Dáil debates

Wednesday, 17 May 2017

12:00 pm

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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Melanoma is a cancer predominately of the young with potentially many lost years of life and with devastating effects on many families. Ireland is the 14th most susceptible country to melanoma in the world. We are very far behind in terms of treatments for advanced or progressive melanoma and a proper national screening programme, which we do not have. If we had one, it would avoid many of the expensive immunotherapy treatments available. The problem is that, notwithstanding the very considerable advances that have been made in treatments which can extend life for people with melanoma, particularly advanced melanoma, we are far behind as a country. The drug, nivolumab, or nivo for short, is one treatment. In the European Union, only Ireland and Portugal have not approved this drug for reimbursement.

It is an extraordinary situation.

All EU countries, with the exception of Ireland, France, Italy and Portugal have decided to fund the combination therapy of ipilimumab, known as ipi, and nivolumab, known as nivo. This combination therapy has proven to be truly radical and transformative in medical research. Immunotherapy is the new revolution in cancer treatment but we have not approved these particular drugs, notwithstanding the fact they are licensed by the Food and Drug Administration, FDA, the European Medicines Agency, EMA, and by our own licensing authority, the Health Products Regulatory Authority, HPRA. Historically, survival rates were very low prior to the arrival of these particular treatments but since these treatments have come on stream, the impact has been quite transformative, particularly for patients with advanced melanoma. In Ireland, there may be up to 150 patients per year with advanced melanoma, 50% of whom could be suitable for the ipi-nivo combination.

The National Institute for Health and Care Excellence, NICE, in the UK is normally one of the slower agencies in this area but it has been one of the quickest out of the traps in approving this particular drug combination because of the data that has emerged. The most recent and dramatic data has come from the American Association for Cancer Research at its annual meeting in Washington showing positive responses among 60% to 70% of patients. This is very exciting but we are way behind. We have not approved nivo or the combination of ipi and nivo. Professor Carole Longson, the director of health technology at NICE, has said that after one of the fastest drug appraisals carried out by NICE, these promising new immunotherapy treatments for advanced melanoma look set to significantly extend the life of people with the condition. Dr. James Larkin, a melanoma specialist at the Royal Marsden hospital was one of the leaders in a ground-breaking clinical trial of the combination therapy and 60% of his patients responded well to it.

I do not know why we are so slow in this area. I have been pointing out for more than two years that our system is not working. Since the enactment of the 2013 Act, it most certainly is not working and many patients are being left behind in respect of ground breaking treatments that can prolong their lives and lead to significant remission.

12:05 pm

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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I agree with Deputy Martin that the system we have had here for many years is not up to speed in the context of major new drugs that are approved by the FDA and similar authorities. Furthermore, being a small country, we do not have the financial reach to be able to provide for all new drugs that come on stream very quickly. The case made by the Deputy about melanoma is one of many such cases. I received a letter from a major pharmaceutical company recently about a number of drugs that are produced by the company that are not used in Ireland but which are exported around the world.

The recent situation in respect of Orkambi is instructive here. Orkambi is exceptionally expensive, for very good reasons. In that context, we had international collaboration looking at the whole question of the priorities attached to drugs, how they should be funded and the relevant costs that should apply. Rather than proceeding alone, as one country, this is the way to go in the future. In collaboration with a number of other countries, significant reductions were brought about in the cost of that particular drug, together with an analysis of the improvement in the quality of life that the drug would actually provide for cystic fibrosis sufferers.

The process in respect of melanoma is under way in the HSE and the relevant agencies. The point Deputy Martin makes is that we are not in a position to provide ultra modern drugs that come on the scene which clearly bring about serious improvements in the lives of patients suffering from various ailments. I was struck by the fact that no sooner was the decision made, money provided and an agreement reached for Orkambi, another 35 to 40 new drugs were being named as coming on stream for different ailments, many of which were also very expensive.

We need to look nationally at the scale of what we provide for drug purchase in respect of a range of ailments, and internationally at whether we can collaborate with other countries on the purchase of modern drugs for specialised ailments, including various forms of cancer. Perhaps that is the way to go. I am quite sure there is a measure of agreement across the House on these matters. As the Deputy is aware, we do not have an endless pit of money. I think we can improve the way we deal with the provision of drugs, thereby leaving aside the priority attached to the drugs for which we can actually provide money.

12:10 pm

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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There was a time when we were far more ahead of the curve in approving new technologies and treatments. We have fallen well behind in recent years. These approvals often get caught up in the system. This does not happen because of cost grounds initially. There is a suspicion that this might be the underlying reason, but it is never stated. There is significant evidence here. Why are Ireland and Portugal the only EU countries that do not approve nivo on its own? The combination of ipi and nivo is captivating cancer researchers around the world, particularly those involved in skin cancer research. The US Food and Drug Administration approved this combination in 2015 under an accelerated approval programme because the results showed rapid and deep regressions of patient tumours. These dramatic results captivated doctors and patients alike. People in Ireland need this treatment at the moment. Medical oncologists have told me that people in Ireland who have the resources to do so are paying €4,000 or €5,000 for this treatment. People who do not have such resources are considering whether they should sell their houses or take other steps to get access to the ipi-nivo combination. This is a real issue. Approximately 50% of the 150 people in this country who are diagnosed with advanced melanoma each year would be eligible for this treatment. This should be doable. In my view, something is not right somewhere in our system. We are way behind the curve when compared with other countries that are well advanced in approving radical breakthrough treatments for forms of cancer that were not treatable in the past.

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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The advances made over the years in medicine generally and in particular ailments have been astounding. The pipeline of new drugs coming on stream has simply exploded because of the research, the innovation and the work that is going into precise and specific elements for which drugs are now produced. The Health (Pricing and Supply of Medical Goods) Act 2013 sets out the legal and statutory process in this regard. The HSE makes the decisions here. We are awaiting a decision in the case of the melanoma drugs mentioned by the Deputy. As he has pointed out, responsibility for such decisions has been transferred from those involved in the political process to those involved in the quality-of-life process who have the clinical excellence and so on. There has been an explosion in the number of new drugs coming through the pipeline. Now that the Orkambi case has been settled, we are awaiting the provision of finance to provide between 30 and 40 new drugs to patients with particular ailments. The Minister for Health travelled to Malta earlier this month to sign the Valletta declaration, under which Ireland and seven other countries have agreed to work together on procuring, deciding on priorities and bringing about cost reductions so that more patients will be able to access new and specific drugs. I am sure that any Minister for Health would like to be able to say that as new drugs for particular chronic ailments, including melanomas, come on stream and are approved by the US Food and Drug Administration, he or she will be in a position to provide for those drugs. Even though cost reductions have been secured in the case of Orkambi for a very good cause - cystic fibrosis patients - I understand it is the most expensive drug in this country's history. The Minister and the Department are aware of this issue. I think that by bringing about international collaboration between the countries that have signed up to the Valletta declaration on joint procurement, we will bring about an improvement in this situation.

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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We are way behind on melanoma.

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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The assessment for the two melanoma drugs mentioned by the Deputy is under way with the HSE.

The Minister can give the Deputy more precise details of the work involved in or the point of that assessment.

12:15 pm

Photo of Donnchadh Ó LaoghaireDonnchadh Ó Laoghaire (Cork South Central, Sinn Fein)
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Joe and his family were known to the Health Service Executive child and family services since he was a young child. There was a history of domestic violence and alcohol abuse in the family home. He had been listed by Tusla as a high priority case and, sadly, took his own life at the age of 15 years. Despite the fact that he had been identified as a high priority case, he had not been allocated a social worker because of staff shortages.

Dylan was in the care of the State after leaving the care of his mother who was struggling with a drug problem. He died just before his 17th birthday, with a high level of toxicity in his system. A recent review of the case by the national review panel found that issues with his welfare had been known about for long periods, that a succession of social workers had been involved but never for long enough to develop a relationship and that a child protection plan had been made but never implemented.

Avril's family background was described as being categorised by domestic violence, criminality and changes of accommodation. She had been out of contact with the social work department for nearly two years when she died, not fully 17 years old, with her case closed.

These cases, among others, were examined by the national review panel which found systemic failures by Tusla and the social services. In each instance it emphasised that no specific action or inaction by social workers had been responsible for the deaths but, it found time and again failures that could be attributed to a high turnover of social workers and pressures of work which had led to fire fighting. These cases underline a system that is broken and that stretches resources too thinly, including social workers who are doing their best but who are utterly overworked, exhausted and overwhelmed. Efforts to resolve the issue are falling far short. Tusla is losing 150 social workers a year. Despite efforts to recruit, the net increase in the number of the child and family social workers in 2016 was a mere 56. There are three times as many child and family social workers in the North per head of population as in the South. Best practice internationally suggests social workers should have a caseload of approximately 15, but I have come across social workers who are dealing with 26 and more and that is not to mention the unallocated cases, of which there are 5,720. Of these, there are 1,057 high priority cases. There are 1,000 Joes, 1,000 Avrils and 1,000 Dylans who are at risk as we debate the issue here. Does the Taoiseach accept that the social care system has been stretched to breaking point, that it has long been neglected and that is is a national scandal which requires urgent intervention by the Government?

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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Because of the importance of family and care services for children, the Government set up a ministry with responsibility for children, the Department of Children and Youth Affairs, held a referendum on children's rights and established the Child and Family Agency, Tusla, which is funded very substantially by the taxpayer every year. The Minister for Children and Youth Affairs has pointed out that there is quite a number of vulnerable children in different locations around the country who are not being left unattended and that the recruitment of the social workers required to provide individual attention is still under way.

The Deputy mentioned the issue of domestic violence. Clearly, it impacts on families such as the ones he mentioned. I do not have the details of the cases he outlined but obviously they were very serious for the two people to whom he referred. Perhaps he might talk directly to the Minister for Children and Youth Affairs who would advise him of the situation so far as Tusla is concerned. Obviously, it is a new agency. There are more and more pieces of information coming to light on challenges for various families and children throughout the country and social workers are under pressure to deal with all the cases with which they have to deal. Arising from the incidence of domestic violence cases, quite a number of initiatives have been taken to enable such incidents to be dealt with and, where possible, prevented but where they do happen the children involved should be catered for properly. On the two individual cases mentioned by the Deputy, of which I do not have the details, I suggest he talk directly to the Minister for Children and Youth Affairs.

Photo of Donnchadh Ó LaoghaireDonnchadh Ó Laoghaire (Cork South Central, Sinn Fein)
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The Taoiseach appears to have misunderstood the context. They are not two or three cases that I have come across. They were examined by the national review panel, which was set up by the Government to provide information for Tusla, the HSE and the Health Information and Quality Authority on the failures that were happening in cases involving children.

The Department and the Minister are aware of this. I have raised the matter of unallocated cases on numerous occasions with the Minister. The point made that Tusla is a new organisation does not wash any more as the agency has been there for over five years now. The current predicted net increase of approximately 62 social workers falls short of the target set for the end of last year. Recruitment efforts to try to bring in anything near the adequate numbers of social workers are falling way short. The matter is not being given adequate emphasis or priority by this Government.

We have a scandalous history in this State when it comes to protecting children in the care of the State. Now we have the resources, we should deal with this. Will the Taoiseach commit to increasing the number of social workers that will be taken on and, at a minimum, doubling the number for what is currently projected for recruitment? Will he ensure no stone is left unturned with the current resources so children at very serious risk, including those who end up in very tragic circumstances, will not be left to face those challenges alone?

12:25 pm

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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That was the reason for setting up Tusla in the first place and having a senior Minister responsible for children and a Department of Children and Youth Affairs. The Joint Committee on Children and Youth Affairs met representatives of HIQA this morning to discuss inspections of foster car and foster care cases. There was €37 million allocated for Tusla for 2017 and 400 new staff are being recruited.

Photo of Donnchadh Ó LaoghaireDonnchadh Ó Laoghaire (Cork South Central, Sinn Fein)
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I was there this morning. There are no regulations for foster care.

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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I assume many of those recruited will be social workers allocated to cases involving people who are vulnerable or challenged. It is not perfect by any means and there are serious improvements to be made. I will have the Minister follow up the two particular cases mentioned by the Deputy.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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Yesterday, the Minister for Public Expenditure and Reform formally invited public sector unions to commence talks on a successor to the Lansdowne Road agreement. Having gone through two rounds of public sector pay talks, I reiterate my view that this is very late in the day. Of course, I wish the Minister, Deputy Donohoe, well in his negotiations. A fair deal that recognises the sacrifices made by public servants over recent years would be very welcome.

In the course of the forthcoming talks, the public services committee of the Irish Congress of Trade Unions, ICTU, will head the trade union side. I welcome the fact the Garda and the Defence Forces associations have also been invited to attend. Today I focus on the broader issue of trade union recognition for both of these groups. The Taoiseach previously committed to introducing legislative change to give the Garda associations the right of access to the Workplace Relations Commission and the Labour Court. Unfortunately, although the commitment was given last November, we still have not even seen the heads of the Bill that would bring this about. To date, the Taoiseach has explicitly ruled out making any similar commitment on the Defence Forces, although he could make that as Minister for Defence.

Since the formation of this Government a year ago, the Taoiseach is one of the Ministers who has failed to enact any legislation relating to his brief. He may not have time to see through a Bill now, given the changing political circumstances, but even signalling his support for such a change would be really important. There are approximately 13,000 members of An Garda Síochána and 10,000 active personnel in our Defence Forces. These people carry out some of the most dangerous public sector roles in this country but they have no entitlement to access even the basic industrial relations machinery of the State. We all know issues must be carefully dealt with and agreements must be made relating to the right to strike or take industrial action that would put public safety at risk. These matters are well versed and rehearsed elsewhere. Allowing gardaí and those in the Defence Forces to affiliate to ICTU would be a welcome step, as would giving them full access to the Workplace Relations Commission. Making them full partners rather than merely attendees at public sector pay talks would be even more important.

At a time when morale within An Garda Síochána is terribly damaged, this would be a good time for the Taoiseach to act. Will he bring forward legislation recognising the trade union representatives of the Garda and Defence Forces?

12:30 pm

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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It is important to say to Deputy Howlin, who made several public pay agreements, that what is at stake here is an extension of the Lansdowne Road agreement because there were particular benefits gained on both sides in that agreement, and the Minister for Public Expenditure and Reform will engage on an extension of that with his officials and the trade unions starting next Monday.

The resolution of the dispute last year in respect of the Garda included a commitment to the introduction of legislative change to give the Garda associations the right of access to the Workplace Relations Commission and the Labour Court. A commitment was given that the legislation would be put in place before the end of this year and that commitment stands and will be followed through.

On 20 December last the Government approved the preparation of the heads of a Bill to provide the associations with access to the WRC and to the Labour Court. In addition to the technical legislative change required to provide access, the Government decision noted that some very significant issues will fall to be considered, including the status of the Garda associations established under An Garda Síochána Acts and the related question of the constraints upon members of taking industrial action. Do we want a situation where members of the Garda Síochána go on strike? Providing access to the WRC and the Labour Court does not of itself imply the removal of either the prohibition on members of the Garda Síochána joining trade unions or the constraints on industrial action. To assist in the consideration of these and some ancillary issues a working group chaired by Mr. John Murphy, the recently retired Secretary General of the Department of Jobs, Enterprise and Innovation, has been established. The working group is considering some of the technical and practical issues that will arise and it is drawing on the experience and expertise of the relevant Departments and bodies of the group. The working group has identified several key issues that will require consideration. These include whether the associations should become full trade unions, the question of constraints on industrial action, the range of matters on which access is to be provided to the WRC and the Labour Court, what internal processes are to be put in place and be exhausted prior to issues being brought to the WRC - and that is part now of the structural work the commission announced yesterday and which it will also consider in terms of the workings of An Garda Síochána - how industrial relations should operate within the Garda Síochána and when access to the WRC and the Labour Court has been provided. The Garda associations have met with the working group so that their views are heard at an early stage in the process. The implementation of the Labour Court recommendations is ongoing and substantial progress is being made in addressing those.

Day to day management of the Defence Forces is the responsibility under statutory instrument of the Minister of State at my Department, Deputy Kehoe. He is considering a range of issues in respect of the Defence Forces, their personnel, their families and facilities.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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I welcome the Taoiseach's reiteration of the fact that legislation on foot of the agreement of last year will come before this House, although I detect a significant rowing back on the commitments. Will the working group have any interaction with the Members of this House, so that it can democratically have an input into deciding on the appropriate legislative base to be brought forward?

I hear no commitment in respect of the Defence Forces. Is it the Taoiseach's view, as previously announced, that he would not countenance the recognition of the Defence Forces associations in the way that he has agreed to recognise the associations of An Garda Síochána? Is it his view that the Defence Forces associations should have access to the WRC and the Labour Court?

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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The working group comprises representatives of the Departments of Justice and Equality, of Jobs, Enterprise and Innovation, the Taoiseach-----

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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I asked about this House.

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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-----the Department of Public Expenditure and Reform, the Garda management and the WRC. The working group is to report on these substantive issues by 31 May this year. I assume that report will be brought here for discussion.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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Will this House have no input in advance?

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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No because the working group has its terms of reference.

The report will be brought to the House for discussion and the Deputy will have plenty of opportunities to make his case at that point. The Government will have to consider it, as is the case with any other report.

In respect of the Defence Forces, as the Deputy knows they are the backup to the civil power. As I said, there are substantial issues that must be addressed in respect of the legislation being prepared arising from a decision to give the Garda access to the WRC and Labour Court. The Minister of State at the Department of Defence is engaging with the Defence Forces representative.

Given the constraints upon us, I want us to continue to provide the Defence Forces and their personnel with the very best facilities in order that they can do their job. I am always open to discussion, but I am not giving any commitment. It is important that we recognise the value of the contribution given by our Defence Forces, which have never let the State down.

12:35 pm

Photo of Michael CollinsMichael Collins (Cork South West, Independent)
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Articles 41.2.1° and 41.2.2° of the Constitution state, "In particular, the State recognises that by her life within the home, woman gives to the State a support without which the common good cannot be achieved" and "The State shall, therefore, endeavour to ensure that mothers shall not be obliged by economic necessity to engage in labour to the neglect of their duties in the home." While the homemaker's scheme introduced in 1994 went a long way to increase the rights of homemakers by making it easier for them to qualify for a contributory State pension, they are still a generation of women who have been forgotten about. A group of women is in limbo and has been actively discriminated against by the introduction of the homemaker's scheme.

The scheme only goes back to 1994, which precludes women who worked in the home prior to this date from benefitting from the scheme. Some women were discriminated against in the past when forced to give up their jobs in the late 1960s and early 1970s because of the marriage bar. Subsequently, other women chose to give up their jobs and remain at home to rear children or care for a sick child or relative. They are discriminated against because they are not included in the current homemaker's scheme which is only applicable from 1994. The scheme recognises women who choose to leave the workforce for a period not greater than 20 years to care for children or a sick child or relative. I urge the Taoiseach and the Minister for Social Protection to apply the same scheme retrospectively from 1970.

The women precluded from the scheme are either on reduced pensions or do not have enough contributions to qualify for a full rate, or are receiving a pension as a qualified adult which is related to their husband's pension. This is not a payment in their own right. The payment is means tested and some women struggle with the concept of continuing to be dependent on their husbands in retirement. They feel their contribution to society is not being recognised. It is very unfair and results in a loss of dignity.

These women are being discriminated against deliberately, but in terms of their pensions it is discrimination on two grounds, namely gender and age. Can the Taoiseach tell me that the homemaker's scheme will be backdated to 1970?

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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The cost of increasing pensions for those currently not eligible prior to 1994 would be about €300 million. If that money was allocated, one would probably not have any money to increase pensions as a consequence. The Minister for Social Production has examined the way in which contributory pensions are calculated. The Oireachtas Joint Committee on Social Protection will be in receipt of a suite of options which will be presented for its consideration in the next couple of months.

Deputy Collins read out two articles from the Constitution as it was written. There have been increased opportunities for women in the home who want to participate in the labour force due to increased employment levels and many other methods. The point the Deputy has raised is an issue. There is a cost attached to it and I suggest that he wait until all of the options presented to the Joint Committee on Social Production in the coming months for discussion by Deputies have been considered.

12:40 pm

Photo of Michael CollinsMichael Collins (Cork South West, Independent)
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I thank the Taoiseach for his reply. He referred to the huge cost increase this would represent, but that is to fail to take into account the value of the women who stayed at home during those years. I urge him to address this anomaly immediately. In 1970 and before, women chose to remain at home to raise children or care for elderly parents. We know the contribution they made to the community and I want it to be recognised. This could be done simply and without huge cost to the State by recognising the years spent out of work and granting the women concerned eligibility for a pension in retirement. This society recognises equality attempts to gender-proof legislation and avoid situations which give rise to discrimination. This is one area that must be addressed. I ask the Government to examine the matter and address it without delay.

Photo of Enda KennyEnda Kenny (Mayo, Fine Gael)
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It is all about choices because one does not have the resources to do everything that might be desirable. While this is a desirable option, it would cost €300 million to go back to 1970. If that is done, there will be no capacity to increase pensions, lone-parent allowances or other measures. There is no endless pit of money, which is why all of the actuarial assessments and different options are being prepared for consideration and will be brought before the committee in a couple of months. It is a choice. If we do what the Deputy suggests, while desirable, it will implicitly suggest we will not have any money to increase pensions or a range of other allowances that would be catered to in the normal course. As such, it is important to lay out the facts before priorities are assessed and decisions made.