Leaders' Questions

Yesterday the waiting lists were published and, unfortunately, it was like Groundhog Day all over again. Ten years ago there were 21,000 people on waiting lists for surgical and medical treatments and day-case or diagnostic treatments. Yesterday the list showed that there were 684,800 patients waiting on lists of various types: outpatient, 494,530; inpatient day-case, 80,894; endoscopy - active, 19,300; inpatient day-case, 18,000; inpatient day-case planned procedures, 11,700; planned procedures for endoscopy, 51,000; and endoscopy, 8,294. The reason I reference all those lists is simply that nobody knows how many people are waiting anymore because we consistently change the goalposts. We consistently change how we assess the numbers of people on waiting lists. We now have a situation where we have so-called suspended lists. One is suspended from the list, one is in abeyance, and then one is brought back onto an active list at some stage. People suffering with juvenile arthritis, scoliosis and several other paediatric illnesses and diseases are waiting inordinate periods of time for outpatient and inpatient procedures. It is wholly unacceptable.

In the NHS in England, there are 1,511 people waiting more than a year for an inpatient appointment. In Galway hospital alone, there are 2,914 waiting more than a year for an inpatient appointment. The fact of the matter is the health services are in crisis. Yesterday, if the Tánaiste wanted to seek clarity on that, all she had to do was read the Minister's two press releases, both contradictory, one trying to correct the other in terms of targets achieved and targets missed, numbers who were seen and numbers who were not seen. There were corrections even in the context of the press releases sent out.

Finally, we have a situation where advertisements are being issued for winter readiness and proofing of the health services for winter. One senior hospital manager told me that the only programme in place was the flu vaccine and prayers. The flu vaccine and prayers were how prepared we were for the winter initiative in some of our hospitals.

I raised this a number of weeks ago. Will the Tánaiste accept that a great deal has to be done, both in the context of the waiting lists themselves, enhancing capacity and ensuring people are seen in a timely manner, but also in the short and medium term on the issue of ensuring that our hospitals can cope with what will be thrown at them this winter?

Dealing with these issues is a priority for the Government. It is a priority for the Minister for Health, as every action he has taken supports that. This is shown by the budget that has been given for the health service, the new initiatives, the increase in the funding for the National Treatment Purchase Fund and the €1 million per week extra that will be spent on dealing with waiting lists, and the fact that the trend is downward.

There is much work to be done. Nobody questions that. I ask the Deputy to look at four hospitals with the lowest numbers on trolleys since 2006, Beaumont, Mayo, Cavan and Connolly. It is important to note this progress.

No doubt there is a huge challenge. Given the demographics, the fact people are living longer and the demand on the health services, and as we develop more primary care centres, of course, the demand continues in the hospitals. It is important to note that the home care packages, numbering 45 extra a week, will help deal with these issues because people will be able to get the services they need at home.

The truth in regard to waiting lists is that the latest NTPF figures show that the number of patients waiting for a procedure has fallen by over 2,000 in the past month and it is the third month in a row the inpatient day-case list has fallen. This is the category of patients who are actively waiting for treatment and these reductions have to be seen as real progress.

I accept the Deputy's point that more needs to be done - we cannot relax for one moment in regard to this because of the level of demand - but let us look at what is happening in the context of the trend being downward. There were significant decreases in October in both the 15-to-18 month waiting list, which was down over 1,000, and the over 18 months category, which was down over 1,000. For the second month in a row, there was also a decrease in the total number of patients waiting for an outpatient appointment with 788 fewer patients waiting for an outpatient appointment.

On the Deputy's point that patients were suspended because their doctors had decided they were unfit or unable to attend for clinical or personal social reasons, that is a reasonable thing to do because the people were not in a position to take up the appointments, and Deputy Kelleher himself asked for this.

The Minister has accepted the Deputy's broader point about the accuracy of waiting lists and how waiting lists in this country compare with those internationally. Trinity College is conducting a study on how waiting lists are compiled in this country and how it compares internationally and we will have that information at the beginning of next year.

If the Tánaiste wanted any evidence that our health services are in crisis, all she need do is go over to the Oireachtas print shop and see the number of Fine Gael Ministers and Deputies dispensing leaflets pointing out that one can get EU cross-border treatment and avail of treatment abroad schemes. Deputy Michael Collins from west Cork raised a case quite recently of a 91 year old man from west Cork who had to go to Belfast for cataracts because he was waiting so long. The fact of the matter is even the Tánaiste's own Cabinet colleagues and Deputies are running around the countryside dispersing leaflets advising people that the only way one can get treated is in another jurisdiction because of the Government's failures. That is what is happening.

They were exposed by Deputy Michael Collins.

Could we just accept for one moment that there are huge pressures on the health services? All this spin has to stop because people across the country are waiting inordinate periods of time in agony. Recently, a case was brought to me by Deputy Dooley of a very elderly man waiting over two years for an appointment even though it was marked urgent and he was in chronic pain and in need of a hip replacement. Every Deputy in this House could bring the Tánaiste instances of this. Will the Government accept that a great deal more has to be done, other than the spin and the PR, moving the targets and extending the waiting times, as was done by the Minister, Deputy Harris's predecessor who is now the Taoiseach? That is the reality of what is happening with Fine Gael's health policies at present and its only answer seems to be deliver leaflets to advise people how they can get treated outside this jurisdiction.

The Deputy referred to individual cases. Of course, nobody wants to see anybody waiting a day longer than is necessary.

Thousands of them.

Seven hundred thousand.

It is extremely important that the Deputy accepts that every effort is being made to deal with the waiting lists. The trend is going in the right direction. I accept that is no help for the individual to whom the Deputy referred.

The point is that it is an absolute priority to deal with this issue in a variety of ways. First of all, real money is being put in to deal with the 500 more operations for those who need hip and cateract procedures, etc., by the end of the year. There is €1 million a week to deal with waiting lists. The National Treatment Purchase Fund will have an allocation next year of €55 million, a huge increase to deal with people on those waiting lists. We accept that people are waiting too long.

In terms of Deputy Kelleher's point about people informing citizens of their rights as EU citizens-----

It was the Goverment's only answer.

-----it seems reasonable to me that that should be done.

It is, but it is the Government's only answer.

Is Deputy Kelleher suggesting that they should not be told what their rights are as EU citizens? The Deputy will be aware we have always had, and encouraged, cross-Border health care initiatives. That has worked well. We would like to see that continuing.

The Tánaiste knows it is an utter failure.

We accept that this is a huge challenge. I reiterate it is an absolute priority.

Our evidence is of providing leaflets rather than interest in the health service.

We care every bit as much as the Deputy about people who are on waiting lists, which is why we are making every effort to make sure people will spend less time on waiting lists and that the necessary resources will be given to the health service. It was an absolute priority in the budget to provide the kind of money that would make a difference and reduce waiting lists. The Deputy should acknowledge that the trend is in the right direction, but it is a huge challenge.

At the end of September, the European Medicines Agency in London held a public hearing on the epilepsy drug sodium valproate, better known in Ireland as Epilim. The purpose of the hearing was to consider whether the warning against taking the drug while pregnant was strong enough. It followed on from a review in 2014 based on which the European Medicines Agency took the decision to strengthen the restrictions on valproate containing medicines owing to the risk of malformations and developmental problems in children exposed to the drug in the womb. The agency's most recent summary guide for health care professionals on the risks associated with valproate for female patients issued in 2016 states: "Sodium valproate should not be used in female children, in female adolescents, in women of childbearing potential and pregnant women unless alternative treatments are ineffective or not tolerated because of its high teratogenic potential and risk of developmental disorders in infants exposed in utero to valproate". In its most recent valproate patient toolkit the HSE states: "If you take valproate when you are pregnant it can harm your unborn child". The leaflet goes on to state that for women who take valproate while pregnant around ten babies in every 100 will have a birth defect and that about 30 to 40 children in every 100 may suffer from developmental problems. Shockingly, it was only earlier this year that instructions were issued to include a warning label for the outer packaging of Epilim products that had been introduced in Ireland, but they still not being adhered to everywhere. Unfortunately, these measures have come too late for some. A number of women in Ireland, some of whom are in the Visitors Gallery, were not informed about the harmful repercussions for their unborn child when they were prescribed and took sodium valproate while pregnant. In 2013 Epilepsy Ireland estimated that the drug had affected at least 400 children. The syndrome which affects these children is known as foetal anticonvulsant syndrome or foetal valproate syndrome. It can give rise to spina bifida, heart defects, breathing difficulties, overlapping fingers and toes, club foot, hip dislocation and distinctive facial characteristics.

Last week, I met Karen, Wendy and Susan, all of whom had been prescribed sodium valproate while pregnant and all of whom have children with foetal valproate syndrome. They are not looking for much. Will the Government undertake an investigation into the current and historical use of the drug? Will it acknowledge that these women should be compensated for the impact of the drug on their families? Will it also commit to establishing a State-wide register for those who are on the medicine and those who will be prescribed it in the future, as well as a register for the children who have been affected by foetal anticonvulsant syndrome caused by exposure to sodium valproate? As a matter of urgency, will it put in place appropriate pathways for the diagnosis and treatment of foetal anticonvulsant syndrome, as well as providing additional services for children with the syndrome? Previous Governments did not exactly cover themselves in glory when it came to women's health issues. We have seen Taoisigh and Ministers for Health stand where the Tánaiste is and apologise to women. She has a chance to do this right. I ask her to take that chance.

The Deputy raises an issue about a drug that women have been prescribed during pregnancy. As she said, this is not the first time issues have arisen about drugs prescribed during pregnancy which potentially have extremely adverse effects. We have seen this happen in the case of thalidomide and numerous other drugs and women have had to fight quite hard to prove the consequences of the use of such drugs. I am not familiar with the details of the particular drug, but the Minister for Health is informed on issues such as this by the Chief Medical Officer, CMO and the Health Products Regulatory Authority, HPRA, which regulates the use of medicines and drugs. Obviously, there are always clinical decisions involved in the use of a particular drug or prescription. The Minister has heard what the Deputy said and I have no doubt that he will seek a report from the CMO and the HPRA on the particular drug and revert to the Deputy with the details of the information available at this point. The Deputy has said that up to 400 children have been impacted on. If there is information to that effect - I take the Deputy's word for it - clearly it is an issue that needs to be addressed. Further information must be obtained and the clinical position in terms of prescriptions and their impact and so on will have to be examined. I am not in a position to give the Deputy a detailed answer on the drug today, but the Minister will get the information and revert to the Deputy on it.

I thank the Tánaiste for her response. The families affected believe they have been ignored, sidelined and let down by the State. I am giving the Tánaiste an opportunity to make a statement on behalf of the Government to the effect that it will consider the issues of compensation, establishing a register for those who have taken or will take valproate and the putting in place of appropriate care pathways. The women concerned have had to fight for every single element of treatment for their children. They have had to fight and scrap hard and want to hear that the Tánaiste, the Government and the Dáil are on their side. They want to know that the Government is on their side and will not treat them in the same way it treated other women who fought for themselves and their families. There is a black mark on the history of the State in that regard, as the Tánaiste has acknowledged. We have an opportunity to do this the right way and I urge the Government to take it.

As the Deputy said, the European Medicines Agency has started a review of the approach to use of this drug. Very strict warnings are in place in prescribing it for women and girls. It is a drug that is prescribed across Europe. A review is under way and it is expected that a decision will be made by the end of the year by the European Medicines Agency on whether there should be further warnings about the drug being given to women who are pregnant or girls. This is a European as well as an Irish issue. I have no doubt that the Minister for Health will take the results of the review fully into account when making a decision on the management of this issue, as will the HPRA.

I refer to the finding of the Workplace Relations Commission, WRC, that one of the Government's Ministers of State, Deputy John Halligan, discriminated against a serving civil servant during the course of an interview. A number of issues arise. First, on the payment of the fine imposed, I am concerned that a double standard is being applied. The Tánaiste will recall that when the Government finally confirmed that an unlawful overpayment had been made to a Minister of State, through no fault of the Minister of State concerned, it was determined that the sum should be repaid. I understand arrangements for the Minister of State to repay the money are in place, but we have not heard a word from the Tánaiste or the Government about this fine, despite the fact that it had been imposed as a result of the Minister of State's own personal breach of employment equality legislation. In that context, I ask the Tánaiste to clarify whether the Minister of State will be required to recoup to the Department the full amount of the fine.

The next issue is apologising to the victim of the discrimination. During the course of the aforementioned interview the Minister of State began by saying, "I know I shouldn't be asking this;" therefore, we can see clearly that he had full knowledge that on what he was embarking was wrong. Without playing word games, will the Tánaiste take the opportunity to apologise and make it clear that this approach which we thought had disappeared from interviews 20 years ago or more is not tolerated as part of normal procedures?

Will there be other consequences for Deputy John Halligan, given that he is a Minister of State in the Department responsible for equality law and has broken that law?

I was disturbed by and disappointed to read the decision of the Workplace Relations Commission. I read it again this morning. It is absolutely clear that the Minister of State's questions during the interview were discriminatory and unacceptable.

The Minister of State, Deputy Halligan, has expressed regret for what happened. The incident should never have happened and he has accepted that. Deputies will be aware of the importance I place on gender equality. Many of us in this House, including Deputy Howlin, worked for a long time to make sure that having a family should never be interfered with, whether one was promoted or got a job. We worked hard to ensure there would be strong anti-discrimination and equality legislation in place. Indeed, Ireland's body of employment law protects all persons employed in Ireland. Clearly, we never want to see sexual orientation, religious belief, age, disability, race or membership of the Traveller community placing a barrier when one is looking for a job. That is the first point, on which I think we are all extremely clear.

The Minister of State, Deputy Halligan, has issued a statement and has expressed regret. In regard to the Deputy's point about an apology, of course, the person is owed an apology and I would unequivocally give that on behalf of the Department. We certainly regret what happened and accept the decision of the Workplace Relations Commission which was issued yesterday. In regard to the fine, the obligation falls on the Department to pay that fine, and that is the situation, whatever approach the Minister of State, Deputy Halligan, takes. I am sure, no doubt, that when he returns on Sunday - he is abroad at present - he will give a more detailed statement-----

Is there a war in Thailand as well?

He will give a more detailed statement in regard to some of the issues the Deputy has raised and in regard to some of the discrepancies the Deputy mentioned. As I said, the Deputy has raised a number of issues in regard to this. The Minister of State has expressed his regret and I certainly accept that he has done that.

I thank the Tánaiste for the clarity of her response. The battle for equality in terms of employment for women has been a very long battle and it is not over. On the notion that Ministers would revert to practices that we really thought were gone, I do not think anyone in any interview situation would begin to believe one could ask those sorts of questions now. This level of clarity might be something positive to emerge from this debacle, and I thank the Tánaiste for that. There should be no ambivalence in regard to the type of questions that are appropriate because other employers will look at and take signals from this. I welcome what the Tánaiste has said. I ask her to go further and be crystal clear that the whole process of ensuring complete equality in terms of employment and interview processes will be maintained, not only in the public service but across the entire employment sphere.

My Department this morning issued an email to all Department staff to remind them again of the policies and procedures that are in place. It is important to note they are in place across the Civil Service, in particular the dignity at work policy and grievance procedure. The dignity at work policy defines what is meant by bullying, harassment and sexual harassment. Indeed, we have been hearing an awful lot about this in our media recently. There is a mechanism for reporting and for investigating bullying or harassment complaints. Similarly, the grievance procedure is in place to ensure that managers and staff encourage and maintain good employee relations. I agree that a lot of work was done over 20 years ago to make sure this was understood but I would make the point that, as we see from all the recent revelations, this issue in regard to women's equality is ongoing and needs constant vigilance and monitoring.

The Paradise Papers, so-called, or what I think should more accurately be described as the parasite papers, reveal a nexus of elite, super-wealthy individuals, banks and corporations, such as Apple, stashing away countless billions of euro in offshore bank accounts, in places like Jersey in the Channel Islands, in order to hide those billions from the taxman here in this country, and robbing the people of this country of valuable revenues that we need to deal with the housing emergency, the shambles in our public health service, the gross inequalities in income, the poverty and the massive deficits in our infrastructure - all the many urgent and desperate needs. Billions upon billions being stashed away has been revealed in these papers.

I want to ask why it is that the Taoiseach, Deputy Leo Varadkar, when he was Minister for Social Protection, using public money, ran a nasty, unfounded campaign about welfare cheats. Where is the campaign about the super-wealthy corporate tax dodgers who are genuinely robbing us all of the hundreds of millions and billions we need for housing, health and other urgent social problems? Where is the campaign? Where is the outrage? Where is the opprobrium? Does the Tánaiste not agree that the Government and Deputy Michael Noonan have very serious questions to answer about tax changes that were made in 2014 and revealed in the Paradise Papers, that coincided with Apple restructuring its tax arrangements when the double Irish tax scam that cost us €13 billion in tax revenue was rumbled because of international and public outrage? Coincidentally, Deputy Michael Noonan changes the tax regime to benefit Apple and other corporations at the same time that they relocate some of their subsidiary companies to the Channel Islands and, as a result, we lose up to €800 million in tax revenue from Apple alone, never mind the other companies that almost certainly took advantage of this change.

He is making it up as he goes along.

It is absolutely true.

Deputy Boyd Barrett, without interruption.

Is it a coincidence that Deputy Enda Kenny met the CEO of Apple in January of 2014 at the same time that outrage was being expressed and pressure was coming on the issue of the double Irish? Then, lo and behold, in the budget of October a new loophole was opened up in the tax code to benefit Apple and other corporations like it.

Thank you, Deputy. The time is up.

It is too much of coincidence. Where is the investigation? Where is the outrage? Where is the campaign against these super-wealthy tax dodgers who are robbing the people of this country and the world of these tax revenues?

The ICIJ leaks make a number of points about changes in the Irish tax system. It rightly points out that Ireland has already acted to address definitively the issues around stateless and double Irish companies. In the Finance Bill this week - the finance committee is meeting as we speak - the Minister for Finance will be discussing the changes he has already brought forward to our regime for capital allowances. Ireland has played a full part in implementing international tax reforms and we are currently holding a consultation process about how we implement the remaining reforms. Issues of concern will be investigated, as appropriate. The issue of aggressive tax planning by multinational companies is a global problem, as the Minister for Finance has said again and again, and it does require a global solution.

They are facilitating it.

Ireland continues to take a very active part in that global work to reform the international corporate tax system. The publication, for example, of the OECD base erosion and profit shifting, BEPS, report in October 2015 was a significant milestone in this work. From the beginning a key aim of the BEPS project has been to better align the right to tax with real economic substance. That is important in regard to the many international companies we have here, which have real substance in terms of their commitment to this country, the number of their employees and the contribution they make to the Irish economy. This is real; this has substance. We want to make sure the key outcomes of the BEPS project align with our tax strategy. We have fully committed to that process, which is very important, and we are playing our full part in its implementation. The Minister for Finance and the Taoiseach have made that very clear again and again.

They have trashed our reputation.

Ireland has already begun that process by introducing country-by-country reporting and the OECD-compliant knowledge development box. Ireland is playing a strong role in ensuring that this issue is dealt with at an international level.

Not a word from the Taoiseach when he met Mr. Tim Cook recently in the United States about the aggressive tax avoidance of Apple.

Deputy Boyd Barrett was not in the country.

We are probably going to be investigated by the EU for a second time. This will be on top of the investigation into the €13 billion tax dodged by Apple in the double Irish scam. Commissioner Vestager is discussing investigating-----

-----what happened, what Deputy Noonan did in 2014 to change the tax code and the restructuring of Apple's tax arrangements as regards the Isle of Man. The Government will not even take the €13 billion from Apple and put it into an escrow account as it has been ordered to do by the EU. The EU is taking infringement proceedings over our failure to ratify the anti-money laundering directive, which we were supposed to have ratified in June and which relates to tax evasion and-----

Look at the developments.

-----the beneficial ownership of deposits. The figures are stunning. After this tax break was introduced by Deputy Noonan, benefitting Apple and other corporations, tax breaks on intangible assets increased from €2.6 billion to €28 billion in one year.

I thank the Deputy, but time is up.

That is hundreds of millions, if not billions, of euro in tax revenue lost as a direct result of what Deputy Noonan did in 2014.

Where is the outrage? Where is the investigation? Where is the campaign on buses-----

The Deputy's time is up. Will he conclude, please?

-----paid for with public money asking people whether they want to deal with these tax dodgers who are cheating us all?

Deputy Boyd Barrett would set us back-----

Durkan's tax haven.

Can Deputy Durkan contain himself, please?

I am sorry. It is difficult sometimes.

There are actors on both sides of the House.

Ireland is taking strong action at international level-----

It is a tax haven.

-----as I have made clear. Indeed, we are one of the leaders internationally. It needs to be addressed internationally.

Regarding Deputy Boyd Barrett's point on the escrow account, the Minister has made it clear that the Department of Finance is working on this matter. It is one of the most complex international transactions that the Department has ever had to deal with, but the Department is working to ensure that the money is put into the account.

As long as Apple agrees.

At international level, the focus is on examining whether new rules are needed to reflect the increasing digitalisation of global business. This issue needs to be examined internationally. The agreement on the anti-tax avoidance directive by all EU member states was another significant step towards the implementation of the BEPS reports to which I referred. Ireland will implement the directive in line with the deadlines agreed therein.