Marcella Corcoran Kennedy (Offaly, Fine Gael)
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I am very pleased to have the opportunity to address the House on Second Stage of the Health (Miscellaneous Provisions) Bill, which was passed on 6 December last by Dáil Éireann. The Bill includes some provisions which relate specifically to my health promotion portfolio. When it comes to health promotion and encouraging behavioural change in relation to tobacco, alcohol and unhealthy diets, what we need is a whole of government and a whole of society approach. This is crucial if we are to be successful in stemming the tide of non-communicable diseases and their impact on our population.

Healthy Ireland, the national framework, aims to make it easier for more people to stay healthy, stay out of hospital and make positive changes that will enhance their lives. Part 5 of this Bill aims to progress the Healthy Ireland agenda by making amendments to the legislation that introduces standardised packaging of tobacco. Standardised packaging is just one of the many important public health measures we are introducing in order to reduce the number of deaths of Irish people from non-communicable diseases. The Bill has five Parts, with 16 sections. Part 1 sets out the Title to the Bill. All Parts will be commenced on enactment.

Part 2 amends the Irish Medicines Board Act 1995 to allow for the payment of fees to members of the Health Products Regulatory Authority, formerly the Irish Medicines Board. This is in line with the practice of other similar boards, where fees are paid to board members in order to attract individuals of the highest calibre and expertise to apply for board membership, for example, to the Medical Council and the Pharmaceutical Society of Ireland. Currently, under section 8(7) of the Irish Medicines Board Act 1995, as amended, only the chairman of the authority is entitled to a fee. There is an onerous responsibility and a significant time commitment placed on members of the authority. Some people may be self-employed and, without the modest fee that will be paid under this amendment, it would be very difficult for them to give the time commitment involved. There is no additional cost to the Exchequer relating to paying board members of the authority, as it is mainly self-funding. The fee approved for payment to each board member, in keeping with the guidelines issued by the Department of Public Expenditure and Reform, is €7,695 per annum. The additional cost to the authority will be approximately €61,560 per annum. However, some members may choose to waive their fee and the one person, one salary system will also apply to members who are in receipt of a salary from the public service.

Part 3 of this Bill proposes to amend the Nursing Homes Support Scheme Act 2009 in order to exclude certain ex gratiapayments which have, or will in the future, be made to individuals under specific schemes approved by Government for the purposes of assessment of means under the nursing homes support scheme, commonly known as the fair deal scheme. The fair deal scheme is a very important scheme that provides financial support for those assessed as needing long-term nursing home care. Participants contribute to the cost of their care according to their means while the State pays the balance of the cost. The scheme aims to ensure that long-term nursing home care is accessible and affordable to everyone and that people are cared for in the most appropriate settings. All applicants to the scheme must undergo a financial assessment which is carried out by the HSE to determine how much a participant in the scheme will contribute to the cost of care. The scheme has a number of important safeguards built into the financial assessment to ensure that nobody will pay more than the actual cost of care and to ensure that an applicant will keep a personal allowance of 20% of his or her income or 20% of the maximum rate of the State pension, whichever is greater.

This proposed amendment to the Nursing Homes Support Scheme Act is a critically important provision for many of our senior citizens, as it will exempt payments made to persons under ex gratiaschemes approved by Government from being included in the assessment for State support under the fair deal scheme. This provision applies to persons who have received awards under four schemes: the surgical symphysiotomy payment scheme, which has made awards to around 400 women; the Lourdes hospital redress board, involving 119 women; the Lourdes hospital payment scheme, which compensated women who were excluded from the redress board on age grounds alone and relates to 47 women; and payments made either by the Government or by the German Contergan Foundation to 32 Irish survivors of thalidomide.

I am also particularly pleased that the Bill proposes to amend section 36 of the 2009 Act to provide for the Minister to make regulations to allow an exemption for other similar groups that may in the future receive ex gratiaawards, provided that the Government has approved the scheme. This future-proofing is an important and significant feature of this part of the legislation. For any individual who has received an ex gratiapayment under a Government-approved scheme, it is a very important principle that, on reaching a more senior stage of their life, people should not be in any way disadvantaged financially when it comes to making an application under the fair deal scheme. In summary, the proposed amendments to the Health (Miscellaneous Provisions) Bill are key, age-related provisions for people who have received an ex gratiaaward and who now in their older years are seeking supports under the nursing homes support scheme.

Part 4 of the Bill amends Part 1 of Schedule 3 to the Health (Pricing and Supply of Medical Goods) Act 2013. The purpose of this proposed amendment is to allow the HSE to consider reimbursing over-the-counter products, where appropriate. The amendment corrects an anomaly in existing legislation, where current rules only allow medicines that are prescription-only to be supplied in the community drugs schemes. This anomaly affects a number of products that were prescription only and are now over the counter, as well as some over-the-counter items that have long been available in the schemes. The 2013 Act gives a temporary reprieve on supplying over-the-counter medicines until 2018 and the amendment I have proposed will make this permanent. This means that some very useful medicines, such as emergency contraception and nicotine replacement, will continue to be available on the drug payment scheme, medical card scheme and other schemes. Patients will, however, still need an authorisation to get an approved over-the-counter product under the various schemes. This applies to all schemes and to both over-the-counter and prescription-only items. This is a very important control, both clinically and for the financial operation and governance of the schemes.

Specifically regarding access to emergency hormonal contraception, there are a number of important points that have been carefully considered by the Department. First, it is important to note that medical card holders already have access to emergency contraception. It is currently available free to medical card patients, provided they get a prescription first. It is also available as an over-the-counter treatment, so any person can go into a pharmacy and buy it without a prescription. In the 12 months to August 2016, just under 13,000 emergency hormonal contraceptive prescriptions were dispensed across all the schemes, and over 12,000 of these were on the medical card scheme. The barrier, therefore, for medical card patients in getting emergency contraceptive as soon as possible is not access, as over 12,000 people per year go to their doctor and then to the pharmacy.

The issue is when women need emergency contraception but cannot get a prescription in time to get the treatment, for example, it might be at the weekend, they cannot get an urgent appointment with their GP or they cannot afford to buy the product. The Minister, Deputy Harris, and I share the concerns that have been raised by some Deputies in the Dáil over timely access to treatment for medical card holders. I fully accept that there should not be unnecessary barriers to women getting this treatment and this is being addressed. The Minister for Health has instructed officials to change the process for supplying emergency hormonal contraception to medical card holders as a matter of urgency and work on the development of service and clinical structures is under way.

Much of the IT infrastructure needed was trialled in the recent minor ailments pilot, in which pharmacies treated medical card patients with over-the-counter medicines for minor conditions, without needing to see a GP. In line with the Minister’s instructions, the HSE is developing the operational structures to implement this service safely and effectively, including procedures for identifying pharmacies in compliance with the Pharmaceutical Society of Ireland’s professional practice guidelines for dispensing over-the-counter emergency contraception, as is done for the vaccination programmes and also secure claiming and verification processes.It is expected that the measures for emergency contraception will be in place in the second quarter of this year.

Senators will appreciate that significant steps have already been taken to remove barriers to timely treatment for medical card holders for both emergency contraception and over-the-counter products in general.

Concerns also have been raised about the availability of emergency contraception to women where a pharmacist may not be able to provide the treatment or may have personal reasons for not wishing to do so. The statutory code of conduct for pharmacists requires that where they are unable to provide a service, pharmacists take reasonable action to ensure the patient's care is not jeopardised. In practice, the patient should be referred to another pharmacist, pharmacy or health service. All pharmacists must subscribe to this code. If a patient is unhappy with the conduct of a pharmacy or pharmacist in this or any other matter, he or she should contact the Pharmaceutical Society of Ireland, which regulates the profession.

There is also provision in the Bill to remove the unintentionally restrictive provision referred to in paragraph (a), which excludes products authorised by the European Medicines Agency and parallel imports from the medical card and community drugs schemes. Parallel importation is the importation from a European Union, EU, member state or a country within the European Economic Area, EEA, of a medicinal product which is essentially similar to a product already authorised in Ireland, by an importer who is someone other than the importer appointed by the marketing authorisation holder of the product on the Irish market. The parallel trade of medicinal products is based on the principle of the free movement of goods within the Internal Market of the EU. It was never the intention to exclude such products and any such inference would be contrary to free trade principles.

For the information of the Senators I would point out that the explanatory memorandum which accompanied the Bill noted that "Allowing reimbursement of certain over-the-counter medicines under the GMS and community drug schemes will give rise to some additional cost from loss of prescription charges over time, but this is not expected to be significant." However, this is not correct. My officials have confirmed that there are in fact no additional costs arising from the amendments proposed in Part 4.

Part 5 of this Bill holds a particular interest for me in my capacity as Minister of State with responsibility for health promotion. It seeks to amend the Public Health (Standardised Packaging of Tobacco) Act 2015, which is a significant tobacco control measure. I acknowledge the tremendous work of the former Minister for Health, now Senator, James Reilly in enacting this important public health legislation. I know that introducing this legislation is of great importance to Senator Reilly and I assure him and all the Senators of my commitment and that of the Minister, Deputy Harris, to ensuring this legislation is commenced fully in the near future.

The aim of the legislation is to make all tobacco packs look less attractive to consumers; make health warnings more prominent and prevent packaging from misleading consumers about the harmful effects of tobacco. It gives effect to Ireland's obligations under the World Health Organization Framework Convention on Tobacco Control. Standardised packaging of tobacco is Ireland's next step towards creating a tobacco-free Ireland. Evidence indicates that tobacco packaging is a critically important form of promotion. This is more relevant in Ireland, where we have comprehensive advertising and marketing restrictions. We know that branding works, particularly on children. If the tobacco industry did not addict our children, its industry would disappear within a generation. Given that 78% of smokers in a survey said they started smoking before they reached the age of 18, it is clear that our children are targeted to replace those consumers who die or quit.

The amendments to the 2015 Act put forward in this Bill are of a technical and practical nature and some seek to provide basic information to the consumer. These amendments will permit the following elements to be included on tobacco retail packaging: text to indicate the type and weight or number of tobacco products contained in the packet; the inclusion of a tab to allow consumers to reseal the pack excluding cigarette packs; the inclusion of a calibration mark, which may be necessary for the automated production of the packaging; contact details of the manufacturer and additional information on cigar bands. The amendments also set out new transitional times to reflect the time that has elapsed since this Bill was initiated in the Dáil. The original timeframe for the manufacture of the new standardised packaging from 20 May 2016 has now passed. The approach taken in the Bill is in line with the original intention of the Public Health (Standardised Packaging of Tobacco) Act 2015. It is my intention to give key stakeholders, including the tobacco industry, adequate notice of the commencement date referred to in the Bill. The amendments set out in this Bill will enable Ireland to proceed with the introduction of standardised packaging of tobacco products. The objective of this measure and many other tobacco control measures is of course to dissuade people from starting to smoke, to encourage current smokers to quit and ultimately to save lives. It is the combination of past, present and future tobacco control measures that will reduce tobacco consumption in Ireland and not one measure in isolation. All of the measures outlined in our tobacco policy, Tobacco Free Ireland, will have a role in reducing the prevalence of smoking in Ireland.

This Health (Miscellaneous Provisions) Bill serves to make important changes to four Acts in the interests of equity or, in some cases, patient safety and of course the tobacco legislation is to help protect public health. I hope Senators will give their support to the Bill. I therefore commend this Bill to the House.

Keith Swanick (Fianna Fail)
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Fianna Fáil will support this Bill, which makes necessary changes in several areas. I welcome the amendment of the Nursing Homes Support Scheme Act 2009, which underpins the fair deal scheme, to exclude ex gratiapayments to patients of the Lourdes Hospital redress scheme, the Lourdes Hospital payment scheme, the symphysiotomy payment scheme and schemes for individuals disabled by thalidomide, as well as the Magdalen laundry redress scheme that was catered for in a previous Act in 2009.

Separately I acknowledge the importance of including several over-the-counter medications under the general medical service, GMS, scheme for people with medical and long-term illness cards. It includes nicotine replacement therapy and emergency contraception. Unfortunately, however, prescription charges are not covered in this legislation and as we are all aware, prescription charges have increased in recent years from 50 cent per item to €2.50 per item. I believe this sole action discriminates against elderly patients who have many core mobility issues and are on multiple drugs but not of their own free will. I have always advocated a flat prescription fee or, ideally, no prescription fee should be put in place because in that way people who are vulnerable will not be jeopardised. This charge diminishes the quality of life of elderly citizens. As for the nicotine replacement therapy, it is worth remembering that there are almost 31,000 hospital admissions per year for cigarette-related illnesses in this country at a cost of €5,400 per admission. This equates to a staggering €164 million per year. To put this in perspective, the Minister afforded €40 million to the winter initiative.

Fianna Fáil fully supports the introduction of legislation to allow the Minister to make regulations to add certain elements to tobacco packaging and we published our legislation on this issue in 2012. Cigarette companies use marketing techniques to deliberately target young people. The Marlboro brand, identified by its iconic red chevron, is worth $21 billion, which is truly staggering.

In September 2015 the Seanad passed a Second Stage reading of a Private Member’s Bill, the Longer Healthy Living Bill, introduced by the Independent Senator, Professor John Crown. The Bill was supported through Second Stage by Senators from Fianna Fáil, Sinn Féin, Labour, Fine Gael and the Independent benches. The then Minister for Health, Deputy Varadkar, did not oppose it and highlighted a few suggestions including minor technical changes to improve it. During that debate the Minister stated "In terms of recruitment, there is an international shortage of consultants, doctors and nurses." I have been examining the retirement of key personnel in the health service. It has now reached the point where significant changes are required. There are too many times when critical professionals within the health services are forced to retire due to their age and for no other reason. Our current health system is embattled by staff shortages, shortage of senior consultants, not enough general practitioners and a dearth of highly qualified specialist nursing staff. As Professor Crown said during the debate "Are we so flush with trained, experienced staff that we can afford to offload them involuntarily?" Since being elected to the Seanad I have engaged widely on this topic and while it does not address conditions, pay or otherwise, it is an evidence-based solution to an ever increasing problem.It is my intention to submit extensive amendments on Committee Stage which will be designed to allow health professionals to postpone their retirement with the mutual agreement of their respective employers in the HSE, organisations funded directly by it, the Department of Health and all other major health service providers. To ensure the amendments would be workable, I have reviewed and taken cognisance of the issues identified by then Minister for Health, Deputy Leo Varadkar, during that debate. I am seeking to incorporate them into the amendments I will be tabling on Committee Stage.

Colm Burke (Fine Gael)
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As the Minister of State outlined, the Bill amends several Acts, including the Irish Medicines Board Act 1995, the Nursing Homes Support Scheme Act 2009, the Health (Pricing and Supply of Medical Goods) Act 2013 and the Public Health (Standardised Packaging of Tobacco) Act 2015.

Like my colleague, I welcome the amendment to the Nursing Homes Support Scheme Act 2009 and its application to persons who have received compensation awards under the surgical symphysiotomy payment scheme, the Lourdes hospital redress board scheme and the Lourdes hospital payment scheme, as well as payments made to survivors of thalidomide. A small number of people, around 600, benefited from these schemes. In the case of a recipient who is over 70 years and has these moneys on deposit, will they be taken into account when calculating his or her entitlement to a medical card? I have recently come across cases of pensioners over 70 years who may have a pension of €450 per week but who may have more requirements, whether it be for medical or other care.

An old structure is in place for determining what interest a person is deemed to have earned on such moneys. We all know that the interest one earns on deposits is now extremely small, but there has been no adjustment made for several years to take account of this. I have encountered people who were not able to qualify for a medical card because of the interest they were deemed to be earning when, in fact, they were earning nothing. Will the Minister of State examine this issue and incorporate it into the Bill? I might be wrong, but it is my understanding the Bill does not deal with it. Most of those who received compensation under the schemes in question are now over 70 years. It is an issue to be examined from the point of view of entitlement to a medical card.

On standardised packaging, it is important all tobacco products carry adequate health warnings. The manufacturing industry raised its concerns with me about the date of operation. The Minister of State clarified that the commencement date would be set in a statutory instrument or regulation as opposed to being the date the Bill was passed. The industry has a lead-in time for the production of packaging and will require additional time. The Minister of State has clarified the issue.

It is important that every aspect of advising people of the risks of smoking be outlined clearly. Every week we come across cases of people with an illness or cancer as a direct result of smoking for a long time. A significant number of people commence smoking before they reach the age of 18 years. While it is more difficult to encourage smokers to stop, it is only right that we discourage people, particularly younger people, from taking it up. For several years there has been an increase in the number of young girls who are smoking. While it may have levelled off, it needs to be monitored to ensure the legislation put in place and the information made available has an effect.

On the prescription charge which medical card patients must pay, it was introduced at a time when people in Ireland were consuming more medication per head of population than in any other European country. In 2000 the State’s annual bill for medications was €500 million; it is now over €2 billion. There may be cases of people receiving medication under the medical card scheme and not using them. It might be interesting for the Department or the HSE to carry out some research on the effect of the prescription charge in the acquiring of medication. From what I understand, it has had an effect. Should the limit be increased to take into account the fact that older people require more support? More research needs to carried out. We need to get the message across that drugs should be used effectively. Will we end up in a situation several years from now where, no matter what drug is prescribed, they will have no medical effect? It is a growing problem, particularly in the United States.

I welcome the legislation as it amends key legislative provisions. It is important that it be progressed to ensure it will come into effect as soon as possible.

Maire Devine (Sinn Fein)
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I welcome the Bill on several fronts. Obviously, the most important aspect of it is the Part which refers to the plain packaging of tobacco and the potential health benefits this amendment can deliver. Ireland has been a world leader in enacting progressive legislation to reduce tobacco consumption. This is certainly another measure that will continue that strategy.

This legislation has been called for by many public health organisations for many years, including the Irish Cancer Society, the Irish Heart Foundation and ASH Ireland, among others. Sinn Féin gives its absolute support to the legislation. Its wish is for it to pass through the House and be signed into law without delay. We are all too aware of how intensively the unscrupulous global tobacco companies lobby to protect their interests. It is admirable that such a firm line has been and is being taken by the Government to enact this legislation. It would be remiss of me, however, when talking about this issue not to reference another extremely important public health Act that is currently working its way through this House and hopefully will come before us soon, namely, the Public Health (Alcohol) Bill 2015. The same firm and principled line needs to be taken in respect of the intrusive lobby being instigated by global alcohol firms. We have been world leaders in advancing progressive public health legislation to reduce tobacco consumption. Let us treat the alcohol industry in the same manner in the interest of our health and the health of our future generations. The Minister of State will have Sinn Féin's firm support in this manner in both instances.

Getting back to standardised packaging, I see it as imperative that we deal with this legislation in as timely a fashion as possible. Plain packaging is shown to reduce the appeal of tobacco products, increase the effectiveness of health warnings, reduce the ability of profiteering companies to mislead the public about the effects of smoking and bring consumption down. It also ties in with the idea of visibility in the Public Health (Alcohol) Bill 2015. We know young children can name the brands of popular beer, with this measure they would hopefully not be able to recognise the name of the most popular brands of cigarettes.

One of the biggest threats to this type of legislation and indeed the Public Health (Alcohol) Bill 2015 is the possible ratification of global trade deals such as the Transatlantic Trade and Investment Partnership, TTIP, and the Comprehensive Economic and Trade Agreement, CETA, by this Government. Little thought is given to the ramifications that this legislation can embed. I specifically refer to the international state dispute mechanism, ISDS, contained as part of these deals. Provision is given to global companies to sue governments when, in their greedy eyes, inhibitive legislation prevents them making profit. These deals are wrong, against public interest and should be resisted by all well meaning parties to put people and our society first. Sinn Féin will certainly continue to lead the fight against these backroom deals and keep informing the public of their ills.

With relation to the general medical services scheme, GMS, and prescriptions aspects of the Bill, I would first like to outline Sinn Féin’s firm recognition of the importance of ensuring that over-the-counter medicines continue to be available under the GMS and community drug schemes. Public health and affordability of such medicines is our primary objective. Prescription fees continue to push many ill citizens beyond the poverty barrier and leave them choosing between essential food on the table or accessing their medicines. Sinn Féin wants to see these fees abolished in full over a measured timeframe. In the meantime, some medicines that are currently dispensed on a prescription basis could be switched to a non-prescription basis. The Health Products Regulatory Authority, HPRA, regulates these medicines and we would again request this authority to review which drugs could be transferred to a non-prescription footing. This would immediately cease fees on certain medicines for struggling families and individuals.

I would urge a certain caution, however, in the whole area of prescription and non-prescription drugs. This week RTE aired an extremely thought-provoking documentary on over-the-counter drug consumption. I am particularly cognisant of prescriptions for persons who present to GPs with mental health issues. At recent dual diagnosis conferences, held throughout the Thirty-two Counties and hosted by Sinn Féin, I was taken by the comments from the consultant psychiatrist in the HSE. What he said is well known, and we need to educate people about this. He said that short-term prescriptions work, but in the long-term they will do more damage and become addictive. Education is the key here and we need to roll that out nationwide. We should always remember that drugs, prescription or otherwise, are poisons and their overuse will have detrimental health repercussions.

The fair deal scheme has had public attention recently for all the wrong reasons. In my health statement last week I referred to the comments of the senior HSE management towards elderly patients, suggesting that they were taking up hospital beds to protect their finances, and I again want to outline my disgust at this uncompassionate and untrue statement. Getting away from that, the exclusion of funds received through the Magdalen laundries, Lourdes hospital and symphysiotomy schemes as financial means for accessing nursing home care is extremely welcome. It is a caring, compassionate and, dare I say, republican thing to do. It is the right thing to do for citizens who have suffered so much in our past.

As a party which promotes the interests of workers' rights, we absolutely respect the right to a fair day's pay for a fair day's work. Therefore, we do not have any issue with board members of the HPRA receiving remuneration for work carried out on behalf of the authority. We would just ask that in light of many controversies uncovered over recent years with public agency bodies and funds, transparent oversight procedures are put in place to manage the payment of such moneys. I acknowledge also that one person, one salary will apply and that approximately half of the existing members would be subject to this principle.

To conclude, certainly from my viewpoint, the most important change as part of this legislation is the plain packaging of tobacco products. I would like us to follow the strategy of Finland which recently announced that it aims to have the country tobacco free by 2040. The Minister of State has said a generation, which I believe is approximately 25 years, but it could happen in a generation if we put our minds to it. This would require further measures similar to those in Finland, such as increasing the price, introducing licences with a cost for sellers, banning of advertising, health promotion measures and limiting the public spaces and areas where smoking can take place. I know the Minister of State will be taking on the wrath of more corporations and probably thinks there is enough to do with the Public Health (Alcohol) Bill 2015, but she will be practised and well-rehearsed at that, so I encourage her to go for it.

My final words will be on the Public Health (Alcohol) Bill 2015. It is the next public health measure that we need to emphasise to improve our nation's health. I again encourage all Senators in this House to do what is right by the people and not what is right for the corporate interest. I applaud the Minister of State. Go raibh maith agat.

Alice-Mary Higgins (Independent)
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I will be very brief. I welcome the Minister of State to the House. I commend the legislation, which we are very supportive of. It addresses a number of important key issues. I particularly welcome the measures taken in respect of those who have been identified under the thalidomide scheme, the Lourdes hospital payments scheme, the symphysiotomy scheme and of women who were residents of certain institutions. I have a number of concerns about the symphysiotomy scheme overall and how it has been administered but that is not a matter for today.

Today we should recognise a positive gesture in terms of access to the fair deal scheme. There are, however, two wider issues that need to be pointed out. First, what measures or information schemes are there to ensure people are made aware of this measure and aware of some of the other specific things included and covered in their scheme? I know there has been concern in the past about women who have been eligible for previous schemes and who are now living abroad but who may potentially be thinking about returning to Ireland to retire. Many such women and their families may be currently resident in the UK and elsewhere. What plans are there to ensure awareness of this measure and of the other supports and social protection provisions that can be accessed by such women?

I would also really like to point out that, while this Bill identifies specific schemes, we need to look to a wider principle. Over the next year I hope to work with others across the House to consider some of the wider principles of redress and how we engage in redress or restorative justice for institutional violence or wrongs of various forms. This Bill is an example of the kind of good practice that we would want to include in that, along with other important principles, such as really re-examining the use of waivers as we currently have them and the principle of first person testimony and how it is reflected. I welcome this very much.

I welcome discussion on the pricing and supply of medical goods. Particular concern has been highlighted with regard to the morning after pill and emergency contraception. I am aware that it is something the Minister of State's colleague, Deputy Kate O'Connell, has raised and championed at various points. As a pharmacist, she understands the issue very well. I am also aware that there are groups, including a very good and vibrant campaigning group called Real-Productive Health, which have really sought to put this on the agenda. I may table amendments to the Bill to move this issue a little further along, but I am not sure if I will. The Minister of State spoke to it earlier, but could she clarify exactly if it is now the case that over-the-counter drugs will definitely be available without a prescription to medical card holders?While it is available without a prescription, I suggest that medical card holders would be able to get it on the medical card scheme without a doctor's prescription. Obtaining a doctor's prescription is a considerable problem with a time-sensitive issue and requires securing a doctor's appointment and getting the consultation. It causes serious concern and with respect, I suggest that the fact that 12,000 people may have used it and achieved a prescription is not an indication that there are no obstacles. We only know that 12,000 people have got a prescription. We do not know how many may have found themselves delayed from accessing it, whether it was 5,000, 4,000 or 10,000, and because of our laws in other areas we do not know what the consequences might be and we have no way of measuring those who did not access emergency contraception and who dealt with the consequences of that in whatever way. That is information we do not have.

Many, including me, believe there are real problems with the conscientious objection clause as it is currently operating where pharmacists are concerned. As the Minister of State rightly said, this is the pharmaceutical industry's own administration. It is something which we have lobbied them about in the past. There are concerns which relate to the State, including whether the alternate provisions, which are being recommended by those pharmacists who are exercising that objection, are adequate. Perhaps we need to have an examination of whether alternate provisions are feasible. In rural areas, do they reflect the transport constraints, particularly on weekends?

Another concern I have in that regard arises on Sundays in rural areas in particular. While pharmacists have a Sunday rota in some parts of the country to ensure a pharmacist is always available, that is not the case in other parts of the country. This is something on which I might consider an amendment or the Minister of State might tell me of other ways in which the introduction of a Sunday rota system might be addressed. Again, I would like to welcome that and seek a little more clarification on how the Minister of State envisages this fitting in with the other provisions mentioned that are being considered by the Minister, Deputy Harris, to increase and support access to these vital and time-sensitive measures.

My last point is on the regulation and setting of a standardised maximum price. We know that with emergency contraception, the price of the same drug can vary from €25 up to €70. These are amounts which are not readily available to many of our citizens and certainly not necessarily readily available within a matter of hours. The Minister of State might let us know what she is thinking in terms of the standardised maximum pricing and how to address the case of medical card holders.

I want to echo others in giving my full-hearted support - and I believe that of the rest of our group - to plain packaging and these important measures on plain packaging. I again raise the question, as others have, of the Public Health (Alcohol) Bill 2015 as the matter of plain packaging underscores the question of the power of suggestion, advertisement and visibility. It is a reminder to us that persistent suggestion, which we have in many cases in our lives, including the easy visibility of alcohol products in spaces such as grocery stores, is an issue and a concern. It underscores all the evidence which shows the power of that suggestion and I will conclude by stating I support it. We also will provide strong support to the Minister of State on the Public Health (Alcohol) Bill 2015. I urge that we move expeditiously through this because I share the same concerns regarding the Comprehensive Economic and Trade Agreement. If we move towards its full implementation, we will leave ourselves open and regulation is now imperative because unfortunately, new regulation will face new obstacles and new threats in the future.

Jerry Buttimer (Fine Gael)
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I welcome the Minister of State to the House and commend her on the role she is playing in respect of her health promotion portfolio.

In the context of this Bill, it is important to focus predominantly on the issue of health promotion. I refer to and agree with the point Senator Colm Burke raised on prescription drug costs and the charge being allocated or ascribed to medical card patients. At a time when our population is getting older, is living longer and is in need of more complex and varied health care and medical intervention and given the economy is now more prosperous, through her good offices with the Minister, Deputy Harris, the Minister of State might consider how we could improve this section because Senator Burke is right. While the issue of over the counter and prescription drugs was raised on "Prime Time", we did not need such a programme to know we probably are a nation that is oversubscribing to prescriptions and to painkillers. That is a matter on which we also might have a debate in the House in order that we can have a holistic approach to it.

I wish to speak today on the issue of health promotion. There is an expectation and a view taken by some that it is up to the State or others to bring about behavioural change, be that in tackling obesity, on the issue of tobacco or on the issue of alcohol. There is a combined approach to be taken by the individual person in tandem with family, community, Government and so on. I note "Operation Transformation" is appearing on our television screens at present. As the Minister of State noted in her contribution, it provides a six-week window in which people focus on changing bad diets. It is not a fad or a six-week programme but is a life-changing experience that we need to promote and pursue. We have seen the significant impact that Tobacco Free Ireland has brought and I refer to Deputy Micheál Martin's smoking ban, Senator James Reilly's banning of smoking in cars and in playgrounds and the overarching plain packaging proposals to make Ireland tobacco free.

I listened to Senator Devine speaking about powerful industry lobbyists. I assure her that as a Member of this Seanad and a former Chairman of the Oireachtas Joint Committee on Health and Children, industry does not play any role in how I make my decision.

Maire Devine (Sinn Fein)
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Lucky you.

Jerry Buttimer (Fine Gael)
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The health of our nation will be well supported by the issue of the Public Health (Alcohol) Bill 2015. I hope that Bill will return and will be passed. As a nation, we have a relationship with alcohol that needs to be changed and addressed. There is the issue of the price of alcohol and we all support minimum unit pricing. At least I hope Sinn Féin will support it since they had a minority report in the report from the Joint Committee on Health and Children two years ago. There is the issue of how we make alcohol available, price it and promote it. We also have an issue with availability. The abolition of the groceries order by Deputy Micheál Martin was a huge mistake because alcohol is now to be found in shops, petrol stations and forecourts. I visited the United States before Christmas and in certain states, one could walk into supermarkets with no alcohol in them, which is good. Obviously we are not going to go back to that but I am just making the point.

The other point we need to consider, which is arising frequently in my office is the issue of the fair deal scheme and how we can make it accessible. If we can tweak it any more, it would be important to do that. As a former Chairman of the Committee on Health and Children, I had the huge pleasure - I use that word deliberately - of dealing with the Irish Medicines Board, now the Health Products Regulatory Authority. The people who worked there and who appeared before our committee were of the highest calibre.

I listened to Senator Higgins's remarks on the whole issue of regulation. We need regulation and to have a robust, strict regulatory regime regarding medicines and medical devices. That is my worry in the context of the new regime in America and the new President. If one listens back to his remarks with leaders of business, he spoke about the cost of medicine the other day at a press briefing. We cannot allow a situation to happen where regulation is diminished in the areas of medicines, products and devices. The Minister of State is doing a wonderful job and is really setting a high standard for other Ministers in terms of health promotion. I will make one final appeal on the issue of vaccination and vaccines.As a nation, we need to be proactive, whether it is on the flu jab, the HPV vaccine or whatever. There is a job of work for the Minister of State in association with others in the health promotion areas of the HSE and the Oireachtas. There is a great deal of misinformation out there and populism is rising. We have a job to do to counteract that and to address some of the concerns people have in a real and tangible way.

Trevor Ó Clochartaigh (Sinn Fein)
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Cuirim fáilte roimh an Aire Stáit. Ós rud é nach dóigh liom go bhfaca mé í ón uair gur ceapadh í mar Aire Stáit, ba mhaith liom comhghairdeas a ghabháil léi. Cuireann mé féin agus Sinn Féin fáilte roimh an mBille seo, go háirithe na forálacha a bhaineann le pacáistiú tobac. Cé go bhfuil an reachtaíocht seo le moladh as an méid a bhfuil ann, léiríonn sí an méid atá fós le déanamh sa chóras sláinte. While this is welcome legislation, it is clear more legislation is required to tackle the worst of our health problems. I note there are six distinct parts of this Bill, many of which are designed to close off loopholes or remedy anomalies in the system at present. Unfortunately, there are many other anomalies in the working out of health services, which need to be addressed. Perhaps it is something that will be taken on board through the next Stages of the Bill.

One such anomaly is the issue in the west where people presenting with acute alcoholism are not entitled to care based on that alone. GPs are no longer able to refer patients with an alcohol addiction to the HSE services unless they have been diagnosed with a co-morbid mental health illness. This meant that over Christmas, people were being turned away from the present services, which is a totally unsatisfactory situation. This was communicated before Christmas in a HSE west e-mail to the service providers. Galway has a population of 75,000 people but only one full-time and one part-time counsellor for adult problem drinkers. Waterford, in comparison, has a population of 47,000 but five counsellors for drinkers, as well as one outreach worker and a number of other personnel.

Turning to the hospital situation, a sick relative of Sinn Féin Councillor Gabriel Cronnelly was admitted to University Hospital Galway, UHG, over the weekend. He was admitted on Friday evening with an illness and was not placed in a bed until 9.30 p.m. on Saturday evening. At the same time, there were 43 people on trolleys in the same hospital. I take on board what has been said about health awareness and making people aware of the situation but the fact of the matter is the primary health care services are in dire need of more resources in areas like Connemara. Those primary health care centres need to be fully staffed and rolled out properly. Cuts are being experienced to basic services such as that of the physiotherapist in Connemara, who has not been replaced. People are being brought into the acute system because of issues in the primary care system.

I attended the hospital in Galway recently for a minor situation and the staff there were absolutely brilliant. Without the professionalism and compassion of the hospital staff who do their utmost to put patients on trolleys at ease as best they can, there would be a revolution. As of this morning, there are 35 people on trolleys in the same hospital. Doctors and nurses are not only holding the health service together, they are effectively ameliorating the worst effects of Government neglect through their care. This is something we need to come back to. I call on the Minister of State to implore the senior Minister to have a look at the hospital situation in Galway. I have stated a feasibility study is needed into the need for a new hospital-----

Paul Coghlan (Fine Gael)
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It is not relevant to the Bill.

Trevor Ó Clochartaigh (Sinn Fein)
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It is the Health (Miscellaneous Provisions) Bill and I am suggesting there may be other issues that could be brought on board on Committee Stage.

Colm Burke (Fine Gael)
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It is not relevant to the Bill.

Paul Coghlan (Fine Gael)
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The Senator has five minutes. I will not interrupt him further.

Trevor Ó Clochartaigh (Sinn Fein)
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I understand why the Senators opposite might want to stifle debate around these issues because they are very embarrassed about them. What would be quite useful-----

Colm Burke (Fine Gael)
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The Senator should stick to what is on the agenda.

Trevor Ó Clochartaigh (Sinn Fein)
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-----is instead of announcing------

Paul Coghlan (Fine Gael)
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Order, please.

Trevor Ó Clochartaigh (Sinn Fein)
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-----that the Minister will be coming to visit UHG-----

Paul Coghlan (Fine Gael)
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Order now. Senator Ó Clochartaigh, without interruption.

Trevor Ó Clochartaigh (Sinn Fein)
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Instead of announcing that the senior Minister or the Taoiseach will visit UHG, they should come unannounced and see what things are like on an ordinary day. UHG has lists of more than 30,000 outpatients awaiting appointments, of whom 4,700 or more have been waiting for more than 12 months.

I have another issue, which I am not sure can be addressed in this Bill, but is something the Minister of State might consider. I understand there is a working group on the fair deal programme, which is looking at an issue that particularly affects farmers. The Minister of State is from an agricultural background and is very aware of farming issues. Assets of the farm are being used in the calculation of the fair deal package. It was raised with me yesterday at the farmer's protest that a working group is supposed to be looking into this and coming up with a solution. Perhaps this miscellaneous provisions Bill will be an opportunity to address this anomaly and the Minister of State might revert to us and let us know whether that working group has come to a conclusion on how to address those issues. It would seem to be the right thing to do because there are reports that farmers' land is causing an issue where it is not really an asset when they are running a farm at a loss. It is an issue of which I am sure the Minister of State is aware. There was also a highly insulting claim about this issue in an internal e-mail that farming families were leaving relatives on hospital beds to avoid any financial penalties they may suffer under the fair deal scheme. I hope that reported action will happen and that this anomaly can be remedied. Let us not forget the average farm family income is €26,000.

I welcome the drug reimbursement aspect of the Bill. I draw attention to the fact that the HSE has failed to reach an agreement on the Orkambi drug for cystic fibrosis sufferers. An initial figure offered by the drugs company Vertex was €159,000 per patient. The HSE estimated this would cost the State €400 million over three years. This is obviously a big figure and we hope this can be resolved. The Minister of State should take on board some of my suggestions. It might be something the Minister of State can address in the Bill on Committee Stage. I hope the Minister of State takes the suggestions I am making in a positive light and will come back to us on Committee Stage with any suggestions she has.

Marcella Corcoran Kennedy (Offaly, Fine Gael)
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I thank the Senators for their contributions to the Second Stage debate on the Health (Miscellaneous Provisions) Bill. The provisions in this Bill will allay the fears of the recipients of the ex gratiaawards that have been approved by Government. It would be most unfair if people who receive such an award were then disadvantaged in their financial assessment for support under the nursing home support scheme by virtue of receiving an award. I hope this will give peace of mind to the individuals concerned and their families.

Some raised the question regarding medical cards. The Bill today makes proposals on the amendment of the Nursing Homes Support Scheme Act 2009 or the fair deal scheme and accordingly it does not relate to the eligibility for medical cards. I assure Senators that where questions have been asked that were not relevant to the Bill, I will bring the message to the Minister and the Health Service Executive, which is the relevant body, and we can ensure Senators' opinions are carried to the right areas. On the issue of support for accessing services by women who have had a symphysiotomy, services for them are facilitated by symphysiotomy liaison officers, who are based around the country and the provision of a medical card is included in that. I hope that provides some clarity.

With regard to public health, it is important to remind ourselves why tobacco control measures like this one are so important. A total of 23% of Irish people are daily and occasional smokers and 8% of our ten to 17 year olds smoke. While the reduction in these figures over the past number of years is significant and welcome, we are a long way from reaching our 5% prevalence rate set out in our Tobacco Free Ireland policy. Nearly 6,000 Irish people are killed annually by smoking. The human cost of smoking in Ireland today is overwhelming. In the Tobacco Free Ireland policy, we aim to be tobacco free by 2020. The minimum rate is a 5% prevalence rate, which is set out in that policy.

Less important but still significant is the economic cost of smoking in Ireland. Annual health care costs associated with it are €506 million; lost productivity costs are €1 billion and the cost of litter associated with smoking is €69 million. This economic assessment undertaken on behalf of the Department of Health also estimates the costs associated with the deterioration in an individual's ability to live a full life. The value of loss associated with this deterioration has been estimated as being more than €9 billion annually. These costs are very significant and show how reducing smoking in Ireland can both improve the health and well-being of the people and reduce the cost to taxpayers in dealing with the impact of smoking in the longer term. While work must continue on reducing smoking rates, we can be proud of what we have achieved over the past couple of decades.I refer to such measures as the introduction of the workplace smoking ban in 2004, the ban on point-of-sale display and advertising in 2009, picture warnings in 2013 and the ban on smoking in cars in which children were present in 2016. These measures have contributed to increasing awareness and reducing the harm caused in Ireland by tobacco, but we will not and cannot stop there. Standardised packaging is the subject of one of a number of recommendations set out in Tobacco Free Ireland. I am committed to ensuring we will continue to implement this policy to ensure our children and our children's children will get to experience a tobacco-free Ireland. I ask all Senators to support not only the standardised packaging measure being discussed but all future tobacco control measures implemented by my colleague, the Minister, Deputy Simon Harris, and me.

The provision included in the Bill to amend the Health (Pricing and Supply of Medical Goods) Act 2013 is also intended to benefit the health of the population. It provides that, when considered appropriate in the interests of patient safety or public health, over-the-counter medicines can continue to be reimbursed for medical card holders after May 2018. This means that products such as nicotine replacement products and emergency contraception can continue to be provided under the medical card scheme. The amendment to the Irish Medicines Board Act 1995 will allow the payment of fees to members of the Health Products Regulatory Authority in line with the arrangements made in other boards in order to continue to attract experts of the highest calibre to apply for board membership at no additional cost to the taxpayer.

I thank Senators for their valuable contributions on Second Stage and look forward to further constructive examination of the Bill on Committee Stage. I reiterate that the relevant points that will not be dealt with in this legislation will be taken on board and conveyed to the Minister and the Health Service Executive.

Paul Coghlan (Fine Gael)
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When is it proposed to take Committee Stage?

Colm Burke (Fine Gael)
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Next Tuesday.

Paul Coghlan (Fine Gael)
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Is that agreed? Agreed.