Traveller Health Care Services: Discussion with Pavee Point.

I welcome Ms Ronnie Fay, director, Mr. Martin Collins, Ms Missie Collins, Ms Mary Brigid McCann and Ms Fran Keyes from the Pavee Point Travellers' Centre. Before we begin, I draw attention to the fact that while members of the committee have absolute privilege, the same privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

The delegates will make a detailed presentation, after which there will be a question and answer session with members of the committee. I hope all the delegates will have an opportunity to speak.

Ms Ronnie Fay

We thank the Chairman and members of the committee. We are delighted to have the opportunity to be here. We have provided a comprehensive and detailed background paper which we appreciate the committee will not have had time to read in advance but which will serve as a reference document should it need it in the future. We will give a quick overview of the issues involved and leave time for a discussion which will be the best use of the committee's and our time.

I will highlight three key issues regarding Traveller health, the poor health status of Travellers and the impact of living conditions on health status; the positive developments that have occurred in the past decade; the need to ringfence and protect the Traveller health budget.

On the first point, when the report of the task force on the Traveller community, the seminal policy document on Travellers, was published in 1995, it represented a State-led response to the widely acknowledged difficulties experienced by the Traveller community. In her preface, Senator Mary Kelly, chairperson of the task force at the time of publication, stated:

...there is universal agreement that the Traveller community in Ireland today should no longer be obliged to live in conditions which are reminiscent of refugee camps. What is proposed in the Report of the Task Force is an integrated package; without the provision of adequate accommodation, improvements in educational and health provision will be difficult to undertake.

The task force made two key recommendations on the overall health status of Travellers and placed environmental health in Traveller accommodation at the centre of this approach. It defined equity as a fundamental principle of Irish health policy and stated increased funding, commensurate with the scale of the issue, should be allocated to tackle the unacceptable health status of the Traveller community and the widespread obstacles to Traveller access to health services.

The second recommendation, ER2, was that the immediate improvement of the accommodation of Travellers is a prerequisite to the general improvement in their health status. Health boards should periodically inspect all halting sites to report on health and safety matters and those reports should be made public. The task force made two additional recommendations around the establishment of Traveller health units in each of the then health boards, ER4, and around the establishment of a Traveller health advisory committee in the Department of Health and Children to draw up a national health strategy for Travellers, ER3.

We are pleased to report that three of these four recommendations have been acted upon. We have succeeded in getting a dedicated Traveller health budget, the establishment of the national Traveller health advisory committee, NTHAC, in the Department of Health and Children and the development of the national Traveller health strategy, NTHS, published in 2002. Unfortunately, there has been little positive development on environmental health concerns including accommodation provision.

The population grid for Travellers is a pyramid shape, which is usually what one associates with a developing country. It indicates a very young population with very few older people. A population bell is normal in a western European country. According to the 2006 census the age profile of Travellers is in stark contrast to the national population. It is worrying to see that while the national population in Ireland is aging, the Traveller population is dying at very young age. The average age of Travellers was 18 years when among the national population it was 33 years. Some 41% of Travellers were aged under 14 years compared to a national figure of 20%. This differential has significant implications for the State when planning and developing targets, initiatives and services for younger Travellers, particularly regarding training, education, youth, health, accommodation and employment opportunities. The census showed that only 2.6% of Travellers were aged over 65, whereas the national figure was 11%, and only 25 Travellers in the country were aged over 85 years. We want to show that Travellers have very poor health status and that one's living conditions clearly have an impact on one's health status.

It would be remiss not to acknowledge the very many positive developments over the past decade in particular. Traveller health units were established at regional level, coterminous with the old health board structure. There are more than 40 primary health care projects, PHCPs, for Travellers throughout Ireland, where Travellers are being trained as primary health care workers. In the implementation of the all-Ireland health strategy more than 400 Traveller women collected the census for the forthcoming all-Ireland study. We have FETAC accreditation of PHCPs so they are clearly of a standard and there are outcomes from them. We have a dedicated Traveller health budget. The Royal College of Surgeons has a positive action initiative whereby two Travellers are being trained as doctors. A number of the regional technical colleges have introduced Travellers to the positive action measures where they can be trained as nurses and social workers.

The Our Geels, meaning "our community" in Cant, the Travellers' language, all-Ireland Traveller health study was launched in 2007 and the fieldwork commenced last autumn. That will provide baseline data and evidence on Traveller health status and, we hope, inform a new Traveller health strategy. Travellers have been included in the intercultural health strategy and an ethnic identifier is being rolled out in Traveller health. That is useful because one can see which services people are and are not accessing, and ask why.

While acknowledging these positive developments we also acknowledge the new health needs emerging among Travellers including a growing problem of drug misuse, mental health issues, the emerging needs of older Travellers and intergenerational issues such as a breakdown between generations. There is a growing incidence of suicide among the Traveller community. These emerging health issues need to be addressed.

We acknowledge the support and goodwill of a range of individuals in the Department of Health and Children and in the HSE. The health sector has engaged actively with Travellers and Traveller organisations over the past decade and this has led to increased demands and expectations of them. We highlight that as against the Department of Education and Science and some other Departments which have not actively engaged in partnership with Travellers and Traveller organisations. However, there are structural issues which can cause problems, not least of which were the introduction of the HSE and the impact of the reform process at both a national and a local level.

Traveller organisations are being increasingly distanced from decision making and there is increasing bureaucracy as well as the potential dismantling of proven structures to reflect new HSE geographic boundaries. That is causing problems at a stage where good partnership had just begun to work. There has been staff changeover in the HSE and loss of institutional knowledge. This has also impacted on Traveller health structures and budgets.

Finally, I want to highlight the negative impact on Traveller health budgets. We argue for the need to ring-fence and protect the Traveller health budget for which the members voted in the Finance Act. Money has been allocated to address the health needs of Travellers. We understand that over €13.2 million has been allocated in additional funding to Traveller health developments since 1998. That emanated from the task force on Travellers. Unfortunately, since the establishment of the HSE it has become increasingly difficult to account for the funding allocated to Traveller health developments because the HSE has responsibility for the budget and there is a lack of transparency around what is allocated and where.

We understand that in 2007, €1 million was allocated for Traveller health developments, of which €100,000 was allocated towards the all-Ireland Traveller health study and the remainder was put towards balancing the HSE budget. Similarly, in 2008 a further €1 million was allocated to Traveller health developments and the HSE introduced a stipulation that one could only spend in 2008 what was spent in 2007. Therefore, once again €900,000 of the Traveller health budget went to balancing the HSE budget. Out of a potential €2 million for Traveller health development funding, given Traveller health status, given the all-Ireland study and given the significant needs, €1.8 million was used to balance the HSE books. This is unacceptable, and in our view immoral, given the health status of the Traveller community.

This situation is also having a negative impact on the training and employment opportunities available to Travellers who, according to the 2006 census, have a 75% unemployment rate. In 2008 we finally succeeded, through working with FÁS, in getting FETAC accreditation for Traveller primary health care projects. However, because of budget cuts in the HSE there is no funding available to Traveller organisations to employ qualified primary health care workers. There are examples throughout the country where people have spent three years training in Drogheda, Tuam, Carlow, Kilkenny and Kerry, and FÁS now states that it will not fund further training in primary health care because there are no outcomes. The reason there are no outcomes is because the HSE has kept the money that should be used to employ Travellers. For us, it is a double whammy and to say the least, it is annoying.

Of equal concern is the loss of funding from the Traveller health base budget up to 2006. For example, in the Traveller health unit in the eastern region — the old ERHA region — the funding allocated between 1998 and 2006 was €3.125 million — we have given a detailed breakdown in the comprehensive briefing document. Of the €2 million which we think was allocated since that time, the eastern region could have expected, given population numbers, to have received a further €500,000. Therefore, in theory, there is a budget in excess of €3.6 million available to Traveller health developments in the eastern region alone. However, in 2009 the eastern region has been allocated a provisional budget of €1.7 million and in a recent letter from the HSE we have been told there will be a further cut of 2%.

In effect, this means that less than 44% of the budget that the HSE has been allocated for Traveller health developments in the eastern region is going into Traveller health. The HSE has kept in excess of €2 million in the eastern region alone to balance its books. This is unacceptable, particularly given the health status and needs of the Traveller community. The HSE has to be held accountable and the funding should be released to address the urgent health needs of the Traveller community. This is particularly the case given that findings and recommendations for implementation emerge from the all-Ireland Traveller health study, that funding should be available to implement the policy.

In this short presentation, I highlight those three issues. There are many more but there is enough food for discussion in that. I thank the committee.

Ms Missie Collins

I am very concerned. I am one of the women who approached the health board in the first place for primary health care for Travellers, given that our health was so bad. I suppose we are the role model in the primary health care project. Around the country some of the projects are not up and running but they are important. It took us several long years to get the health strategy and one of its recommendations was the provision of primary care services for Travellers. It is like taking one step forward and three or four steps back. Therefore, we are always battling. I strongly emphasise the money is for Travellers' health services seeing that a big number of Travellers are not working. This is the first time in history that anything like this has ever happened for Travellers, especially Traveller women of my own age. The funding should be secured.

If there are jobs within the HSE, why not integrate the younger generation? However, I am strong about the health strategy and involvement in the all-Ireland health study. We did our own research, which involved Travellers talking to Travellers, and nobody could do better than us because there was no fear among Travellers about a Traveller talking to a Traveller. For the number of years I have been involved in Pavee Point I have met every Minister for Health and Children and had good links with them. I said I did not want to be promised anything but wanted things to happen. It has to happen for us. If we are to break the cycle of Travellers dying young, theses changes need to be made but we need support at the higher level.

I welcome the delegates and thank them for their presentation. I have a feeling ofdeja vú in that the committee has argued against hiving off the mental health budget for some time. The Traveller community faces the same difficulties in that €1.8 million of its allocation of €2 million which was welcomed at the time has been hived off, leaving only €200,000. The expectations created by the original allocation were ground down to a €200,000 investment. HSE representatives will appear before the committee in a few weeks and will have to respond on this issue. It was recognised by the HSE, the Department and the Minister that €2 million was needed for Traveller health service development in 2007 and 2008. The problem was recognised but only €200,000 was spent. This reflects the HSE’s attitude towards the needs identified by everybody, including the executive.

I had an Adjournment debate matter taken in the Dáil on 18 February about the suicide rate among Travellers. I was involved in the launch of Mary-Rose Walker's report. I was informed by the Minister that the national suicide prevention office funded the national Traveller suicide prevention project officer to build on the work of Pavee Point and local Traveller groups. How is this operating? The Minister outlined a strategic plan that had been developed. How has it developed with the national suicide prevention office and the project officer? The suicide rate among Travellers is three times that among the general population but males are nine times more likely to die by suicide than females, whereas the equivalent rate among the general population is four times.

We also find that while the Traveller community want their children to have primary education and to be able to read and write, there is reluctance when it comes to second level education. Pavee Point's figures show there is a level of second level education among Travellers. However, I have a great deal of contact with Travellers and I have found there is not the same support among them for children to move into second level education. I remember a time when there was the same reluctance in respect of primary education. There has been a great improvement in terms of sending children to primary education but it would be so progressive if there was a more positive approach to second level education because that would create the opportunity for them to move into third level. The group might comment on that.

I note also that when we as a community or as public representatives try to engage with the Traveller community, it is invariably the women who communicate with us. Rarely, if ever, do we see a male representative of the Traveller community, although they are the leaders within their community.

It is also the case that travellers are seen as a homogenous group, but they are not. Some travellers are very rich and could buy all the houses in Rathkeale that they want and seem to have unlimited resources while others are very poor and in need of housing. That is not understood by the general population. Assimilating travellers into the community, therefore, can never work because of the diversification among the Traveller community itself, the different relationships and differences in status within the community, just the same as in the settled community. Much work needs to be done in getting the general public to understand the Traveller community and how it operates. There is a need for the settled community to be more open. Where I live there is a high level of understanding and tolerance by the Travellers of the settled community and by the settled community of the Travellers. Approximately 40% of our community in Rathkeale are Travellers but it has the tenth lowest crime rate in the country. While there is not a great deal of engagement between the communities, there is a lot of understanding between them. We often say we know our Travellers from other Travellers who come in and sometimes cause trouble because our Travellers do not cause the same level of trouble. That level of understanding should be built on by the State which has a primary need to do so. It should look at where there have been successes in the relationships between Travellers and the settled community and try to understand that it can work very well. The experience where I live has been extremely positive in terms of relationships between the Traveller community and the settled community.

I welcome the Pavee Point Travellers' Centre Group. I support Deputy Neville's first point. We have previously encountered that situation whereby budgets assigned for a particular purpose have disappeared into the black hole of the HSE. The mental health and palliative care budgets were gobbled up in some way as well. We did, however, pin down one or two individuals who work in the HSE and got some of those budgets ring-fenced. This committee needs to raise that issue with the HSE, find out who has responsibility for the budget, and make sure it is ring-fenced for the Traveller community as intended. That is a positive step that the joint committee should take on board on behalf of the Traveller community.

The mortality rate in the Traveller community compared with that in the general population is very high. I was particularly struck by the very small number of Travellers over the age of 85 years. Clearly, the negative factors of Traveller health must be addressed in a specific budget.

I understand from one of the speakers that Travellers were trained to identify primary health care needs among their community. I would like to hear more about how that scheme works. Are there statistics on Travellers' health to compare the health outcomes for Travellers who live in houses or on official serviced sites as opposed to those living in temporary accommodation or on unofficial sites? I would like to know if the relative impact of Travellers' living conditions and their state of health has been established.

I would like to be associated with the warm welcome extended to the Traveller group. It is very important that we hear what they have to say. The statistics on life expectancy should make everybody sit up and take notice. The Chairman will not mind me referring to my colleague and predecessor in my constitutency, former Deputy Chris Flood, who would be known to the movement. I have daily contact with him on these issues and know he would want me to support the Pavee Point Travellers Centre group.

There have been good projects and good integration in Tallaght. I find that Travellers come to me in the normal course of business to discuss normal problems. It is important not to be afraid to represent these issues.

What struck me about Ms Fay's presentation was the relationship between life expectancy, health issues and living conditions. I was on a halting site yesterday and was appalled by what I saw, on a site with a good reputation. For whatever reason, matters have gone astray and a unit damaged by fire before Christmas has still not been fixed. That has caused problems.

It has been said women are the leaders in the Traveller community.

Mr. Martin Collins

I am comfortable with that.

I certainly met men from the Traveller movement who were very vocal.

We must continue to make the point to the local authorities about the health implications of the standard of halting sites and accommodation in order that they will ensure they are kept in very good condition. Members will know that in my constituency many Traveller families live in houses. While that is good, it reminds us that there has not been a great deal of progress made in regard to transient sites. We were told by the Dublin local authorities that such sites would be provided, but there has been a significant lack of progress. That puts pressure on services.

When I was a member of the health board, there was talk of mobile health units calling to Traveller families, not only on halting sites but also those living by the side of the road. I am not sure progress on this initiative has been maintained, which is a matter of concern.

Deputy O'Hanlon and I are members of the British-Irish Parliamentary Body, as the Chairman, Deputy Ó Fearghaíl, was. We have a particular interest in what will happen to the all-Ireland health study. Is there a concern about this issue?

Can I draw the delegates on how they see the Traveller health units working? Is enough being done in this regard? I support what Deputy Neville said, but it strikes me that not enough is being done for Travellers in terms of drug treatment, suicide prevention and disability services. Such services should be ring-fenced. There is a very good suicide prevention project in Tallaght that I am happy to support but I am not sure enough is being done on disability services for Travellers. There is a real challenge in that regard.

Where should we stand with regard to the Traveller health study of 2002 to 2005? Every time this committee meets demands are made on the health budget and health services but, without wishing to be patronising, Travellers should be able to raise the challenges they face with us. Everyone who has spoken so far has tried to outline this point and it is important we support the delegates in that regard. I thank them for being here.

I thank Ms Ronnie Fay and Ms Missie Collins for their presentations and the useful documentation we received. I listened to Ms Fay speak about the Health Service Executive and we will raise the issue of designated funding. It is time we had an integrated service for everyone, with access for all, regardless of culture or place of residence. The delegates spoke about three interlinked issues: housing, health and education. It is important that we address all three as one. Education is fundamentally important, not only in terms of the opportunities it gives but also for good health; people should know what they need to do when seeking assistance. Health services should be uniformly available to everyone; a designated health service should not be necessary for any section of the community. Everyone should have equal access. I would like to see this area developed.

I am very disappointed with many local authorities because I find them inflexible, particularly regarding Traveller families which would like to settle in a certain area. For their own reasons, some Travellers may not wish to settle in a housing estate in a town. Therefore, local authorities should be more flexible and move more quickly to facilitate people. Not enough work is being done to give them the housing they need.

Good health depends on continuity of care. The fact that members of the Traveller community move around a lot creates difficulties for them and medical professionals. If a Traveller moves from one end of the country to the other, the family doctor or hospital may not have access to his or her health history which could be very relevant if he or she has a chronic illness. Perhaps the idea of an electronic strip containing health and medicinal history is worth considering to ensure Travellers who move around will have access to the highest quality health care. This issue needs to be addressed.

I would like to see a more integrated approach to providing the best services for the Traveller community. What three things would the panel like to be done as a matter of urgency to move matters forward?

I welcome the group. The HSE practice of hiving off money specifically earmarked for a particular project is not new. As Ms Fay said, it is impossible to secure clarity from the HSE. We cannot be certain we will receive an answer but we will ask it for one.

Reference was made to culture by numbers. Travellers are distinct from the general population, not just in ethnic terms. The census 2006 statistics speak for themselves in this regard. There are 22,435 Travellers but Travellers estimate that the figure is between 30,000 and 40,000. Will our guests explain this?

I share some of the views of Deputy O'Hanlon on this subject. On what do the delegates wish the budget to be spent? They said €100,000 went towards the all-Ireland health study but is there a specific reason it is critical to retain the Traveller health budget? The health budget is for everybody — whether they are Travellers or settled people. If the delegates wish to highlight a specific need, we will bring it to the attention of the Minister.

The number one issue for Travellers is living conditions and it is particularly relevant to my constituency. I am concerned that many Travellers do not have access to sewerage and water facilities and are living in freezing conditions. If a group has to park a caravan at the side of the road, none of these facilities will be available.

Looking at the breakdown across various counties, I see that in my county there are 950 Travellers. Has any local authority been particularly good at housing Travellers, by providing halting sites or taking other actions that might serve as a template for others? Are all local authorities similar in this regard? Do those Travellers who wish to settle in homes receive a fair crack of the whip in the allocation of houses? Until we solve the basic problems such as providing heat, sewerage and water facilities, we will not make much progress in addressing the issue of Travellers dying at a young age.

I will add some of my own questions to those that have been asked. The statistics on infant mortality and life expectancy are absolutely shocking. In that context, the fact that the HSE appears to be raiding the Traveller budget is particularly reprehensible. Reference was made to a dedicated health budget but Deputy O'Hanlon has made the point that health services should be accessible to all. Is there anything in Traveller culture that makes Travellers reluctant to avail of health supports and services?

Deputy Neville referred to the fact that the Traveller community was perceived as a homogenous ethnic group. I was discussing cystic fibrosis recently and was told the country's limited gene pool was a factor. Given the fact that there is intermarriage in the Traveller community, to what extent, if at all, does the delegation believe the resultant limited gene pool affects health?

I spent a number of years serving on a Traveller consultative accommodation committee. Local authorities seemed to place a very heavy emphasis on the provision of halting sites or group housing. I have a sense that large group housing schemes lead to segregation. How do the delegates feel about the issue? Should we not move towards greater integration whereby Travellers would be housed in the same way as the public in general?

Mr. Martin Collins

We are very concerned about the health care budget which is in a so-called black hole. The Traveller community and organisations have been sold short and feel demoralised that the budget has been interfered with in this way. The statistics on life expectancy and the infant mortality rate that Ms Fay has outlined demand that the budget be reinstated. If there is anything the committee can do to lend its support to ensure the fund is reinstated for its original purpose, it would be appreciated.

The primary health care projects are a valuable model which works and delivers. Several issues have been raised, of which we are conscious, for example, that we have a broad analysis of health which is not focused on symptoms. We consider the causes, to some of which Deputy Neville has alluded in respect of education, accommodation and employment.

Racism and discrimination also have an impact on health. Let us not forget Travellers are one of the most marginalised and excluded groups in this society. I am not alone in holding this view. It has been documented by UN and Council of Europe human rights bodies, as well as by domestic bodies such as the Human Rights Commission and the Equality Authority. There is a body of evidence to substantiate that argument. Racism, discrimination and exclusion have an impact on one's health, as has been proved by suicide rates and high unemployment among the Irish community in Britain. We take a holistic view of Travellers' health needs. We need such an inter-disciplinary approach if we are to make a serious impact on or inroads in addressing these needs.

The accommodation problem is frightening because as we speak approximately 1,500 Traveller families need accommodation, this despite the Department of the Environment, Heritage and Local Government being in the third cycle of the Traveller accommodation programme. I represent Pavee Point on the national Traveller accommodation consultative committee. We are not making an impact commensurate with the resources and efforts directed at meeting accommodation needs. It is no exaggeration to say this is a crisis. Those 1,500 families account for between 6,000 and 7,000 individuals living in deplorable conditions with none of the basic services that most take for granted such as running water, sanitation, refuse collection, electricity and so forth. That needs to be addressed. It is a question of having a real choice, whether local authority standard housing or what we call Traveller specific accommodation, be it on halting sites or in group housing schemes.

There needs to be real consultation and genuine dialogue with local Traveller organisations and communities. We cannot be prescriptive. It is a matter of consultation, dialogue and so forth. It is worrying that recently, as part of the third cycle of the Traveller accommodation programme which must be adopted by the end of April, Galway County Council made it public that it would not provide halting site accommodation for Travellers. During the assessment of need Travellers made it clear that their preference was for such accommodation. Galway City Council thinks otherwise and has made it clear that halting site accommodation will not be part of its accommodation plan and will not be provided. Dialogue and meetings are taking place behind the scenes to see if the matter can be rectified. That is one example of many local authorities which do not listen to or engage in dialogue with Travellers to hear about their real needs and concerns.

A total of 3,000 Traveller families live in local authority standard housing in contrast to Traveller specific accommodation. We are worried about this because in many of these cases it was not a genuine choice. Local authorities give an ultimatum to the effect that Travellers must take a local authority standard house or nothing. That is on record. That is why I am saying there needs to be real dialogue and consultation between local authorities and other stakeholders, Travellers and Traveller organisations to ensure the real needs are met. Otherwise it is in nobody's interests; resources and time are wasted, which nobody wants.

This is a package of measures. One cannot deal with one issue in isolation from others. Deputy O'Hanlon has correctly said they are all interlinked. That is the analysis we in Pavee Point bring to the Traveller question. We are very concerned about education, for example, 63% of Travellers have finished their education by 15 years of age. That is appalling and frightening and we are very concerned about it. In 2006, 700 Travellers enrolled in secondary education, only 80 of whom got their leaving certificate or leaving certificate applied. That is appalling and we are all concerned about it. We should do our best to address the matter and one way to do so is to reconstitute the Traveller advisory committee. This committee put together the Traveller education strategy that was published in November 2006. Once the strategy was published, the committee which was instrumental in putting it together and which included representatives from Traveller organisations such as Pavee Point and others was dismantled. Therefore, Pavee Point and the other groups have no way of monitoring what progress, if any, is being made on the strategy. Any support this committee could lend would be very much appreciated because this is the only opportunity we have to ensure we increase the number of Travellers accessing, surviving and coming out with good attainment levels from the education system.

Ms Fay has spoken about the positive action measure in the Royal College of Surgeons where two Travellers are training to become doctors. That is inspirational and very symbolic. They are serving as very powerful role models for the rest of the Traveller community. However, resources and support must be provided to make it happen. In education, employment and health care we very much support the concept of integration. Ultimately that is what we are about, but for some Travellers we are not yet at that stage. There is a need for targeted, not segregated, positive action measures to ensure we can take that step from where we are to integrated services. Travellers should expect and are entitled to access services on the same terms and conditions as every other Joe and Josephine Soap in this society.

Ms Fran Keyes

I want to comment on suicide prevention which was mentioned. It is a source of major concern. The national Traveller suicide prevention working group has a steering group which comprises representatives from Traveller organisations and Travellers. It is working with projects on the ground and Traveller organisations and trying to work with many of the primary health care projects to raise awareness of the issue and examine ways of addressing it and what some of the barriers are. Access to services for Travellers is a major barrier when it comes to mental health. Although it is a national group, the working group has only one staff member; therefore, the amount of work she can do is limited. The group has done much work at regional level with projects on the ground and we have a national event on 26 March in Croke Park. We are inviting people to come along to workshops. The group is also piloting a training programme with Traveller youth and a primary health care project in Pavee Point with which we are working on the issues of prevention and awareness. We are looking for more resources for this work, even designated workers to examine the issues involved and how some of the services can become more culturally appropriate and how one can access them. Often Travellers with mental health issues such as depression only get as far as the GP. They do not get much further into the services available.

Ms Mary Brigid McCann

One of the questions on the all-Ireland health study was about accommodation. When I was interviewing people for the study, I found that many were not happy with their accommodation, particularly in group housing schemes. One of the women I called back out to every week had been waiting eight months to have her range fixed. We had to keep telephoning and it took a long time. I interviewed another young mother of two children living in standard housing in a particular area. Water was coming through the roof. She had a four-ring electric cooker in the kitchen and she had to light two of the rings to heat the house — there was no central heating. This landlord was getting €1,000 a month for the house that this woman was living in. We went out on a weekly basis to give this woman support and contact names. Finally, she got alternative accommodation, but she told me that it was like a jail sentence and she could not believe that she was getting out of it. She spent five years in that house with no central heating.

We also work at halting sites where electricity wires run everywhere because the next bay is not open to them. One will find four or five families in the bay using the same toilet and washing facilities and all the electricity cables running nearby. It is quite dangerous and there are health and safety issues as well.

Ms Ronnie Fay

Our approach is one of mainstreaming Travellers into the health service. We can never achieve integration until Travellers are policymakers, politicians, health service planners and health service deliverers. Until there is that kind of integration, the reality is that the health service will remain one designed by settled people for settled people with the best will in the world. Until we get to the stage where there is meaningful Traveller engagement and participation at all levels, we think we have a step to go.

We see primary health care as one step in our mainstreaming approach. One of the issues we have raised with the HSE is that as the biggest public employer in the State, it has employed very few Travellers. The HSE should be setting targets in terms of quotas for Traveller employment. The HSE could be providing role models. It is by people being physically in place that a ripple effect begins.

There are 40 primary health care projects around the country. They create a model for Travellers' participating in the health services delivering services to their own community, but are more about making sure that the health services are inclusive of Travellers. We would argue that through the very existence of such a targeted initiative, we have much more engagement within the health services.

On some of the specific questions asked, our view would be that the health service has often seen itself as a sickness and medical service. It should be a health service not a sickness service. It is an important fundamental difference in approach.

One of the key aspects at which we are looking, is Traveller inclusion in primary care teams at the outset so that it happens by design, not by accident because there was a person who had a particular interest who knew one was there. One of the issues in that regard has centred on general practitioner services, whether one operates on general practitioner lists or on geographical areas. We would say it is important one operates on geographical areas because many general practitioners refuse to take Travellers as patients. Until that is dealt with, there can be further exclusion down the line.

Deputy Flynn asked about the existing budget. One of the services that was pulled was an initiative in which Pavee Point was trying to work with the Irish College of General Practitioners, ICGP, which planned to provide in-service training to general practitioners to promote a Traveller proofing of general practitioner services and to pilot a general practitioner service which would be inclusive of Travellers. That is a practical example of something that could be done so that when there are those 500 primary care teams that are meant to come into existence over the next period, at least Travellers would be included by design, not by accident. That is the kind of mainstreaming approach. It is through the existence of primary health care projects that this will happen.

Deputy O'Hanlon made a suggestion that an electronic strip containing health and medicinal history is worth considering to ensure Travellers who move around will have access to the highest quality health care. One of the recommendations in the Traveller health strategy has been the development of a hand-held record, which is practical and is easily done. It has been done in Britain. There has not been movement on it because of a lack of funding, as in the case of many developments that would make a significant difference to Travellers.

Did I hear Ms Fay say that many general practitioners refuse to take Travellers as patients?

Ms Ronnie Fay

That is correct. It is well documented. One must get written refusals from three general practitioners, from whom it is quite difficult to get a written refusal, and then go to the Department of Health and Children which assigns a general practitioner. There are many examples where Travellers have been assigned a general practitioner who told them his or her list was full and he or she did not want to take them. One can imagine how one feels going to such a general practitioner.

There are also wider issues in disadvantaged areas where there are too few general practitioners to provide a service. Many Travellers live in disadvantaged areas. One GP could be over-represented with Traveller patients, while another might not have any. There are many issues; that is why, as a model of good practice, we are trying to work with the Irish College of General Practitioners on a positive model, for which funding is not available. Many mental health issues cannot be progressed because of the lack of funding. A study by the Central Mental Hospital shows that Travellers are ten times over-represented in mental health institutions. We would have no problem spending the money but have to get access to it to do so.

With regard to integration, we welcome the Traveller inclusion and intercultural health strategy. At a wider policy level Travellers were one of the target groups in the national action plan against racism which ended last November. They were centrally included in the work of the national consultative committee on racism and interculturalism which was, unfortunately, axed in the last budget. Responsibility for anti-racism and interculturalism in the State is being given to the Ministry with responsibility for integration which has stated it explicitly excludes Travellers. How can we have integration when the Ministry is excluding Travellers? These are the problems we are up against and often they are reduced to seeing Travellers as the problem, as against the institution, the personnel, and the structures and systems which are put in place by design to exclude. They do not set out to do so but that is their effect.

We were asked to list three priorities. The first is implementation of the Traveller health strategy, given that between 70% and 90% of the recommendations have not been implemented. We could start with what took seven years on which to elaborate, as Ms Collins said, to get to the stage of publication. The strategy should be implemented. Second, the ring-fenced Traveller health budget should be protected and made available for Traveller health developments, including implementing the forthcoming findings of the all-Ireland Traveller health study because other issues will emerge from it and we will have to have the funding to act on them. Third, there needs to be Traveller participation at every level, including service design, service planning, policy development and service implementation. If we had this, we could make a considerable impact in addressing the low health status of Travellers and the other emerging issues.

I apologise for being late. This is an important issue. The statistics are frighteningly bad, particularly those relating to longevity, mortality and the suicide rate. Longevity and mortality are as much predicated on one's living conditions as on health care. I totally accept what Ms Fay said about a health service which tries to keep people well rather than having to intervene and the related educational needs. I am focused on this area and support Pavee Point in that regard.

Ms Fay may have seen me smile when she mentioned 500 primary care teams. I am sorry but she will forgive me for being cynical at this stage, eight years into the primary care strategy. We will all be long dead before that target is reached at the current rate of progress. However, actions can be taken. I support the need to ring-fence the money and the need for transparency. Deputy Neville has referred to other areas to which funding has been allocated by the Oireachtas but used elsewhere, which is totally unacceptable, particularly in the context of this issue.

I refer to refusals by GPs. While I accept what Ms Fay said, I have never refused anybody, regardless of his or her background. With people moving around, it can be difficult to maintain continuity, the hallmark of general practice. Pavee Point's input in this regard would be welcome in the context of the Irish College of General Practitioners devising protocols to help maintain continuity. Carrying an individual card with one's medical history which could be brought from doctor to doctor would be very helpful.

I am shocked to hear the Department with responsibility for integration excludes the Traveller community. It seems like an oxymoron. We shall have to look into that matter further.

If nothing else happens as a result of this meeting, at least a strong message will be sent by all members of the committee that the Traveller health budget should be ring-fenced and used transparently. We should all know to whom the money goes and how it is spent.

I thank the delegation for attending and apologise again for not being here earlier.

Will Ms Collins make some concluding remarks?

Ms Missie Collins

Seeing that there is such a bad state of health among members of the Traveller community, we need to get down to brass tacks, promote health and encourage Traveller women, in time, to have smear tests and breast checks done, to seek hearing tests for children and so on. That will save money in the long term, given the costs that will be incurred if any of these women gets sick and has to go into hospital. A small amount of money should be put into the hands of the right people who would work with it. I am not educated but I can assure the committee that if money comes my way, I will know how to use it.

On behalf of the joint committee, I thank the Pavee Point Travellers' Centre for its presentation. I hope we can meet again and follow up on the points raised. We will take up these matters with the Department of Health and Children and the HSE as a matter of urgency.