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Seanad Éireann debate -
Wednesday, 1 Jun 2022

Vol. 285 No. 11

National Maternity Hospital and Women's Health Action Plan: Statements

I welcome the Minister for Health.

I thank the Acting Chairperson and Senators for inviting me to speak about the women's health action plan and the national maternity hospital, NMH. The new NMH has, of course, been recently debated extensively and the concerns raised regarding ownership, governance and influence have been addressed in the legal framework that has been published. In approving the legal framework, the Government was satisfied it had achieved the State's objectives to ensure all legally permissible services will be available, with no religious influence in the operation of the new hospital now or at any time into the future, to safeguard the State's investment and, critically, to ensure we will have a state-of-the-art, modern, co-located national maternity hospital that will be able to expand greatly and deepen the services provided.

The State will own the hospital and the land for 299 years under leasehold ownership, a common ownership approach with multiple operators, such as apartments. The new hospital will be entirely secular. Its founding rules, contained in the constitution of the new NMH, state there can be no religious ethos or influence whatsoever. The published legal documents make clear there can be no religious ethos in the provision of any services or operations at the new hospital. The documents also state that not only can the new hospital provide all services but that it must do so. The State, via the Minister for Health, will have the power to intervene directly if the hospital fails to meet these requirements relating to services and remaining secular. All services that should be provided in a maternity hospital, including all those currently provided in Holles Street, will be available in the new NMH. To further address concerns about the availability of services in the new NMH, in the context of the Government's decision of 17 May, it was also agreed an annual report will be published on the operation of services at the new NMH for five years from when it opens.

These past few weeks of debate on the matter have helped to highlight the overwhelming support from clinicians, midwives and doctors for this project to proceed. It includes unanimous support from the clinicians, doctors and midwives at the National Maternity Hospital and the directors of midwifery from all 19 maternity units in the country. There is also clear support from the medical board of St. Vincent's Healthcare Group, representing more than 250 clinicians. I fully share the confidence of these clinicians and experts who support the project. We cannot delay this process any further. As I said recently, the need is too great and the delay to date has been too long. The task now is to get this hospital built as quickly as possible in order that we can improve experiences and outcomes for women and girls for generations to come. I hope we can all work together to ensure the hospital will now be built as quickly and effectively as possible.

Turning to the women's health action plan, improving the outcomes and experiences of women in our health service has been a priority since I became Minister for Health. On International Women's Day in March of this year, the women's health action plan was launched. It is the first plan of its kind in Ireland and represents a revolution in women's healthcare services here. We have listened to women throughout Ireland over the past two years. They have spoken of their experiences of our health service and told us which issues they feel need most attention. Their requests were simple, that is, to keep listening to them, not to make promises but to take action, to respect them as experts through experience, to empower them with trusted sources of information and, most important, to give them access to the women’s health services they need, that is, services that are accessible, expert and empathetic. The women's health action plan places women in control of their own experiences in healthcare. We place women's health at the heart of everything we are doing in the plan. We are advancing initiatives that will have a direct, positive experience on women's experiences and outcomes.

Last year, I had the great honour of opening the first publicly funded dedicated menopause clinic in Ireland. This year, five further specialist menopause clinics will be opened, meaning there will be six such clinics by the end of the year serving the needs of women experiencing complex menopause symptoms. Last year, we opened nine see-and-treat gynaecology clinics, while this year, we are opening a further 11, creating in just two years a national network of 20 such clinics. These clinics provide necessary care to patients in just a few hours in one visit, instead of multiple visits over many months and sometimes well in excess of a year. It is one of the vital steps we are taking to reduce gynaecology waiting lists.

Last week, I visited the new women’s health services on the Lee Road, Cork. The clinic is focused on addressing waiting lists for all related investigations a woman may require. For example, a woman with urinary incontinence requires a diagnostic test called urodynamics prior to a doctor's consultation. In February 2019, the waiting list for this procedure stood at 500 patients and the average waiting time for those patients was two years. Today, the figure has fallen to just 77 women waiting and the average waiting time has fallen to just two weeks.

In the coming months, we will introduce free contraception for women, beginning with 18- to 25-year-olds, and set up four new postnatal hubs that will provide wrap-around care to mothers in those critical first weeks with their babies. This plan also brings a new spotlight to women's mental health and well-being, including growing supports relating to self-harm, setting up new eating disorder teams, examining supports needed by carers, a majority-female workforce, and developing an inpatient mother and baby unit.

Six publicly-funded regional fertility hubs have been established to support women and their families in their fertility journeys. Women expressed the need for more support in making the choice to breastfeed. As colleagues will be aware, we have the lowest breastfeeding rate anywhere in Europe. In response, we have more than doubled the number of lactation consultants trained to provide specialist hands-on support. That now includes all 19 maternity units and for the first time we have national coverage.

We have prioritised initiatives like rolling out the first maternity bereavement study this year, an important study which allows us to understand how best to help mums, dads and families during the hardest time imaginable for any parent. All of this has been made possible through a significant increase in funding for women's health services. To put this in context, in 2020 new development funding for women's health services was about €4 million. The full-year cost for the new developments for this year alone will be €50 million. That gives Senators a sense of how this investment has been prioritised.

I would like to acknowledge the major work done by the women's health task force, my Department and healthcare workers across the HSE. I also very much acknowledge the tireless work done by Members of the Oireachtas, including many Senators - in many cases the work was led by Senators - who have campaigned for years for many of the measures being rolled out in the women's health action plan. I hope the plan will be seen not so much as a plan of Government, but rather as a plan of the Oireachtas. Most importantly, I acknowledge the time and participation of the women across Ireland who contributed to the plan and the radical listening exercise, and gave up their time and shared their experiences, sometimes very good and sometimes very difficult and painful experiences. That input, and their voice and testimony, have helped us to create a plan and design services that are what women have said they want and need.

We will all agree that we have wonderful clinicians in Ireland working in women's healthcare across the country. In spite of this, there has never been sufficient investment in women's healthcare here. There has never been the range and depth of services needed for generations, and which are still needed today. We are changing that. We are not interested in making things a little bit better each year or having marginal incremental change. Our ambition is to radically improve women's healthcare services in Ireland and to do so very quickly. Between last year and this year alone, we aim to have put in place 20 see-and-treat gynaecology clinics, six specialist menopause clinics, six endometriosis clinics, six regional fertility hubs, nine eating disorder teams and 24 additional lactation consultants.

We will have fully funded the national maternity strategy this year and last year for the first time. We will have expanded perinatal mental health teams to all 19 maternity units. We are investing in period poverty. We are strengthening sexual assault treatment centres. We are introducing free contraception, starting with 17- to 25-year olds. We are expanding research into women's health. We are increasing support for GPs for women's health and will launch a HPV vaccine catch-up programme. There is more in the plan. It will take several years to build up the level of services to where they need to be. Over last year and this year, we have got off to a very good start.

I thank the Minister for his comprehensive statement and all of his work on the plan.

The Minister is welcome to the House. It is fantastic to hear him going through all of the delivery that has happened for women's health over the past two years. It sounds like he has been doing this for much longer. There has been a huge amount of delivery despite the fact that he was dealing with a pandemic for most of his term of office.

The Minister hit the nail on the head when he spoke about women's experience of feeling not listened to. We often hear the term "gaslighting" whereby women are told something is not wrong with them when they know that is not the case. It is welcome to reiterate our position that we will listen to women and shape our services around what they need.

The work that has been done around menopause clinics, see-and-treat gynaecology clinics, free contraception and trying to reduce waiting lists is all very positive. Waiting lists are probably the number one issue women are raising with us, in terms of the length of time it takes to be seen. I agree with the Minister that the clinicians and doctors working in this space are the best trained in the world. Getting in the door and being seen is the problem. I know the Minister is doing significant work to reduce waiting times. When something is termed an elective procedure, very often people think it may not be necessary. However, the women behind the statistics are often living with chronic and rehabilitating pain and have no quality of life while waiting for much-needed procedures.

I would like to focus on the areas that would be a priority for me. One is an issue I have spoken about for many years, namely, endometriosis. It is an issue close to my heart and Senators in the House will have heard me mention it numerous times. I welcome that we have additional endometriosis clinics, which is great, but there needs to be a greater focus on those at the severe end of the spectrum, namely, those with stage 3 or stage 4 endometriosis who require complex surgery which often involves more than one surgeon operating at the same time. We know for a fact that women are still travelling to the UK, Poland and Romania for such surgery because there is a view among the community that access to the specialist surgery required, namely, excision surgery which, rather than ablation, is the gold standard, is quite limited here. We are doing a good job in treating and providing access to services for women at the milder end of the spectrum with stage 1 or 2 endometriosis. However, those with more severe cases often require surgery on their bowels, reproductive organs, including the uterus, and, perhaps, the rectum, diaphragm and lungs. Such surgery can be lengthy and extensive. It requires theatre time, which can be difficult to secure because three C-sections could be performed within the time it would take a surgeon to perform complex endometriosis surgery. Competition for theatre time has proven to be a challenge in terms of booking surgeries.

In the next phase of dealing with this disease, which affects one in ten women, I ask the Minister to put a particular focus on those at the more severe end of the spectrum and those requiring complex surgery. Ultimately, I would love for no woman to feel she has to travel to another country to get that surgery. We should be the best place, not just in Europe but in the world, to get that surgery. We should have the top surgeons and doctors and provide that treatment here in Ireland. Currently, the view of the people with the condition is that is not the case today. It is something we need to work on.

The Minister has committed to funding IVF for couples and women. I have no doubt he will make the case to the Ministers for Public Expenditure and Reform and Finance in the upcoming budget talks which will kick off this summer. Many of us will have had contact with couples and women who are waiting for this much-needed financial assistance. Without it, they simply will not be able to have a chance of having a family. I ask the Minister, when he enters into budget negotiations, to make it a priority to secure much-needed funding for IVF cycles.

We can do better than three cycles; we should be able to do four or five. We have to ask ourselves whether we should limit the number of cycles. Infertility is considered a disease. Do we limit treatment for other diseases? It depends on what we think is reasonable. Cost will always be a factor. Perhaps the doctors working in this space will have a better idea of what will be a reasonable level of assistance. As it stands, we are an outlier and one of the only EU countries that provides no financial assistance whatsoever to couples facing infertility. Infertility is classed by the WHO as a disease. We can do better on that front. The Minister is committed to delivering for the women and couples who require much-needed fertility treatment.

As I have said, I welcome that the new national maternity hospital has got the go-ahead. I sincerely thank all of the consultants, doctors, midwives, nurses and others working in healthcare who have been involved. Many of them came out in their droves to support the project. They are not public people and did not want to have a public profile, but they knew the project was on the line and because of that, they staked their reputations on defending the project. That is why it is going ahead. I thank them for doing so and articulating the point so well on behalf of women and girls in this country. We could have been waiting another decade to get the hospital started otherwise.

The Minister is very welcome to the House. I acknowledge the significant challenges he faces and his dedication to the portfolio he holds, which is probably one of the hardiest portfolios in government. We are here today to talk about the new national maternity hospital and women's health in general.

I will start by commenting on the national maternity hospital. It is a very good thing and is long overdue. The Government has committed to building the facility and providing the €1 billion or more it will probably cost to build. There were concerns, and I was one of those who raised them. I was not the only one. Ministers in government also raised concerns. That is why the Minister, along with the Cabinet, correctly decided to defer the decision for two weeks to allow for further consultation, engagement, discussions, clarifications and the provision of information.

That was a good thing. I am a member of the Joint Committee on Health, which engaged on the issue for 12 or 13 hours between public and private meetings. We engaged with the Minister for four and a half hours. That was a positive meeting because the Minister and the team at the committee provided quite an amount of information. That meeting brought clarity to many people. It was an open discussion and in no way disrespectful. People with strong views aired and exchanged them and I believe that clarity was provided.

Of course, the situation is not ideal. The Religious Sisters of Charity should have provided the facility as a gift, as had been mooted. In fact, it was not far off being agreed before the situation suddenly changed. As the Minister rightly said, the land was not for sale at the time so we were not in a position to buy it. As a result of that, we are now dealing with a complex legal structure. Although a lease is in place for 299 years, it remains a complex legal structure involving companies, landholdings and so on. However, I believe the assurances that have been put into the record of the health committee in particular have a legal standing because they put the plan and programme around the lease into context. I believe the fact that the context has been put into the record of the House will stand the test of time. That was a useful exercise.

There is a lot of confusion about the golden share. The Minister might like to comment on the matter and bring more clarity.

The project is going ahead and I want to be sure there will be no delays. The Government has decided to go ahead at the site on the St. Vincent's campus. The Minister might give us a timeline as to what he expects to happen in year one, two and three. When does he expect construction to actually begin? When will the tender process end? I know we have planning permission, which is great. How long will the tender process take? How long will the construction process take? As I said, we need to drive the project on as quickly as possible because it is needed.

Speaking of maternity hospitals, I draw his attention to the fact that the maternity hospital in Limerick also needs to be upgraded. I know that plans are in place to move it to the campus of University Hospital Limerick. The Minister might advise the House as to where we are with that plan. No more than the women who use the facility in Holles Street, the women who use the facility on the Ennis Road in Limerick are using an old building where numerous people are sharing one room. I do not believe the building is fit for purpose. The care that is provided there is second to none and I know many of the midwives who work there. However, the new facility is needed to serve the entire mid-west region, including counties Kerry, Clare, Limerick, Tipperary and elsewhere. I would be interested in the Minister's views.

I will move to consider women's health in an overall sense. An awful lot has happened in that regard. We need to pay tribute to and to thank the task force on women's health that was set up by the Minister's predecessor, Deputy Harris. The task force has done great work. It is something to which we are all committed. It is part of the ethos of Sláintecare. It has full, cross-party political buy-in. I welcome the fact that the Minister launched the programme on women's health in April.

I sincerely thank him and the Minister of State, Deputy Rabbitte, for waiving all fees in respect of the HPV vaccine. I campaigned for that for two years. I believe the HPV vaccine saves lives. Ms Laura Brennan, from my own county, campaigned tirelessly on the issue. There was a significant issue with the catch-up because there was vaccine hesitancy with a small portion of first-year students or their parents. Now that the catch-up programme is being rolled out free of charge, there is no impediment to anybody getting the vaccine. In his summing up, the Minister might like to outline what format the catch-up programme is going to take, when he plans on rolling it out and where he plans on delivering it. The pharmacies could have a significant role to play in that regard. I would be interested to hear the Minister's beliefs and how his Department plans to roll out the catch-up programme.

Cuirim fáilte roimh an Aire. As the Minister did, I will start by commenting on the national maternity hospital because I would like to put on the record how disappointed we are at the deal that went through the Cabinet a couple of week ago. Nobody was denying the need for a maternity hospital. Concerns were raised by a wide group of people who were legitimate in raising those concerns and diligent in their attention to the details involved. Those concerns were not addressed. They related to the difference between a leasehold and a freehold, but particularly applied to the retention of the "clinically appropriate" language. We heard there were people who had no objection to the removal of those words, yet they remained. It is deeply disappointing that while the decision was delayed for two weeks, it seemed to be a box-ticking exercise in the hope that the furore would die down and we would move on two weeks later as intended. I express my disappointment in the regard. The situation is disappointing to those of us who raised concerns and feel those concerns were not addressed.

I would also like to raise a couple of other issues. We know that woman have had to go to the courts for years to access healthcare. Even though we have repealed the eighth amendment, there remains an issue around the accessibility of abortion services in this country. One in ten GPs still does not offer abortion services and only nine out of the ten existing maternity hospitals offer those services. The Minister has been in this House numerous times promising to deal with the issue of safe access zones and we are still to see progress in that regard. The Bill to legislate for that has passed all Stages in the Seanad. We need those safe access zones and that legislation passed so women are not having to run the gauntlet to access healthcare in this country.

There were awful images on social media during the week of protests outside a clinic in Stepaside. We also heard of one incident where a GP service has had to shut down its entire clinic on Saturdays because protesters were attending every Saturday. That means that not only woman who want to access abortion services are being denied access on a Saturday but all patients of that GP clinic are being denied access. We need progress on that issue. There must be no more delays in that regard.

I will also raise an issue in respect of assisted human reproduction. My Sinn Féin colleagues recently met parents who have had children through international surrogacy and have clearly outlined the unacceptable issues and challenges they have faced every day due to the lack of regulation. While the assisted human reproduction legislation is very welcome, albeit long overdue, we cannot just omit certain issues that are deemed to be too difficult and decide to tackle them at another time or allow another Minister to address them. We have seen that approach to the Children and Families Relationships Act. Certain issues and certain members of society have been left in situations that are either unregulated or without the necessary legal protection. I was concerned to hear from representatives of the Assisted Human Reproduction Coalition that the Minister has not engaged with them. There has been a lack of engagement and reassurance that this issue is going to be addressed. I would like the Minister to respond as to why he is not engaging with the group.

My party wants strong legislation that is fit for modern Ireland and that serves the interests of the thousands of people who find themselves grappling to deal with infertility issues each year. The assisted human reproduction legislation has been in the works since 2005 and as in the case of the national maternity hospital, no one is looking to delay it. However, we must make sure we get it right. We need the legislation to deliver for those families.

I remind the Minister of the commitment in the programme for Government on the provision of free period products. I believe a pilot scheme is being launched. We are more than two years into the term of this Government. The provision of the products they need every month in all public buildings is low-hanging fruit when it comes to women's healthcare.

From the experience of the organisations that are filling that gap and delivering those products, I know the need is greater than ever. We now have Ukrainian refugees and the organisations have stepped up to provide those women with these products. We were told those in direct provision centres would be able to access the products yet all of the time these organisations are being contacted by women in direct provision who are saying the products are not being provided by the managers of those centres. The need for food banks has also increased. There is a great need out there for the provision of period products. I urge the Minister to progress that. We do not need a pilot. We just need to put the products in the bathrooms of all public buildings.

Before moving to the next speaker, I will acknowledge the presence in the Visitors Gallery of the minister from Canada, Mr. Bloyce Thompson, who is joined by the Minister of State at the Department of Agriculture, Food and the Marine, Deputy Heydon, and his delegation. He is very welcome to the Upper House.

I thank the Minister for coming into the House. I will confine my comments to the women's health action plan. I have made my views on the maternity hospital very clear. I warmly welcome the women's health action plan. There are a lot of very good people behind it. I refer to the women's health task force. Services that have long been fought for are now committed to in this plan.

I am struck by the theme running through the document and mentioned on the cover, which is "Listen. Invest. Deliver". That is what Government and politics are about, are they not? They are about listening, investing and delivering. I want to ask the Minister about the particular issue of delivery. On 11 May last year, 55 weeks ago now, the Minister made an announcement after listening to those of us who have been campaigning for breastfeeding supports for many years and listening to people within his own party and Government colleagues. Bainne Beatha, Cuidiú, La Leche and other groups have also been campaigning for breastfeeding supports. The Minister announced 24 new lactation consultant posts. I absolutely welcome that. That would be progress. It is still far off what we need, but it is progress.

However, as of 18 May this year, recruitment was only commencing for these posts. I do not know if I misheard the Minister's statement when he seemed to convey that these consultants are in place but, from the reply to a Commencement matter I put down here just two weeks ago, it was very clear that despite being halfway into the year, recruitment was only commencing for these posts. We really have no idea as to whether they are going to be filled. If we look at the 2020 commitment, we would not exactly be filled with hope that the 2021 will be realised and delivered upon because, in 2020, 10.5 lactation consultant posts were approved under the national maternity strategy but, two years later, only eight have been filled while two and a half posts remain open. We welcome the commitments but ultimately we can only judge them based on delivery and, to date, we are not seeing that.

I welcome the commitment to embedding perinatal mental health services within all maternity units. We know that postnatal depression and other mental health issues relating to pregnancy and postpartum have been very much the poor relation in maternity services over many years. Provision has been very patchy across many maternity services. I respectfully suggest that the Department might start by reviewing all partner restrictions across maternity units because, as I understand it, partner restrictions remain in place across the majority of maternity units. I know Holles Street has lifted its restrictions but many others have not. We have heard from the Better Maternity Care campaign and psychologists with expertise in the area that the environment and conditions in which a baby is born can have a significant impact on a mother's mental health. I ask the Minister to engage with the maternity units and ensure that those restrictions can be reviewed and, indeed, lifted as soon as possible.

The GP lead on women's health is another important introduction. I ask that the Minister ensure that, when that person is appointed, he or she has a specific remit to look at migrant women's health issues because I know from talking to AkiDwA, the organisation representing many African people and people with African descent in this country, that knowledge and expertise in dealing with African people's issues among GPs in this country is very patchy, disappointing and insufficient in many parts. Again, I ask that the GP lead look at that.

I will refer to something that is not referenced in the document. There is nothing with regard to home births. There is a long-standing issue in that the HSE has effectively failed to properly provide for the second midwife in a home birth situation. They are only paid €160 and are not paid if the woman is transferred to hospital. I ask the Minister to do something about this.

In the last few seconds available to me, I will mention that we have had a commitment to a Bill on assisted human reproduction for many years now. There is a commitment in this document as well. Many of us are waiting for this Bill, all for our own individual reasons, political and personal. We know that the Bill has been delayed for an unacceptable length of time. The Minister has to progress this Bill and he has to ensure recognition and legal certainty for the parents of the babies born via surrogacy. Any provision put into this legislation must have retrospective application because it is simply not good enough that there are babies who were born via surrogacy whose parents will not have legal recognition in this country.

The last thing I will say is that none of this matters unless the staffing is in place. The Minister knows better than the rest of us here the staffing shortages that exist right across the country. There are shortages among medical scientists, in the therapies and in the children's disability network teams, CDNTs. Children are waiting three years or longer to get a diagnosis within the CDNTs. Their only option is to go private. People are being approved for home support hours but simply cannot get them because the staff are not there. What is the Department doing with regard to workforce planning? We are at a really critical point now. People are not being paid enough to do the jobs that are vitally necessary. We need a comprehensive response from the Department with regard to the shortages right across the health system.

I will take the reverse of the approach of the previous speaker, even though there are very many interesting aspects of the national women's health strategy, many of which I hope to tease out in the future. I will specifically note one point in respect of breastfeeding. I encourage the Minister to lend his support to the proposals currently being considered by the Minister, Deputy Catherine Martin, with regard to bans and restrictions on the advertising of formula milk. However, I am going to focus on the national maternity hospital.

I will focus on the fact that many of the concerns were not addressed. In fact, they were heightened. It is really regrettable that the time was not taken to review or make any change whatsoever to the proposed legal paperwork to reflect the concerns that were not resolved, but heightened, over the course of the two weeks of hearings in the Joint Committee on Health, in which I participated. With regard to the language used regarding delay, we should be very clear that the primary delays in this project to date have come from those with whom the Government has been negotiating. For example, three to four years passed while Vatican sign-off on the transfer of lands was awaited. Let us be clear, those were the cause of delay in the project rather than those activists who pushed and who were pressing many years ago for the hospital to be publicly owned and for things like a compulsory purchase order, which could have been activated at that time but were not.

It is astounding to me that the key issue I want to highlight was not addressed. I refer to the phrase "clinically appropriate". Over the course of the two weeks, we heard multiple interpretations of what that might mean, including multiple interpretations from legal advisers.

One of the core phrases in the context of the leasehold agreement is "permitted use". Is it all clinically appropriate and legally permissible healthcare services or is it all clinically appropriate or legally permissible services? This is a double test and is really important. We also heard that this was to make sure that it would only be services related to a maternity hospital but there already was a line which said that it would be legally permissible healthcare services provided by a maternity, gynaecological, obstetric and neonatal hospital. Again, that was already specified.

The phrase "clinically appropriate" which is not defined and has an ambiguous meaning, was left hanging. One may well say that legally permissible services are there but if they are subject to a double test, for example, of clinically appropriate, then the question is not just what services are available but when they are available, how they are available and whether they are available on an elective basis. To simply say all services will be provided is not enough. Abortion was available in Ireland even while the eighth amendment still stood but it was only available if a woman was dying and even then, doctors had to determine how close to death the woman was. We all heard in the committee about such determinations - is the risk of death 20% or 40%? Similarly, we also know that some of the services in St. Vincent's Healthcare Group such as sterilisation were made available when clinically necessary for other reasons but not solely for the purposes of birth control. Symphysiotomy was clinically indicated in Ireland at times by certain physicians. These things matter.

Over the course of the hearings the National Maternity Hospital, St. Vincent's Healthcare Group and Mr. Mulvey himself suggested the phrase "clinically appropriate" be either deleted or defined but the Government did not choose to seek a definition or a deletion. In the lease that phrase is interpreted by the landlord, St. Vincent's Healthcare Group. The group was asked directly about its values, not about its religious ethos but its values as expressed in its new constitution which includes references to things like human dignity. I asked if this is human dignity as set out in the Universal Charter of Human Rights, which is from birth, or as set out in the declaration on human dignity by the Dignitatis Humanae Institute, which is from conception to natural death. Which definition is the St. Vincent's Healthcare Group's definition and how does that apply to its interpretation, as the landlord, of "clinically appropriate"? These questions were not answered.

The decision was made to rush through with an ambiguity which will be the subject of potential debate and interpretation for many years. This will have significant financial consequences because the State has also managed to reach a deal in which it has no exit clause. If this hospital expires after 70 years, as we have been told it will, the State will have to build another one and then another one because if, at any point, there is not a hospital on that ground, the rent reverts to €850,000 per year. St. Vincent's Hospital Group can throw us out if we do not have a hospital on that ground but the HSE's own legal adviser, when I asked what would happen in 70 years, said that if we do not want a hospital there after 70 years we could build something like a shopping centre or an apartment block and force St. Vincent's Healthcare Group to terminate the lease. We will have to try to get ourselves thrown out. In terms of the business case, is it four hospitals that we are building? The business case has not been answered and if the State cannot get a good deal on that and cannot even get first right to purchase the site if it is put up for sale after 30 years, how are we are going to be in a good position in terms of the negotiations we are facing for the next 299 years on the board of this hospital? Again, a disservice has been done to future generations.

I welcome the Minister. He really has had a baptism of fire since becoming Minister for Health. He had no ministerial experience, and I do not mean that in any disrespectful way, but he has shown good leadership. He has settled very well into his brief. He is dealing with a lot of issues that had not been dealt with for years and particularly in relation to the National Maternity Hospital, he and his officials took a very wise road. Despite all of the assurances and reassurances given, he decided to pause the process for two weeks to allow for further consultation and clarification.

The creation of a new maternity hospital is the greatest infrastructural investment by the State in the area of women's health. It is going to provide world class facilities for women, girls and babies for generations to come. Women and infants have not been well treated and are not well served by the existing cramped facility at Holles Street which is no longer fit for purpose. The National Maternity Hospital and St. Vincent's University Hospital have worked together for decades. Approximately 40% of consultant staff at the National Maternity Hospital are employed by St. Vincent's and work between the two hospitals at present. The new hospital has very strong support from clinicians at the National Maternity Hospital. In relation to this debate and the clarifications, if we do not want to believe the Minister or his officials, surely we can believe the clinicians. For me, as a lay person and a politician, the clinicians clarified the situation over and over again. We should never forget that 52 clinicians at the hospital outlined the strong need for a new hospital. Of course, there are one or two people who are against the development going ahead but that means that around 90% are in favour, with 10% against. That is fine and people are entitled to their opinions.

I was talking to one clinician who gave me a briefing. She said that she was exhausted because despite all of the explanations, people would still not believe her. For me, the clinicians are the people who are dealing with this. They made statements over and over again. They took time out, spoke to the media, and met all of the groups that wanted to meet them. The Minister was right to pause the process but the people want this to move on now. That was the clear evidence I heard in my own part of the country and in other parts of the country. People are saying "let's move on now" and I am hopeful it will work and that everything will be fine.

Budget 2022 delivered an additional €31 million for women's health. This additional money provides a foundation for a fully funded action programme for women's health in 2022. The action plan will focus on improving the foundations of women's health by investing in policy implementation, tackling the issues that women have said they want to see improved and funding innovative new approaches to women's health. Budget 2022 saw the investment of almost €9 million in additional funding to ensure the continued implementation of the national maternity strategy beyond 2022, building on the significant investment of 2021. There are many other positives to which I can refer, including the continued improvement in our gynaecology services through the establishment of a further six ambulatory "see and treat" gynaecology clinics, bringing the total to 20 clinics nationally. The Government has also invested almost €9 million to fund access to contraception for women aged from 17 to 25 and an additional €5 million in the Women's Health Fund to fund innovative new approaches to women's health services nationwide.

I could go on but in conclusion, I want to acknowledge the support the Minister is giving to two very important projects in my own county. I thank him for his support for the building of a new 50-bed unit at Roscommon Sacred Heart Hospital and Care Home for our older generation, which is much needed and very welcome and a ten-bed rehabilitation unit at Roscommon University Hospital. The Minister is very much behind these projects and is progressing them by providing funds to ensure that they become a reality. Outside of Dún Laoghaire, Roscommon will be the only place in the State that will have such a facility. These are important developments for my part of the country. I am pleased that the Minister and his officials can see their importance. I will be working with them and the HSE to progress those projects as quickly as possible because they are so important. When the Minister visited Roscommon University Hospital last November he was highly impressed with the management and staff and with everything that was going on there. I welcome the fact that he is behind those projects and look forward to working closely with him and his officials on them into the future.

I am thrilled that the Minister is here and we are not talking about Covid-19.

The Minister has come in so many times and we hoped for a day like this when we would deal with the normal everyday issues. I congratulate him of the women's health action plan, which is a considerable piece of work, and it is fantastic to bring forward what was begun in the task force under my colleague, Deputy Harris. I also congratulate him on bringing it to reality and negotiating the budget. It has significant elements in it. I welcome the clinics; having a focus on maternal bereavement supports is really important. A cohort in our society needs a response to what is an appalling tragedy in their lives and there are other dimensions to that. I really welcome that.

We are beginning the review of the Health (Regulation of Termination of Pregnancy) Act 2018 and in that I call for the need for safe access zones. I understand, I have heard and I take on board what the Minister has said previously on whether legislation is required but the fact is that it is happening. Women are intimidated from accessing services and GPs are intimidated from providing services so we need to implement that. I also welcome the Minister's commitment to the funding of IVF. It is important that IVF services are accessible and affordable and that there are supports in place for all couples. Where I would bring that conversation would be how will we determine who gets access to it. We need to ensure no impediments are put in the way of women and couples with disabilities.

The most fantastic campaigner from the Independent Living Movement Ireland, Selina Bonnie, has been in before the Joint Committee on Disability Matters and the Joint Committee on International Surrogacy. Her experience before she could access assisted human reproduction services in her long journey to the birth of her child was that at one stage she was asked to prove that she would not have a disabled child before she could be permitted access to the services. When we are putting the supports for IVF in place we need to make sure there are no impediments for anyone with a disability, that there is the same access and that, if anything, we have positive discrimination in favour of people with disabilities to be supported on their journeys to growing their families. That needs to be a priority. Aligned to that is the fact that many same-sex couples, particularly women, need the support of assisted human reproduction to grow their families but they are put through fertility tests and all sorts that they have to pay for in private clinics in Ireland, which are totally and utterly unnecessary. We need to be mindful of that and I hope the assisted human reproduction authority has a role in prescribing that. One of the untapped gems or Cinderellas of women's health is polycystic ovary syndrome and we need to raise awareness of this. There is an awful lot of patient and sufferer blaming in this regard and one of the myths is that people lost weight this would be fixed and it is important that we dispel that myth.

The Minister knows what I will say next. We are doing fantastic work on the Joint Committee on International Surrogacy and witness after witness has come in and said we need to legislate for international surrogacy in the AHR Bill and we need to do so urgently. The best way to safeguard the interests of women who would be surrogate mothers, regardless of where they live and the best way to preserve the rights and interests of everybody involved in the surrogacy journey, is to provide legislation for it. The New Zealand Law Commission has contacted us and it has done extensive work and reviews. It has a comprehensive solution that will assist us and that should inform us. We need to expand section 7 to include international surrogacy. This has been said by witnesses ranging from the likes of the Children's Rights Alliance and by the Ombudsman for Children. These are not people who would be perceived to be biased but who are truly objective in this space. We have to be brave and legislate retrospectively as well. It is reasonable that we set a high threshold but we have to ring-fence those children who have already been born via surrogacy.

There are also anomalies arising from the Children and Family Relationships Act that still have not been dealt with, such as the fact that same-sex couples are denied rights and a full legal parental relationship with their children, which is aligned to surrogacy and yet is not anything the same. In those instances, if these people had their fertility journeys abroad they are being denied those rights in Ireland. There are issues such as that that the Minister has a unique opportunity to bring home in his Bill to make us a world leader in safeguarding the rights of everybody on fertility journeys and to ensure that Ireland is setting a standard worldwide in it. We have a unique opportunity to do that.

I welcome the Minister to the House and I commend him on the publication of the women's health action plan. I wish to raise two issues. The first is the issue of free contraception for women aged 17 to 25. The Government has repeatedly said that programme will commence in August and I want to ask about that. We are just a couple of months out from that roll-out and I hope the Minister will be able to tell me how prepared we are for it. Have the regulations been signed to enable this to start in August? Will an information and publicity campaign start so that people know where to go and know about the roll-out? Has that been finalised so that people will know where they can get access to free contraception? There is a commitment on the training of medical professionals and I have heard there is a delay in rolling this out. Is that the case? Is the Minister confident that there is sufficient capacity in the system so that women will have access to their choice of contraception in all parts of this country? The Government stated this will commence in August and, therefore, can he confirm that women aged 25 on 1 August will be eligible to avail of free contraception to ensure they will not age out of the programme if it does not start until mid-August, when people are turning 26?

The other issue I want to raise is the fact that there is a national emergency in transgender healthcare in this country. There is a waiting list of up to ten years in the National Gender Service. Many identify this as a gatekeeping bottleneck. Up until recently the National Gender Service was refusing to engage with the trans community and it seems to have cut ties with NGOs. I wonder what that is about. Many trans people, including friends of mine, have taken to fundraising online and taking on debt to travel for hormone replacement therapy, HRT, treatment abroad. Many Irish trans people go to Poland and places that have been declared lesbian, gay, bisexual, transgender, LGBT-free zones to access the basic care they need and deserve. There is a commitment under the programme for Government on World Professional Association for Transgender Health, WPATH, standards and the National Gender Service is not following those standards. People are being delayed in accessing treatment and so they are being denied treatment. It is an emergency if the waiting list is approximately ten years long. I would appreciate any response to those issues.

I thank colleagues for their time and input. Rather than giving a pre-written speech I might respond to the Senators who are present on the issues they have raised. I might engage with Senator Warfield further on the transgender issue. If there are barriers to access that should not be there, then we need to know about them and to identify them. I am open to discussing that with the Senator.

He and I could meet and the Senator could write a note on the issue. If progress can be made, let us make it.

We are on track with regard to free contraception. I always say that with my fingers crossed slightly because healthcare is complex, as is rolling out things that have never been done before in Ireland. It is a priority and we are on track. It does not mean everything will work perfectly in August but we have negotiations ongoing with the IMO, which is very involved, as are the pharmacists and, to a lesser extent, hospital providers. Most of this will be led by GPs and pharmacists so that is where the main discussions are and they are progressing.

Several colleagues asked about assisted human reproduction. The Health (Assisted Human Reproduction) Bill was not originally envisaged to include international surrogacy, as colleagues will be aware, and it would have been law by now if we had not stopped it. It has been years in the making, as several colleagues said, and is urgently required, regardless of international surrogacy, for people in Ireland. We need to regulate this sector domestically. The assisted human reproduction legislation, which is on Committee Stage, has been paused. I was asked to stop it for several months and have done so but I am keen that we get going with that Bill quickly.

We agreed to a 12-week pause while a special committee was established to look at international surrogacy. That work is going well and there have been many positive contributions to the committee. There have also been contributions to the effect that we have to take our international human rights obligations deadly seriously. Few countries in the western world facilitate international surrogacy and we understand why. It is because it is complex, not just in respect of what happens in our country but also what happens abroad. It is a complex ethical space and we are balancing all manner of international human rights obligations and obligations to people living here. I hear clearly the calls from colleagues around retrospectivity.

We cannot indefinitely pause the Health (Assisted Human Reproduction) Bill. We will see where that process is at. It was agreed there would be amendments ready to go within 12 weeks. We need to address the matter domestically and internationally. If that can be accommodated within the current Bill, it will be. However, we cannot indefinitely postpone the Bill while we wait for an amendment. Amending legislation can be brought at any time. We can pass a Bill and make it an Act, amend that Act, bring in a different Act or amend on Committee Stage. It is in the hands of the committee as to where that goes.

The Minister is being disingenuous with people who desperately need that legislation.

It is not remotely disingenuous.

It was clearly agreed that we would set up a special committee which would take 12 weeks and report back with proposed amendments. We have stopped the Bill to wait for and accommodate that process. That has been agreed. The special committee has been set up and is meeting. We have paused the Bill and are waiting to hear back from the committee after 12 weeks. That is the process that has been agreed. Let us see where that takes us. Both domestic and international surrogacy need to be addressed. It is just a question of timing and sequencing.

Safe access zones were raised and much progress has been made on those. I hope to bring the heads of a Bill on that issue to Government soon. The heads of Bill would then go to the Joint Committee on Health for pre-legislative scrutiny. I think we can move through that process quite quickly. There has been healthy and important debate of the issue in the Seanad and it has been addressed in a Private Members' Bill brought forward in this House. That legislation has been examined and the clear advice I have is that we need a new Bill. I think we are in a good space on this and colleagues will like the Bill when they see the heads. We will then bring it through drafting and, hopefully, through both Houses as quickly as possible.

On lactation consultants, I will get Senator Sherlock a detailed note on the position in that regard. Funding has been provided and the posts have been sanctioned. I have met several of the support groups. It is going well, both in the maternity units where some of the additional support is and through community support groups. I met one group about two weeks ago and I have met a few others around the country. They are going well. I will check the position because we need those experts in place as quickly as possible.

On home births, I agree this issue has not moved at the pace it should. It is address in the national maternity strategy. There has been much good work done on midwifery-led care, new birthing units and better facilities, but more is needed on the community care and home birth sides. Home birth is not where it needs to be and I am working with the national women and infants programme to see how we can move it along.

Deputy Sherlock is correct on recruitment and workforce planning. It is a bigger question than we have time to address today. Suffice it to say that we have sanctioned more posts than ever and over the last two years the HSE has hired more staff than at any time since its foundation. A huge amount of work is being done but we want to hire many thousands more clinicians and other staff.

A few Members stated I have committed to introducing IVF services. I have committed to seek the funding to introduce it. I want this service to be publicly funded. However, that is subject to budgetary constraints. We are an outlier and need to move on this issue. It is a matter for discussion with clinicians and the Department as to who it applies to.

Regarding Senator Seery Kearney's input on people with disabilities, for anyone to be asked the question she raised is completely unacceptable. I would take it as a given that a disability would not preclude anybody from being able to access IVF treatment. I am horrified by the question that person was asked.

HPV vaccination is something we all support and I was keen to see a HPV vaccination catch-up programme put in place. I sought NIAC advice, which came back and was positive. It has referred to an age cohort of up to 25 years of age. I am seeking additional advice now. Some countries have moved from a three-dose to a one-dose regimen. I believe the NHS has moved to that too. I am seeking additional advice on that because it will have a big impact. On the back of the NIAC advice, I have written to the HSE and asked for options to initiate a catch-up programme. There are two parts to this, namely, a catch-up programme for boys and girls still in school who were offered the vaccination but did not take it or missed it, and also for young women up to 25 years of age. Those are the operational pieces I am looking for.

Going back to the start of this, which is around women's healthcare, this debate shows how far and quickly we are moving. It does not mean we are getting everything right or that we can do everything in one or two years but over last year and this we will, by the end of the year, have built up a national network of women's health services that did not exist previously, including fertility hubs, endometriosis support, menopause support, see-and-treat gynaecology clinics and other women's health facilities. It is an exciting time in terms of women's healthcare and I am delighted to see political support across the Seanad and Dáil for continuing to make this a priority, investing in it and growing out the services.

Cuireadh an Seanad ar fionraí ar 5.19 p.m. agus cuireadh tús leis arís ar 5.33 p.m.
Sitting suspended at 5.19 p.m. and resumed at 5.33 p.m.