Nithe i dtosach suíonna - Commencement Matters

Vaccination Programme

I welcome the Minister of State, Deputy Feighan, to the Chamber. It is appropriate that he is with us as he is a former Member of the Seanad. He will be responding to all of the matters selected today.

I thank the Minister of State for attending and for his ongoing work in his brief in the Department of Health. However, I would like the Minister for Health, Deputy Donnelly, to make an effort to come to the House in future. In the previous Seanad, the attendance record of Ministers with particular briefs was very poor and we will be pushing for them to attend the House. That is not a reflection on the Minister of State who is welcome.

My Commencement matter relates to the HPV vaccine. The reason I raise this issue today is that for some years, there has been contention surrounding the vaccine, including misinformation and campaigns that have caused huge concern about it. This has negatively impacted on uptake rates and the impact on disadvantaged communities has been much more significant than on other communities. This could be for a number of reasons, including inadequate access to information and peer reviewed research and to professionals who could be asked appropriate questions on the safety of the HPV vaccine.

I was surprised to learn in recent weeks that although we have a brilliant campaign and brilliant efforts and public messaging around the safety of the HPV vaccine, there is no scope for parents and children who change their minds and respond positively to that campaign to access the vaccine. Children who do not get the vaccine in their first year at school are excluded from the vaccination process unless the fee of €700 can be paid. Disadvantaged communities have had the biggest drop in uptake of the HPV vaccine. Should families respond positively to the public messaging and campaigns around the vaccine, they are basically excluded from a whole area of health and health equity, affecting their future health prospects.

In the 2019-20 academic year, the programme was extended to boys, which is a positive development. However, I believe the length of time that boys receive the vaccine is much longer than in the case of girls. A 2014 study in the Irish Medical Journal found that disadvantaged schools had a 6% lower mean uptake rate of the HPV vaccine than other schools and were twice as likely to have an uptake rate of below 50%. The 2019 annual report of the Health Protection Surveillance Centre states that the national uptake of stage two of the HPV vaccination programme, which involves the completion of a two-dose course, was 64.1%, which is a slight increase on the 50% figure in the 2014 study.

On receiving adequate information, some parents in my community, including some of my friends, approached the HSE and asked that their daughters receive the HPV vaccine along with first-year students. These girls could be in third or fourth year, but the requests were refused. The parents then approached their general practitioners and were told that because GPs do not stock the HPV vaccine, a €700 fee would be payable in order to access the vaccine. As Senators can imagine, not many families have €700 to spare, particularly those in disadvantaged communities. I would like the Minister to reassess this policy and create avenues that will allow parents who positively engage with the HPV programme to access the HPV vaccine for their children, free of charge, while they are still in second level education.

I, too, welcome the Minister of State to the House and congratulate him on his appointment. It is great to have a former Senator, with whom I had the pleasure of sitting in this House, back in the Seanad as a Minister of State.

I thank the Leas-Chathaoirleach for his kind remarks. It is always good to be back in the Upper House, even if it is sitting in the Dáil Chamber today.

I thank Senator Ruane for affording me the opportunity to speak on this very important matter. The immunisation programme is based on the advice of the National Immunisation Advisory Committee, NIAC. The committee's recommendations are based on the prevalence of the relevant disease in Ireland and international best practice in relation to immunisation. It makes recommendations on vaccination policy to the Department of Health.

The NIAC continues to revise recommendations to allow for the introduction of new vaccines in Ireland and to keep abreast of changes in the pattern of disease.

Therefore, the immunisation schedule will continue to he amended over time. In 2009, the national immunisation advisory committee, NIAC, recommended HPV, or human papillomavirus, vaccination for all 12 to 13-year-old girls to reduce their risk of developing cervical cancer when they are adults. In 2010, the HPV vaccination programme was introduced for all girls in the first year of secondary school. The NIAC recommended that the HPV vaccine should be given to boys. On foot of these recommendations, the Department of Health asked the Health Information and Quality Authority to undertake a health technology assessment to establish the clinical and cost-effectiveness of extending the current immunisation programme to include boys in the first year of secondary school.

HIQA completed the health technology assessment in December 2018, which recommended the HPV immunisation programme be extended to include boys. A policy decision was made to extend the HPV immunisation programme to include boys, starting in September 2019, with the introduction of a 9-valent HPV vaccine. However, the HIQA reports published in December 2018 did not recommend an HPV catch-up programme for older boys for the following reason: vaccinating boys in first year of school provides the best possible protection against HPV infection and boys already benefit from indirect herd protection provided by the girls' HPV vaccination programme which started in 2010.

The ages at which vaccines are recommended in the immunisation schedule are chosen by the NIAC to give each child the best possible protection against vaccine preventable diseases. As the HPV vaccine is preventative, it is intended to be administered, if possible, before a person becomes sexually active, that is, before a person is first exposed to HPV infection. It is important to note that HPV vaccine has not been shown to have a therapeutic effect on existing infection or cervical lesions.

The gender-neutral vaccination programme targets all girls and boys in the first year of secondary school to provide maximum coverage. It should be noted that all vaccines administered through the school immunisation programme are provided free of charge. The Department of Heath will continue to be guided by the NIAC's recommendations on any emerging evidence in the future.

I have listened to what Senator Ruane has said about the brilliant safety campaign and to the fact that if people change their mind, they can be charged up to €700 and what she says makes sense. I will bring that back to the Department in order that it might be looked into.

I thank the Minister of State. It would be great for that issue to be brought back to the Department. The idea that the vaccine is most effective at the age of 12 or 13 is based, and I am open to correction on that, solely on the idea that any person after that age may become sexually active and would reduce the levels of impact. That is based on assumption. It seems that giving access beyond first year was more about cost-effectiveness rather than that the giving of the HPV vaccine at any age will have some effect. This may be based on the inaccurate assumption that anyone who is looking for the vaccine beyond first year has become sexually active.

I will be happy to further engage with the Ministers and the Department to remove the barriers so that when the campaigns do succeed in helping people to receive the proper information, it is not only those who are privileged enough who protect themselves against cervical cancer but that health equity should be for all. It should be a right and we should remove any barriers for anybody who has positively engaged with the Department of Health’s campaign to reverse the uptake statistics, which have gone down very poorly every year until this year. I thank the Minister of State.

I thank the Senator. Vaccines are one of the most successful health interventions of all time. They have saved thousands of lives in this country and have helped make diseases like polio and smallpox, which previously caused devastation to families and communities, largely a thing of the past.

Cervical cancer is the fourth most common cancer in women worldwide and one woman dies of cervical cancer every two minutes. Almost all of the cases of cervical cancer can be attributed to HPV infection.

HPV also causes other cancers.

For example, approximately 60 men and women are diagnosed with HPV-associated cancers of the mouth and throat every year in Ireland in addition to other HPV-associated cancers.

Thankfully, the introduction of the HPV vaccine has had a significant impact in many parts of the world and countries with high vaccine uptake rates have seen the highest impact.

I will take on board the point about the cost of access. There are differences of opinion between the national immunisation advisory committee, NIAC, and the Senator. The Department of Health takes its guidance from the NIAC but I will bring the Senator's concerns to the Department of Health and to the Minister.

Health Services Provision

The Minister of State is very welcome to the Chamber and I thank him for responding to this matter. It is fitting that we are here today to talk about access to contraception given that tomorrow, 26 September, is World Contraception Day.

As the Minister is aware, a working group on access to contraception was established in April 2019 by the then Minister for Health, Deputy Harris, to consider the policy, regulatory and legislative issues relating to enhancing access to contraception following the recommendation of the Joint Committee on the Eighth Amendment of the Constitution. That working group produced a report almost 12 months ago. The report identified various barriers to accessing contraception. In particular, there are significant barriers relating to choice of contraception and accessing the most effective form of contraception.

While the cost of delivering this universal free contraception was estimated by the group to be in the region of €80 million to €100 million a year, it emphasised that considerations which go beyond purely economic considerations needed to be taken into account when accessing this scheme.

Provision of universal free contraception in particular negates the harmful consequences of crisis pregnancies. Those harmful consequences would be avoided if universal free access to contraception was introduced in Ireland. However, the working group outlined three alternatives to full universal access if that was the concern of the Government of the day. First, a universal State-funded contraception scheme based on the GMS scheme but including the copper coil; second, the expansion of the GMS scheme as it relates to long-acting, reversible contraception, to be available to all women; and, third, a phased approach to the introduction of free contraception beginning with younger women in the 17 to 24 year age group. The group estimated that that would cost in the region of €18 million to €22 million a year.

The then Minister, Deputy Harris, told the Dáil in October 2019 that free contraception would be available at the beginning of 2021. The programme for Government commits to providing free contraception over a phased period starting with women in the 17 to 25 year age category. Can the Minister of State outline the work that has been undertaken to establish this State-funded contraception scheme to date? Can he give a clear timeline for the implementation of the programme in its entirety because it is urgently needed, although I am aware legislation will be required to introduce this contraception scheme?

Detail is also needed on how and when free contraception will be available to all women, not only those in the 17 to 25 year age category. Women's contraceptive needs do not stop in their mid-20s. Barriers to accessing contraception are not only experienced by younger women. We know from the UK abortion statistics relating to 2018 that 69% of Irish women who accessed abortion care in England and Wales that year were over the age of 25.

Choice of contraceptive methods is empowering for women and it will be critical to the success of any scheme. I hope the Minister of State will confirm that the State-funded contraception scheme will provide access to all methods of contraception.

It is crucial that long-acting contraception methods, such as coils and implants, be accessible to all. It is important to remember that not every contraceptive works for, or is suitable for, every woman. Women's contraceptive needs change over time so it is important that the Minister of State confirm to us today that all methods of contraception will be included in the scheme.

I thank the Senator for raising what is an important issue — increasing access to contraception. The Government understands the need to promote women's health and equality and, as such, the new programme for Government includes a commitment to expand access to free contraception for women aged between 17 and 25, as outlined by the Senator.

The Senator has made me aware of the recommendations of the Joint Committee on the Eighth Amendment of the Constitution. The working group was established in April 2019. This group was charged with examining the range of policy, regulatory and legislative issues in respect of improving access to contraception. The group's high-level report, published last October, identified the complexities associated with this issue and highlighted the need for any State-funded contraception scheme to provide women with the opportunity to choose the most effective and suitable types of contraception for them, based on their health and lifestyle needs and preferences.

Following the report, it was clear that a sizeable body of work would need to be addressed in order to develop and finalise the policy approach, bring forward the necessary legislative proposals and ensure the implementation of service-delivery arrangements. Unfortunately, work on this matter has been disrupted significantly by the need to prioritise the response to the COVID pandemic, although it will be considered further in the context of the Estimates process.

There are already several supports in place to facilitate individuals' access to contraception. For example, the national condom distribution scheme, which was established to promote condom use among individuals and groups who may be at increased risk of negative sexual health outcomes, distributed over 730,000 condoms and almost 450,000 lubricant sachets in 2019. This scheme has been expanded further, with the rolling out of condom dispensary services in November 2019 to over 23 third-level colleges.

The Senator may also be interested to know that, in partnership with the Irish Pharmacy Union, IPU, the HSE last month launched Play it Safe, a major new information campaign encouraging young adults to consider their sexual health and well-being during the current pandemic. This campaign involves making sexual health protection packs available in pharmacies nationwide, offering valuable information and supports to young adults, whom we know from public health data are most affected by crisis pregnancies and sexually transmitted infections.

In addition, it is important to remember that approximately 125,000 people accessed contraceptive services through the general medical services scheme in 2019. These individuals received their contraception free of charge. Those with a GP visit card are also supported in accessing contraception as they do not have to pay costs arising from GP visits.

I am very disappointed with the Minister of State's response. I understand the Covid pandemic is causing havoc, particularly for the Department. This issue existed long before Covid so I am very disappointed to hear that no progress at all has been made on it. It is a core issue in the programme for Government. I will be taking it up with the Minister, Deputy Donnelly, to determine whether we can make progress on it because life needs to go on alongside Covid.

The national condom distribution scheme, while welcome, is a male-focused form of contraception. It is not female centred.

Women's lives are transformed by access to contraception and they can plan and control their lives and their own fertility. While the condom distribution scheme is welcome it is not at all sufficient. I appreciate the Minister of State saying Ireland is ranked 12th of the 46 countries on access to contraception but this does not mean women can access suitable contraception. By "suitable" I mean longer acting contraception such as coils and implants, which are vital. It is clear from the report that these methods of contraception are not readily accessible in Ireland. I am disappointed with the response but I want to work with the Minister of State and the other Ministers at the Department of Health to get this up and running and delivered.

I appreciate the Senator's concern about this very complex issue. The working group highlighted that the majority of people in Ireland can and do access contraception without difficulty. Contraception use in Ireland is high and stable. This is a fact that we welcome but there are issues we need to address. At the same time, the Government is supportive of the need to expand access to contraception even further and move towards the provision of a free contraception service over time. This is reflected in the commitment made in the programme for Government. It is not a straightforward process and a number of regulatory, legal and policy issues will need to be addressed before the final parameters of a State-funded scheme are determined. The issue of access to contraception has not been forgotten. As outlined, the opposite is the case and much valuable work has been undertaken to ensure effective supports and information are available to those who need them most.

Medical Cards

I welcome to the House my good friend and colleague for many years, the Minister of State, Deputy Feighan, and I congratulate him on being elevated to a very important position. I know he will give it 100% commitment as he did to everything he has done over the years.

I had submitted this particular Commencement Matter for consideration last Wednesday week but that Seanad was abandoned that day. It had been accepted and I have been submitting it since. Luckily enough, it was accepted today. The reason I tabled it in the first place is because those aged over 70 now have a legitimate expectation that they will receive medical cards. In the budget last October, there was a commitment that there would be a change in the criteria for those aged over 70 with regard to qualification for medical cards and that it would come into operation on 1 July. Many old people were waiting to apply for their medical cards on 1 July. What happened subsequently was that the Dáil was dissolved but apparently legislation was required for this to happen. In July, in the last week of the first term of the new Dáil, the Seanad passed the necessary legislation to facilitate the Minister signing the regulations to change the criteria. My question is very simple. When will it be done? Why have we had this delay? The legislation was passed on 31 July. It is now 25 September and, as of yet, there is no indication whatsoever for the thousands of people aged over 70 who are waiting patiently to apply for their medical cards. The primary care reimbursement service is telling people it is not aware of this change and has not been given any indication. On what date will those aged over 70 be able to apply for their medical cards under the new criteria? Senator Wall will speak about those who are terminally ill for whom this debate is equally important. I look forward to hearing the reply.

I welcome the Minister of the State to the House and I thank Senator Conway for sharing time on this very important matter.

The Minister of State will no doubt be aware of the delays in these income limits, as has been outlined by Senator Conway. We are now just three weeks away from budget 2021 and the Government has not yet delivered on these simple budget commitments from last year. The budget commitments meant income limits for medical cards should have increased by €50 per week to €550 for a single person and to €1,050 for a couple by July.

It is unacceptable that up to 56,000 elderly people are waiting on medical cards due to the Government failing to relax the income limits it promised. As Senator Conway asked, the Minister of State might let us know when these new limits will be brought in.

I received assurances in this House from the previous Minister for Health, Deputy Harris, that the medical card renewals would be delayed and medical cards would be extended to 2021 because, as it was said, we are all in this pandemic together. Unfortunately, my experience is the opposite. My office deals with a large number of renewals each week. Will the Minister of State confirm why we asked medical card holders to renew their cards during this pandemic? Should we not allow those with medical cards the comfort blanket having a card gives to so many during these unprecedented times?

I had the pleasure yesterday to speak to Mr. John Wall. I am sure The Minister of State is fully aware of his campaign to extend medical cards to terminally ill patients. On his behalf and on behalf of those he campaigns for, what is the update on the provision of cards for those who are terminally ill at this time? The campaign seeks to extend these cards by 12 months for those at this stage of their life to take away the worry of filling in another form or worrying their family will be left with large medical bills. I am informed that extending this card by another year would have little financial consequences to the State. To those who are seeking them, however, it would be that comfort blanket which, I am sure, the Minister of State will agree is the least they deserve at this difficult time.

I thank Senator Conway for his kind remarks. It is great to be back here in the Seanad. I am delighted to see Senator Wall here. I serve with his dad in the Oireachtas so it is great to see him back here as well.

Before addressing the medical card limits for the over-70s, which both Senators have raised today, it is important to acknowledge the difficult year that older persons in our society have experienced as a result of Covid-19. In particular, social distancing and cocooning were and remain challenging for many older persons. They continue, however, to show tremendous strength and resilience in helping to fight the spread of Covid-19.

Budget 2020 provided for an increase in the medical card thresholds for persons aged 70 and over. Although it was intended that this measure would be implemented from July, as Senator Conway stated, it was not possible to legislate for the necessary amendments to provide for this measure until there was a fully constituted Dáil and Seanad. It is welcome, therefore, that the Health (General Practitioner Service and Alteration of Criteria for Eligibility) Act 2020, which provides for the increase of the income thresholds, was passed by the Houses of the Oireachtas and subsequently enacted on 2 August 2020. However, relevant sections in this Act which provide for the increased income limits have not yet commenced, and this has undoubtedly been a source of frustration to those people aged 70 and over who may be eligible under the new thresholds.

While the delay is regrettable, it is important to understand that this budget 2020 commitment was contingent on the realisation of certain savings within the health budget. Those savings, however, could not be achieved this year due to the impact of the Covid-19 pandemic and a substantial allocation of additional funding to the health service to deal with this pandemic. It is in this context that decisions on the associated funding and implementation of the measures are being actively considered by Government. I will bring to the Minister the Senator's issue of the thousands of over-70s who have raised their concerns.

Turning to Senator Wall's query regarding reviews of eligibility, the HSE temporarily suspended all reviews of eligibility at the outset of the pandemic in March until last month. All cards that were due to expire during that period had their eligibility extended for up to one year and will be reassessed on a planning basis. This step demonstrates the practical and compassionate approach taken by the HSE during unprecedented times.

While periodic eligibility reviews have since resumed, it is important to recognise that the HSE operates a sensitive assessment process and may also exercise discretion and grant a medical card where individuals exceed the income guidelines but face other difficult circumstances such as extra costs arising from an illness.

In the case of terminally-ill people, the HSE has a compassionate system in place for the provision of medical cards when it is informed a patient is receiving end-of-life treatment. This is where patients unfortunately have a prognosis of less than 12 months. These applications do not require a means assessment nor are they reassessed. However, not all terminally-ill patients may qualify for a medical card and this understandably causes upset and concern. To that end, the HSE clinical advisory group, CAG, was established in December 2019 to review this issue. The work of the CAG has now concluded. A report was submitted to the Department and is currently under investigation and consideration. Senator Wall outlined what a comfort blanket the card can be for terminally-ill people with 12 months or less to live and their families, which I fully accept. I will bring the issue to the Minister's attention.

I thank the Minister of State for his reply but it clearly states that the commitment was contingent on savings being achieved at the Department of Health. We all know that not alone have no savings been achieved but the Department's budget has been substantially increased. It also says the matter is being actively considered. Is the commitment there to implement the measures contained in the Act passed last July? There is no commitment to a timeline. If it is being actively considered, when will such consideration end and a decision be made? That is what I am trying to ascertain.

I thank the Minister of State for his kind comments. I recently dealt with a 69-year-old gentleman who spent five months in hospital and then came home to County Kildare. The first letter he got from this Government was not congratulations on beating Covid or the disease he had, it was instead a renewal letter for his medical card. His first comment to me was, "Do they want to put me back in there again?", such was the distress the letter caused him. I am sure the Minister of State is aware of that but it needs to be brought back to the Minister. We need to suspend renewals again while we are in the pandemic. We are being told the pandemic is not over. The HSE section dealing with medical cards needs to realise that.

Terminally-ill people are looking for an extension of 12 months only. They do not want to have to fill in medical card applications again or go back to doctors to get them to do likewise. That is all they are asking for and I am told it will not cost the State much. I ask the Minister of State to bring that back to the Minister.

Senator Conway mentioned savings being achieved and obviously that has not occurred, due to Covid. As was said, currently 75% of people aged 70 and over have a medical card and if the potential beneficiaries of this measure - an estimated 56,000 people - materialise then an increase in the income thresholds will result in over 88% of this cohort now being eligible for a medical card. The Senator suggested we stop the active consideration and making a commitment and I will bring that back to the Minister. There is no doubt, however, that this would prove to be a very beneficial measure for these additional eligible persons who will now have access to a range of health services at an affordable level. It is therefore important to assure Senators Conway and Wall that decisions on the associated funding for this measure and a potential implementation date for the commencement of this provision are being actively considered. The Senators want a commitment which I cannot give today but I will bring it to the Minister.

It should be noted that the programme for Government, Our Shared Future, also includes a commitment on the matter of medical cards for terminally-ill patients and a further update will be provided on this to Senator Wall once the report of the clinical advisory group has been fully considered. I take the Senator's point that this could cause a lot of pressure and undue hassle for a 69-year-old man who had just spent five months in hospital and I hope it will be resolved.

Sitting suspended at 11.15 a.m. and resumed at 11.30 p.m.