Dáil Éireann díospóireacht -
Thursday, 31 Mar 2022

Vol. 1020 No. 4

Women's Health Action Plan: Statements

Minister for Health (Deputy Stephen Donnelly)

I am sharing my time with the Minister of State, Deputy Feighan.

I am delighted to discuss this important issue. Improving the outcomes and experiences of women in our healthcare system has been an absolute priority for the Government and will remain so throughout its term. This month we launched the women's health action plan, the first of its kind in Ireland and showing a new future for women and girls. I acknowledge the support and input to this work of Members of the Dáil and Seanad of all parties and in both government and opposition and the Independent ranks. I acknowledge the input of the Oireachtas Joint Committee on Health and the input and work of the Oireachtas women's caucus. Many of the actions in the plan are ones for which Members of both Houses have advocated, sometimes over many years.

I acknowledge the valuable input from civil society, including the many groups convened by the National Women's Council, on the priority policies and the best way to roll them out. I acknowledge the amazing work of the women's health task force, which has been working on this matter for a considerable period and has been central to policy development and the creation of our first-ever women's health action plan. The action plan involves invaluable work that will have a substantial impact on healthcare services for women and girls of all ages in our country for many decades.

We have worked with and listened very carefully to women all over Ireland over the past two years. They have spoken of their experiences of our healthcare system and told us the issues they feel are most in need of attention. Their requests were that we should keep listening to them; not make promises but instead take action; respect them as "experts by experience"; empower them with trusted sources of information; and, most important, give them access to the women's health services they need - services that are accessible, expert and empathetic.

The women's health action plan places women at the heart, and in control, of their own healthcare. It does this in several ways. I will share with the House some of the most exciting developments in the plan and what we are rolling out this year. Last year, the first publicly funded, dedicated specialist menopause clinic was established. This year, we will open a further three. By the end of last year, we had fully funded and opened several see-and-treat gynaecology clinics. This year, we will open a further 12, totalling 20 around the country. There will be a national network of these clinics. They are incredibly effective and can provide necessary care to women in just a few hours in one visit, instead of multiple visits over months or, as in some cases, several years. It is a vital step in improving healthcare outcomes and access for women and in reducing gynaecology waiting lists.

I opened the see-and-treat clinic in the Rotunda recently. In its first 12 weeks of operation, it reduced the long-waiter list by 90%, which is amazing. In the past few weeks, I visited the Galway clinic, where staff explained to me that before its establishment, a woman might have required four separate visits. The first involved a referral from a GP to a gynaecologist, who might have had to make a referral elsewhere for diagnostics. After diagnostics, the woman had to go back to the gynaecologist and, finally, the latter might have made a referral for a procedure. This could have taken six months or sometimes two years. This is now all happening in one visit over just two or three hours, so the outcomes are very positive.

Critically, we will see this August the introduction of the first phase of free contraception for women. As colleagues will be aware, we are beginning with women aged between 17 and 25.

My intention, and hope, is that we will roll that out to all age groups and phase it in during the years to come. We are setting up two new postnatal hubs to innovate in how we provide wraparound care to mums in those critical first weeks with their babies.

It is also important that we address women's unique mental health experiences and service requirements. This plan brings a new spotlight to women’s mental health and well-being. We are increasing supports around self-harm, enhancing eating disorder supports and setting up several new teams around the country. We are also examining the supports needed by carers and, as we know, this is a group that is mostly, though not exclusively, female. Additionally, we are developing an inpatient mother and baby unit. We are also, and we were just discussing this initiative this morning, gender-proofing the actions in the Sharing the Vision strategy, which is the national mental health strategy. It is an excellent strategy, but it was not gender-proofed at the start and we are doing that now. We are also establishing six publicly funded regional fertility hubs to support women and families in their fertility journeys. Additionally, fertility support will be increased through the stronger regulation of the assisted human reproduction sector through new legislation. I look forward to the Health (Assisted Human Reproduction) Bill 2022 being before the House shortly. Not only will that legislation bring in much-needed regulation, but it will also pave the way for publicly funded IVF treatment. Therefore, we are laying the foundations for these things to come to fruition in the coming years.

Women have expressed the need for increased supports when making the choice to breastfeed. In response, we have more than doubled the number of lactation consultants trained to provide specialist, hands-on support to help women to succeed on this journey. I had the great honour and privilege of meeting some of the lactation consultants and some of the mums in one of the clinics recently. As we are all aware, in an international context, Ireland has a very low rate of breastfeeding and we must focus on this area. All the feedback we are receiving from these clinics is positive regarding this national network of lactation consultants and the support available for mums in hospitals and when they go home.

We must, of course, do much more to understand women’s experiences of healthcare, the services provided and the outcomes. That is why we are engaging in several new initiatives, including, for example, our first maternity bereavement survey, which we are doing this year. This will help us to understand how best to support mums and families in what of course is the hardest time imaginable for any parent. It is also why we have put such a strong focus on increasing research and innovation in women’s healthcare in the women’s health action plan.

As I said previously, many women engaged with the women’s health task force and contributed directly to the action plan. They told us what they wanted to see from our healthcare system, and now it is up to us to respond accordingly. The women’s health action plan is a first step in this process. It is about our sisters, our mums, our daughters, our friends and about every woman and girl in this country, and about providing them with modern healthcare and the kind of health services required. The ambition and energy underpinning this plan is a testament to the emphatic message received from women from all around Ireland and from all walks of life who contributed fundamentally to its development. It matches the dedication and fervour of incredible healthcare professionals whose work we want, and need, to support to make the difference that women are asking for.

Budget 2022 gave us an investment of €31 million for women’s health to fund the plan. Additionally, the full-year cost of the measures we are introducing this year total a little under €50 million. Therefore, a substantial amount of money is being invested in this area. We hope this is just the beginning. I will of course be seeking more new development funding in the years to come to continue to expand and grow these services. We are not looking for incremental change and we are not seeking to make things a little better year after year. Women’s healthcare has never had the focus or investment it should have had and we have not had the level, range and coverage of services in this country that should have been available to women for a long time. What is needed is a revolution in women’s healthcare, and this women's health action plan for this year is an important step on that path.

This year, we are also taking a leading role internationally by developing a targeted, Government-led health agenda specific to women and their health. I am informed by the Department that having this type of specific women's health plan, designed according to the entire life cycle from cradle to grave, will make us one of the only countries in the world to have taken this approach. It is something we should all be proud of. Equally, as I said, I believe this health plan is not owned by the Government but by the entire Oireachtas, civil society and the many women who contributed to it.

The publication of the women’s health action plan marked a new, important era for Ireland as we tackle some of the remaining taboos linked to aspects of women’s health. With this plan, this Government has committed to listening to, investing in and delivering for women when it comes to healthcare. We will keep listening in order that we can build a responsive health system that improves not only women’s health outcomes, but also their experiences of healthcare.

As I finish, I again acknowledge the time and the participation of women right around Ireland who contributed to the plan. Their words and experience have allowed us to understand what needs to happen, and the women’s health task force, by working with women all over Ireland, has created an unshakeable momentum behind this important and much-needed agenda.

An Ceann Comhairle

I call the Minister of State, Deputy Feighan.

Minister of State at the Department of Health (Deputy Frankie Feighan)

I will make a statement at the conclusion of the debate.

An Ceann Comhairle

Okay. I call Deputy Cullinane.

Deputy David Cullinane

There is time and there are plenty of opportunities for the Opposition to hold the Minister and the Government to account, but there are also times when we must thank the Minister and acknowledge the work that has been done. The shining of a light on women's health, the establishment of the task force and the putting in place of this plan and strategy will really benefit women. I refer to measures being undertaken already, because action plans are not always implemented when they are published. The measures to be undertaken here will require ongoing interventions and some of these actions will be implemented over time. Already, however, we have seen investment in several areas and that is welcome. I commend the Minister on his work in this area, and all those in the women's caucus and the task force who looked at all these measures.

The Minister would accept, I think, that we were all left a legacy from previous Governments. This was not a good society for far too many years when it came to women's healthcare. There have been far too many tragedies and crises, far too many things happened that should never have occurred and far too many women were let down. This aspect must be acknowledged as well. The Minister will also acknowledge there is still more we can do and that we can always build on the strategy he launched several weeks ago and which is the subject of this debate. Therefore, I welcome this opportunity to speak on issues in women's healthcare.

I start with the topic of women and the menopause because it is an area on which I published proposals several weeks ago. Between November 2021 and January 2022, I conducted a survey to hear directly from women about their experience with menopause and their access to supports and healthcare services. More than 1,000 women gave their perspectives and shared their personal experiences of supports, treatments and the general impact on their health in this context. We heard from women from right across the island, north and south. The survey results showed that 98% of respondents believed, at that stage, that the Government was not doing enough to support women experiencing menopausal symptoms. I am sure the task force found similar views were expressed when it was doing its research and work, because this was something we were not talking about and it was a taboo subject.

We were not doing enough in this area and there were not enough supports. Even in the context of awareness in the medical fraternity, much work remains to be done. I can understand completely where women were coming from in respect of issues in the workplace, access to proper supports and primary care and the absence of specialised clinics and staff. The fact that we have started to move in the right direction in this area now is testimony to that. We must, however, admit and acknowledge that up to that point we were failing women going through the menopause and not doing enough to support them. Some 88% of respondents also felt there was still a stigma in Irish society about discussing this issue.

Because of this, many women are not comfortable discussing their concerns with their doctors. Some 85% of survey respondents do not believe healthcare professionals in Ireland are equipped to give advice on those issues. Many doctors themselves will admit they are not equipped because they have never had the opportunity to learn.

There are a number of things we can do in this area to build on the work that the Minister has done. We need more clinics. We need more of the support hubs, which have been established. There are a number of very good hubs that are up and running already. We could do with many more of them throughout the State. We need to expand out and learn from the clinics and the hubs that are in place and look over time at how we can expand them throughout the State.

We also need to look at hormone replacement therapy, HRT, and, first, at the supply issue. It is my understanding there is a shortage. In some areas there is a crisis. Will the Minister focus on that to ensure the HSE is alert to that and it is responding to make sure we have proper supplies of treatments, medications, gels etc.? We also need to look at all the other wraparound supports women need. I would add supports in the workplace to that. That is important. One of the issues that came back strongly to me was the absence in most HR policies of any reference to the menopause, such as to symptoms, awareness, training for staff and training for managers. There is a general lack of support. It is not, for example, part of any sick pay entitlements in most organisations or under most employers. We have not put a focus on this, and I think that we should.

I want to deal with the issue of endometriosis, which I know the Minister has discussed several times and something on which he wants to see movement. A number of women have spoken to me about living with endometriosis which went undiagnosed as a result of the same problems: a lack of awareness and training among clinicians, being bounced across waiting lists for years, and only being diagnosed when they were lucky to get the right specialist.

Sometimes an unfair burden is put on GPs, and I know there is a really heavy workload. The Minister and I have spoken about the need to reform GP contracts and to make the contracts more fit for purpose for a modern GP practice. General practice has changed for the better, in my view, but GPs are doing an awful lot more and there is always training required. When it comes to women's healthcare, however, and to those two areas I have referenced, there seems to be a dearth in knowledge and understanding among some GPs and some healthcare professionals. It is important the HSE puts a focus on that and the Irish College of General Practitioners, which I understand would have a role to play in this, would provide the training to make sure women have proper supports and, most especially, when they go to see their GP, who is very often the first point of contact, the GP understands the issues, the needs and what supports are in place in order that the GP can make the referrals and ensure women are on the right treatments, which is very often not the case.

I genuinely commend the Minister on the work he has done and the spotlight he has brought to this issue. He has not just shone a spotlight on it but has taken real, concrete actions. I have no doubt much more will have to be done in the time ahead.

Deputy Patricia Ryan

I welcome the opportunity to speak on this topic. Sinn Féin has been to fore in the area of women's health with a number of progressive proposals in our 2020 election manifesto. The area of health has been a sphere in which inequalities are particularly acute for women. From the outrageous wrongdoings of thalidomide and symphysiotomy of the past to the more recent vaginal mesh implant and CervicalCheck scandals, we can see where inequalities have existed and where they continue to recur.

On the subject of thalidomide, I would like to support the campaign of the Irish Thalidomide Association, which is asking all those completing the census 2022 next Sunday, 3 April, to include them in the time capsule section. The association is asking that everyone simply write the word “thalidomide” and draw a line. In 100 years, no one will remember the thalidomide story, but with our help, historians will google it or use whatever the research tool is in the year 2122. This simple gesture of inclusion will means they will learn whether 2022 was finally the year where a line was drawn under that tragedy in Ireland. They will also learn that the 40 Irish survivors were amazing in all they achieved in ordinary, daily lives despite levels of unique disability.

In our own women’s health document, Sinn Féin proposed additional spending to fund and implement the national maternity strategy. Many of the recommendations in the national strategy have not been implemented due to a lack of funding, and this needs to change. We need to extend free contraception to all, to provide focused care for cardiovascular disease in women, and compassionate care to women from ethnic and other minority backgrounds. The Government’s new women’s health action plan has stopped short of setting any targets for the reduction in gynaecology waiting lists for the 35,793 patients who either need to see a specialist or need to receive treatment. Without targets we cannot measure success.

The plan also promises additional breastfeeding supports and expanded eating disorder services, but this comes against a big rise in demand for eating disorder treatments during the pandemic, putting an already poor service under more pressure. There are currently just three inpatient beds for adults in the State for people suffering from eating disorders, and these three beds are only available in the catchment area of community healthcare organisation, CHO, 6. This area includes south-east Dublin, Dún Laoghaire and east Wicklow. In other parts of the HSE, adult patients are currently admitted to local general adult mental health units. I have spoken to families recently who feel their loved ones do not get the specialist treatment they require when they are admitted to generic mental health hospitals. What often happens is patients get referred to a generic adult mental health unit and they are kept in until their body mass index, BMI, has increased. The symptoms are treated rather than the illness. Patients are often discharged back to the community without any specialist help. That is not good enough. I understand the Mount Carmel eating disorder unit has been delayed and may open before the end of this year, but we need these services in other areas of the country as well. There is more beyond the M50. Rural areas need to have services like this.

We must ensure the plan addresses the full range of health issues for women, from chronic disease to mental health to violence against women. It must also prioritise the women most likely to experience health inequalities, including women from deprived areas, Traveller women, homeless women and women living in direct provision. Consistent funding must be put in place to ensure this plan is a success. Recent years have seen a serious decline in the structures for women’s health, from the dissolution of the Department of Health’s women’s health council to the demise of the network of women’s health officers in the HSE.

We have a lot of ground to make up, and Sinn Féin will continue to hold the Minister to account to account for that. I do appreciate everything he has done so far.

Deputy Sorca Clarke

I welcome the opportunity to speak on this key issue of women's healthcare. In March 2021, I asked the Minister a parliamentary question specifically about gynaecology waiting lists. At that time, there were 30,180 women waiting on an outpatient department appointment. This figure did not include inpatients and was for outpatients alone. In his reply, the Minister referenced the impact of Covid-19. However, at that point 8,223 women had been waiting for an appointment since before Covid-19 ever came into existence.

In recent weeks, I asked the Minister the same question again. Despite his reply last year, this reply showed that the waiting lists had not just stayed static but had actually increased to 30,805 women waiting on an outpatient appointment. I am glad the Minister referenced women and girls in his reply, because 293 of those 30,000 are with Children's Health Ireland at Crumlin. I am urging the Minister to act now to end these long gynaecology waiting lists. They are spiralling.

I said in this House before and I will say it again: we are creating the perfect storm when it comes to women's healthcare. No woman requests a gynaecology appointment on a whim. It is done because often there are debilitating symptoms that need urgent medical care. These include abnormal bleeding, fibroids, endometriosis, cysts and prolapse. Behind each and every one of these 30,805 figures on a waiting list are real people with real stresses, a real concern and a real medical need. Delayed appointments and delayed care results in delayed diagnosis and delayed treatment. It is not acceptable and women deserve better.

How much of the €350 million in the waiting list action plan will be allocated directly to gynaecological services? Will the Minister publish a specific plan for gynaecological care to ensure each and every one of those services is sufficiently resourced to reduce these waiting times? There is not one area that does not have a significant number of women waiting on this medical care. Failing to address this problem now, which has increased in the past 12 months, continues to fail each and every one of those people on that waiting list. Women deserve better and they expect Government to deliver.

Deputy Duncan Smith

I acknowledge and welcome this plan and the work that has gone into it. The three guiding words as set out in this plan are "listen", "invest" and "deliver". To listen is vitally important. A great shame of this country in its 100 years has been the fact it did not listen to women on many issues, not least on health. We do not need to go back over the whole list now. There has never really been an issue with the amount of money invested in health but with where it has actually been directed. A definite decision has been made here to direct it to areas that for too long have gone unnoticed or ignored at the very back of the queue, if they were ever even in the queue at all. Delivery is the test of any plan and it will be the test of this one.

A deliberate decision has been made regarding the €31 million in this plan. The Government could have put €31 million into any one of these areas and perhaps bring them on further. A deliberate decision has been made to get started or maybe progress things from a very small base, however, across a number of different areas such as endometriosis, maternal healthcare and sexual and reproductive health. I think that is the right way to go as long as that investment is continued and increased.

More than 100,000 women are diagnosed with endometriosis in this country but there is a nine-year waiting time for diagnosis for many cases. Many women are still undiagnosed, so a focus on endometriosis in such a way is required. I would, however, like this to be the first step towards looking at developing a national strategy for endometriosis such as exists in France and Australia. The Minister could work on that with the Endometriosis Association of Ireland, which has done some really good work on it.

The Minister has done work on care in terms of the menopause. Sinn Féin produced a policy paper on this within the past week. This is good progress because, again, this is another area that for too long has been ignored. Women have had the impacts of menopause ignored by healthcare professionals. They have been unable talk about it with their family members and, in many cases, their support networks. That is changing and we need the clinical back-up for that. The opening of three clinics is welcome.

There are a number of aspects to the plan in terms of breast cancer and HPV vaccine catch-up. Much of that is actually catching up on massive delays that occurred over the course of Covid-19. We need to have a whole other debate about undiagnosed illnesses and conditions. This action plan is not going to deal with that and I do not think it does, but I am just careful about putting it in.

I welcome free contraception for women aged 17 to 25. That is quite radical and very progressive but, again, contraception should not just be a woman's responsibility and we cannot let men off either. I understand putting in the provision in terms of the consequences of contraception all being borne by women. There also needs to be proper messaging in terms of the responsibility for men.

Rolling out period poverty initiatives across the local authorities is welcome. I acknowledge the work of Senator Moynihan in that regard. She did much work in terms of getting it on the agenda here and it has been taken up by Government. In terms of delivery, however, it will need to get from the local authorities to the people who need it. I would like to see the detail of how the delivery of that is going to happen. It is a very real issue.

The Minister was unable to attend the debate last week on the Health (Assisted Human Reproduction) Bill 2022. I know he would have liked to have been there because it is a very long, detailed and important Bill. The move towards publicly funded fertility treatment is something that needs to be expedited as quickly as possible. We all know it is a difficult issue with technical elements to it and all the rest. Time is of the essence in terms of fertility treatment, however. At the moment, it is only open to people who can afford it. We do not need to go through the whole list of factors that are affecting people in this country, from the cost of living and energy bills to mortgages and rents and everything else. Many people just cannot afford fertility treatment in any way, shape or form. That is something that needs to be expedited.

I tabled a parliamentary question on the safe access zones Bill, which was going to be taken this morning but we ran out of time. There is a cross-party Opposition Bill in the Seanad. I ask the Minister to progress it and not wait until the back end of 2022. I believe it is something the Minister wants to see brought in. I believe his bona fides on it but he has to prove it. A good Bill is there, which we could progress and get through.

As with any plan, the Minister has set a menu for himself and we will all be able to look at it over the coming months and years and hold him to account. That is our job. Again, this is not a suite of measures that will resolve any of these issues in 2022 or, indeed, in 2023 and 2024. We will need to build investment in it. In the areas of endometriosis and the menopause particularly, it is very welcome to see a consistent light being shone and investment being made. It is to be hoped we will see the delivery of that.

Deputy Emer Higgins

I welcome the publication of the women’s health action plan. Its publication speaks to the tide change that is happening in the area of women’s health. It is something I very much support. Women’s health goes far beyond just family planning.

I am glad to see this action plan recognising the many facets and areas of women’s health that need and deserve attention. We have a very long way to go in ending the health-based discrimination women face. It can be very difficult for women to get the treatment they need. There are countless stories of women’s health issues being belittled, downplayed or even denied by health professionals and society at large. This action plan goes a long way to tackling the stigmas and creating access to research and treatment that will have a real and genuine impact.

I want to take time to highlight some of the key elements of the plan and what will change in 2022: €9 million to expand free contraception to women aged 17 to 25; 24 additional lactation consultants nationally; nine specialist eating disorder teams operating nationally; local authority period poverty mitigation measures; 20 see-and-treat gynaecology clinics; six regional fertility hubs; four specialist menopause clinics; the expansion of specialist services and out-of-hours care for paediatric gynaecology; the first GP lead for women’s health; the expansion of endometriosis services in counties Dublin and Cork; and a maternity bereavement experience survey, which is the first of its kind. These are all very welcome initiatives and they span the gamut of women’s health from maternal health and sexual and reproductive health to gynaecological and menstrual health, as well as wider physical and mental health.

In recent years, we have delivered significant improvements in our country's approach to women's healthcare. The repeal of the eighth amendment, for example, was a momentous achievement but, unfortunately, the legislation is not providing the access so many of us hoped it would. I know this action plan commits to progressing the review of the operation of the legislation, and that is so important. I am disappointed that improving access to and safety of terminations in Ireland and the provision of safe access zones do not feature more prominently in the action plan. I suspect this is because the review into the legislation is ongoing and actions will be based on that review. I hope the review results in an improved service.

Despite the pandemic, almost 200 women and girls travelled to Britain for an abortion last year, and one of every three women who did so was seeking a termination due to a fatal foetal anomaly. As I have said previously in the House, when Ireland voted overwhelmingly to repeal the eighth amendment, that is not what we expected or asked for. There remain counties with no abortion services and part of the reservation for many GPs may come from not wanting to attract protests or intimidation from anti-choice groups. I have previously raised the issue of safe access zones and I again call on the Minister to enact legislation quickly that will protect women, couples and healthcare professionals from these cruel acts of intimidation. Not only are protests happening regularly outside GP clinics and hospitals that provide abortion services but we are now also seeing a new phenomenon, namely, anti-abortion advertising outside these healthcare settings. It is important that a ban on such advertisements be included in our safe access zone legislation.

The expansion of endometriosis services in Dublin and Cork is welcome. This has been a really underserviced area. It can be very difficult for women to get a diagnosis. There are waiting lists for women currently in the process and there have been missed opportunities for diagnosis for women who have come forward with symptoms in years gone by. As recently as ten years ago, there was not the same level of awareness or investment that exists now. I have much concern for the many women who will have seen their doctor years ago regarding symptoms of endometriosis. They may have been advised they were likely to have endometriosis but that the diagnostic procedure would be painful and complicated and that, even if they did get a diagnosis, at the time there was not much that could be done or offered as treatment. Many women, therefore, did not go ahead with a diagnosis and have had to learn coping mechanisms.

In the meantime, however, there have since been substantial advances in technology, medicine, treatment and diagnosis and it is important we do not forget those women who gave up on a diagnosis long ago. Whether through an information campaign or direct GP outreach, it is important that all women suffering from endometriosis get the support they need. As we know, endometriosis can lead to fertility challenges. Sadly, I have heard reports of fertility clinics suspecting that a woman has endometriosis but choosing not to raise their suspicions with the woman in case she decides not to go ahead with fertility treatment if she knows it may have a lower chance of success. Those kinds of reports, if true, emphasise the need to regulate the fertility industry. This should be an important part of the improved model of care for infertility. I acknowledge it is an issue we discussed in the House last week. Ensuring a woman’s best interest is at the heart of healthcare is the only way forward.

Support for women experiencing menopause is another area I have been speaking about regularly in the Dáil. In 2019, the women's health task force recommended that we improve supports for women experiencing menopause. Last year, the country's first specialist menopause clinic was established in Dublin, which is very welcome. I welcome also the Minister's confirmation that the three additional menopause clinics that were promised will be delivered this year. Many women have contacted me to raise the issue of shortages in the supply of HRT patches and gels and the inability to access them, an issue I raised recently in a parliamentary question. I was glad to learn the Health Products Regulatory Authority, HPRA, has had regular and ongoing engagement with suppliers in this regard and they are collaborating to improve supply. Finally in this context, I welcome the creation of a group to examine how we can better support Civil Service employees who are going through menopause. I hope the group will examine the international experience and the recently introduced menopause supports for the staff of London’s City Hall.

It is important these kinds of working groups be established not just for the public sector but within private businesses as well. The Menopause Hub has found 22% of women experiencing moderate to severe menopause symptoms have missed three or more days of work and 85% felt they could not tell their employer the real reason for that time off work. Strikingly, almost half of these women have considered giving up work because their symptoms are so severe. It is sobering to hear that in 2022, many women going through menopause feel they may have to give up on their career. Some organisations are beginning to recognise the challenges of menopause for women and doing more to educate their managers and broader workforce. It would be great to see more employers design organisational policies on menopause as well as delivering menopause training for managers and HR staff to increase awareness of these issues in the workplace.

New Zealand is an example of a country with a progressive approach to women's health. Its approach to miscarriage, in particular, is one I would like to be replicated in Ireland. A number of my party colleagues, including Deputy Carroll MacNeill and Senator Seery Kearney, and I have been advocating for statutory miscarriage leave to be introduced to provide women with the necessary support in the event of early pregnancy loss. Sadly, one in every five pregnancies is lost in the early stages. The sadness and difficulty of early pregnancy loss needs to be addressed. Women should be supported in taking the necessary time to heal, both physically and emotionally. In 2022, the first national maternity bereavement experience survey will be carried out. It will ask women about their lived experience of bereavement care in Ireland’s maternity units and hospitals. It will be such a worthwhile exercise in order to find out what needs to be improved. Nevertheless, I am disappointed there is no mention of miscarriage in the women’s health action plan. I hope this matter will be added to future health action plans to improve the support available to women and their families. Women's healthcare does not begin and end at family planning. It is multifaceted, and I hope we will continue to see further development in all areas of women’s healthcare.

I very much welcome the commitments of this women’s health action plan and I commend the Minister and his team on ensuring they will come to pass.

An Ceann Comhairle

I call on Deputy O'Reilly, who will share time with Deputy Martin Kenny.

Deputy Stephen Donnelly

A Cheann Comhairle, I wish to apologise to colleagues in advance. I really wanted to stay for the entire debate but a sub-committee meeting on health is scheduled to be held at 3 p.m. This is a very important issue for me and I wanted to be here for the full debate. Deputies will understand that when I leave, it is not that I want to go anywhere else but rather because I have been summoned. Again, I apologise.

An Ceann Comhairle

You cannot bilocate.

Deputy Louise O'Reilly

We expect much of the Minister but we do not expect him to master the art of bilocation, and we thank him for his apology.

I welcome the publication of the women's health action plan. It is a positive step and I am thankful for the opportunity to discuss it. It is a good plan but, as the Minister knows well, it will succeed only if it is backed up with funding, commitment and dedication driven by him and his team in the Department. In 2018, when both the Minister and I were sitting on the Opposition benches, I launched a similar publication on behalf of Sinn Féin entitled A Vision for Women's Health. I would like to think my work in the Oireachtas over recent years has highlighted my interest in, but also my passion for, women's health services and the provision of decent healthcare for women.

I have spoken often in this Chamber from the point of view of someone who uses the healthcare services and has been on the business end of some of the deficiencies, despite much great work being done by the men and women who deliver that care every day. It can at times be angering and frustrating to be a woman in this State and being the mother of a daughter can sometimes be equally so. So many injustices have been visited on women, and while I will not go through all of them, they relate to issues including symphysiotomy, thalidomide, CervicalCheck, transvaginal mesh implants and - I never speak about women's healthcare without mentioning this - Sheila Hodgers, who died too young along with her baby and whose anniversary took place recently. We have a long history of letting down women, but here is hoping this action plan represents the start of delivering on what is needed. The policy commits the Minister to listening. I am glad he has been doing that and I hope he will continue to do so because it is very important. The lived experience of women within our healthcare system is very telling, and if the Minister wants to know what needs to be done, they will tell him.

The health service is riddled with inequalities, especially for women. As someone who suffered with endometriosis in my 20s, I can say that while undiagnosed endometriosis is bad, having it misdiagnosed as something that may be just in the person's head is a billion times worse.

That dismissive attitude has to go.

I will say, in relation to this strategy, that Traveller women have a mortality rate five times that of the national rate. If the Minister's plan works and delivers, those Traveller women will see a real and appreciable difference in their life expectancy.

Deputy Martin Kenny

I also welcome this plan today. It is certainly a decision to move in the right direction. As has been said by many others, we have had a chequered past in regard to women's health in this country. Hopefully, we can keep that in the past and ensure there is no reoccurrence of it.

I particularly want to raise with the Minister today the issues in regard to menopause services, particularly for women in rural Ireland. The two issues are the lack of services nationwide; and the shortages we are experiencing right now across the entire country in regard to hormone replacement therapy, which are having a negative impact on many women's lives. Deputy Cullinane and others in Sinn Féin produced a survey recently in respect of that and a policy document around it. The stakeholders were unanimous in saying it is far too difficult to get access to trusted and relevant information, especially in rural areas, and there are no private clinics such as exist in some of the urban settings which people can sometimes access. The public clinic, which is now open in Dublin, of course, is only dealing with the most complex of cases. That needs to be recognised and I welcome that there is work being done to advance this.

Deputy Cullinane and my party leader engaged with the Minister in regard to ensuring action is taken to deal with these shortages of crucial medicines that women need. On the notion that this is somehow always an issue for the HPRA to deal with and that it can be left to the authority, the Minister needs to take grip of this particular issue and not pass it on to an agency to deal with because it simply is not working and it is too significant. The medication regarded by many in this particular instance would be as important as beta blockers or, indeed, anti-depressants, if they were missing and people were not able to use them who had issues there. We need to recognise the real importance of them.

I acknowledge that this is movement in the right direction but given the particular conditions that many women face when they are menopausal, it is problematic that so many GPs in the country do not take it seriously and do not deal with it, as I know from talking to women. Interestingly, this was brought to light through Mr. Joe Duffy's radio show a couple of months ago when it was spoken about over a couple of weeks. On occasion, I have issue with some of what Mr. Duffy may do but sometimes he does a good job on something. On that particular item, Mr. Duffy did a good job of highlighting that issue and ensuring it was brought to the forefront in people's minds and, hopefully, in the minds of policymakers as well.

I welcome the document. I will put full wind in the Minister's sails if he can deliver on it and ensure it is delivered on for everyone, particularly for the many women in the country who have been let down in the past.

An Ceann Comhairle

Deputy Whitmore is sharing with Deputy Shortall.

Deputy Jennifer Whitmore

I would like to take this opportunity to briefly raise the issue of the new national maternity hospital with the Minister and the language that is being used surrounding the debate at present. I want to get on the record how disappointed I am with the language that the Minister, in particular, has used over the past few months in relation to the concerns that have been expressed by women in Wicklow, across this country and, indeed, in this Chamber. Referring to these concerns as "malicious", "misinformed" and "misleading" comes across as a calculated tool to silence women when it comes to matters fundamental to their health. Let us face it, it is not the first time in the history of the State that this kind of mechanism has been used to silence women. It is certainly not in line with the policies that the Minister states here today when it comes to listening to women and their concerns.

I have a specific question and I would appreciate if the Minister could respond. Will the legal agreement that the Minister states copper-fastens that all medical procedures allowable under the law will be available in the hospital specify when they will be allowable and if they will be allowable on an elective basis? There is a big difference between having something technically allowed and it being actively provided to women. If a woman goes in and actively asks for a termination or a sterilisation, will that be allowed? If it is not specified within that legal document, how can the Minister guarantee that the ethos will not prevail over the wishes and needs of women when it comes to maternity?

Deputy Róisín Shortall

I welcome the publication of this women's health action plan. It is good to have concentration of the issue brought under one document to put a focus on that but I would say it is important that we bear in mind that women's health issues should be mainstream issues. Sometimes when there are women's sections or women's groups, that can result in the sidelining of those issues. Women's health issues should be mainstream, at the front and centre of the health service.

As I say, it is good to bring the various elements together in this but it amounts to a repackaging of several initiatives that are already in train and have been announced for some time. For example, the provision of additional lactation consultants under the national breastfeeding action plan was planned between 2016 and 2021 but has not been fully delivered on. Four of the six regional fertility hubs are already operational, and that is a 2019 plan. The new specialist eating disorder teams were in a 2018 plan that has not been delivered on. The mother and baby units - the specialist perinatal mental health model of care - are from 2017. It is fine to bring those together. The Minister talks about radical listening and that is important, but we also need radical action in relation to implementing a number of those plans that are already in existence and are moving very slowly. I would say that the commitments still fall quite far short of what is needed or recommended in previous plans.

In relation to target setting, there are no targets for the reduction of gynaecology waiting lists, for example. Those waiting lists currently stand at 35,700. There are 35,700 women on waiting lists for gynaecology services. Targets for those would be welcome.

There is something that has been omitted from this and that is the role that cost plays in being a barrier to accessing care. Of course, that applies to people across the board, men and women, but for women, in particular, cost can be a barrier to accessing services and it is important that this should be referenced.

In terms of ensuring that services are responsive to women, it is important to have women involved in decision-making in the health service. We saw, for example, with the National Public Health Emergency Team, NPHET, and throughout the past two years in respect of Covid, there were very few women involved at a senior level. Time and time again, we saw the NPHET press conference and then the various Ministers who had responsibility in that area, and not a single woman among them on a regular basis. It is important that we have women involved in decision-making, and on interview panels. I note what happened in relation to the new master of the Rotunda Hospital. Ten of the 13 people on the interview panel were men. We need people at senior levels in the health service and at decision-making levels.

In relation to radical listening, I echo what Deputy Whitmore has said. The Minister has not displayed radical listening in respect of the new national maternity hospital, which is the flagship development in respect of women's healthcare. The Minister and his predecessor listened to St. Vincent's, they listened to Holles Street but they did not listen to women. The Minister is continuing to fail to listen to women in respect of what they want. The vast majority of women - the Uplift survey showed that 73% of the public are in agreement with this - want the Minister to take steps to purchase the site for that hospital. It is utterly unacceptable that this was a deal that was hammered out between two hospitals without reference to the people who would be using that hospital - without reference to women - and that is a significant failing.

There is no justification for handing over a €1 billion asset to private interests, irrespective of whether they are religious or otherwise. That is the first point. Of course, this is a religious organisation, St. Vincent's Holdings, about which we know very little but which is the successor organisation to the Religious Sisters of Charity. The fact that the Minister is handing over the control of the hospital to that body is completely unacceptable.

I noted the Minister's comments this morning about the importance of independence and his statement that there would be an absolute guarantee of full independence, but there cannot be independence if the new national maternity hospital is a wholly owned subsidiary of St. Vincent's Holdings, which is the proposal on the table and what is planned by the Minister. In such circumstances, the new national maternity hospital cannot be independent. I urge the Minister to face up to that fact.

An Ceann Comhairle

Our next contributor is Deputy Mitchell, who is sharing time with Deputy Cronin.

Deputy Denise Mitchell

I broadly welcome this plan. It addresses many issues that Sinn Féin has been raising for years. Much will depend on how it is resourced. Words are all well and good, but real action is needed. I welcome the fact that €31 million has been ring-fenced for the plan. I hope that it is targeted towards service delivery so that women benefit from it.

In Sinn Féin's "Advancing Women's Healthcare" document, we called for universal access to contraception. It is good to see that 17- to 25-year-olds are being catered for, but we would like to see the scheme expanded. Some €700,000 is being allocated to tackling period poverty and the Minister stated that a policy was being worked on. When can we expect to see it?

Sinn Féin has been calling for mobile health units for homeless women for years. There is nothing in the document that focuses on improving access for women who are homeless, which is disappointing. There is no mention of women in direct provision either. Two of the most vulnerable groups of women have been overlooked in this plan.

My colleague, Deputy Clarke, received an answer to a parliamentary question stating that 31,000 women were waiting on gynaecology appointments. This is a perfect example of the challenges that women are facing in accessing the care they need. If it is a staffing issue, it must be addressed immediately rather than in a couple of months' time.

The four menopause clinics are welcome. Work needs to begin on them as soon as possible.

Resources need to follow this plan for it to be effective in a way that benefits women. Like all good plans, delivery is key.

Deputy Réada Cronin

Sinn Féin welcomes this plan, which recognises women's health in its own right at long last. All too often, women do not feel listened to when it comes to our health and our real concerns can be minimalised or dismissed. We have all heard of the anxiety that turns out to be heart disease or the normal period pain that ends up being endometriosis. We suffer from a gender gap in medical science and research as well.

I welcome this plan, but there are a few areas in which we could go a little further. I am concerned that, while Viagra is reimbursed on the drugs payment scheme and the medical card, the drug to help women with hyperemesis gravidarum in pregnancy is not. I suffered from it myself, so I know how it wipes you out when you are pregnant. I know of many women in my constituency of Kildare North who are looking for Cariban. While I recognise from replies to parliamentary questions that the supplier has not engaged in the process to make it available for reimbursement, I ask that the Minister engage with the supplier. There needs to be reimbursement.

In my day, which was a while ago, we all read the book What to Expect When You're Expecting. In terms of postnatal depression, though, what new mothers need to read is a book that would be called "What to Expect When You're Not Expecting Anymore". I would like to see much more attention being given to the postnatal depression that haunts the lives of many women and families, sometimes with devastating consequences. As women, we buy into the lie that childbirth is great and easy when it is often the case that the loss of control, the fear, the trauma and so on are hell. We need to listen to women who have just given birth and are struggling and exhausted.

I welcome the added attention to breastfeeding. We need to be shouting from the rooftops about how convenient it is once women get support from the start. I cannot speak about breastfeeding without saying that Ireland needs to take an ethical look at the exporting of baby formula to countries where breastfeeding is the norm. The line is "Breast is best", and it is certainly is. It is also more important than bottom lines.

I welcome the plan. We still have a way to go, but it is a step in the right direction.

I have a Bill on bereavement leave that is going through the legislative process. I introduced it with Deputy O'Reilly. I welcome that the North managed to introduce bereavement leave. Our Bill is worth a mention.

An Ceann Comhairle

Next is Deputy Bríd Smith, who is sharing time with Deputy Barry. Deputy Gino Kenny is not down on the list, but he is more than welcome to contribute as well.

Deputy Bríd Smith

It should be myself, Deputy Gino Kenny and Deputy Barry.

An Ceann Comhairle

On you go.

Deputy Gino Kenny

I welcome this document, which is subtitled "Listen. Invest. Deliver." For many years, however, none of that was done. In fact, many women were never listened to and there was disinvestment in women's health and society as a whole. As a consequence of that, women's health was subordinate in society and in healthcare.

One of the greatest advocates for women's healthcare in recent times has been Vicky Phelan. Her testimony and life experience have been instrumental in how we deal with women's healthcare. Vicky advocated for something very unique in Irish society, that being, a change in perception and encouraging women to challenge the paternalistic culture that exists in healthcare. It is a top-down culture that looks down on women from the very top. Vicky's input so far has been fantastic.

I wish to speak about this document. It is important that perinatal mental health services have been advocated for. I welcome that there will be more specialists, not only in Dublin but also in Cork. From my understanding of endometriosis, on which I do not have much information, a large number of women are not being diagnosed and have had to go elsewhere to get treatment.

My final point is on one of the most important issues and relates to progressing the early detection of breast cancer. There is a very strong argument to be made for lowering the age for breast screening from 50 to 40. There are undoubtedly pros and cons, but a very good argument for lowering the age not only has to do with early detection, but, most importantly, saving women's lives. I urge the Minister, who has just left the Chamber, to consider early detection and to lower the breast screening age to 40.

Deputy Bríd Smith

I am glad to speak on this plan. The first issue that jumps out at me is the reason we are discussing it, which is that women, by our physiological and psychological nature, are complex creatures and our health needs a complex response. This document makes mention of contraception, period poverty, menopause, endometriosis, breastfeeding, gynaecology, including paediatric gynaecology, maternity bereavement and fertility hubs. I could go on and on because there are so many issues.

It is not some kind of achievement for the Department to fund its own strategy. In fact, I would make the criticism that the €31 million of ring-fenced funding is slightly less than double the amount dedicated to the horse and greyhound industries. It is no great achievement.

I must say something before I go any further. Due to all of these issues and the very fact that our health, physiology and psychology are built around our ability to reproduce life, all of this has to be linked to the strategy around the national maternity hospital. Opposition to the deal on the hospital has been disgracefully portrayed as somehow being hysterical or ill-informed. I regard that as patronising and misleading. To repeat what has been said many times in the House, if I said that a State-funded and State-built facility for women's reproductive health was being vested in the hands of a body that was set up and ultimately controlled by a religious order in this day and age, post repeal, one might think I was having a laugh.

It is no laugh but a very serious issue. We will not accept dismissal of our concerns around the national maternity hospital. It is bizarre that any Minister would think, given our recent past, that women should trust any assurances from the church or the State on their healthcare. The new national maternity hospital has been paid for by the public and it must be controlled, run and overseen by public authority.

Deputy Mick Barry

Why does this society tolerate an extreme shortage of an essential medicine for women? That is precisely what has been happening with the scarcity of HRT patches. Would the same toleration be shown if, for example, the medicine in extreme short supply was Viagra? The hot flushes, joint pain, anxiety, insomnia, pain and discomfort caused by menopause has, when untreated, caused women to give up their jobs and make other unnecessary sacrifices. Why are only 10% of women in Ireland prescribed HRT? Yes, there was a cancer scare but it was a false one and it was 20 years ago. Menopause is barely studied at medical school. This needs to change. Menopause affects all women from their 40s on and some much younger. It needs to be taught. While we are at it, what training are doctors and medical professionals being given to combat gender bias in medicine? A recent worldwide study on women's pain not being taken as seriously as men's makes for sober reading. Last but not least, HRT, as an essential medicine, needs to be free of charge. That is the case in Scotland and Wales. It needs to be the case here too.

Deputy Mark Ward

I welcome the opportunity to contribute on the women's health action plan. I also welcome the plan but it does not go far enough. I will focus my contribution on two areas; perinatal mental health services and eating disorders.

Depression during pregnancy is prevalent and a specialist perinatal mental health service is needed. There is currently no mother and baby unit, North or South, on the island of Ireland. Mothers who need inpatient care are currently admitted to acute psychiatric units. A response to a parliamentary question stated that the specialist perinatal mental health service model of care published in 2017 recommended that a mother and baby unit be developed in Dublin. It is now 2022 and nothing has happened. Reports are not worth the paper they are written on unless they are acted upon. This action plan states that embedding perinatal mental health services in all maternity units is a goal this year. That is very welcome but it must be delivered as a matter of urgency. Shortcomings in our maternity and mental health services have directly led to heart-rending instances, including the tragic deaths of some mothers and children.

We must have a specialist perinatal mental health service that is fit for purpose and free to act in the best interests of women's health. In this day and age, it is unacceptable that there is no mother and baby perinatal unit on this island. Mothers who need inpatient care are currently admitted to acute psychiatric units without their children. I am aware that a preferred site has been chosen for a specialist perinatal mental health service in St. Vincent's Hospital, Dublin, but we need to see much more progress if the island of Ireland is to get its first mother and baby unit for mothers who require inpatient mental health supports. This action plan for women's health calls for a mother and baby inpatient perinatal service but it does not set a date for such a facility. Recommendation 53c of the Sharing the Vision implementation plan calls for a new mother and baby unit to be in place in 2024. Will the Government meet this target? Why was this date not included in the women's health action plan we are discussing? This omission does not fill me with confidence.

I will speak to the critical importance of services for eating disorders. There are currently just three inpatient beds for adults in the State for people suffering from eating disorders. These three beds are only available to those who live in the CHO 6 catchment area. In other parts of the HSE, adult patients are currently admitted to local general adult mental health units. I have recently spoken to families who believe their loved ones do not get the specialist treatments required when they are admitted to generic mental health hospitals. It often happens that patients are referred to generic adult mental health units and kept in until their body mass index has increased. I have reports that they are then discharged back into the community without any specialist help and with little follow-up.

There is no mention of increasing inpatient beds in this action plan. There is no commitment in this plan whatsoever to increase the three beds we have for the entire State for people suffering with eating disorders. The national clinical programme for eating disorders, published by the HSE in 2018, committed to putting in place 16 specialist hubs nationwide over five years offering specialist multidisciplinary teams of clinicians. Next year, the five-year target of delivering these 16 specialist eating disorder hubs nationwide is up. The plan we are talking about today only commits to nine eating disorder hubs. This is 57% of what was called for in 2018, while families throughout the State continue to suffer under the major strain and distress of managing this life-threatening condition and are met with wholly inadequate treatment and support. An eating disorder service was meant to open in Mount Carmel Community Hospital in December 2021. We were told this would be delayed until June 2022 and there is now a further delay. We need to see urgency because this is critical for people suffering with eating disorders at present.

Deputy Verona Murphy

I welcome the opportunity to discuss the women’s health action plan published a few weeks ago. Before looking at the details of the plan, I reiterate a point I made earlier in the week when I had the opportunity to speak about waiting lists. It is very important that we get the basics right. We can have all the fancy plans in the world but if waiting lists are getting longer and longer, then the plans will not meet their targets and people will not receive the help and support they need.

Women's and men’s health outcomes will be improved by the reduction of waiting times for important consultations and treatments. What worries me when reading through this plan is that many of the welcome initiatives will go the way of everything else in the HSE, namely, waiting lists, lack of staff, lack of capacity, etc. This is my major fear because I sincerely hope that the aims and objectives in this plan will be successful and a lot better than those we had for Mesh Survivors Ireland, who had to primarily go abroad in most cases for treatment.

I will focus first on the section of the plan entitled "What will change in 2022?" because that is what is most important. What is the plan actually going to achieve? The aim is to have nine specialist eating disorder teams operating nationally. I hope they will be properly staffed because the long-time absence of a dietician in child and adolescent mental health services in Wexford shows the difficulty in staffing in related areas. I also welcome the provision for an improvement in maternity bereavement services. It is a devastating time for parents when a child is lost, either through miscarriage or premature death. The availability of support services should be widespread to help people cope with such a loss.

The plan in general focuses on the headings "Listen", "Invest" and "Deliver". In fairness to those involved in healthcare provision and those at Government level, listening and investment are usually done pretty well. We have more than adequate funding of our health service. The Department of Health budget has increased from €13.6 billion in 2016 to just under €22 billion in 2021. No one could say we are not investing. However, it is the return on that investment that continues to be a question, which is the delivery part in the HSE. In the delivery section of the report, many phrases are used, such as "We will improve", "We will develop" and "We will support", but the action plan is bereft of specific targets. Maybe they will be published later but without specific targets there is no means to judge whether this action plan will work. Using phrases such as "We will improve" and "We will support" is vague and non-specific. We need a different approach in health because the current approach to accountability and achieving outcomes is just not working, as the length of our waiting lists demonstrates all too clearly.

We need specific targets and budgets to achieve those targets, and specific people for ensuring that those targets are met. We can then easily compare the plan with the results to measure its success and hold people to account for any shortcomings.

I have spoken about menstrual health in the past. Twelve months ago, in the debate on International Women's Day, I said that we need to ensure that no woman in this country is unable to access menstrual products due to poverty or is reluctant to ask for provision due to embarrassment. I am pleased this is referenced in the action plan alongside gynaecological and pelvic health. The plan mentions two specialist endometriosis services for complex care. The Minister will be aware that March is endometriosis month. There have been calls for fertility clinics for women in late stages of endometriosis and free contraception for women with endometriosis and polycystic ovary syndrome. There needs to be more awareness of both as they are severe illnesses.

In his closing remarks, I ask the Minister of State to confirm that he is aware of the serious shortage and lack of availability in HRT patches and gels that many women say are life-changing and life-saving medications. The Irish Countrywomen's Association has written to all Oireachtas Members to consider the call by the National Women's Council for a dedicated Minister for women and equality or one for domestic, sexual and gender-based violence. Violence against women must end and action must be taken with that in mind. I acknowledge the initiative of Colour Her Way taken by two Wexford ladies, Christine Doyle of Christine Doyle Wellbeing and Amy Murray of D’lush Café. They are providing purple gilets with personal alarms built in for women and girls who wish to walk or run so that they can feel safer and more confident.

Deputy Peadar Tóibín

I welcome the opportunity to contribute on the women's health action plan. First, CervicalCheck screening is not 100% accurate. There needs to be a public information campaign on this to ensure women who have symptoms do not ignore them because their screening test was clear. It is vital that if a woman has symptoms of cervical cancer that she goes to see her GP regardless of whether she received a clear smear test result. We need to reiterate this in every debate we have on women's health. It is so important. I would also appreciate a progress report from the Minister on the construction of a new screening laboratory. Where are we on this? Are we still outsourcing the analysis of slides?

The action plan for this year and the national maternity strategy mention increasing support for pregnant women who are suffering from addiction. Figures released to us show that the number of children addicted to drugs or alcohol has increased in recent years and particularly during the Covid crisis. The image of a midwife weaning a newborn baby off illegal drugs is shocking and distressing. People suffering from addiction need compassionate help and support. These are people like us with different life circumstances. We need to do everything in our power to help them. What specifically is the Government doing to tackle this issue?

I wish to pay tribute to Róisín and Mark Molloy for their advocacy on maternity services. Mark Molloy resigned from the HSE because of his poor experiences with the Department. One of the most shocking aspects of their treatment was the raiding of ring-fenced money. The Molloys were advocating on behalf of their son, Mark, and for other babies who died unnecessarily in the Midlands Regional Hospital. They were trying to save babies' lives. In 2019, the ring-fenced funding for the national maternity strategy was diverted by the Government to pay for the roll-out of abortion. The Government took money that was intended to save women's and babies' lives and diverted it to rolling out a procedure that ends babies' lives. This was utterly shocking, especially in the context in which the Molloys had lost their baby son. Will the Government apologise for the way it treated Mark and Róisín and will it return the ring-fenced funding that it raided from the national maternity strategy?

All the action plans on the planet are wonderful but if they are not implemented, funded or resourced, they will not make any difference to people's lives. We speak on a day when emergency departments across the country are under serious pressure due to overcrowding. In the past year, I learned that 107,000 people had adverse incidents caused to them by actions taken by the HSE. We desperately need proper management of the HSE and proper resourcing.

Deputy Catherine Connolly

The women's health action plan is welcome. When I welcome it, I must put it in context as I try to do always. We are talking about radical listening. "Listen, invest and deliver" has never happened for women in Ireland. The senior Minister had to leave and had a genuine reason but I wish he was here because I never like to contribute when he is not here.

Let us first look at the national maternity strategy. One hundred years after 1916 we managed to pass a national maternity strategy. It took 100 years to be revolutionary. Then we sat on that and did nothing. Last June, I tabled a motion and the Government agreed to it, fair play to it. It was on foot of HIQA's concern about the lack of action on the strategy's implementation. We get lots of strategies which are very positive. The strategy could not be faulted but it was not being implemented. Then today the House was told that for the first time last year and this year, the strategy was being fully resourced. Imagine that it took until 2021. That strategy came on foot of the deaths and suffering of women, as has this strategy. We look at Savita Halappanavar, Portlaoise, Portiuncula and many other hospitals where women, or their children, died or suffered. When finally we get a strategy we do not implement it. We table motions here and then, finally, a little bit is implemented.

Now we have this strategy. It would be churlish of me not to welcome the positive elements in it and some of the money that has been ring-fenced. However, when looking at what we are doing and the need for it, it is extraordinary. We are highlighting the basic services that should be there as of right and saying they are radical. I am not of that view; I am of the view that we simply cannot have an equal society and a thriving economy without good health for everyone but particularly women and children because they are the most vulnerable. That would help our economy yet we have never done it. It has never made sense to me that we talk about strategy after strategy and action plan after action plan around domestic violence, for example, when every year it costs the economy €2.2 billion at a conservative estimate. It makes eminent sense to deal with the challenges that face us immediately and in an equal way. We have not done that and, therefore, we find ourselves here today discussing this document, which states it will "listen, invest and deliver" and, more patronising still, we are told that it is radical listening. The Government has not listened to us on the national maternity hospital, has it? I am not personalising it with the Minister of State, but each time this side of the House has raised it with the Taoiseach - and we have exhausted the democratic means of raising the national maternity hospital to show our concern and worry - we have received a cynical response that we should bring a motion before the House. We brought three motions forward. I brought a motion on 2 June calling, among other things, for the implementation of the national maternity strategy and for the national maternity hospital to be in public ownership on public land. My motion was approved by the Government. Deputy Shortall tabled a motion the same month, which the Government did not oppose, and then my colleague, Deputy Joan Collins, tabled another motion. We have used all our Private Members' time to say that we are extremely concerned about what is happening. There is no radical listening there. There is just a patronising three males at the top telling us that they are assured about it and then they will reassure us.

I will be coming back to that tonight. The words "empowering women" jumped out of the national maternity strategy but they do not jump out of this plan so much. What jumps out are the words of the women who engaged, and the various organisations. They said enough is enough and they want action. We look at what is happening in relation to women and the recent study, "Midwives’ views of an evidence-based intervention to reduce caesarean section rates in Ireland". We talk about empowering women and normalising the birth process. What do we find? Words fail me when it comes to the rate of caesarean sections, which increased from 34.3% in 2019 to 35.4% in 2020. That is some medical intervention by a patriarchal medical model. Are we empowering women with that? I have not enough time to go into it but it is worth reading.

With regard to breastfeeding, I welcome that money is ring-fenced for lactation experts but that is not the solution at all. Of course, it will be helpful but we have to normalise breastfeeding. We have to make it normal and that is not what is happening. We are now making it into an expertise. There is a role for experts but it is the normalisation part we are ignoring and the system is deliberately geared to keep the figures extremely low. Does the House know what the percentage is for women at six months? At six months, fewer than 6% of babies in Ireland are exclusively breastfed. From my own experience and that of my friends and colleagues I know how difficult it is and how not-normal the set-up in the hospitals is where breastfeeding is concerned. The answer being supplied is more experts. That is not the answer but I can see the use of them on occasion.

On assisted human reproduction, I think the Minister commented that he is looking forward to the Bill coming very soon. It is not going to be very soon. That Bill is extremely complex, notwithstanding that the discussion started in 2000, which is 22 years ago. I am over time so I will stop, a Cheann Comhairle. I give out about sticking to time so I will stick to time.

Deputy Joan Collins

The publication of the women's health plan and the objectives outlined in it are very welcome. There are specific issues that relate to women's health and the recognition of that is an important step forward. I welcome especially the proposal for free contraception for 17- to 25-year-olds and the commitment to roll that out to those over 25 in the next period. It would be interesting to find out if there is a plan to roll that out and when. The proposals on period poverty are also very progressive. The increase in gynaecology centres is needed and the nine eating disorder support clinics are very welcome. Other issues were brought up but as everybody has said, this will all depend on whether the money needed for these services is provided, whether the commitment to introduce them is there and whether we have the staff to implement the plan. The devil will be in the detail.

The national maternity strategy is a key part of the overall plan, with a commitment to build four new state-of-the-art modern national maternity hospitals co-located with acute hospitals in Dublin, Cork and Limerick. We have a very serious problem with the new maternity hospital to be built on the Elm Park site in Dublin. I make no apologies for concentrating on the issue in this debate. The scheduled debate on the national maternity hospital later is yet another insult from the Government and the Minister for Health on this key issue. The debate will take place in the twilight zone of Dáil business to an empty Chamber as the majority of Deputies will have left to go back to their constituencies. In his foreword to the women's health plan, the Minister makes great play of listening to the concerns of women but on the key issue around the national maternity hospital the Government is not listening, and the Minister certainly is not. He did not attend the debate on the motion I moved on the national maternity hospital just two months ago. The Government did not oppose that motion, which called for the State to use a compulsory purchase order to acquire the Elm Park site to ensure the new national maternity hospital would be built on State-owned land and be operated as a fully State-owned facility. The Government also did not oppose two previous Private Members' motions calling for the new hospital to be fully State-owned and operated. This is not an honest position by the Government or the Minister. It is a tactic to avoid any real debate on the issues involved. So much for listening to the concerns of women.

The facts of the matter are simple, namely, co-location of the national maternity hospital with St. Vincent's acute hospital has been taken off the agenda. That was the key element of the Mulvey report that caved into the demands of the St. Vincent's Hospital Group. Instead of co-location, the national maternity hospital, to be built by the State at a cost of up to €1 billion, would be integrated into the St. Vincent's Holdings group, which would license the new hospital back to the HSE. No amount of negotiating and manoeuvring can disguise this basic fact. The national maternity hospital will not be co-located. It will not be built on State-owned land. It will, in effect, be handed over to a private company that is a proxy for the Religious Sisters of Charity and the Catholic Church. If that happens - and I have no doubt it is now the intention of the Minister and the Government, while dressing it up as something else - it will be a shameful abdication by the State of its responsibilities to women. It will be an abdication of the desire to achieve a single-tier, free-at-point-of-use, universal and secular public health service. We know what subservience to the Catholic ethos has meant in the past, namely, the shame of the mother and baby homes, forced illegal adoptions, young girls forced to go away to have their babies and then give them up, the lonely journeys to Liverpool and elsewhere to end a crisis pregnancy and the barbaric practice of symphysiotomy. We need to send a very clear message that is all in the past and a message to the Religious Sisters of Charity and others that they no longer rule the roost. We need to stand up and the Government needs to listen.

An Ceann Comhairle

I thank the Deputy. I call the Minister of State to respond to the debate.

Minister of State at the Department of Health (Deputy Frankie Feighan)

I thank the Ceann Comhairle. I begin by thanking my colleagues for their considered remarks on this important topic. Both the Minister and I share their passion and commitment to providing women in Ireland with a healthcare system that is agile and responsive to the issues raised.

As Deputies will be aware, women’s health was in the programme for Government as a key priority for the Government. This is a commitment we have since backed up with €31 million in additional funding for women’s health in budget 2022 and we have now launched the Women’s Health Action Plan 2022-2023 to set out the actions that will realise our investment. We are conscious there is much more to do and this plan is a reflection of the immense effort and input from our partners and stakeholders but it is first and foremost a commitment to keep working for the women of Ireland. Our ultimate ambition is to support a culture of care where women's voices matter and are represented in decision-making, where women’s health needs are researched and understood and no health issue is taboo, where women’s health is a priority and where women’s concerns about their health are never dismissed.

We understand there are multiple factors that can impact a person’s health. These factors include age, income, sexuality, race, religion, disability and geographical region. This plan strives to ensure the impact of these differences does not impact the quality of healthcare women receive. We have made a specific commitment to focus on how marginalised women experience healthcare in Ireland and we want to make sure these women can connect into health supports in settings that are comfortable and convenient. During the life of this plan we will bring particular focus to women from disadvantaged communities and those at risk of poverty and social exclusion, including Traveller and Roma women and women with a disability.

The goals I have described are ambitious and this is why we have embedded accountability into the plan. Our listen, invest, deliver framework ensures we will never take our progress for granted or become complacent about the promises made in this plan.

We are committed to listening by seeking opportunities every year to hear from women, healthcare professionals and advocates. We will use this input to co-design new policies and actions that continue to drive momentum in improving women's health outcomes. We will continue to invest in women's health, making sure Ireland is at the cutting edge of women's health innovation and that we are agile and responsive to the needs identified by women in Ireland. We will use all of the measurements available to us to hold ourselves accountable as we deliver on this work programme. This will include existing processes in place to support, report and monitor HSE performance. We will continue to rely on the expert review and input of the women's health task force and our partners across the health sector, a group I have no doubt will continue to push for the very best we can deliver for the women of Ireland. At the end of 18 months, we will repeat this process, endeavouring to embed progress and to drive innovation in a fashion that reflects the urgency of women's health needs.

Many issues were raised by Deputies during the course of the debate, including a call for a Minister for women, which I would welcome. There was also a lot of talk about women and addiction. Part of my role includes responsibility for the national drugs strategy, which is all about reducing harm, supporting recovery, and destigmatising people who use drugs. We have made good progress in that regard and I thank all those who worked so hard on the strategy from 2017 on. We are in the middle of a mid-term review now but we are looking at a health-led approach to drug use. We are currently preparing for a citizens' assembly on drug use and it is hoped we will hit the ground running on that early next year.

Deputy Connolly argued we need to normalise breastfeeding, and I agree we need to work on increasing breastfeeding rates in this country.

Deputy Ward mentioned that the eating disorder unit in Mount Carmel has not opened yet. I understand it is due to open in June, but I will seek clarification on that.

Deputy Cronin referred to fact the drug Cariban is not available through the public system. I understand that is being looked at by the HSE and the Department of Health. It is an issue of which I am very aware and I have been pushing for progress on it within the Department of Health.

Period treatments and fertility treatments, including IVF, were also raised and we are moving in the right direction in that regard. A lot of these issues would be considered mainstream now. Much work has also been done on period poverty and progress is being made on that front too. I thank the Senators, in particular, who have worked extremely hard on that issue. The availability of HRT patches and gels was also raised during the debate.

It must be acknowledged that those of us working in the health sector are not alone in our efforts and that work is ongoing across Government on gender and equality as we work to recognise and address the multiple and overlapping social determinants that contribute to women's health. All Departments and stakeholders have an important role to play in supporting women in Ireland to live healthy lives. Some of today's contributors said that, 100 years after the foundation of the State, we are now beginning to listen to women. We will deliver a genuine and lasting step change for women in Ireland by working together.

I thank Deputies for their contributions to this important debate, which were very measured, informative and helpful. The Minister for Health, Deputy Donnelly, and the Ministers of State at the Department, Deputies Rabbitte, Butler and I, share the Deputies' passion and commitment to providing the women of Ireland with a healthcare system that is responsive to their needs. We have provided significant funding for women's health in budget 2022 and now we must put the systems in place to ensure this funding is spent appropriately in the context of the women's health action plan.