Dr. Tony Holohan:

I thank the Chair and members of the committee for the opportunity to address it. As the Chairman said, I am joined by Ms Geraldine Luddy, head of the bioethics unit at the Department of Health, and our colleague, Ms Aoife O'Brien, who is also from the bioethics unit.

I thank the committee for the opportunity to speak about the ancillary recommendations contained in the Citizens’ Assembly’s final report and recommendations on the eighth amendment of the Constitution. The committee received in September the Department’s submission on the recommendations, so I will try to summarise them briefly.

The first ancillary recommendation which I will address concerns improved access to reproductive health care services, including contraception, sexual health services and termination of pregnancy. With regard to contraception and family planning services, the Department of Health launched the National Sexual Health Strategy 2015-2020 in October 2015, following Government approval. The strategy is being implemented under Healthy Ireland, the National Framework for Improved Health and Wellbeing. It is a cross-governmental policy, which is being delivered in partnership by the Department of Health, the HSE and the Department of Education and Skills. The national sexual health strategy’s key aims are to improve sexual health and well-being, and to reduce negative sexual health outcomes.

The strategy aims to ensure that everyone in Ireland will receive comprehensive and age-appropriate sexual health education and information, and will have access to appropriate prevention and promotion services. It also aims to make equitable, accessible and high-quality sexual health services, targeted and tailored according to need, available to everyone. I will not address the service provision aspects of the national sexual health strategy, as I believe our colleagues from the HSE are in a better position to do so. They will address it as part of their presentation and will support any questions committee members may have on it. However, just to note that implementation of the strategy got under way quickly, with an action plan prioritising an initial 18 actions, covering areas such as clinical services, education, communications and governance structures. All of these actions have commenced, and ten have already been completed, including the appointment of a national clinical lead for sexual health in the HSE, and the reconfiguration of the HSE crisis pregnancy programme to encompass sexual health as the new HSE sexual health and crisis pregnancy programme. As the Chairman said, this is represented at the meeting. In terms of achieving good quality outcomes, the Department considers that full implementation of the strategy, together with the measures outlined in the national maternity strategy, which I will address shortly, will significantly advance the good quality outcomes envisaged by the Citizens' Assembly.

The second ancillary recommendation which I will address concerns standards of obstetrical care in Ireland. I want to cover a number of elements of this. Over recent years, as members are aware, there has been significant focus on the development of a national maternity policy to ensure that our maternity services are developed in a coherent and evidence-based manner. Last year, we published Ireland’s first ever national maternity strategy, Creating a Better Future Together 2016-2026, again following Government approval. The HSE's standards for bereavement care following pregnancy loss and perinatal death were also published in 2016, and I will speak a little more about these later. Also, in 2016, at the end of the year, HIQA's national standards for safer better maternity services were launched. They aim to give a shared voice to the expectations of women using maternity services, service providers and the public. They are intended to show what safe, high-quality maternity services should look like.

Committee members may be aware that each of the 19 maternity units is now required to publish a maternity patient safety statement every month. The first of these were published in December 2015. They are published monthly in arrears, and report information on 17 metrics, dealing with clinical activities, major obstetric events, modes of delivery and other clinical incidents. Taken together, all of these developments are key building blocks which will enable us to provide a consistently safe, patient-centred, high-quality maternity service. They will also help advance the quality outcomes envisaged by the Citizens' Assembly in its ancillary recommendations.

In terms of overall governance structures, a national women and infants health programme has been established within the HSE, the leadership of which is represented here today, to lead the implementation of the national maternity strategy. It spans obstetrics, aspects of gynaecology and neonatal services across community, primary, and secondary care. The programme will oversee the establishment of maternity networks across the country, which will formally link all maternity units within each hospital group. It is recognised that smaller maternity services cannot, and often should not, operate in isolation as stand-alone entities. Given their size, some of these units cannot sustain the breadth and depth of clinical services required by the populations they serve. Through the establishment of maternity networks, we will ensure efficiency in the provision of, and access to, specialised services and support smaller units to provide safe and quality services.

The Department is aware that a key concern of the Citizens' Assembly in its ancillary recommendation was that all pregnant women, regardless of geographic location or, indeed, ability to pay, should have access to early scanning and testing. On this point, the maternity strategy is very clear that all women should have equal access to standardised ultrasound services. We know that there are challenges, but we intend to build capacity in our ultrasound services. To that end, additional funding will be provided to the national women and infants health programme in 2018, subject to finalisation of the service plan, to develop a more equitable and consistent antenatal screening service. We will hear more detail on this from colleagues in the HSE in a moment.

The recently published maternity strategy implementation plan addresses the current regional inconsistency in service provision. Pending full implementation of the strategy’s recommendations on anomaly scanning, the programme will continue to work with the six hospital groups to ensure increasing access to anomaly scans. In particular, it will work to ensure that clinical pathways are in place within each network, such that where clinically indicated, a woman can be referred to a larger maternity unit for such a scan.

In relation to the ancillary recommendation on improving counselling and support facilities for pregnant women, I do not propose to go into the detail on the service delivery side, given that colleagues from the HSE will address it. I am aware the committee previously had speakers before it on this from the HSE sexual health and crisis pregnancy programme, which is also represented here today. I will briefly note that the programme funds the provision of crisis pregnancy and post abortion counselling services, which operate out of more than 40 locations throughout the country.. All services also provide access to post-termination counselling and a number provide free post-termination medical check-ups.

The national maternity strategy pointed to the need to improve access to mental health supports and to that end a number of its recommendations are relevant. The maternity strategy implementation plan addresses the issue and sets out specific actions to identify women at risk and ensure that they get the necessary support during their pregnancy and postnatally.

Earlier I referred to the national standards for bereavement care following pregnancy loss. I draw members' attention to the fact that they were published last year. We anticipate that the standards will drive the development of clinical and counselling services within our maternity services overall. The standards describe the standardised structures, clinical processes and compassionate responses that should be in place across maternity services for parents who experience a pregnancy loss or a perinatal event. The standards will also apply in situations where there is a diagnosis of foetal anomaly that may be life limiting or fatal. The linkages between maternity bereavement care and other hospital and associated services such as primary care, public health nursing and palliative care are also outlined in the standards. Each hospital will have to have systems in place to ensure that bereavement care and end-of-life care for babies is central to the mission of the hospital and is organised around the needs of babies and their families. The implementation of the standards has begun and teams are being established in each maternity unit and hospital around the State.

The HSE is today launching a perinatal mental health services model of care for Ireland. I expect we will hear something more about this from contributions by colleagues in the HSE. I note that the model of care is closely aligned with the national maternity strategy, and contributes to the implementation of the strategy’s actions on mental health. The model is based on the maternity networks that I spoke of earlier. This means that specialist perinatal mental health services will be aligned within hospital groups and developed to provide for each of the 19 maternity units. It is a significant development in addressing the mental health needs of women both during pregnancy and in the year following delivery.

The Citizens’ Assembly recommended that further consideration should be given as to who will fund and carry out termination of pregnancy in Ireland. I will preface my remarks here by pointing out that action in this area will be subject to deliberations of this committee and further deliberation by the Oireachtas on recommendation this committee decides to make. It will also be subject to the outcome of the referendum which the Government has committed to holding next year.

Terminations of pregnancy carried out in Ireland at the moment, under the Protection of Life During Pregnancy Act 2013, are limited to the 19 public hospital obstetric units. That is to say, they are only done in the public system and are funded by the State. It was appropriate that terminations in this context took place in obstetric units to ensure all the expertise and facilities appropriate to provide safe medical services, and ancillary services, to pregnant women whose lives were at risk and to the unborn.

Other than in emergency situations, doctors who can certify or permit access to a procedure under the Act must be registered by the Medical Council in its specialist division. At the moment, a termination of pregnancy may only be carried out by or under the supervision of a consultant obstetrician. This is irrespective of whether the medical procedure for carrying out the termination is by medical or surgical means. On the point about medical terminations of pregnancy, I must note that there are currently no medicines indicated for the termination of pregnancy currently authorised for that specific use in Ireland. In the event of any change to the Constitution and to legislation around access to such services of drugs for medical termination, it would be the responsibility of the manufacturers of such medicines to seek - as they do - a marketing authorisation for such use in Ireland. This would be in line with the normal procedure for authorising any medicines to the Irish market. Members are aware that the Health Products Regulatory Authority, HPRA, is the competent authority responsible for the regulation of human medicines in Ireland. It has a structured assessment procedure in place for conducting this assessment process.

If there is a change to the eighth amendment and if the grounds for termination of pregnancy are widened from what is currently provided for, then this will have implications for the health service provision. Pending a decision on the policy direction, the Department of Health is working with the Office of the Attorney General and the Department of the Taoiseach to explore and research the constitutional and policy issues involved so that as much preparation can be done and drawn upon in the context of any recommendations or decisions that are made over the coming months. Once direction is clear, consideration will be given to the issue of funding and carrying out terminations of pregnancy in Ireland, and to drafting further legislation in order to ensure access to such services and good quality outcomes.

I thank the Chairman and her fellow committee members for the opportunity to address the committee today and I wish the Chairman well with her work. I also look forward to the report. I am available to answer any questions that members may have.