Mary Lou McDonald (Dublin Central, Sinn Fein)
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Vicky Phelan died three weeks ago. The Taoiseach knows she spent her final years fighting for change. She was very clear on what she wanted to see. To recall, she said to the political system:

I don't want your accolades or your broken promises. I want action. I want change. I want accountability.

It was a most eloquent and heartbreaking call to action for all of the women and their families affected by the CervicalCheck scandal.

As the Taoiseach knows, mandatory disclosure and a duty of candour was one of Vicky's core demands. Mandatory disclosure means a legal obligation on clinicians and health care providers to tell a woman if there had been a discordant, erroneous or incorrect reading of her cervical cancer screening slide. There was consensus in the Oireachtas that the original patient safety Bill did not provide for this demand. The week that Vicky died the Taoiseach assured the Dáil that an amendment to the legislation to correct for this flaw would be brought forward.

At that time I said to the Taoiseach that the Opposition would work with the Government to get the legislation right and get it over the line before the Christmas recess. This remains my position and our commitment. However, we have a problem in that the amendment proposed by the Minister, Deputy Donnelly, does not provide for mandatory disclosure. There is provision for a right to review and this is welcome. However, there is a distinction between a right to review and a positive obligation on a clinician or a health service provider to reveal and pass on information. Mandatory disclosure where the legal responsibility is on clinicians and organisations is what the women fought for. It is the measure recommended by Dr. Gabriel Scally in his scoping inquiry.

Let me cut to the chase in all of this. I believe there are still serious flaws in the legislation. I do not believe the amendments the Minister has proposed address these flaws. Above all else there is no way that two hours today is sufficient time for us to tease our way through this legislation to get it right. The objective here has to be to get this right. I do not believe either that the House should divide on this matter. We were of one voice when we marked the death of Vicky. We said that we would work together. I am asking the Taoiseach as head of the Government for us to work together. What this means in my strong opinion is that we have the debate for two hours today after which we adjourn it and that more time is made available next week.

There is concern beyond the definition of mandatory disclosure or the duty of candour about the review process itself. There is no legal obligation for the woman at the point of diagnosis to be told she has a right to the review. What is very worrying from my point of view is a provision that means in the case of CervicalCheck and the laboratories that the laboratories themselves would decide the scope and shape of the reviews. I do not believe that we can pass legislation that lets these things go. Again I ask the Taoiseach to work with us. I know I have the support of the Labour Party and others on the Opposition benches. We really have to get this right. I believe we can get it right and over the line before we rise for Christmas.

Micheál Martin (Cork South Central, Fianna Fail)
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I appreciate Deputy McDonald raising the issue and the manner in which she has raised it. We did all agree that we would commit to getting the legislation through the House before the recess, particularly in light of Vicky's passing and her strong exhortation that we would fulfil all of the recommendations arising out of the Scally review and the expert reference group that dealt with interval cancer. The report was published in October 2020 and the legislation is in line with this report. We must remember that the report was made up of input from professionals as well as patient representative groups and all involved from a patient perspective.

The report recommended, essentially, that CervicalCheck should establish a process to conduct patient requested reviews of all invasive cancers and establish a standard operating procedure for this purpose:

Patient-requested reviews should only be undertaken following receipt of written consent from the patient. These reviews should be available to all women diagnosed with invasive cancers, including historic cases of women who did not participate in any other National Screening Service or Royal College of Obstetricians and Gynaecologists cytology review processes.

I am quoting directly from the expert reference group's interval cancer report. The expert reference group recognised the educational value of programmatic review of cytology of all invasive cancers including interval cancers. The report states:

The Expert Reference Group recognises the educational value of programmatic review of cytology of all invasive cancers including interval cancers. The Expert Reference Group therefore recommends that Clinical Audits be conducted only where either (1) such Clinical Audits are both blinded and anonymised; or (2) legislation protecting the confidentiality of Clinical Audits is passed by the Oireachtas.

Essentially persons presenting for screening would be advised that they may seek a review of their case files in the event of an interval cancer arising between a first and second screening. The Bill now states there is a mandatory obligation to disclose to every patient who seeks such a review of their files and an that the files would be made available to the patients. This is exactly in line with what the recommendation of the expert reference group has ordained. This is a positive amendment and we need to go with it. It would deal with issues the Sinn Féin spokesperson raised at the committee with regard to the patient review approach. It was not in the Bill when it last came before the House. The Minister undertook to go back and has come back with a very important amendment that provides for mandatory disclosure. This is what we are all seeking.

The expert review group went through in quite considerable detail clinical audit as opposed to a patient requested review.

There is a lot of merit in how the expert group has proceeded on this front. The Minister stands ready to engage further with Sinn Féin's spokesperson and others on this issue. We want to do what is best for the women of Ireland. This pertains to all screening programmes. Programmatic audits are about identifying issues at system level and we need to have such audits across all various screening programmes, including bowl and breast screenings, etc. That needs to happen regularly to indicate opportunities for improvements in such programmes. The person who has been screened should have a right enshrined in law to access that and this is what the amendment provides.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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The Taoiseach does not have to convince any of us of the need for that kind of meta-analysis for educational purposes and, more important, for quality control and assurance. I remind the House that this legislation is about the provision of information. It is not about medical malpractice or any other legal processes. This is about information. I believe the Taoiseach, like the rest of us, wants to get this right for women. There are serious matters in this Bill that need to be teased through to ensure we get it right. Two hours for the debate is simply not sufficient to get that work done. At the end of the day, people will ask what real difference would this have made in Vicky's or other women's cases and what difference it will make going forward. I am concerned about the anonymised nature of the audits. While the right to a review is welcome, there is no legal obligation for a patient under CervicalCheck to be informed of the right of review. These things need a little bit more time and we have the scope, this week or next week, to afford more time to this. I ask that we adjourn after two hours and afford more time to the debate to be absolutely sure that we get it right. We have waited for four years and a half years for this legislation. A couple of more hours is required to make sure we get it right.

Deputies:

Hear, hear.

Micheál Martin (Cork South Central, Fianna Fail)
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The expert review group report, which was published two years ago in 2020, is very clear on how programmatic audits should be carried out - properly and professionally. In the most recent report, Dr. Scally stated the CervicalCheck programme was greatly enhanced because Vicky Phelan and others raised very serious issues pertaining to how the programme and audits were conducted. The expert review group, which was informed by patient advocates, representatives of the 221+ group and professionals, recognised the approach of patient requested reviews. The big difference is that people going forward for screening will be told they may seek their files if, for example, an interval cancer arises between the first and the second screenings. As per the programme they will be able to get full access. Due to the amendment to the Bill, it will be mandatory for the programme to disclose all information pertaining to the individual. I will ask the Government Whip to speak to the Sinn Féin Whip about what can be done.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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We need more time.

Micheál Martin (Cork South Central, Fianna Fail)
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It is imperative we get this through-----

Mary Lou McDonald (Dublin Central, Sinn Fein)
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It is imperative we get it right.

Micheál Martin (Cork South Central, Fianna Fail)
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-----as we collectively committed to. Remember, this amendment is not being rushed. It is the outcome of a considered analysis by the expert group in 2020.

Catherine Connolly (Galway West, Independent)
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I ask Members to turn off the electronic devices and phones, please.

Ivana Bacik (Dublin Bay South, Labour)
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The Labour Party reiterates its support for the call for more time on Report Stage to debate the Patient Safety (Notifiable Patient Safety Incidents) Bill. It would be sensible to adjourn the debate rather than to conclude the debate after two hours today, and I note the Taoiseach's comments that the whips should co-ordinate on that matter. A substantial number of amendments have been tabled and concerns have been raised about flaws in the Bill, therefore, it would be sensible to adjourn the debate and give it a little more time next week. That is the wish of all of us in opposition.

I raise the issue of increasing concerns among parents and teachers in recent weeks. They have been expressing their concern about severe staff shortages in schools, which was the subject of an earlier debate today. I am also increasingly hearing of frustration from parents of younger children, children of preschool age, who cannot access a place for their child in early years education and care in my constituency and others around the country. I have raised this previously and thank the Taoiseach for his engagement on specific issues about individual crèche closures, but this is part of a broader, systematic problem with childcare and early years education in this country. We need urgent State intervention to address this problem. What is lacking is a real acknowledgement at the centre of Government of the lack of provision of childcare services for children and parents who rely on childcare providers and, indeed, a lack of supports for providers that are closing. I acknowledge incremental steps have been taken. In particular, we in the Labour Party have welcomed the establishment of the employment regulation order for early years workers and professionals. I also acknowledge the Big Start campaign and SIPTU's input into that. Notwithstanding improvements in pay for professionals, there is still a problematic and flawed system for parents. They are now being told to reserve their child's place when at the very early stages of pregnancy, before the child is even born, and even then they cannot be sure of getting a place at a childcare facility.

Tonight, Labour Senators will table a motion in the Seanad to address the crisis in Ireland's childcare system and to call for a change in policy to ensure we no longer have the postcode lottery that so often determines the availability of places and their affordability. High, exorbitant and rising fees are a huge issue for many parents. Several parents have come to me to say they simply cannot afford a childcare place even where there is one available. Let us remember Ireland has the highest proportion of private providers of childcare in the OECD and many smaller providers are being squeezed on costs. We need a universal, publicly-funded childcare system in Ireland and we in the Labour Party have been calling for that consistently. Will the Taoiseach commit to the rolling out of such a scheme and will he commit to reduce the cost of childcare as part of that to a cap of €200 per month per child, as we have sought?

Micheál Martin (Cork South Central, Fianna Fail)
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I thank the Deputy for raising what is an important issue. It has always been my view that, historically, Ireland has been slow in respect of the early years sector. So rapid is the development of a child, human beings learn more from birth to the age of three than they will in the rest of their lives. From birth to six years of age, we need to provide the best of education and developmental opportunities for children. As things have evolved in Ireland over the past 30 years we have had community-led early educational childcare services. That became more organised through many private providers and some State providers, some of which focus on disadvantaged communities and others on special needs. There is no doubt in the past two to three years there has been a substantial increase in funding and an expansion of childcare services. In last year's budget, the focus of the Minister, Deputy O'Gorman, which I supported, was to improve pay and conditions and the overall environment and career pathway for people working in the early education sector. There was good news in autumn this year, following the budget and the provision of funding, when an employment regulation order was agreed, the first ever between employers and employees. I would like to see that advanced and progressed in the years ahead.

The Deputy will know there was a substantial increase in core funding in this year's budget. Last year was about trying to get significant improvements in terms of conditions for staff. This is it was about affordability for parents. Substantial resources have been made available which will result in a substantial reduction in the cost of childcare for parents. The third issue is capacity. We have to continue to expand capacity and we are open to work with the Deputy, Sinn Féin and others, in that regard.

With regard to ECCE services, that is, the sessional services where there has been a change in the model and concerns expressed by some providers, the allocation has gone up from €14 million last year to €27 million per year on top of standard capitation. That is a 90% increase this year alone. The federation had agreed to cancel the previous objective of closing services on the day to highlight issues it had. The Minister, in light of the concerns raised in respect of sessional services, in order to provide additional timely and robust data in preparation for developments to core funding in year 2, has signalled the Department will now undertake an independent review of the financial viability of small sessional services to be completed in quarter 1 of 2023. He has written to the federation regarding this review.

Ivana Bacik (Dublin Bay South, Labour)
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I thank the Taoiseach for that engagement. However, I was in London to meet with Keir Starmer and other colleagues from our sister party, the British Labour Party, as well as with the Irish ambassador, Martin Fraser. While we were there, a report was published by the Institute for Public Policy Research and the charity, Save the Children, that made a recommendation central to this point of childcare. It recommends a universal childcare guarantee be introduced in Britain as a means of boosting economic growth and cutting inequality, particularly gender inequality. That sort of visionary moment is needed here.

We need to see a vision set out for the provision of early years education here in Ireland, a vision akin to that of the Fianna Fáil Minister, Donogh O'Malley, 50 years ago, when he introduced free secondary education for all children. It was a groundbreaking vision that has changed Irish society so much in the intervening half century. However, we need to see that vision rolled out and a Donogh O'Malley moment for early years education. We need to see a universal childcare guarantee of the sort being pushed for in Britain done here. Will the Government commit to that sort of visionary approach to childcare in early years education?

Micheál Martin (Cork South Central, Fianna Fail)
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We are committed. The important thing about the Donogh O'Malley-Fianna Fáil Government was that school transport was a key implementer of the free secondary education initiative. It was radical at the time but-----

Brendan Howlin (Wexford, Labour)
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He did not tell his colleagues about it.

Micheál Martin (Cork South Central, Fianna Fail)
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Sorry?

Brendan Howlin (Wexford, Labour)
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He did not tell his colleagues about it

Micheál Martin (Cork South Central, Fianna Fail)
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As a former Minister for Public Expenditure and Reform, the Deputy will understand why he did not tell his colleagues. They may not have been forthcoming.

Ivana Bacik (Dublin Bay South, Labour)
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Maybe that is what we need.

Micheál Martin (Cork South Central, Fianna Fail)
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I have to be sensitive to my Green Party colleague, the Minister for Children, Equality, Disability, Integration and Youth. He put meat on the table. We need to have the vision but we also need to put flesh on the bone. We need to follow through with resources. I also take the Deputy's point on the organisation of childcare. We need universal access to childcare and we need to make sure every child has access but I am conscious of how the sector has evolved in Ireland. There is a multiplicity of providers, all of whom jealously guarded their domain. We have to work within that framework but I take the Deputy's overall view. These are the most important years and we have to provide universality.

Michael Healy-Rae (Kerry, Independent)
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I want to highlight to the Taoiseach the absolute failure of this country to look after the health needs of children. I will do this by giving an example of a case that proves the dysfunction in our system. Michael O'Sullivan of Dromroughty, Kenmare, County Kerry is a ten-year-old boy who is profoundly autistic and has a working diagnosis of alpha thalassemia X-linked intellectual disability, ATR-X, syndrome, which is rare. He has two loving parents in Jean and Teddy who care for him and go above and beyond the call of duty on a daily basis to care for their young son who is being failed by the health service in this country.

In 2019, at the age of eight, Michael suffered from a perforated bowel. Prior to this he had been waiting to see the gastro team in Crumlin hospital. It is no exaggeration to say that the perforation in his bowel when taken to University Hospital Kerry, UHK, that night almost killed young Michael. When suggested that he be airlifted to Dublin from UHK, a consultant said, "He won't make it in the air". That is how serious the matter was. Michael spent a total of 13 weeks in hospital following this. Following his stay in hospital, he continued to have serious issues with bowel movements, to the point where he now cannot have a bowel movement without the assistance of several doses of laxatives on a daily basis. For anyone who has experienced the discomfort of constipation and the pain it can cause, he or she can imagine facing this pain as a ten-year-old little boy on a daily basis.

Michael had to wait until January 2021 before meeting the gastro team in Dublin again. He met with them for half an hour and was prescribed medication that did not work. All subsequent appointments were done by phone rather than face to face. In October 2021, Michael spent a further two weeks in hospital where they were told they again would need to see the gastro team. Roll on to October 2022 and Michael was finally to see the team in Dublin. The appointment was cancelled and rescheduled for a few days later, but that dreaded call came from Dublin to say the appointment was cancelled. Michael, Jean and Teddy are still awaiting to get a call back with a rescheduled appointment.

The Taoiseach can stand up, blame Covid and talk about how much money the Government has spent on healthcare, how much capacity it has added and how winter has an impact on the system. Winter comes every year and the Government has done nothing to help Michael and, importantly, other children like him who, on a daily basis, are let down and left to suffer. I ask the Taoiseach to deal with this. The HSE is broken beyond repair.

Michael is suffering. He is crippled in pain every day. He cannot have bowel movements without laxatives and, worse again, he cannot get help. Why do we only have one gastro team for children in Ireland? Why do we not have one in Cork that could do appointments in UHK once a month? As Jean said, "Everyone is going the same direction up to Dublin - a never-ending bottleneck of people trying to access the one service, where you could be in Cashel and told your appointment is cancelled yet again".

Micheál Martin (Cork South Central, Fianna Fail)
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I thank the Deputy for raising the issue. It is a very serious issue for young Michael and his parents, Jean and Teddy. The objective is, and should be, that this young child gets the very best of treatment for that young child that guarantees the best outcome and enables him to live a reasonable quality of life. From what the Deputy has said, that has not materialised from the health service. I do not have the individual background to the case, but I will follow it up. The Deputy has identified a very rare condition. In addition to being on what I think he said was the serious end of the autism spectrum, the fact that Michael has a rare condition with significant implications for gastro health seems to suggest he needs a referral and to be treated in the national centre in Crumlin and, eventually, in the new children's hospital. That requires a certain level of expertise that would only be provided in a national centre with a level of gastro expertise that would not be available in every centre in the country similar to cardiac, cancer or other major issues or, indeed, other rare diseases that affect different organs of the body. One needs that access.

The point the Deputy legitimately raised is that once those appointments happen and the requisite level of expertise is applied to the case, there should be a facility whereby whatever is prescribed or whatever programme is outlined for young Michael should be communicated, certainly to CUH, in order that there could be intermittent reviews and so on and a linkage with Crumlin in respect of how young Michael is treated and so forth.

The rarity of the condition is such that expert advice is needed. I will follow up the case on the Deputy's behalf to see if additional external expertise could be brought to bear on the case. The Deputy will appreciate I am not fully au faitwith the case but I will follow up on it.

Michael Healy-Rae (Kerry, Independent)
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I thank the Taoiseach. I acknowledge the presence of the Minister for Health and I ask him, the Taoiseach and the Government please to take this young boy on board. I ask them to take him into their heads but, most importantly, before Christmas, I ask them to take him into their hearts.

We have gastro teams for adults but, as the Minister knows, we only have one gastro team dedicated to children. It is disappointing and heartbreaking for Jean, Teddy and young Michael to have an appointment and to get ready for the enormity of getting their bags packed and their car ready for the long journey to Dublin, only to have that pulled out from them at the last minute. Many Members present are parents. I ask them to take into their hearts and heads how it would be if that was their child, nephew, or niece, if they knew that the child had a pain in their belly every day and knowing the pain that creates in their heart. I ask them to please take this case on board. Let him get the attention he needs.

I would be the first person to compliment the Taoiseach. I raised a case here not too long ago when two children needed millions of euro to be spent and the Government, Minister for Health, Taoiseach and Tánaiste took it on board and did it. I was grateful for that and ask the Government to please do the same again. I thank the Taoiseach.

Micheál Martin (Cork South Central, Fianna Fail)
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It is truly awful for parents to get that phone call when everything has been prepared to make the journey to Crumlin. Many of us as Deputies encounter families where are significant health issues and I always recommend that a child would go to Crumlin because I would always be concerned that there may not be sufficient local expertise to deal with a rare condition. The issue is they should not have to face the kind of cancellations that occur. That is what the new national children's hospital is about. Unfortunately, it is taking time to complete that. That will create capacity. It will also separates outpatients from inpatients and so on. Equally, once a certain level of expertise and treatment has been applied, there should be linkages so that people are not travelling all the time. The nearest hospital could then deal with some issues that invariably arise from time to time with such conditions. However, we will follow it up.

Michael Fitzmaurice (Roscommon-Galway, Independent)
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The Taoiseach is well aware of the housing situation and the construction sector around the country. There is a dire need to get work done and to get houses built. I know the Government is bringing Bills forward in the coming weeks. Regarding the construction sector, I acknowledge the Minister, Deputy McGrath, revised figures for what we would call Government jobs that contractors would do, but there is a serious problem around the country where houses are being built and other works that are not Government-related are ongoing and the price of materials and of doing the job has gone up. Battles are going on. Looking at the statistics, the number of companies ceasing business or going into liquidation is worrying. The Taoiseach saw earlier this year what happened to one of our biggest road contractors, Roadbridge. We see this week after week, especially in the Dublin area. Unfortunately, many of the companies that are ceasing are from Northern Ireland. The big problem is that smaller subcontractors, whether brickie or a person with excavators to do groundwork or people who do other phases of work, are being left high and dry. This has a knock-on effect on those subcontractors. In fairness to him, former Senator, Feargal Quinn, tabled a Bill that required a certificate which contractors could later go into court with.

We have to try to nip this in the bud. If a client employs a main contractor, the subcontractor that works for the client should have a signature or certification before the client gives the main contractor the money to make sure that subcontractor is paid. I know the Taoiseach will move positions in the next week. I do not know where he will go. Whether he has the trade portfolio, or in whatever part of government this is required, I ask that a regulation or legislation be brought in so that where the client is paying the main contractor, there is a certification system so that every subcontractor is paid on-site. It is not complicated. Revenue has all the details of any subcontractor that works on-site. It is not a long list to have to go through. I urge Government to do this because there are many small employers that have two, three or four people working for them and they are being left high and dry. It will put them to the wall. Will the Government look at that in the coming months?

Micheál Martin (Cork South Central, Fianna Fail)
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I thank the Deputy for raising the issue. Capacity in the construction industry and the economy more generally has expanded significantly in the past year. Some 416,000 more people are working in the economy now than in 2020, so the bounceback from Covid was significant. Many people lost jobs as a result of Covid but it is still an extraordinary figure. We set a target of 2.5 million people in employment for 2024. It has already been exceeded in 2022, since there now at 2.55 million people working in the economy. That is notwithstanding Brexit, the pandemic or the war in Ukraine, all of which have had significant impacts on the cost of building materials and so on. It is interesting to see that approximately 40,000 more people are working in the construction sector than last year and approximately 20,000 more than in 2019. Capacity is being built up and we are trying to build more.

The Deputy raised specifics about subcontractors. He referred to the Construction Contracts Act 2013, which provides for the regulation of payments to subcontractors in particular. This is an issue that was raised at that time. He is right that former Senator, Feargal Quinn piloted it through the Seanad and then the Oireachtas. In light of what the Deputy said, we will undertake to review that Act. I will ask the Minister for Public Expenditure to review it to see if it can be improved. If the Deputy has any input and potential amendments to make, it could help to get the balance right. I recall much discussion of that Bill at the time. We are open to such reviews.

Michael Fitzmaurice (Roscommon-Galway, Independent)
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I thank the Taoiseach for his reply. I acknowledge the additional people working in the economy. I am talking about when a client, be it the State or a private client, hires a main contractor. At the moment, some of those are going into liquidation. Unfortunately, many seem to be coming from Northern Ireland, from the trend I have observed. The subcontractor, which is a smaller outfit, is then left high and dry for the money. That is the big problem. I acknowledge the great work of Feargal Quinn. Given time, the then Government brought it in. However, subcontractors need a certificate and it is only after the event that they can try to go to court. It is not much good if the main contractor has gone into liquidation. I welcome that the Taoiseach is open to reviewing this again. I am proposing that before the main client, whether the State or the client who is building something privately, pays the main contractor, there should be some type of certification that the subcontractors on the site have signed to make sure that their payments are kept up to date.

We have seen significant fallout from what happened with Roadbridge over the past six or eight months. Smaller subcontractors are being put to the wall because they cannot withstand the hit that they must take by not getting paid, whether for a month or two months. Generally, it runs to three months. If they have machines or people hired for different work, the figure builds up. Subcontractors do not have the capacity to withstand the belt from that. It is okay for whoever has gone into liquidation. They are a different story.

However, these people have to face everything and try to survive it, which is impossible. I welcome what the Taoiseach said about being open to reviewing it.

Micheál Martin (Cork South Central, Fianna Fail)
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I again thank the Deputy for raising the issue. He might feed through some of the individual examples to the Minister, Deputy McGrath, or me. That is one aspect of it. On the second aspect, we will give this further consideration in the form of a review of the existing Act and the regulations that govern this area of payment of subcontractors, to see if we can get the balance right.