Holly Cairns (Cork South West, Social Democrats)
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Since this is my final contribution on Leaders Questions in 2023, I extend a huge thank you to the staff in Leinster House and wish them all a happy Christmas.

Much has been made of the date for the upcoming referendums on care and the family. For some reason, the Government has decided to have them on International Women's Day. Is that because it thinks women are excited about the prospect of a referendum on care and that they will be celebrating if a sexist and legally powerless constitutional provision is replaced with a more progressive-sounding but equally powerless amendment? Should that not be the bare minimum? Perhaps it makes sense in one way that these referendums will take place on International Women's Day in that it will continue a long-standing tradition of the Government patronising women rather than listening to them.

It is seven months since Ms Marie O'Shea published a review on abortion services. The Government reacted with barely disguised horror to that report because it was so clear and straightforward in its findings. The current legislation is failing women in numerous ways. Among the recommendations of Ms O'Shea are that the mandatory three-day waiting period be removed, that the threatened criminalisation of doctors be ended, that there be more clarity when it comes to providing abortion in cases of fatal free foetal abnormality and that there be more balance between an individual's right to conscientious objection and a woman's right to healthcare. These barriers to care are not just an inconvenience for women; they are a danger. Yet, the Government failed to act on the report's very clear proposals. Instead, it kicked the report out to the health committee for a review. That review has now been completed. The health committee is about to recommend that all legislative changes proposed in the report be implemented without delay. The question for the Government now is whether it will act on the recommendations. We all know that so many women still face unimaginable pain every year when they receive a diagnosis of foetal abnormality and are forced to travel abroad for care. The most recent tragic case of this nature was raised by Deputy Bríd Smith in this House yesterday. These women are being failed by the State.

The Tánaiste said he is not convinced that the three-day waiting period is a barrier to women receiving abortion care. I wonder whether he read the part of Ms O'Shea's report that details precisely how this completely arbitrary delay can time women out of care. The three-day wait is not just a potential barrier to care; it is also an insult to the intelligence and autonomy of women all over the country. Is the Tánaiste aware of any similar legal impediment or delay to somebody accessing healthcare that they want or are entitled to? Does he believe pregnant people are somehow more mentally frail or indecisive and therefore require a patronising provision? If the Government really wants to do something meaningful that will have an impact on International Women's Day, will it commit to implementing the recommendations of Marie O'Shea's report by then?

Micheál Martin (Cork South Central, Fianna Fail)
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I thank the Deputy for raising two issues, namely, the constitutional amendments and the review of the operation of the Health (Regulation of Termination of Pregnancy) Act 2018. She consistently endeavours to characterise the Government's position as one of patronising women. She is entitled to her perspectives but so are people on the Government side of the House. I do not believe her characterisation of the Government's position is an accurate one.

The amendments to the Constitution we have proposed in respect of 8 March were the subject of a lot of detailed work by the Cabinet sub-committee and a great deal of legal advice on the optimal position and on removing language that is clearly anachronistic and outdated in respect of women, the aim being to modernise the Constitution and play constitutional catch-up, as one Minister put it.

That has been debated around this House and in committees for 20-odd years. It is now going to happen and the Government is going to deliver that. There is a change regarding care that has not been in the Constitution before.

There is a legitimate debate in terms of the separation of powers about how much we want it to be deliberated on by the courts and how much we want it to be deliberated on by the Executive and the Oireachtas. This is a fundamental debate that should not be sneered at or dismissed because it is the Oireachtas that must allocate resources and prioritise the allocation of resources. That is a consideration in terms of the ultimate formula or amendments that have been brought forward. Ultimately, if you get the balance wrong, you cede all decision making to the courts and denude Parliament and the Executive of the day of any capacity sometimes to target resources and prioritise the allocation of resources because resources are finite. That is perhaps for another day.

Regarding the review of the Health (Regulation of Termination of Pregnancy) Act, an operational group was established as a consequence of that report to progress the implementation of the operational recommendations and a draft implementation and action plan has been developed. That implementation group is a multidisciplinary group comprising healthcare professionals across the termination of pregnancy pathway and service users and it is chaired by the national women and infants health programme. Significant progress is being made in respect of various recommendations in the report and a significant number of additional sites have introduced termination services in the past months. Legislation providing for safe access zones has now passed all Stages in Dáil Éireann and will now go before the Seanad. The proposal recommending legislative changes has been referred to the Oireachtas Joint Committee on Health for consideration. Termination services in early pregnancy are currently provided in 17 out of the 19 maternity hospitals. This is a significant addition to what was the case a year ago.

Holly Cairns (Cork South West, Social Democrats)
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The Government does not need help from me for it to be characterised as sometimes being paternalistic in its attitude towards women. There is evidence of that in multiple pieces of legislation such as the mother and baby homes legislation, which told people they are somehow unaffected because they spent less than six months in an institution, and legislation that tells women they have to wait three days to access healthcare, something we do not see in any other kind of healthcare provision, so it is not some kind of narrative I am setting about the Government. There is evidence of that and here we go again. We are supposed to be celebrating because finally the statement that a women's place is in the home in 2023 is going to be removed from the Constitution and the Government is doing it on International Women's Day as if it is some kind of huge gift to us.

The Taoiseach previously stated that he would feel reluctant and uncomfortable to make changes to the repeal legislation. I feel reluctant and uncomfortable at the prospect of healthcare decisions for women being informed by politicians' comfort levels rather than women's autonomous decisions, expert advice or doctors' clinical judgment. The Taoiseach's reluctance to amend the law also flies in the face of the legislation itself. We said we would review the legislation and I think everybody can agree that the idea was that the review would inform how the legislation can improve. Will the Government take on the recommendations of Marie O'Shea's report?

Micheál Martin (Cork South Central, Fianna Fail)
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As I said and as the Deputy confirmed, this was sent to the Oireachtas Joint Committee on Health and that committee has now completed its report. If we did not send it to the committee, I would respectfully suggest that the Deputy would be standing here this morning asking why it was not referred to the committee and why the committee should not deal with it. We have to follow up on that report in terms of the review. I am very open to the recommendations to come from the report of the committee and the Government will give that very serious consideration.

My overriding concern involves the referendum the people passed. A set of criteria and conditions were put before the people - the referendum itself and the legislation-----

Holly Cairns (Cork South West, Social Democrats)
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-----that there would be a review.

Micheál Martin (Cork South Central, Fianna Fail)
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-----including the review but we cannot dismiss the fact that we put certain arguments before the people at a given time not so long and people voted on the basis of those arguments. That was the Taoiseach's point and it is a valid point. That said, the review was also contained within the Act. We have had the review and we will act on it. The Government will give that active consideration.

I was very unhappy that maternity hospitals were not providing services. That was the first priority. There are two more that are needed to make sure they fulfill their obligations under the Constitution and the law and they will come on stream in 2024.

Peter Fitzpatrick (Louth, Independent)
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It has been one year since the tragic death of Private Seán Rooney, a member of the 27 Infantry Battalion in Dundalk. Today our thoughts and prayers are with his family and friends.

There seem to be more and more problems for cancer patients applying for a discretionary medical card. A discretionary medical card gives you the same services as a means-tested medical card, however, a few of my constituents have not qualified for a medical card based on the means test. If someone is self-employed, young, without private health insurance, ineligible for a medical card or does not have savings, he or she is left in the very vulnerable position of being unable to manage basic expenses such as heating and travel to hospital for treatment. We are hearing from an increasing number of these people. It is only right that a discretionary medical card be granted to people who are over the financial means test but would suffer "undue hardship". However, the issue is that the discretionary medical card application process is the same as that for a means-tested medical card whereby you also must provide information about your family's medical expenses.

My office regularly sees constituents coming in with long-term illnesses who are struggling to get the services or medicines they need. There are people coming to me whose lives have changed due to a cancer diagnosis and are concerned that they may find themselves out of work due to the need for treatment. Many of these people are faced with a financial burden they cannot afford. At a time of utmost need, I have a constituent who is a cancer patient with very ill health who knows they are over the means test yet is being sent around the houses to gather private pension information for a family member who has no interest in applying for a medical card.

Why are we making it significantly more difficult for cancer patients to be awarded discretionary medical cards on the grounds that their diagnosis causes undue financial hardship? This is not only causing undue stress for the person but is doubling the work of the medical card approval section. Where is the efficiency? It is ten years since the HSE looked at medical card eligibility on medical grounds and how effectively the system of assessment for a discretionary medical card is working. Will the Taoiseach consider a review of the medical card eligibility and assessment process, especially for those with a medical condition? It is crucial that we review the recommendations from 2014 report of the expert panel on medical need for medical card eligibility to see if those recommendations have been implemented and if they are working and are fit for purpose in 2023 and 2024.

Micheál Martin (Cork South Central, Fianna Fail)
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I thank the Deputy for raising this issue. It reflects the hardworking nature of the Deputy in terms of the cases that come to him via his constituency office and the people he meets on a regular basis and I respect that. More generally, I would make the point that there has been record investment in health since this Government came into office. This has focused a lot on reducing costs for patients generally. We have removed inpatient hospital charges and have had the biggest expansion of access to free GP care in the history of the State, including an expansion of free GP care to children aged under eight and people earning no more than the median household income. We have reduced the drugs payment scheme costs, funded diagnostic scans for patients and agreed a new consultant contract to which approximately 1,000 consultants have already signed up.

Regarding medical card eligibility, there are approximately 1.6 million medical card holders in the country and over 623,000 GP visit card holders. Some 185,000 have access to discretionary medical cards and in many cases these are people with illnesses who would not normally qualify because of the means test but they do qualify because of the nature of their conditions and illnesses. As the Deputy noted, people who cannot without undue hardship arrange for the provision of medical services for themselves and their dependants may be eligible for a medical card on a discretionary basis. This is then determined by the HSE.

It has always been a long-standing position of both the Department of Health and the HSE that medical cards be allocated on the basis of a means test threshold as the fairest way, as opposed to condition-based mechanisms. As the Deputy said, we have introduced discretion, particularly since March 2021. Persons who have been certified by their treating consultant as having a prognosis of 24 months or less are now also awarded a medical card. That reflects a programme for Government commitment to extend eligibility for medical cards to persons with a terminal illness.

As regards the expert panel on medical needs and medical card eligibility to which the Deputy referred, and as to whether eligibility should be determined on the basis of a particular disease or illness, that group concluded in 2014 that it was not feasible, desirable or ethically justifiable to list medical conditions in priority order for medical card eligibility. It has stuck with the means test process. Where the HSE can operate its discretion, other costs, or the costs of the illness, can be taken into account in respect of enabling a person to be eligible for the medical card.

The Deputy might have a number of cases. I would be interested in getting examples of them in order that we could reflect that or, if there are gaps in the system or in the situation we have, that that could be remedied.

Peter Fitzpatrick (Louth, Independent)
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The word "cancer" puts fear into every household in the country. It changes peoples' lives. I guarantee the Tánaiste that not one person in this House does not have examples similar to those I will give him today. The bottom line is that if you are not working, you are not earning. I had a self-employed man come into my office this week whose wife was diagnosed with cancer. He is self-employed and he has to start working. The wife is in hospital getting treatment. I refer to the simple things of getting children up in the morning, taking them to school and cooking their meals. They are trying to remain a normal family.

It has been ten years since this system has been looked at. There is no better man than the Tánaiste, a former Minister for Health, to understand this situation. We can all talk about money being spent and everything else, but there is a lot of hardship and a lot of suffering among normal families at the moment, and it is not fair. When you see a husband come into your constituency office with his three children and his wife in hospital, it is wrong. When they have to chase around family members looking to fill in forms and everything else, it is absolutely dreadful. The last thing they want to be worrying about is who will pay the bills. Just because you are working today and may be earning good money does not mean that something will not happen that will stop you working and earning.

The doors opened by the medical card are unbelievable. It is ten years since this was looked into. I am asking the Tánaiste to give us a commitment today that he will try to help ease the hardship of these families who are suffering. One of them has a cancer condition.

Micheál Martin (Cork South Central, Fianna Fail)
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I thank the Deputy for raising those issues. Since 2015, medical cards are awarded without the need for a financial assessment to children under 18 years of age with a diagnosis of cancer. More broadly, the Government took a position whereby if there was a terminal prognosis of 24 months, the Government would facilitate the granting of a medical card. In other words, eligibility does not relate to a specific illness. There is neurological disease, which can shorten a person's life significantly, heart disease, COPD, stroke - there is a whole range of conditions that essentially mean a person's prognosis is terminal. The Government has taken the view that, based on the diagnosis of any particular condition, if the prognosis is 24 months or less, a medical card will issue.

On a more general level, we have dramatically expanded medical card coverage to try to cover the situation the Deputy has outlined, particularly in terms of the median income, which has been a very significant expansion of the card. Again, I would be interested to hear the details of some of the cases the Deputy has identified.

Micheál Martin (Cork South Central, Fianna Fail)
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I thank the Deputy for raising multiple issues under the overall umbrella of farming and agriculture. The fundamental objective of the Government is to protect farm family incomes. The most effective mechanism to do that is through the Common Agricultural Policy. We negotiated a Common Agricultural Policy for the period 2023-27, with a strong focus on supporting family farms regardless of size or location. We are looking at close to €10 billion in total between EU and Exchequer funding that will support over 120,000 farm families under the new CAP. There is a 50% increase in Pillar 2 in rural development funding compared with the last CAP as well as a fivefold increase in support for organic farmers and, for the first time, specific supports for women farmers. In the first year of the new CAP, some €1.2 billion has been paid to farmers. Payments will continue to issue to farmers this month across a number of schemes.

The Deputy raised knackeries, fallen animals and so forth. I think he was implying, perhaps, that the environmental standards are too high. He might clarify that. We need to be cautious there. We have to have strong environmental standards in respect of the disposal of animals. These days we cannot play fast and loose with that. I did not quite get the context in which he referred to that but he might clarify that.

In respect of the meeting in west Cork, I think the Deputy referred to my going down there-----

Micheál Martin (Cork South Central, Fianna Fail)
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He said "senior politicians".

Micheál Martin (Cork South Central, Fianna Fail)
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I know he was not there but I was there. Deputy Christopher O'Sullivan facilitated it.

Micheál Martin (Cork South Central, Fianna Fail)
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Actually, it was a very constructive meeting. We went to see how farmers in the Timoleague-Kilbrittain area were dealing with a research project with Teagasc in respect of water quality.

We spent a good three hours there. It was informative and insightful.

Mattie McGrath (Tipperary, Independent)
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You would make a poor Santa Claus.

Micheál Martin (Cork South Central, Fianna Fail)
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The bottom line in the discussion afterwards was about how we avoid losing the derogation or going below 220 kg. There was much realism at that meeting. Many people realised the reality of the situation. It was critical that, nationally, we take every effort, working with the farming community, to make sure we do not go below the 220 kg limit and that we retain that at the time of the next review. It is important we work collectively and in partnership with the farming community to achieve that.

Deputy Collins knows that ACRES was initially planned to take in applicants from two tranches, with 30,000 in tranche 1. The Government made a decision to accept all valid applications submitted last year. There are up to 46,000 farmers actively in the scheme, if not more. That has created pressure on the Department in respect of the payments. Department officials are working flat-out to get advance payments to ACRES farmers, commencing on 18 December. Up to 992 ACRES participants in County Cork will be included in that. Everything is being done to pay, as soon as possible, all ACRES participants who clear prepayment checks. I think it is a good sign that there was such high demand for ACRES. It shows farmers believe it is worthwhile and impactful. It has proved very popular. We took the right decision to expand it and to include as many farmers as possible.

Micheál Martin (Cork South Central, Fianna Fail)
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The Deputy raised a multiplicity of issues. The farm organisations are being invited to meet the Revenue Commissioners and the Department of Finance to discuss the VAT issue next week. The Department works with the farming organisations and farmers on these issues.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Please.

Micheál Martin (Cork South Central, Fianna Fail)
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The Department is also working to resolve the issue in respect of the knackery situation, the fallen animals and the issues that have arisen. I am confident it can get a working resolution of that issue for farmers more generally.

Our whole approach is to get payments to farmers to facilitate this. That is why we have allocated the resources. We are not out to get anybody or undermine anybody. I think ACRES has been a successful initiative. The evidence of that is the number of people who have applied. I have no doubt that the Department will do everything it possibly can. The extra numbers were significant. It was originally planned for 30,000. There are now 46,000 to 50,000 involved. That, by definition, increases the pressure on the Department.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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That concludes Leaders' Questions for today and, indeed, for 2023. I beg the indulgence of the House to make a few remarks before we proceed to Questions on Policy or Legislation. As 2023 draws to a close, it is worth noting that, up to the end of November, we have processed 52,145 parliamentary questions. When today ends, we will have sat in plenary session for something in excess of 1,000 hours. We have initiated in the year 85 Bills, passed 26 Bills, held 941 committee meetings, and heard from an astonishing 2,915 witnesses. That is evidence of a participatory democracy in action.

I thank the Taoiseach, Tánaiste and leaders of all the parties, Government and Opposition, and indeed all of the Members for their constant co-operation with the Chair. I thank the Leas-Cheann Comhairle who is ever present and ever dependable and the large array of deputy Chairs who are now operating here. Some of the leaders, as evidenced by today's contributions, continue to be horologically challenged. I hope they might learn a little more about timekeeping during the Christmas break.

It has been an unusual year. We will never forget our return in September when we witnessed an unprecedented assault on the Houses, our Members and our support staff. We have, during the year, drawn public attention to the Chamber by the use of expletives, crude and unparliamentary language, something that does nothing to enhance debate or build confidence in the Thirty-third Dáil as a well-functioning parliamentary assembly. In the days ahead, I exhort Deputies to remember those in need in our own country and across the world. Over Christmas, please take time for yourself, your families and your loved ones so that you may return in January refreshed and re-energised to tackle the undoubted challenges that lie ahead. Chun casadh ar an seanfhocal Gaeilge, go mbeirimid go léir beo, ar aon nós, ag an am seo arís an bhliain seo chugainn, b'fhéidir anseo.