entitle the holder to unlimited free travel on the main public and private transport services. The Department would have no way of limiting the use of the pass to ensure it was being used for travelling to and from hospitals for treatment only.

Any increase in eligibility under the scheme would require a substantial increase in the level of funding provided, which currently stands at €90 million per annum. The social welfare payments that allow people under the age of 66 years to receive free travel passes include disability allowance, invalidity pension, carer's allowance and partial capacity benefit. Disability allowance and invalidity pension are long-term illness payments, for which people who are receiving hospital treatment may qualify. Therefore, persons in receipt of such payments are already eligible for free travel.

Under the supplementary welfare allowance scheme, the Department may award a travel supplement if it is warranted by the circumstances of a case. The supplement is intended to assist with ongoing or recurring travel costs that cannot be met from the client's own resources and are deemed to be necessary. Individuals who must travel significant distances to and from hospital for treatment may apply for a travel supplement. Each decision is based on consideration of the circumstances of the case, taking account of the nature and extent of the needs and resources of the person concerned. Therefore, the Minister is not in a position to extend the free travel scheme in the manner proposed by the Senator.

I note the response given by Minister of State who is representing the Minister, Deputy Regina Doherty, but I am not overly impressed by or happy with it. Applications are in the process of being dealt with in many cases, including the case I have highlighted. That is the point I am trying to make. If it was not taking such an inordinately long time to deal with the applications, I would not be here and the lady I have mentioned would not have the problems she has. I am talking about what should happen in the interim when a live application is in process, especially where medical evidence demonstrates that the applicant needs treatment in a location to which he or she must make a long journey. The Minister of State overlooked that aspect of the matter in her response. Although the people to whom I refer are not existing customers of the Department, it is most likely that they will become customers. As I said, the expenses they incur while waiting cannot be reimbursed. I think the Minister of State missed that angle of my presentation. It is likely that the people to whom I refer, whose live applications are in the process of being dealt with, will eventually become customers. In the meantime, they are spending money they do not have. Perhaps that money might be refunded to them when the Department gets around to processing their applications. They should be reimbursed for the money they have spent, or their applications for free travel should be fast-tracked.

I have taken note of the Senator's concerns and will bring them back to the Minister of State, Deputy Jim Daly. I remind the Senator that I mentioned in my initial response that a supplementary travel benefit can be made available to people who find themselves under considerable stress because of the circumstances of their illness. Perhaps it might be possible for the Senator to look into that matter on behalf of the lady in question who may be able to avail of the supplementary travel allowance while she is waiting to hear back on her application for disability allowance.

Diaspora Issues

I welcome the Minister of State, Deputy John Paul Phelan.

Cuirim fearadh na fáilte roimh an Aire Stáit. Gabhaim buíochas leis as ucht a chuid ama a thabhairt don cheist thábhachtach seo. The Minister of State is very welcome.

This straightforward Commencement matter does exactly what it says on the tin. I am looking for an update on the Government's plans for the proposed referendum to extend the franchise in presidential elections to citizens living outside the State, including the North. We hope a referendum on presidential voting rights will take place in 2019. It is important to note the work of Senator Billy Lawless on behalf of the diaspora community. There is growing consensus on the issue among people across a broad shade of political and civic nationalism in the Six Counties. I know that they have raised it directly during their engagements with the Taoiseach and his Government colleagues. The issue which is important in its own right has been highlighted particularly in the context of the jeopardy that hangs over us as citizens in the context of Brexit. I hope the Minister of State will be able to provide us with an update and appreciate his time.

I thank the Senator for raising this issue which has been part of many discussions I have had in the Department in the past 12 months. It has been and will be more prominent in the next 12 months. Like a number of Members of both Houses, the Senator has been a strong advocate for extending the franchise in presidential elections to citizens resident outside the State. The Government decided on 7 March 2017 to accept in principle the main recommendation in the fifth report of the Constitutional Convention that citizens resident outside the State, including Northern Ireland, should have the right to vote in presidential elections and that a referendum should be held to amend the Constitution to give effect to that decision. When it was announced by the former Taoiseach in Philadelphia on 12 March 2017, it received a generally positive response from Irish citizens at home and abroad.

Following the announcement, an options paper which had been jointly prepared by the Departments of Housing, Planning and Local Government and Foreign Affairs and Trade, was published on 22 March 2017 to inform public debate on this significant policy change. The paper provided a focus for discussions at a dedicated session on voting rights held at the second Global Irish Civic Forum on 5 May 2017. The forum was attended by a wide range of representatives of Irish organisations abroad, including groups that had been campaigning actively on the issue for a number of years. Senator Billy Lawless has been mentioned in that context. The participants in the forum welcomed the opportunity to have their say and emphasised the positive role the Irish abroad would play in achieving progress on the issue. I understand those present at the forum seemed to have a broad understanding of the importance of due consideration and preparation being given to the option to be chosen and the wording of any amendment to the Constitution to be put to the people in a referendum.

There was also a broad acceptance that the legislative and administrative change involved means it will not be possible to have voting from outside the State in place before a presidential election later this year even if a referendum was immediately held and passed .

There was also broad acceptance that the legislative and administrative change involved means that it will not be possible to have voting from outside the State in place before any presidential election later this year even if a referendum is held immediately and passed.

At the forum, the almost unanimous view of participants in regard to which citizens should have the right to vote at presidential elections was that the franchise should be extended to all citizens resident outside the State. There was also broad agreement that the extension of the franchise should not be limited to those who have left Ireland in recent years or within a certain time limit. There was a recognition among those in attendance that introducing a requirement to hold a valid Irish passport would be a reasonable criterion for eligibility. In light of the views expressed at the forum, my Department and the Department of Foreign Affairs and Trade are working methodically and carefully through some of the details that could arise in respect of the various options with a view to bringing a report to Government that will assist in identifying a preferred option to be put to the people in a referendum. Preliminary work has also commenced within the Department on the modernisation of the voter registration process, which will facilitate those eligible to vote to exercise their franchise from outside the State should a referendum be passed by the people in due course.

As the Senator may recall, the Government announced on 26 September 2017 that it has agreed indicative dates for the holding of referendums in 2018 and 2019, subject to the timely passage of constitutional amendment Bills by each House of the Oireachtas. It is intended to hold the proposed referendum on extending the franchise at presidential elections to Irish citizens resident outside the State on the date of the local and European elections in late May 2019. Against that background, my Department will, in consultation with the Department of Foreign Affairs and Trade, bring forward an appropriate constitutional amendment Bill on extending the franchise at presidential elections to Irish citizens resident outside the State in good time for the holding of the proposed referendum next year.

I thank the Minister of State. He will not be surprised to hear that I believe his final two paragraphs are key-----

They usually are.

Indeed they are. The detail therein is very important. The Minister of State is correct to acknowledge Senator Lawless and his work with various organisations on the matter. I also have majored on this issue since I was elected to the Seanad. Our experience and that of the Minister of State is that there is a willingness to work collaboratively and try to ensure this is done speedily and correctly. Many contributions on the matter have referenced the work being done by officials and I wish them well in those endeavours because we need to get this right. As we come to the stage where we hope to bring the legislation to the Houses, it is important to have a last round of engagement with the civic and representative organisations in regard to people in the North and the diaspora. I hope that Senator Lawless and I will have the opportunity to discuss the matter with the Minister of State and his officials over the summer recess or shortly thereafter.

I have no problem taking the Senator up on that offer. This issue has rumbled on for several years and there have been many meetings on it. I met the Minister of State, Deputy Cannon, last week on the matter. This Commencement Matter is very timely and there is a general acceptance of the need for change. In the considerations prior to and at the forum, the possibility of a time limit such that citizens would have the right to vote if they had lived in the State within the previous five years or similar was raised but it was decided that that was too messy and that it would be difficult to agree upon a timeframe. Irish citizens with an Irish passport should be allowed to vote. There are other complicating factors. I have met with several groups, in particular in London and elsewhere in the United Kingdom, over the past few years. There is also the issue of where voting centres will be held. In many countries, they are held in consulates or embassies but postal voting is also a possibility. Much work has yet to be completed. The Minister of State, Deputy Cannon, and I will meet with any Member of this House, including Senator Ó Donnghaile, on this issue because the Government intends for the matter to go to a referendum of the people next year.

I thank the Cathaoirleach for allowing me to bring forward this Commencement Matter. I thank the Minister of State for her attendance. I know the Minister, Deputy Harris, is also quite interested in this subject. I raise the national roll-out of a free contraceptive scheme. Ready access to effective contraceptive care is a key part of good reproductive and sexual health for many citizens. Known barriers to effective access to contraceptive care currently contribute to the levels of unplanned and crisis pregnancies. These barriers include cost, particularly for women who are just above the threshold for primary care reimbursement service, PCRS, eligibility, younger women and adolescents. The latter group includes adolescents who may be eligible for services under the medical card scheme but who, for reasons of cost of attendance, confidentiality, particularly when they are on a family medical card, or ignorance - they may be unaware that they are eligible under a medical card scheme or can discuss the matter with their GP, practice nurse or pharmacist - are currently apprehensive about attending a general practitioner, GP, or family planning clinic. There is strong evidence that young people positively view GPs as reliable sources of health-related information but there are also deterrents to their accessing necessary advice and essential services.

The Government should cost and closely consider an improved and integrated primary care contraceptive scheme to provide better access to this key service which is highly relevant in reducing rates of abortion, the risk of unplanned pregnancies, the transmission of STIs and related anxiety among many women and some men of reproductive age in many Irish communities. There should be funding for an integrated primary care contraceptive scheme to increase the capacity of the primary care sector to deliver this essential service. An educational component to ensure that those who would benefit from an improvement in these services are aware and knowledgeable about when and how to access the services is also required. Such scheme would bring us into line with many European Union countries where such such services are largely free at the point of delivery to most EU citizens. It would also be consistent with long-standing Government policy on extending many free primary care services to many of our citizens. Reducing the number of abortions by means of an enhanced and expanded contraceptive scheme is particularly attractive at a time when medical abortions will become available through a process of constitutional change.

Schemes in regard to medical contraception and education should be considered. There are several problems relating to the knowledge and understanding of the population in terms of how and when to access and use these services. As part of the maternity scheme, participating GPs should be required to confirm that they have consulted with expectant mothers in regard to post-partum contraception. Adolescents should be advised that they are eligible to consult with their local pharmacist, practice nurse or GP for relevant services.

As part of an integrated primary care contraceptive scheme, we should provide a related message service for secondary schools, as well as public health messages. The latter should include information on how to access relevant services, as well as clear messages that highlight high risk sexual behaviour, similar to the effective campaigns run by the Road Safety Authority. This aspect of the initiative would build on experience already gained, but it would be more powerful and sustained than previous campaigns on the topic.

At a community level, pharmacists, practice nurses and GPs who are interested should be enabled, encouraged and modestly supported to engage with local secondary schools. I also suggest school boards of management periodically invite interested practitioners to outline the services available and answer questions and inquiries made by students and school staff on relevant aspects of sexual health. Healthcare professionals who are assisting on this aspect of an integrated primary care contraceptive scheme could be engaged, supported and have their activities co-ordinated through high level agreements with their postgraduate training bodies and representative organisations.

Overall, an integrated primary care contraceptive scheme would be very welcome. As I said, we should take on board what the people demonstrated in passing the referendum. Of course, there will be crisis and unplanned pregnancies. We should provide support and consider introducing a scheme that will assist all of the people.

On behalf of the Minister for Health, Deputy Simon Harris, I thank the Senator for raising this matter in the Seanad. The Minister is unavoidably absent as he in the Dáil Chamber dealing with Priority Questions and asked me to come in his place.

The cost of contraception has often been cited as a factor in unintended pregnancies. The Oireachtas Joint Committee on the Eighth Amendment of the Constitution recommended the following: "the introduction of a scheme for the provision of the most effective method of contraception, free of charge and having regard to personal circumstances, to all people who wish to avail of them within the State". There are insufficient data for the significance of the cost of the use of contraception. We know from the Irish contraception and crisis pregnancy study 2010 that other important issues, besides cost, influence access and decisions on contraception. Almost half of the women surveyed for the study said contraception had been used at the time of their most recent crisis pregnancy. Aggregate population data for contraceptive use in Ireland are not available. However, the health Ireland survey 2016 indicated that 46% of respondents used no contraception. Usage was highest among the group of people aged between 17 and 24 years and declined with each age group, with significant numbers in each group using no contraception. Clearly, there are other important issues besides cost in whether people choose to use contraception when pregnancy is not desired. Work in the United Kingdom suggests access to reliable contraception is only one of the measures needed to achieve a reduction in the number of unintended pregnancies. They include relationships and sexuality education, timely access to contraception and information and engagement with appropriate health services.

Contraception is widely and easily accessible in Ireland. A comprehensive range of prescription hormonal contraception is available through the community drugs schemes, including long acting reversible contraceptives. Condoms are not reimbursed but are widely available in retail outlets. Additionally, post-coital contraception is available over the counter in pharmacies and free for medical card holders.

The main cost of obtaining contraception relates to medical care such as consultations, follow-up visits and the fitting and removal of devices. However, 44% of the population have free GP services, either through the medical card or the GP visit card.

I will come back to some of the other issues raised by the Senator.

Does Senator Anthony Lawlor wish to ask a brief supplementary question? I remind him that I allowed him latitude when he made his initial statement.

I thank the Acting Chairman. I probably spoke a little longer because this is my first Commencement matter.

The Minister of State spoke mostly about the cost of contraception. It is easy to discover how much it costs because many people a medical card. Therefore, one can easily analyse the cost per head by analysing how many avail of existing services.

I am disappointed that the Minister of State did not mention sexual health education. There are medical practitioners who are willing, if asked, to go into schools to provide such education. I suggest the Departments of Health and Education and Skills become involved in providing such education. The latter Department could issue directives to various school boards of management to encourage them to invite medical practitioners to their schools. Such education is really important, particularly as the referendum has been passed. It is known that free contraceptive care and increased knowledge reduce the number of crisis and unplanned pregnancies. I urge the Government to introduce an integrated scheme to provide free contraceptive care and the necessary education for all citizens. Let us be mindful of the fact that sexual health is an issue for both males and females.

I shall return to the recommendation made by the Oireachtas Joint Committee on the Eighth Amendment of the Constitution. On numerous occasions the Minister for Health has said he fully supports the recommendation made by the joint committee and its call for contraception to be made available free of charge. Work on the legislation is ongoing, particularly since the passing of the referendum. I do not have information from the Department of Health with me, but I assure the Senator that the Department is introducing a new health and well-being programme into all primary and secondary schools. Two new booklets, one of which is entitled, Tom's Flower Power: A gentle explanation of how babies are born, were launched a few weeks ago. Such education is provided for young people in primary school. I also assure the Senator that the Department of Education and Skills is doing a lot of work at primary, second and third levels, although I do not have a comprehensive reply for him from it. I promise, however, that I will ask the Minister to convey to him what the Department is doing. I shall reiterate what the Minister for Health has said. He has clearly said he will follow the recommendations made by the joint committee. However, it will take some time to put in place some of the measures recommended, some of which are legislative. We are at the beginning of the process which will continue for the next couple of months.

Disease Management

I thank the Minister of State at the Department of Health for taking this matter on behalf of the Minister for Health, on whom I call to consider introducing fibroscans to improve the diagnosis of non-alcoholic fatty liver disease, NAFLD. Ireland is facing an epidemic of liver disease. NAFLD is driven by obesity and diets that are high in fat, sugar and salt. Sadly, many are unaware of the risk such diets pose to their health. NAFLD can be managed and prevented from developing, once detected. In the vast majority of instances it is currently not detectable by a routine liver test - generally a blood test. Fibroscans can accurately diagnose the condition in a timely manner. A fibroscan is quick, simple, pain free and non-invasive. If fibroscans were introduced, they would help to address the under-diagnosis of NAFLD. Non-alcoholic steato-hepatitis, NASH, is the more aggressive form that emerges if NAFLD is left untreated. It is a silent epidemic and as many as 80% of people with NAFLD are not diagnosed routinely. Fibroscans are relatively inexpensive and can be performed by GPs. It would make great sense to introduce them, given the incidence of obesity in the country.

Professor Suzanne Norris is a specialist in the area. She has said: "In my lifetime there will be a tsunami of liver disease in Ireland." It is only in recent times that it has been realised liver disease is caused by a diet high in fat, sugar and salt, rather than alcohol. Up until now it was predominantly suffered by males an alcohol-related but now it is presenting in a large volume of younger people and many females.

I will be very interested in the Minister of State's response because this makes a lot of sense.

I hope the Senator is interested in the response which is wide-ranging, but I will have some notes to add at the end.

Chronic diseases are largely preventable diseases linked with a set of four common risk factors - tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity - and which can remain preventable until late in life. As described in the recent Sláintecare report, they present a major challenge in future health service planning. The demographic profile has changed, life expectancy has risen and the diseases we encounter have changed. Chronic diseases such as cancer and cardiovascular disease now account for over 60% of all deaths in Ireland. The health system needs to reflect these changes and adapt to meet the needs of the current and future populations. Chronic diseases and multi-morbidity require a different type of care that is preventive, ongoing and managed close to home.

Services to treat most chronic conditions are mainly provided in acute hospitals, although significant advances have been made in some areas, particularly diabetes care. The development in 2008 of the national policy framework for the prevention and management of chronic diseases addressed the management of chronic diseases through a reorientation towards primary care and the provision of integrated health services focused on prevention and returning individuals to health and a better quality of life. The Sláintecare report builds on the work that commenced in 2008 under the national policy framework for the prevention and management of chronic diseases. The model of care envisaged in Sláintecare is chronic disease management by multi-disciplinary teams, incorporating evidence-based approaches, care plans, self-management and shared care protocols, which will be community-based. This model of care will offer a comprehensive package of services, from prevention to diagnostic services, disease management and rehabilitation. Referral to an acute hospital will only be for episodes which require specific specialist care, with discharge back to community care, as required.

lt is important to recognise that a significant proportion of the ill health associated with chronic diseases is preventable. Significant progress has been made in the early implementation of Healthy Ireland which provides a solid platform for tackling lifestyle risk factors, social determinants of health and factors which contribute to health inequalities. It also provides the framework within which individuals, communities and sectors can be supported in playing a proactive role in improving the nation's health and well-being and throughout the course of life. In the next decade the focus will increasingly shift to driving monitoring and evaluating implementation. This will be supported by the evolving Healthy Ireland infrastructure. Under the Healthy Ireland agenda, our aim is to prevent much of the chronic disease through action on risk factors and by creating an environment which will support people in making the healthier choices which will reduce their risks of ill health during their lifetime.

Implementation of a range of initiatives is under way, including implementation of the obesity policy and action plan which was approved by the Government in 2016 and which aims to reduce levels of excess weight among the population. Our mission is to get the message of Healthy Ireland into every home and community in order that we can better help and support people in making the healthy changes they want to make but which everyday struggles can make harder to do. It is important that we all work together to deliver clear, simple and consistent messages to encourage people to take those first steps and understand everything they do will count towards a healthier future for their families. No step is too small and the most important thing is to start.

I have held the health promotion and Healthy Ireland brief for almost a year and had the privilege of meeting many people and organisations that are working with us on the Healthy Ireland agenda. I am always struck by how passionate and committed they are about promoting health and well-being in communities. I look forward to continuing our work over the summer and beyond in order that we can support more people in eating, thinking and being well. I will come back to the specific question asked and answer it with a comment I have received in the past few minutes. I know that was a very broad response.

That is appreciated. I know of the good work the Minister of State is doing and could not agree more with the general idea that if we are and keep well, we will prevent disease. This is a tangible and specific way to prevent this disease at low cost. The answer is great, but the prevalence of the disease is worthy of a more specific measure. I would appreciate hearing any further comment the Minister of State has to make.

I know that the Senator is passionate about this subject, as we all are. Obesity is becoming very prevalent, particularly among young children. I do not have a specific answer to the Commencement matter, about which I am disappointed. I was handed this note before I walked into the Chamber and will read it. The Minister and the Department of Health do not have a role in decisions on the diagnostic tests to be provided for specific patient groups. It is an executive responsibility of the Health Service Executive. The investment decisions should be informed by expert clinical opinion, an assessment of patient need, evidence of effectiveness and budget impact. The roll-out of major new technology should be the subject of a formal health technology assessment. I know that will not satisfy the Senator, but I have not been able to speak to the Minister because he has been in the Dáil Chamber. I will come back to the Senator because her Commencement matter is specifically about fibroscans and I do not believe the answer was adequate.

The issue has been highlighted.

Sitting suspended at 11.05 a.m. and resumed at 11.30 a.m.