Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Tuesday, 17 Dec 2019

Vol. 991 No. 4

Saincheisteanna Tráthúla - Topical Issue Debate

Medical Conditions

I commend the Endometriosis Association of Ireland, whose representative spoke in the audiovisual room last Tuesday. I thank Kathleen King, Aimee Brown, Sarah Moloney and Jean Sutton. Their testimonies enlightened me and many others at the presentation.

One in ten women is diagnosed with endometriosis. That is nearly 135,000 women in Ireland. On average, it will take nine years to get a diagnosis. As a person who had very little knowledge of the condition, I find it truly shocking that so many women can suffer in silence and that it takes so long for a diagnosis of endometriosis. Some women have to travel abroad to Romania or Britain, not only for surgery but also for fertility treatment. Endometriosis has almost become the Cinderella of our health system. It is largely forgotten. I hope the Minister of State, Deputy Daly, can shine some light on this issue for the women who are suffering in silence.

There are many health issues neglected in this country and society in general, including that of mental health, but I was absolutely shocked reading the accounts and emails of many women following the briefing organised by Deputy Gino Kenny. There is a pattern in the attitude to women's health. I refer to the view that there is nobility in suffering. The long-suffering woman is a very strong motif in our history and religion but it is not acceptable that people living with chronic, debilitating pain would be dismissed by their doctors, that it takes several years to get a diagnosis and that they would be sent abroad for their healthcare. This is something many women said would not happen after the repeal of the eighth amendment but it is still happening and 155,000 women are suffering from endometriosis. Many go to Britain, or even Romania, for treatment. Let us be absolutely clear that we are dealing with a gender bias in medicine. The type of medical misogyny we saw with cervical cancer is repeated with endometriosis. We need to establish a centre of excellence to diagnose women at very early stage and not dismiss them as just having period pain. Then they should get the treatment they need at a very early stage. I ask the Minister of State to do this.

I warmly congratulate my colleague, Deputy Gino Kenny, on hosting the recent briefing by the Endometriosis Association of Ireland in our audiovisual room. We heard striking testimonies from young women who have been treated appallingly by our health system over the years in terms of the diagnosis and treatment and this debilitating disease. As Deputy Gino Kenny said, one in ten women suffers from endometriosis. Approximately 155,000 women in Ireland have the condition. Of course, the average time for diagnosis is an astonishing nine years. I agree with Deputy Coppinger in this regard. It again highlights the fundamental issue of women's health outcomes and the gender bias in medicine generally.

The chair of the Endometriosis Association of Ireland, Ms Kathleen King, told us that Irish women are having more ineffectual surgeries than their counterparts, sometimes up to 20, and that there is a lack of specialists in the area. The women affected want much greater education on and awareness of the disease and menstruation in general. Young girls need to know that severe menstrual cramps are not normal and that medics need to investigate these issues fully rather than putting young girls on the contraceptive pill for years when the real cause of pain is not discovered until infertility issues arise later in life.

Endometriosis is a condition unknown to most people but those suffering from this chronic inflammatory condition know all too well its debilitating impact on their quality of life. Affected women live with pain, fatigue and risks to fertility. They also experience challenges in maintaining good mental health. The Endometriosis Association of Ireland states one in ten women experiences the condition. I compliment this small charity for its work in offering support to women and their families and also for highlighting this condition. It is a true example of patient activism.

The association has informed us that those living with endometriosis face significant challenges, such as gaining access to effective healthcare, receiving a timely diagnosis, poor public awareness and difficulties in the workplace. Developing patient-centred care is crucial for sufferers. I have a lot more that I could say on this but I hope the Minister of State will consider the concerns raised this afternoon and raise them with the Minister. In this regard, I echo the call for the establishment of a centre of excellence to deal with this disease.

I too am delighted to join my colleagues in speaking about this issue. I have been contacted by a number of constituents suffering from this debilitating chronic condition, including Aoife Halley, Rachel Ball and Aimee Brown. All these ladies have asked for our support. They are deeply frustrated. Their lives have fallen apart thanks to endometriosis and they feel they are hitting a brick wall when it comes to this Government and access to pain relief. That is shocking. They feel unheard and uncared for. The briefing last week in the audiovisual room, for which I thank Deputy Gino Kenny, was deeply moving and full of brave women. One of the ladies, Aimee Brown, contacted me again today with further details about the consultant who performed incorrect and incomplete surgery on her, with the direct result that her life has been changed beyond all recognition.

It is a scandal that these women and young ladies have to go to such lengths to get appropriate treatment and support. I am looking for an absolute and categorical assurance that the concerns raised by these ladies will be addressed without further delay and embarrassment. This is a shocking state of affairs.

I thank the Deputies for raising this important matter and bringing it to the attention of the House. I understand that it is within the scope of a general gynaecologist to diagnose and treat the majority of cases of endometriosis. Therefore, a GP referral to a gynaecologist is the standard pathway of care for the management of endometriosis in Ireland. This is similar to the pathway in place for the management of other gynaecological conditions.

Information provided by the HSE indicates that endometriosis can be a difficult condition to diagnose and treat because of the variation of presentations, which can affect the physical, and indeed the mental, well-being of patients to varying degrees. Treatment may include pain medications, hormone treatment and surgical interventions. The length of time it takes to diagnose endometriosis varies from patient to patient, because of varying, and sometimes ambiguous, symptom presentation. The Minister is assured, however, that the provision of training in the management and diagnosis of endometriosis forms an integral part of the specialist medical training programme provided by the Institute of Obstetricians and Gynaecologists.

The HSE national women and infants health programme has advised that the best way to help the majority of patients with endometriosis is to improve access to gynaecology services. As such, the programme has developed a plan to increase capacity and reduce waiting times for women awaiting general gynaecology, which includes patients with endometriosis. The plan aims to re-orient general gynaecology services to an ambulatory, or see and treat, model rather than the traditional outpatient referral model. An ambulatory care model is a more efficient and effective use of resources. It is also better for the patient as it reduces the requirement for multiple outpatient appointments. The programme will progress as planned in 2020.

It is also worth noting that a new women's health task force was established in the Department of Health in September 2019. The purpose of the task force is to improve women's health outcomes and women's experiences of healthcare. The task force is at an early stage of its work and is considering the full range of issues affecting women's health in Ireland. The task force will tackle a wide range of issues impacting women's health outcomes in Ireland and will work on these on a phased, prioritised basis. Each week, external experts in the area of women's health meet members of the task force in the Department of Health to inform its work. This initiative has been under way since the task force was established.

I understand that the Endometriosis Association of Ireland recently presented to members of the task force, highlighting this important issue that affects many women in Ireland. This issue will be considered by the task force alongside a range of other issues affecting women's health. Priority action areas will be decided by the task force in consultation with stakeholders, including the public. The first action of the task force will be to initiate a national listening exercise, inviting women in Ireland to share their experiences of, and solutions for, the health system, and this will commence in early 2020. More information on the task force is available on the Department of Health website.

There are five Teachtaí Dála and they have half a minute each. I call Deputy Gino Kenny.

It is welcome that, under the women's health task force, endometriosis will be reviewed and so forth. I think, however, that most women looking at this debate tonight will ask why it has taken so long to address this issue. There is a paternal narrative in healthcare and over the past two or three years, in particular, we have seen women being let down completely, not only by the health system but by society as a whole. If we can do anything as legislators or Teachtaí and hold out solidarity to our sisters today, it is to state that we will do as much as we can to try to put this on the national agenda.

The Minister of State seems to be saying this is very difficult to diagnose and, somehow, that is an excuse. Lots of things are difficult to diagnose and lots of illnesses take a long time to diagnose. It is possible to misdiagnose many things. It is not that difficult, however, to diagnose endometriosis in Australia and New Zealand, where there is much quicker diagnosis. Let us be honest. There has been an ongoing neglect of women's health in this country, which is a particularly backward country where the Catholic Church has dominated for many years. The Minister of State is saying that we should wait for the task force. That is not good enough, however, because women are not waiting any longer. We saw that with repeal and the gender quake taking place. Will the Minister of State meet these women and their representative association?

I thank Deputy Coppinger. There are five Teachtaí.

Some 155,000 people are suffering, not ten or 12. We need a task force set up.

There are major delays in waiting to see a gynaecologist. Women can be waiting for up to two or three years. In August, the hospital consultants' association told us that 28,000 women were waiting at the time, 5,400 of whom had waited for more than a year. About a month ago, I asked Beaumont Hospital and the RCSI hospital group the number of full-time endometriosis excision specialists. I heard that there are only two, as far as I can see, in that hospital group. I welcome the point mentioned about the women's health task force, but if other countries can have centres of excellence for this appalling condition, then surely Ireland can do that as well, if the Government will work with the association.

I am trying to be fair, there are five Teachtaí.

I thought we had a minute.

Yes, we thought we had a minute.

I am afraid I have been told that it is half a minute.

That is correct. I call Deputy Corcoran Kennedy.

It has been suggested to me that it takes nine years to be diagnosed here. I also wanted to highlight the difficulties that some patients are having in obtaining treatment abroad, and indeed payment when treatment has been obtained. This has been highlighted to me by a sufferer. I also urge the HSE to work with the Endometriosis Association of Ireland to devise a public awareness campaign to highlight the condition. I see it has very informative leaflets available already.

I am also unhappy with the reply because we need to deal with this issue. We need to take these women out of their suffering and support the organisation they have set up. I also ask the Minister of State and the Minister for Health to meet those women and listen to them. I was also unaware of this condition until I was contacted by these ladies. There needs to be a whole education campaign. It might take nine years to diagnose it in this country, but it should not. The Minister of State is telling us, unfortunately, that it does. We need to deal sensitively and sensibly with this and try to understand the pain and suffering these women, their families and loved ones are going through.

As I mentioned, by improving access to general gynaecology services, services for the majority of patients with endometriosis can be improved. The HSE's national women and infants health programme has developed a plan to refocus existing general gynaecology services towards an ambulatory model of care. This, it is anticipated, will not only improve capacity and reduce waiting times for such services but also provide a better service for women. The programme will progress this plan as a priority in 2020. In addition, the Department of Health is working with the HSE and the National Treatment Purchase Fund, NTPF, to develop the scheduled care access plan 2020, which will include gynaecology services.

I welcome the establishment of the women's health task force, as I mentioned, that is working collaboratively to identify key areas where we can work to improve women's health. Women's voices and experiences will be at the heart of the work of the task force. I encourage all interested stakeholders to engage with the listening exercise, which will commence early in the new year. Information and data gathered through this exercise, combined with other available evidence, will form the basis for future policy and action to improve women's health in Ireland. I will also pass on the invitation to the Minister to meet the group.

Mental Health Services

I have raised the issue of mental health services in Cork city and surrounding areas with the Minister of State previously. I appreciate that we have had many discussions, but on some occasion I would appreciate if the Minister for Health, Deputy Harris, was in a position to listen to some of these discussions. I appreciate the Minister of State's interest in this area and his desire to tackle it, but this is a massive issue and the community health organisation, CHO, for Cork and Kerry seems to be constantly below other areas in respect of the services provided.

Some of the waiting times people in Cork city and the surrounding areas have been experiencing are outrageous. The point of community services is to reduce the pressure on the acute services. That is the theory of them and the primary care centres. If we look at the kind of waiting times that exist for psychiatry and for psychology and for psychiatry and psychology in child and adolescent mental health services, CAMHS, it clearly is not succeeding in that regard.

I will start with psychiatry. In some areas, such as in Carrigaline, there is an average waiting time of six months. In response to a parliamentary question I asked on that issue, I was told that there is not a requirement at present to recruit further.

When one considers the pressure under which the primary care centre is, I do not understand why no positions are required. Is that under A Vision for Change or is some other metric being used to determine that? A six-month wait for psychiatry is far too long. Six months is a tortuous length of time to be waiting for any kind of treatment. Anyone who is referred to a psychiatrist is likely to be facing a crisis situation. It is unacceptable that people in the Carrigaline area, which takes in Douglas and Passage for the purposes of the community health area, are waiting six months to be seen by psychiatrists.

The story is similarly grim, even worse, when it comes to psychology services. Some of the psychology waiting times in community settings include nine months for the Ballyphehane-Togher sector, six months for Douglas and Carrigaline and 17 months for Ballincollig-Bishopstown. Again, it was stated there is no requirement for further recruitment. I cannot understand the HSE’s basis for stating these times are acceptable and it does not need to do any more. It is unacceptable.

The story is similarly dreadful for CAMHS, the child and adolescent mental health services. There are 646 children on the waiting list, 192 of whom have been waiting over a year. These are vulnerable children and adolescents with real mental health issues. In many instances, life may hang in the balance. Certainly, welfare hangs in the balance. To put this in context, two years ago it came to national attention that there were spikes in suicide and self-harm in the Cork city area. It is still the case that the Cork city area is way above the national average for suicide among men and self-harm among women. That has been the case for a decade. While mental health is broader and takes in much more than that, clearly investing in psychology and psychiatry in community and CAMHS settings is crucial to assisting people in crisis situations. In that regard, people are being failed when one is looking at psychiatry lists of between six and 17 months. This is unacceptable.

Mental health continues to be a priority area for the Government. We recognise that mental health service users are among the most vulnerable in society. For this reason, €39 million has been added to the mental health services budget for 2020, increasing the annual allocation to €1.026 billion. This represents an increase of over €315 million, or 45%, since 2012.

This funding will help in the continued improvement and development of mental health services. Funding by itself is not enough, however. We also need to look at how we deliver services and how we can reduce demand for the specialist mental health services by treating people at as early a stage as possible.

In this regard, the HSE is introducing several digital mental health initiatives driven by the Department of Health. These include tele-counselling and tele-psychiatry projects, which will provide remote counselling and psychiatric consultations, as well as helping to improve access to these services. Greater use of available technology will help to deliver services at an earlier stage, helping to ensure that mild mental health issues are dealt with before they become more serious.

These initiatives exemplify the serious intent of the Government to progress and improve mental health services. We have also enhanced mental health services provided in primary care. The introduction of 114 assistant psychologists and 20 psychologists in primary care has produced a 28% increase in referrals, which will total approximately 14,000 in 2019. This has helped to reduce the national waiting list for CAMHS to around 2,000, a decrease of 500 or 20% since December 2018.

Funding for seven of these psychologist posts and 16 of the assistant psychology posts for the Cork-Kerry area has ensured this trend is reflected in this region. The number of young people waiting to access CAMHS has reduced by 14% from 667 in January 2019 to 574 in October 2019. Despite this, it is recognised that the Cork-Kerry region CAMHS waiting list number must be reduced further.

Adult services in Cork are provided through 19 adult community mental health teams, five psychiatry of later life teams, three home-based treatment teams, a specialist rehabilitation team, a specialist homeless team and a mental health and intellectual disability team. In addition, dedicated liaison teams are based in Cork University and the Mercy University Hospitals with plans under way to develop a liaison service in University Hospital Kerry. There is an adult community mental health team for Carrigaline, providing outpatient services in Ravenscourt, St. Finbarr's Hospital, Cork. Cork-Kerry community healthcare faces ongoing challenges in recruiting and retaining both psychologists and psychology assistants. Psychology managers are working to meet these challenges with the HSE's recruitment service and the academic institutes on an ongoing basis.

I am more than disappointed by the reply from the Minister of State. It does not contain a significant amount of detail on the positions in question and the Minister of State has not answered my questions. The replies to parliamentary questions stated there is no intention or requirement to fill additional positions in areas where the waiting lists are unacceptable. What is the opinion of the Minister of State on this? How can it be the case that the HSE believes this is acceptable? It cannot be acceptable for people to wait six months for psychiatry services, as they are forced to in Carrigaline.

On top of that, when I asked these parliamentary questions in the late summer, many of the positions had not been filled. While I accept the Minister of State may not have the information to hand, will he furnish me later with information concerning a position required to be filled for psychology in the Douglas-Carrigaline sector, two positions in the two different sectors in south Lee for CAMHS psychology, a position for psychology in the south-east area, Blackrock, and other positions in CAMHS psychology? That still leaves places which the HSE or the CHO feel they are doing enough and there is no point in asking for more staff. I do not understand this. I would appreciate if the Minister of State could give us an insight into the target being used. Is it A Vision for Change or something else?

A significant number of our problems with mental health services are due to a lack of clinical psychologists and psychiatrists, essentially a shortfall of staff. We have large numbers of students studying psychology and related courses but for whom becoming a psychologist is not a realistic career option because it is too expensive to gain the clinical experience they need to qualify as a clinical psychologist. We need to crack that. Many more people would like to be psychologists but they do not have the opportunity to do so.

The House and the Deputy will appreciate that two minutes will not give me an opportunity to answer his questions or address the range of issues outlined.

There are 34 young people in the Carrigaline-Douglas area on the waiting list for psychiatry. That is what the HSE means when it could not justify taking on an additional psychiatrist in a full-time position. Instead, it is about the better utilisation of resources. I suggest to the Deputy that he engages with the head of mental health services and local management in the CHO 4 area. They will give him more detail rather than me trying to give it across the floor of the Dáil in two minutes.

The overall CAMHS waiting list has reduced by 20% this year across the country, including in Cork. It was done by introducing 134 psychologists into the system last year, on top of the existing infrastructure. It was also done by bringing in a lower level infrastructure which is catching people at an earlier time and preventing it from escalating. That is not a waiting list initiative which will see it shoot back up again. It is a structural reform with better organising what we do and how we do it and building lower level infrastructure. While we could continue to keep employing more psychiatrists, we need to pull back and look at lower level interventions and building that up. That is what we have done and it has worked. The figures have been independently verified. This year it could even be a 25% reduction. That is a significant reduction in any waiting list. More importantly and crucially, it is sustainable.

In my time in office, I have tried to ensure that everything we do is sustainable and replicated year after year. It is not about just throwing an extra €10 million at it this year to bring a waiting list down when it goes back up next year. It is about structural reforms such as the introduction of the phone line which has resulted in better alignment of services and appropriate referrals. Online counselling and psychiatry are sustainable solutions which will, while not building utopia, go a long way to fixing the system.

Hospital Facilities

I thank the Ceann Comhairle for being so flexible in the taking of this topic. It is third time lucky because I have sought to raise this matter for the past two weeks but it was not taken because no Minister from the Department of Health was available to reply.

I take the opportunity to congratulate the community in Longford-Westmeath and the wider area on the fantastic community spirit shown in their efforts to get an MRI scanner for the Midland Regional Hospital, Mullingar. Over the past two years approximately €950,000 has been raised to secure the purchase of this scanner and I acknowledge the work of John McGrath, Deirdre Murphy, Mandy Reilly and other committee members. Schools held pyjama days. There were large balls and tractor runs. Myriad activities took place to generate these funds. It demonstrates what is good about community spirit in Ireland.

On the day of the publication of the HSE service plan, it is positive that the HSE has honoured its side of the commitment, which was that if the local community fundraised to provide for the scanner, the HSE would provide the accommodation to house this much-needed equipment. This equipment is so necessary because patients attending Mullingar hospital often had to wait days or weeks to get an MRI scan in another facility. It was blocking up beds and people were left waiting unnecessarily in the hospital. As it is also a maternity hospital and a children's hospital, it is important that it has a specialised MRI scanner that will be able to deal with paediatrics and maternity care.

I acknowledge that it is in today's HSE service plan. Given that it is in the plan, I hope there will be no delay in providing this extension. Planning permission has been granted and it now needs to go out to tender. Once the tender is awarded, construction should commence without delay. I note that today's HSE plan indicates that it will be in operation in quarter 1 of 2021. I see no reason that cannot be accelerated. It is needed now, and the sooner it can be delivered, the better. I look forward to the Minister of State giving a clear timeframe for the project to move through the various stages at an accelerated pace.

I welcome the opportunity to update the House on this capital development project at the Midland Regional Hospital, Mullingar.

The Midland Regional Hospital, Mullingar is a model 3 hospital delivering a 24-7 emergency department, general surgery, obstetrics and gynaecology, paediatrics, special care baby unit, critical care and general medicine, including regional stroke thrombolysis, alongside a range of local and regional services, on an inpatient, day case and outpatient basis. The catchment area for the hospital includes patients residing in Westmeath, Longford and the greater midlands area. The significant population increase in the midlands, coupled with other factors such as ageing demographic pressures, has placed significant additional demands on the hospital.

The provision of a new MRI scanner is included in the proposed new extension of the existing radiology department there. A design team has been engaged and planning permission has been granted for the proposed extension to the radiology department. The development requires the demolition of an existing building on the site. This building accommodates ambulance staff, and options to accommodate the ambulance staff elsewhere temporarily to enable the MRI project to progress are being explored.

I understand that the Friends of Mullingar Hospital have completed substantial fundraising in support of the MRI scanner and I acknowledge their significant contribution. The Deputy illustrated that very clearly in his contribution.

The provision of a new MRI scanner at the Midland Regional Hospital, Mullingar was included in the national development plan, NDP, announced last year as part of the Project Ireland 2040 policy initiative. The NDP provides €10.9 billion for health capital developments across the country, including both national programmes and individual projects, across acute, primary and social care. The delivery of NDP projects and programmes, including developments in Mullingar, will result in healthcare facilities that allow for implementation of new models of care and for delivery of services in high-quality modern facilities.

My Department and the HSE are currently engaged in a process to finalise the HSE capital plan for 2020. Funding for the proposed extension to the radiology department at the Midland Regional Hospital, Mullingar, including accommodation for the second MRI scanner, has been included in the draft plan. The capital plan will determine which projects can progress in 2020 and beyond, having regard to the total available capital funding and the relevant priority of each project. Once the HSE has finalised its capital plan for 2020, it will then be submitted to the Minister for consideration.

The delivery of capital projects is a dynamic process and is subject to the successful completion of the various approval stages, which can impact on the timeline for delivery. All health capital projects currently at various stages of development, such as projects at the Midland Regional Hospital, Mullingar, are included as part of this process.

The publication of the HSE plan today superseded much of this debate. Nonetheless, as the Minister of State has said, to facilitate the new building, the current ambulance service needs to be relocated. It is important to identify a temporary site that is fit for purpose. When it goes back to the permanent structure, that again must be fit for purpose.

When will the HSE draft plan be adopted as the final plan for 2020? While I appreciate the Minister of State will not have the facts and figures to hand, I ask him to revert to me or have the relevant departmental officials revert to me with the specific timeframe. If any lessons are to be learned from other State contracts, it is the need to put specific timeframes on contracts so that they will come in on time and within budget. While we need to ensure we have the services servicing our constituents, we also need to ensure we get value for money. I ask for officials to come back to me with a detailed reply with the specifics on costings and timeframes.

We have been waiting for a long time. The community did invaluable work in fundraising the €950,000. Our side of the bargain has been met. We want to ensure that there is no time delay and that the final phases are accelerated so that patients can be treated before the end of 2020.

I reiterate my appreciation and that of the Minister and the Department of Health of the local community's commitment to this project. Fundraising that amount is a very significant achievement. Many of us have been involved in fundraising projects and know how difficult and challenging they can be. I assure the Deputy from this side of the House that that community commitment will be recognised and rewarded with a timely delivery.

I will need to come back to the Deputy with the timelines as I do not have them to hand. I will ask the relevant official to provide them to him. I assure the Deputy that there will be very strong support from me and the Minister, Deputy Harris, when that draft plan becomes a final plan, which I hope will happen as a priority early in 2020. This project should proceed on that basis. I will come back to the Deputy with a timeline to follow that.

Cross-Border Projects

I thank the Minister for being present to take this very important Topical Issue matter relating to the cross-Border infrastructural projects, the Narrow Water bridge and the A5 motorway.

On foot of last Thursday's UK election, it is clear that Brexit will happen in some form and that is key to the timing of Deputy Brendan Smith and me raising this matter. A commitment has also been given that in any withdrawal agreement the North of Ireland would be accorded some form of special status. More importantly, the programme for Government made a commitment that the Narrow Water bridge and the A5 motorway would be supported and encouraged.

The Narrow Water bridge will be an important economic stimulus for south Down and County Louth in the context of job creation, investment and tourism opportunities. We need to work with the new UK Government and alongside the EU to create a scheme for funding this important item of infrastructure. The Narrow Water bridge project has been 40 years growing and we all know the difficulties it experienced in the last possible round of funding. A cursory glance at the infrastructure along the Border, leaving aside the A1 and the Belfast-Dublin train line, shows that, believe it or not, we had much better connectivity in the 1950s and 1960s. All one has to do is look at the train tracks that were lifted from Dundalk, Monaghan, Enniskillen, Bundoran, Derry and Sligo.

My colleague, Deputy Brendan Smith, will deal with the A5. We are aware that in recent years almost €17.4 million was offered in respect of this project and that the contract came in at more than €12 million in excess. I want to see this project being delivered as part of a commitment to the all-Ireland economy and to the people of this island, North and South.

I thank Deputy Breathnach for outlining the merits of advancing cross-Border infrastructure. The Minister will have heard me voice many times in this Chamber, and in meetings I have had with him, my concerns on the inadequate infrastructure in the Border region. That inadequacy will exacerbate problems we have and the economic challenges that will arise on foot of Brexit.

A decision was made by the then Fianna Fáil Government - in the aftermath of signing the Good Friday Agreement and the St. Andrew's Agreement - that the State would provide substantial funding towards the upgrade of the A5 in Northern Ireland. This project is particularly important to the north-west of the country, including County Donegal. The Minister will have heard our colleagues, Deputies Gallagher and McConalogue, speak eloquently about the need to advance that project. I am also concerned about the N2 part of that route. The Minister is aware of the ongoing public consultation process in respect of upgrading the part of the route from Clontibret to the Border and the part from Ardee to Castleblayney. It is very important that the views of the local communities are fully taken into account in deciding on the preferred route. I am very anxious for a commitment to be given to ensure that the N2 and the A5 projects will be progressed as quickly as possible. The delay on the A5 has not been on our side of the Border; it has been due to political difficulties in Northern Ireland and to a number of planning issues. We must look at our economy now as an all-Ireland economy. If the infrastructure in Northern Ireland is deficient, it is a deficit for our economy in the South. Similarly, if our infrastructure is deficient on the southern side of the Border it will be a negative for the economy north of the Border. We must look now to our economy in an all-Ireland context. We must also look to the provision and upgrading of infrastructure on an all-Ireland basis. I appeal to the Minister to send out a message that funding will be provided to ensure that there will be no undue delays in progressing the upgrade of the N2, which is critical for County Monaghan, and the A5 project, which is so important for Tyrone, Derry and Donegal.

I thank the Deputies for raising these two very important subjects, which are absolutely related to each other. The current funding arrangements in relation to the A5 are also governed by the Fresh Start agreement. Under this agreement, the Government is committed to providing funding of £75 million towards the cost of phase 1A of the A5 upgrade scheme once the statutory planning process in Northern Ireland is concluded. The implementation of the A5 upgrade project is the responsibility of the Northern Ireland authorities. As is the case for all such capital projects, the A5 upgrade scheme is subject to the planning assessment and approval process in Northern Ireland, and since 2012 there have been a number of legal challenges to approvals related to the scheme, leading to unavoidable delays to implementing the proposed scheme.

Following the conclusion of legal action in 2018, the Department for Infrastructure updated project environmental assessments and undertook a public consultation on a number of environmental reports, including the environmental statement addendum 2019. Having reviewed the responses, the Department concluded that a further public inquiry is required. It is understood that the inquiry will be held in February 2020. Allowing for the time required for the conclusion of the public inquiry and for a new decision to be taken on whether to proceed with the scheme together with the possibility of a further legal challenge, the timeframe for the start of construction of phase 1A of the A5 project is uncertain. In view of the current state of play regarding the A5 scheme and the timeframes involved, provision is not being made in the calendar year 2020 for funding for the scheme. The Government remains committed to the £75 million contribution and the senior officials group established on foot of the Fresh Start agreement will continue to liaise regarding the project with a view to delivering on that commitment.

A Fresh Start - the Stormont Agreement and Implementation Plan, includes a commitment that the Northern Ireland Executive and the Irish Government would undertake a review of the Narrow Water bridge project with a view to identifying options for future development for consideration by the North-South Ministerial Council, the NSMC. A progress report regarding consideration of options for a Narrow Water bridge was considered by the NSMC in July 2016 and the Council decided that work should continue on the development of options. While the NSMC has not been sitting for a number of years, the senior officials group, comprising officials from Northern Ireland and the South, which is responsible for liaison in respect of the Fresh Start agreement, has been meeting. Senior officials have continued to review options around the Narrow Water Bridge proposal, which has included meetings with relevant stakeholders. In engaging with stakeholders, officials have highlighted the need to assess all potential options objectively to ensure the best outcome for the area and the best use of public funds. In this context the criteria identified for assessing options were: linking the two communities on both sides of the Border; encouraging and enhancing overall tourism in the cross-Border region; and protecting the natural environment on both sides of the Border. Following on from that, the Northern Ireland Department for Infrastructure started work on preparing a business case for a Narrow Water bridge scheme. The purpose of the business case is to consider the need to construct a bridge over the Newry river and appraise options to ensure any proposal put forward is likely to represent value for money. My Department has provided input into this work.

It is the case that the proposal for the Narrow Water bridge must be considered in light of welcome developments relating to the Newry southern relief road, NSRR, since 2016. The NSRR, which is included in the Belfast city deal, would provide an alternative route for strategic traffic that avoids Newry city centre and links to the eastern seaboard, the A1-N1 Belfast to Dublin key transport corridor, which includes road and rail links between Larne and the border at Newry, facilitating onward travel to Dublin and improving access to other regional gateways. The Department for Infrastructure has conducted a community consultation on the NSRR this year to help identify clearly the advantages and disadvantages in environmental, engineering, economic and traffic terms of the preferred route.

The current proposal for the NSRR is likely to include pedestrian and cycling provision as well as connectivity to the B79-RI73 Fathom Line leading to Omeath and Carlingford. The overall assessment of the case for a Narrow Water bridge, including in the context of developing a wider tourism initiative for the region, is not at a stage where there is a clearly defined and costed scheme. It is not possible, therefore, to ring-fence funding for a Narrow Water bridge scheme in advance of future decisions on the scheme, including consideration by a reconvened NSMC.

I appreciate the Minister's candid response. I reassure the Minister that Louth County Council has reconfirmed that planning permission is in situ on both sides, and more importantly that both planning permissions have not expired. They are in situ. To date Louth County Council has expended €2.2 million on this project. We need to follow that investment for what I consider an iconic symbol of our preparedness to continue on the road of cross-Border co-operation and to not allow that expenditure go to waste. We have had 21 years of peace. A changing of the political landscape should afford us the opportunity to commit to the Narrow Water bridge as a symbol of peace. We hear plenty of talk about building bridges. If there are people with a vision to build a bridge from Larne to Stranraer in order to link the North of Ireland and Scotland, then this project of a bridge spanning 660 m is infinitely more achievable. A development such as this would bring great trade, tourism and connectivity to both communities.

There appear to be further delays with the proposal to get the A5 upgrade going, which is regrettable.

That is beyond the powers of the Oireachtas or any Minister here. A clear message could go out if the Minister ensures the N2 upgrade is progressed as quickly as possible. Monaghan County Council will do a very good job as the project promoter for the planning and design work on behalf of itself and Louth County Council. The message should go out that there will be no delays following full consultation with the local people and local communities. It is extremely important.

I emphasise that the north west and north east have particular challenges due to the fact we have a Border. We will have additional challenges with Brexit because it will have nothing but adverse impacts regardless of what way Britain leaves the European Union, and we sincerely hope it will leave with a good deal for the European Union and Britain. We need to send out a clear message that the Government and the State are fully committed to cross-Border infrastructure and its development.

With regard to what my colleague, Deputy Breathnach, said on the Narrow Water bridge, in my early days in politics I remember when we spoke about restoring the then Ballyconnell-Ballinamore Canal people told us it could not be done. That was back in the early 1990s. It was transformed and the engineering ability was there. It has become the very successful Erne-Shannon Waterway. The political vision was there to do it at that time and that is what we need again.

If I can satisfy Deputy Smith, and it is probably something that is difficult to do, I would certainly say the commitment of the Government to both of these projects is absolute and total. There is absolutely no pullback on them whatsoever. As the Deputy said, the commitment in terms of funds is there. The £75 million is committed to and we stand absolutely 100% behind it. There will be no pullback on that either. As the Deputy said, and as he knows, what is happening is there are perfectly legitimate, and very regrettable in many ways, delays on this and they are on the other side of the Border. We cannot do anything about them. They have been going on for a long time and every time there is one legal action it seems to be followed by another. These are proper planning objections and they are right. Those of us in a hurry to benefit the Border region and benefit tourism and show commitment to cross-Border roads and bridges regret this is happening but we must allow these procedures to happen.

Let me assure the Deputy that our commitment to the A5, which is a cross-Border commitment and a cross-Government commitment, is as great as his was when he was in government. At the earliest opportunity, that cross-Border project will go ahead. It is not our doing that is holding it back. We are particularly conscious of this not just in the light of what the Deputy has been saying continuously, which has been helpful, but because of what is happening in Brexit. We understand fully the need to promote, and we have acted upon it, activity in the Border regions.

This applies equally to Narrow Water bridge raised by Deputy Breathnach. There is no hesitation there either but there are certain difficulties because of the options presented. Whereas our commitment is equally strong in that case, we cannot actually ring-fence money for something that is not defined at this stage. Our commitment is there and the Deputy can take my word that substantial funding will be made available at the appropriate time when the project is defined and costed properly.