Neale Richmond
Question:783. Deputy Neale Richmond asked the Minister for Health if the introduction of lung cancer screening is a priority for him; and if he will make a statement on the matter. [42090/20]
View answerHealth Screening Programmes
Questions (783)
Written answers
The National Screening Advisory Committee (NSAC) was established in 2019 and has held four meetings to date. The Committee’s role is to undertake an independent assessment of the evidence for screening for a particular condition against internationally accepted criteria and make recommendations accordingly.
As part of its body of workthe Committee will implement an agreed methodology for accepting applications to consider new, or revisions to, existing population-based screening programmes in Ireland.
Ireland has always evaluated the case for commencing a national screening programme against internationalaccepted criteria collectively known as the Wilson Jungner criteria. The evidence bar for commencing a screening programme should and must remain high. This ensures that we can be confident that the programme is effective, quality assured and operating to safe standards.
The addition of any new population-based screening programmes, or modifications to existing programmes, will be incorporated as part of the Committee's work programme following a robust, methodologically sound and detailed analysis of the evidence in each and every case against internationally accepted screening criteria.
Updates in relation to screening will be posted on the NSAC website (https://www.gov.ie/en/campaigns/nsac/)
Cancer Services
Questions (784)
Neale Richmond
Question:784. Deputy Neale Richmond asked the Minister for Health if patient organisations specific to lung cancer are consulted by him on their approach to lung cancer treatment and supports; if so, the groups; if not, the reason; and if he will make a statement on the matter. [42091/20]
View answerWritten answers
The HSE's National Cancer Control Programme (NCCP) has worked closely with voluntary organisations, including the Irish Cancer Society, Breakthrough Cancer Research and the Marie Keating Foundation, in the design and delivery of lung cancer awareness campaigns.
The NCCP consistently recognises and engages with patient organisations as key partners in relation to survivorship initiatives. To this extent the NCCP has delivered new "Think Lung" resources to improve the early detection of lung cancer for use by primary care and community organisations who work with the population most at risk. These include educational slides, a partner pack for community organisations and briefing sheets for healthcare professionals.
The NCCP also supported the Irish Cancer Society Early Detection of Lung Cancer Public Awareness campaign by inputting to intervention design and by providing spokespeople for media interviews. They also worked with the Marie Keating Foundation to develop and deliver an early detection of lung cancer campaign at end of November 2020.
Cancer Services
Questions (785, 786, 787)
Neale Richmond
Question:785. Deputy Neale Richmond asked the Minister for Health if a new approach to lung cancer is required given that Ireland has the second highest rate of lung cancer mortality in Europe; and if he will make a statement on the matter. [42092/20]
View answerNeale Richmond
Question:786. Deputy Neale Richmond asked the Minister for Health if his Department has carried out research into the reason lung cancer mortality rates are dramatically different for men and women in Ireland; and if he will make a statement on the matter. [42093/20]
View answerNeale Richmond
Question:787. Deputy Neale Richmond asked the Minister for Health if a female-centred awareness campaign for lung cancer is required given that female mortality rates for lung cancer are dramatically higher than those for men; and if he will make a statement on the matter. [42094/20]
View answerWritten answers
I propose to take Questions Nos. 785 to 787, inclusive, together.
Lung cancer remains the leading cause of cancer mortality among both males and females in Ireland. The National Cancer Registry advises that data from 2015-2017 shows that mortality rates for lung cancer were higher in males (40.3/100,000) compared to females (28.4/100,000).
While cancer incidence and mortality rates are increasing in females and decreasing in males, absolute numbers of lung cancer cases in both sexes are projected to increase significantly by 2035 due to factors including demographic changes in the population, with our increasing and ageing population. Indeed, increasing lung cancer incidence and mortality rates in females have been observed internationally, with recent academic papers highlighting this as a priority area for future research.
Work to increase awareness and early detection of lung cancer is being progressed in line with the National Cancer Strategy. Lung cancer has been chosen as the first cancer on which to focus in a rolling programme of targeted multi-media based public awareness and education campaigns, aimed at the early detection of specific cancers and with particular focus on at-risk populations. The Lung Cancer Awareness Campaign was scheduled for roll-out in April 2020 but was postponed due to the Covid pandemic.
Reducing lung cancer incidence and mortality remains a priority under the National Cancer Strategy 2017-2026. The HSE's National Cancer Control Programme (NCCP) is working to increase awareness and early detection of lung cancer, and to increase survival rates. There have been many improvements in cancer treatment and outcomes over the last number of years, driven by initiatives under successive cancer strategies. It is hoped that the targeted lung cancer awareness campaigns referenced above will result in more cancer's being detected earlier, leading to better outcomes for patients.
Questions Nos. 788 and 789 answered with Question No. 538.
Covid-19 Pandemic
Questions (790)
Róisín Shortall
Question:790. Deputy Róisín Shortall asked the Minister for Health if clinical guidance from the Royal College of Obstetricians and Gynaecologists in the UK, which states that women who are 28 weeks pregnant and beyond are at increased risk of becoming severely ill should they contract Covid-19, has been considered in line with the HSE's policy with regard to risks that Covid-19 poses to women; and if health and safety leave will be granted in the event that a pregnant woman's doctor recommends going on leave due to a heightened risk of falling severely ill (details supplied); and if he will make a statement on the matter. [42125/20]
View answerWritten answers
Given the role of the HSE's National Women and Infants Health Programme in the dissemination of pregnancy related clinical guidelines, I have asked the Health Service Executive to respond to the Deputy directly, as soon as possible.
Addiction Treatment Services
Questions (791)
Alan Dillon
Question:791. Deputy Alan Dillon asked the Minister for Health the amount of funding allocated in 2020 and planned for 2021 to support services for the treatment of addictions, including alcohol addiction; and if he will make a statement on the matter. [42126/20]
View answerWritten answers
The national drug strategy, Reducing Harm, Supporting Recovery, is the Government roadmap for a health-led response to drug and alcohol use.
Expenditure on HSE addiction services increased from €94 million in 2016 to over €100 million in 2019. This funding is used by the HSE to deliver a wide range of national policy objectives as outlined in the National Drugs Strategy including a focus on early intervention; treatment; and rehabilitation. This in turn helps people with substance misuse issue to achieve better health outcomes.
Additional funding of €3m was provided for addiction services in 2020. This funding supports the implementation of the Health Diversion Programme, to expand addiction services for pregnant and post-natal women, and to develop a community alcohol service in Galway and a residential treatment service for women and children in the mid-west region.
I announced new funding of €4.1m for the following drug and alcohol services in Budget 2021:
- €1m to develop targeted drug and alcohol initiatives through the network of drug and alcohol task forces, and to increase core funding for existing services;
- €2m to increase residential treatment services for people with severe drug and alcohol dependency across the country, including a step-up stabilisation facility in CHOs Cork/Kerry, Mid-West and South East and a low threshold programme in Dublin North East Inner City;
- €700,000 to expand community and family support services, including initiatives in Donegal/Leitrim/Sligo, Louth/Meath, Cork/Kerry, and Dublin North Inner City; and
- €400,000 for harm reduction initiatives, including pilot drug monitoring at festivals and the night-time economy, expanded access to the drugs and alcohol helpline, and increased provision of naloxone.
A further €4.2 million will be provided in 2021 for the continued treatment of an additional 700 clients on opioid substitution treatment (OST), who were given access to OST in 2020 under the Covid-19 contingency plan for people who use drugs.
I believe that Budget 2021 is a significant step forward in delivering on the commitment in the Programme for Government to expand the availability of addiction services, including alcohol addiction.
Health Promotion
Questions (792)
Alan Dillon
Question:792. Deputy Alan Dillon asked the Minister for Health his plans to review progress and renew the Healthy Ireland strategy where necessary, given that we are now seven years into the Healthy Ireland planned timeframe of 2013-2025; and if he will make a statement on the matter. [42127/20]
View answerWritten answers
Healthy Ireland, A Framework for Improved Health and Wellbeing 2013-2025, is the national framework for action to improve the health and wellbeing of Ireland. The Framework is now past the mid-way point for the implementation.
Since publication in 2013, there has been significant progress in implementation. This has included:
- A focus on building an enabling environment for cross-sectoral and collaborative action, supported by a stakeholder engagement and communications strategy;
- Significant cross government and intersectoral partnerships and working has been created by the Framework; and
- A suite of national policies and plans to address risk factors such as obesity, tobacco and physical inactivity have been published, and policy direction across areas such as cancer, maternity care, drugs and mental health has been informed and influenced by Healthy Ireland.
Notwithstanding the progress to date, there is an urgent need to scale and expand the activity across all strands of the work from Government to local level. To support effective implementation, and to capitalise on further opportunities to involve more sectors in implementation.
In late 2019, the Health and Wellbeing Unit in my Department commenced the development of a Strategic Action Plan for the next phase of the Healthy Ireland Framework. Despite the challenges caused by Covid-19, which has caused some delays to the original timeline for this process, significant progress on the development of the Strategic Action Plan for Healthy Ireland has been made. To date the process has already completed a rapid review of previous progress, extensive stakeholder engagement, a desktop review of other jurisdictions for best practice, and a review of goals for alignment with the Sustainable Development Goals and the Programme for Government.
Presently a set of emerging priorities is being considered in partnership with other Government Departments and internally in the Department of Health. The Healthy Ireland Strategic Action Plan is expected to be finalised in early 2021, for agreement across Government and subsequent publication.
Medical Cards
Questions (793)
Alan Dillon
Question:793. Deputy Alan Dillon asked the Minister for Health his plans to provide temporary discretionary medical cards to all cancer patients to offset medical charges for their treatment; and if he will make a statement on the matter. [42128/20]
View answerWritten answers
Under the Health Act 1970, eligibility for a medical card is based primarily on means. The Act obliges the HSE to assess whether a person is unable, without due hardship, to arrange general practitioner services for himself or herself and his or her family, having regard to his or her overall financial position and reasonable expenditure. The issue of granting medical cards based on having a particular disease or illness was previously examined in 2014 by the HSE Expert Panel on Medical Need and Medical Card Eligibility. The Group concluded that it was not feasible, desirable, nor ethically justifiable to list medical conditions in priority order for medical card eligibility. In following the Expert Group’s advice, a person’s means remains the main qualifier for a medical card.
However, every effort is made by the HSE, within the framework of the legislation, to support applicants in applying for a medical card and, in particular, to take full account of the difficult circumstances in the case of applicants who may be in excess of the income guidelines. The HSE may exercise discretion and grant a medical card, even though an applicant exceeds the income threshold where they face difficult financial circumstances, such as extra costs arising from an illness. Social and medical issues are also considered when determining whether undue hardship exists for an individual accessing general practitioner or other medical services.
While it is none the less important to note that eligibility for a medical card remains primarily on the basis of financial assessment, I do recognise that patients require a responsive and efficient health system to meet their medical needs, which may often be required urgently. The HSE therefore has a system in place for the provision of medical cards in response to emergency situations. For example, where persons are in need of urgent or on-going medical care that they cannot afford, medical cards are granted on an emergency basis which are valid for six months with a means test required before the end of this period for the person and their family, where applicable.
Separately, where the HSE is informed that a patient is receiving end of life treatment – that is when patients’ unfortunately have a prognosis of less than 12 months, a medical card is issued within 24 hours of receipt of the required medical report and a completed application form from a healthcare professional. Medical cards awarded on the basis of end of life criteria do not require a means assessment nor are they reassessed.
Furthermore, since 2015 medical cards are awarded without the need of a financial assessment to all children under 18 years of age with a diagnosis of cancer.
Medical Cards
Questions (794)
Alan Dillon
Question:794. Deputy Alan Dillon asked the Minister for Health his plans to issue medical cards or general practitioner visit cards to patients who have a listed long-term illness; and if he will make a statement on the matter. [42129/20]
View answerWritten answers
Under the Health Act 1970, eligibility for a medical card is based primarily on means. The Act obliges the HSE to assess whether a person is unable, without due hardship, to arrange general practitioner services for himself or herself and his or her family, having regard to his or her overall financial position and reasonable expenditure. The issue of granting medical or GP visit cards based on having a particular disease or illness was previously examined in 2014 by the HSE Expert Panel on Medical Need and Medical Card Eligibility. The Group concluded that it was not feasible, desirable, nor ethically justifiable to list medical conditions in priority order for medical card eligibility. In following the Expert Group’s advice, a person’s means remains the main qualifier for a medical card.
However, every effort is made by the HSE, within the framework of the legislation, to support applicants in applying for a medical card and, in particular, to take full account of the difficult circumstances in the case of applicants who may be in excess of the income guidelines. The HSE may exercise discretion and grant a medical card, even though an applicant exceeds the income threshold where they face difficult financial circumstances, such as extra costs arising from an illness. Social and medical issues are also considered when determining whether undue hardship exists for an individual accessing general practitioner or other medical services.
Finally, it should be noted that there are currently over 1.5 million medical card holders and approximately 532,000 GP visit card holders.
Vaccination Programme
Questions (795)
Róisín Shortall
Question:795. Deputy Róisín Shortall asked the Minister for Health if all orders and requests for the flu vaccine have now been provided to general practitioners and pharmacists; if the HSE retains some supply; the extent of those supplies; and if he will make a statement on the matter. [42132/20]
View answerWritten answers
1.95 million doses of influenza vaccine, including 1.35 million doses of the Quadrivalent Influenza Vaccine (QIV) for administration to all persons in an at-risk group and 600,000 doses of the Live Attenuated Influenza Vaccine (LAIV) for all children aged from 2 to 12 years old inclusive, have been made available for the current influenza vaccination programme. The amount of vaccine made available for this winter is almost double the amount of vaccine administered last winter.
Over 1.33 million of the 1.35 million doses of flu vaccine available this winter have been distributed to GPs, pharmacists and other vaccination sites. Deliveries are continuing, no stock is being retained by the HSE and stock is expected to be depleted by the end of the year. In addition, over 460,000 doses of the LAIV for administration to children aged from 2 to 12 have been distributed.
Notwithstanding the large increase in available vaccine this year, the full supply of QIV may be used, representing an increase of 35% in uptake over last year. At that stage, the HSE estimates that sufficient stock will have been delivered for an uptake in excess of 80% in the targeted groups. Not all persons eligible under the programme avail of vaccination, and so it is not possible to quantify the number of persons who may still be awaiting vaccination.
Given the demand on the international market for influenza vaccine, it is not likely to be possible to procure additional supply. As a consequence, from the fourth round of deliveries which started on 23 October, GPs and pharmacists have been asked that of remaining patients in at-risk groups, priority should be given to the over-65s and healthcare workers with direct patient contact, in line with WHO advice.
As of 3rd December, over 1.1 million claims for reimbursement from GPs and pharmacists for the administration of influenza vaccines have been received by PCERS.
The significant increase in uptake among those in the at-risk groups, combined with the addition of vaccination for children aged from 2 to 12, will help reduce the impact of influenza on the community and the health system.
Departmental Staff
Questions (796)
Gary Gannon
Question:796. Deputy Gary Gannon asked the Minister for Health the percentage or number of staff working with a disability within his Department and the agencies under his aegis in 2018 to 2020, inclusive; and the actions being undertaken by his Department to actively recruit and retain persons with disabilities. [42146/20]
View answerWritten answers
My Department has not yet compiled the numbers of its staff with a disability for 2020 but the numbers for 2018 and 2019 are set out in the attached table. On the basis of the numbers for 2019, my Department had achieved the commitment set out in the Comprehensive Employment Strategy for People with Disabilities 2015-2024 to increase the percentage of its employees with a disability on an incremental basis from a minimum of 3% to a minimum of 6% by 2024.
The staff of the Department are recruited through the Public Appointments Service which is strongly committed to equality of opportunity in all its employment practices, including for people with disabilities, and which promotes diversity and inclusion throughout the Civil and Public Service.
The Department has a dedicated Disability Liaison Officer who promotes awareness of disability and the needs of people with disabilities amongst staff, who supports and assists staff with a disability and who reports annually to the Department of Public Expenditure and Reform on the employment of people with disabilities. The Department has also participated in the Civil Service WAM (Willing, Able, Mentoring) and Job Shadow initiatives by providing work placements to people with disabilities. In addition, in early 2020 the Department provided transition year work experience placements to a group of young people with a disability.
The Department has asked the HSE and other health agencies to compile the information requested and to reply directly to the Deputy.
|
Year |
No. of people with a disability |
Total no. of staff |
% of staff with a disability |
|
2018 |
22 |
498 |
4.4 |
|
2019 |
37 |
499 |
7.4 |
Covid-19 Pandemic
Questions (797)
Carol Nolan
Question:797. Deputy Carol Nolan asked the Minister for Agriculture, Food and the Marine the number of calls made to the information line to assist farmers with their queries about current Covid-19 restrictions; the number of staff in his Department assigned to provide the service; and if he will make a statement on the matter. [41102/20]
View answerWritten answers
My Department opened its Covid-19 helpline on 1st April 2020 in order to assist farmers and others with Covid related queries that apply to agriculture and related issues. Since then, the helpline has received a total of 975 calls. The number of staff assigned to this service is kept under review and varies based on demand at any given time.
Currently, two staff are allocated to answering the helpline and, due to the volume of calls, this can take place in addition to other work. This number is sufficient to provide a prompt response time to callers and can be increased as necessary. The Department also provides farmers with information and advice through the Covid-19 Hub on its website - Gov.ie/agriculture.
Trade Relations
Questions (798)
Catherine Murphy
Question:798. Deputy Catherine Murphy asked the Minister for Agriculture, Food and the Marine if his attention has been drawn to correspondence (details supplied) sent to him by registered post; the steps he is taking to address the matters raised; and if he will engage with the correspondent. [41245/20]
View answerWritten answers
I am aware of the correspondence that the Deputy refers to, and I would say firstly that trade policy is a matter for the Department of Enterprise, Trade and Employment in the first instance.
Nonetheless, I am aware that the current trade tensions between the US and the European Union are a matter of concern, given the importance of EU-US bilateral trade to the Irish food and drink industry, which came to an overall value of €1.6 billion in 2019.
Ireland has raised its concerns at EU level, including at recent Informal Trade Policy Committee meetings.
I believe, ultimately, that a negotiated settlement is the preferred way to address this current tariff dispute, as a further escalation would not serve the interests of either the EU or USA. I hope that this will be the case, and that we continue to see the benefits of free trade for manufacturers and consumers, both in the USA and in the EU.
Departmental Legal Costs
Questions (799)
Catherine Murphy
Question:799. Deputy Catherine Murphy asked the Minister for Agriculture, Food and the Marine if he will provide a schedule of legal costs his Department paid to persons in respect of High Court actions in 2008; if he will provide a schedule of compensation payments made to persons by his Department in 2008; and if he will include whether persons that were awarded payments were also reinstated to their duties in his Department. [41252/20]
View answerWritten answers
I understand that information is sought in respect of employees or former employees of my Department only.
I can confirm that for 2008, legal costs totalling €424,579 were paid out in respect of three cases involving employees of my Department.
It is not appropriate for me, as Minister, to comment on individual cases involving employees or former employees of my Department.
Departmental Staff
Questions (800)
Catherine Murphy
Question:800. Deputy Catherine Murphy asked the Minister for Agriculture, Food and the Marine if his attention has been drawn to correspondence (details supplied) in respect of a person; if he has received a full historical briefing in respect of this person; if his attention has been drawn to apparent inconsistencies regarding the person's resignation date; if his attention has been further drawn to claims that the person is of a view that he or she has not resigned as an official of his Department; and the steps he will take to address this case in order to draw it to a conclusion. [41254/20]
View answerWritten answers
As this relates to issues surrounding a former employee of this Department, it is not appropriate for me, as Minister, to comment on this situation.
Equine Industry
Questions (801)
Aengus Ó Snodaigh
Question:801. Deputy Aengus Ó Snodaigh asked the Minister for Agriculture, Food and the Marine the steps that have been taken to ensure that the programme for Government commitment to prioritise equine welfare, based on a robust traceability system, building on existing inspectorate supports across the country and ensuring a consistent approach to dealing with horse welfare issues across local authorities, is progressed. [41258/20]
View answerWritten answers
My Department continues to prioritise equine traceability and equine welfare. Commission Implementing Regulation (EU) 2015/262, which came into effect on 1 January 2016, lays down the rules governing the identification of equidae. This legislation was transposed into national legislation in Ireland via the European Union (Identification of Equidae) Regulations (S.I. No 62 of 2016)(as amended).
Proper identification is comprised of four elements, all of which must be in place within twelve months of the date of birth of the animal. These comprise:
- a single lifetime identification document (passport) containing a unique lifetime identification number (UELN) in respect of the animal, issued by an approved Passport Issuing Organisation (PIO);
- all equines issued with a passport since 1st July 2009 must have a corresponding microchip inserted, by a practicing veterinary surgeon, the unique number of which is recorded on the corresponding passport to ensure an unequivocal link between the animal and the identification document;
- a database recording of specific identification data in the database of the PIO that issued the passport; and
- a database entry in the central equine database of the country where the issuing PIO is approved.
In addition, persons in charge of any premises in which equines are kept are required to register their premises with my Department and to maintain records to assist the Department in tracing horses, should a disease outbreak occur. Furthermore, as part of the identification process for equines resident in Ireland, an owner/keeper who applies to have their horse identified is requested to provide the premises registration number of the holding where the animal will be normally resident to the issuing PIO.
The Equidae (Transfer of Ownership) Regulations 2016 (S.I. No 201 of 2016) governs the transfer of ownership of equine animals and requires that transfer of ownership details be notified to the relevant PIO and the central database within 30 days of date of transfer.
My Department continues to dedicate a substantial level of resources and funding to animal welfare. In December 2019, the largest ever allocation of funding from my Department of €2.906m to 106 animal welfare organisations was announced. A number of other organisations undertake work with equines. I will make an announcement of funding for 2020 shortly.
The Programme for Government also contains commitments to provide additional urban horse welfare programmes. My Department continues to take a proactive approach in tackling challenges by developing facilities for urban and Traveller horse populations and in educating young people among these communities in the care and welfare of horses. This work is carried out in close collaboration with the local authorities, and will be reflected in the new Animal Welfare Strategy which I will launch shortly.
My Department continues to support a number of urban horse projects nationwide, bringing education on all aspects of equine welfare to disadvantaged areas. As an example, the DSPCA with financial assistance from my Department, continues to facilitate castration and ID clinics and education programmes in an effort to address the problem of over-breeding which can add to welfare issues.
The Control of Horses Act, 1996 is currently under review within my Department and plans for replacement legislation are well advanced. My Department will be further engaging on this with stakeholders at an early date. Under the Act, local authorities may take a range of actions in relation to equines including prohibiting horses in certain areas, the issuing of licences, the seizure of horses in contravention of the Act. These powers can be used in respect of straying horses which includes horses put on land without the owner’s permission, including public land. The local authorities may also prosecute offenders under the Control of Horses Act. While still at an unacceptable level, the overall numbers of equines seized have been falling year-on-year from a high of approximately 5,000 in 2014 to less than 900 in 2019.
My Department continues to support other agencies and local authorities in the enforcement of horse welfare related matters.
The Deputy may be aware that my Department operates a confidential animal welfare helpline through which members of the public can report incidents of animal cruelty or neglect for investigation. If the Deputy wishes to pass on details of any cases of alleged neglect or cruelty that she is aware of, they will be fully investigated by my Department and appropriate actions, up to and including prosecution, may be taken.
The dedicated e-mail address and Helpline in place for reporting suspected cases of animal welfare are:
Helpline Phone No. Call Save - 0761 064408, phone - 01 607 2379 and the email address -animalwelfare@agriculture.gov.ie.
Equine Industry
Questions (802)
Aengus Ó Snodaigh
Question:802. Deputy Aengus Ó Snodaigh asked the Minister for Agriculture, Food and the Marine the steps that have been taken in conjunction with local authorities to ensure that the licensing and welfare of horses is taken seriously, especially in built-up areas. [41259/20]
View answerWritten answers
The Control of Horses Act 1996 addresses situations when horses are kept in unsuitable conditions resulting in horses wandering onto public roads or public lands, posing serious risks to the public, especially motorists and young children. The Act provides for the designation, by local authority byelaws, of control areas in which horses cannot be kept without a licence. The Act also contains provisions on the licensing procedure and the identification of horses. Enforcement of the Act is a matter for each Local Authority and the matter of licencing is best discussed with the Local Authorities directly.
My Department continues to dedicate a substantial level of resources and funding to animal welfare. In December 2019, the largest ever allocation of funding from my Department of €2.906m to 106 animal welfare organisations was announced - several of these work with equines. I expect to make an announcement of funding for 2020 shortly.
The Programme for Government includes commitments prioritise equine welfare, and to provide additional urban horse welfare programmes in particular. My Department continues to take a proactive approach in tackling challenges by developing facilities for urban and Traveller horse populations, and in educating young people among these communities in the care and welfare of horses. This work is carried out in close collaboration with Local Authorities.