Leaders' Questions (Resumed)

This week, a harrowing documentary about the medical gaslighting of women was broadcast by Virgin Media. It featured women who spent years in excruciating pain before eventually being diagnosed with conditions like endometriosis and premenstrual dysphoric disorder, PMDD. It featured women whose incredibly serious and debilitating healthcare concerns were repeatedly dismissed or minimised by doctors and women who had to travel abroad for surgery for endometriosis because the specialist care is just not available here. It is shameful that a country as wealthy as Ireland is still exporting so many women for essential healthcare. It is estimated that one in seven women in Ireland have endometriosis. That is 300,000 women and yet, many in the medical profession seem to have barely heard of it. How else can we explain why it takes a woman an average of 14 years to get a diagnosis? That is 14 years of not being listened to, 14 years of being patronised, 14 years of missed diagnoses and 14 years of pain, trauma and fear with hugely negative impacts on the lives of tens of thousands of women and girls all over the country. I acknowledge the Minister has invested in women's healthcare and in endometriosis care specifically but we were at such a low base that any level of funding at this stage is just a drop in the ocean of what is required. The wraparound and surgical services that are needed are often simply not there when women eventually get a diagnosis. "Prime Time" recently featured a doctor, Dr. Rachel O'Connor, who was forced to take out an enormous loan and travel to Poland for her surgery. She was told if she had not had that surgery, she would have died. This lifesaving treatment is currently being denied to many women in Ireland. The other related issue is the medical gaslighting women routinely experience. Women are told the agonising pain they are in is all in their heads. Women are told they are just hormonal or experiencing anxiety. Women are talked down to and patronised by too many medics. My colleague, Senator Patricia Stephenson, has done a huge amount of work in this area and she has a proposal she is hoping the Minister will take on. If any woman presents with the same symptoms three times in any 12-month period, her GP should reflect, review and rethink the case. The GP should reflect on what the patient is saying, review her symptoms and rethink by referring the patient, where appropriate, for specialist tests. This is guidance that was taken onboard in the UK in 2025. It is called Jess' Rule, named after a 27-year-old woman who unfortunately lost her life from cancer despite many consultations. There really is no reason why this guidance should not be rolled out here. What will the Minister do to ensure women are not forced to travel abroad for lifesaving endometriosis care? Is she concerned about medical gaslighting for women? Will she introduce the three point guidance for GPs to reflect, review and rethink when women repeatedly present with the same or worsening unexplained symptoms?

I thank the Deputy for raising this really important issue. Let me answer them in a slightly different order. On medical gaslighting and how women are treated, let me completely acknowledge what the Deputy is saying. Let me completely acknowledge women have been treated differently in the medical system and that research that was done on men is applied to women in circumstances where that is not necessarily true. Let me bring in another area, heart failure, where women's presentation of heart failure is materially different to men. Let me compliment the work of Ken McDonald and the Irish Heart Foundation who have tried to drive awareness about this. We have a programme called Her Heart Matters which tries to identify that this is very different. That is a different example but another example of how medical presentation is different. I thank Senator Stephenson for the work she has done. We have invested €2 million for the first time into research in women's health through the Health Research Board. I will ask it to connect with the Senator on the work she has done and see how that fits in with the broader pieces of academic research that are being done to try to advance women's healthcare more specifically. Deputy Whitmore raised endometriosis as her third point and she is so very right. She is so very right that the starting point was so low. How many women have I spoken to who have been suffering for 20, 25 and 30 years with chronic pain, not being understood, having to leave work, having a completely different fertility experience and having a totally different family life? I compliment the Deputy on her work and Sinn Féin on its work along with Labour. Everybody has raised this in different ways but that is why I brought women with endometriosis into the Department of Health on 1 September last year so we could hear directly from them and from their experience. We did it again in March. The most heartbreaking thing for me that day was looking at two young girls in their school uniforms who were already suffering debilitating pain as a consequence of endometriosis, which is not spoken about enough. As a consequence, the CEO of the HSE and I wrote to every single GP to try to raise awareness that this impacts one in seven women. That is one in seven women, not one in seven people. It affects one in seven women and it is so important because this is so impactful. We introduced a programme to try to fund emergency surgeries abroad because it is a shame on me and everybody else that a doctor in our health system used her HSE salary and a loan to get emergency surgery in a different jurisdiction. We have to fund that on an emergency two-year basis, but we are trying to develop the longer term surgical pathways. We have developed relationships with a specialist clinic in Bordeaux. We have developed a programme where our surgeons are training abroad, and we will have a continual series of fellowships for surgical training and endometriosis so that we never end up in this situation again. Meanwhile, we are trying to recruit specialists as best we can, such as colorectal surgeons to work alongside gynaecological surgeons. I visited one of the super-regional centres in Tallaght, where a new surgeon is doing incredible robotics surgery. However, the Deputy is right; the crisis for women is now and they need those surgeries. We are trying both to address the immediate need by funding emergency surgeries abroad, and to develop a longer term pipeline. I know as well as every single other person here how much more we have to do on that. However, in the last 12 months, we have been on a different pathway, in terms of both awareness and care.

I thank the Minister for her response. It is clear she is passionate about this area, but I am afraid we are not moving quickly enough with this. Last October, the Minister announced €16 million in funding for endometriosis care and 65.5 new staff. As of September, only one of those staff was in place, according to a parliamentary question response I got in September, with one more being onboarded. There is still a huge way to go. I can understand why as an emergency measure women have to go overseas because we do not have the capacity here, but women in Ireland are so sick and tired of being exported every single time our health service is not able to meet our needs. The first response we are given is to send us abroad. It is not the way to treat people, to take them away from their jobs, homes, communities and families. It is costly, it is stressful and there are language barriers. We need to be able to treat these women here. I also think a cultural shift is needed in the healthcare system. Women need to be listened to and believed, and our medics need to be trained to support them. This is very important, and that cultural shift has to come from the Government.

That is one of the reasons we made a presumptive diagnosis in the framework for endometriosis, so that the woman did not have to prove it and would be believed and listened to. Women are the best narrators of their own experience. The cultural shift is really important. We have employed MISE, phenomenal advocates for endometriosis, to go into schools, workplaces and maybe the Oireachtas to talk about endometriosis and its impact. The Deputy is right; we do not want to send women abroad. I want them to get surgeries here, which is why I demanded that an additional 100 surgeries happen in that last quarter of last year to meet some of the need. We did 142, but that is not enough. There is still a need for specialist services. If I have a choice between funding a woman to go abroad or her not getting that surgery in Ireland, of course we are going to facilitate her going abroad to make sure she gets the type of specialist surgery we are trying to build towards. We have also placed a level of priority on this whereby we will have an EU Presidency conference on 3 December to shine a light on this, because it is not just Ireland's problem. It is Germany's problem and France's problem. This is under-researched, underdiagnosed and undertreated right across Europe. On St. Patrick's Day, I visited a specialist clinic in Germany with the German health minister, again to shine a light on the issue. Even through the EU Presidency, we are placing a focus on endometriosis, which is necessary.

Earlier this year, the Minister wrote in the HSE national service plan that we were to get rigorous oversight and transparent reporting over HSE funding. This was to be the year of no supplementary budgets, the year when agency spend was going to go down, not up. How is it then that ten months later, the Minister and this Government are about to record the second largest deficit in the history of our health service, a deficit with very real and potentially deadly consequences for patient safety on the ground? We have heard from Cork with regard to CT scanners lying idle because of a lack of sanctioned staff. We know the national neonatal transport service, NNTP, carrying the most fragile and vulnerable babies across our country has been threatened because of a lack of sanctioned maternity cover. We hear from Limerick and Naas that they are terrified of what is in store and what is going to happen this winter. At the heart of this crisis, the Minister, her Department and the Department of public expenditure and reform are failing to plan. Fail to prepare, prepare to fail, as Roy Keane memorably told us 24 years ago. That is exactly what is happening now. The Government's budget is based on a 2% demographic growth, yet we are seeing actual demand in the health service far outpace that. Emergency department, ED, admissions are up 6.75% this year, general admissions are up 3.5% and there was a 10% increase in outpatient waiting lists last year. I have replies to parliamentary questions from the HSE telling me it is forecasting demand for next year only now, after it has got its budget allocation. No wonder the health service is in crisis. No commercially viable business would ever operate like that, so why does the Government make the HSE, with a budget of €29 billion, operate like that? It is a complete nonsense. If we are to understand the pressure hospitals are under, we should look at the reliance on surge capacity before winter kicks in. I have HSE internal documents which show the south west was relying on 88% more surge beds at the start of October than at the same time last year. In the west and north west, it is 51% higher; in Dublin and south, it is 50%; and winter has yet to come. This is terrifying, and God forbid there is a flu or any other major health event. There are two fundamental issues here: how you plan and, crucially, how you respond when your plan goes wrong. The response by the Government and the Department speaks volumes. We all know agency staff are more expensive than those directly employed, yet when I look at the internal HSE cost and productivity report, we see direct pay is being suppressed. It is €133 million under what is budgeted to the start of October, yet agency is surging ahead by €255 million. All that is taking place alongside an embargo on recruiting graduates. It makes no sense. Then we look at community services. We are all about ensuring more investment in community services to keep people out of hospitals, yet that is where the cutbacks are happening - cutbacks to one-on-one top-up care in nursing homes - and those patients will end up back in hospital. Will the Minister commit to employing those nursing and other health professional graduates who were told they would have jobs in the health service and are desperately needed? Will she commit to a supplementary budget beyond what is needed for drugs? What is she going to do to end the fanciful, flawed budget-making that is taking place every single year within the Department, which ensures we are underproviding for our health service year after year?

In the first instance, it is completely predictable that nurses will graduate every year. That is what we want. The State invests in training our nurses and we want them to stay in Ireland. More nurses are staying in Ireland than we have ever seen before, according to the NMBI, not me, and we want them to stay. Some 83% of graduate nurses this year have been offered positions, which is what should happen. It is incumbent on every regional executive officer to plan strategically for their recruitment for the following year. They got a budget uplift of 6% last year and 6% this year, higher than other parts of the Government, and they have an obligation to plan every year for what is known, such as things that are going to open. These include new community nursing beds, a surgical hub and the fact graduate nurses will come on stream and be available to work in the system. These are things that are planned. This year, with the NSP, I am requiring a strategic recruitment plan from each region to show, as HSE Dublin and North East is well able to do, how recruitment is going to be used each year. The Deputy mentioned a CT scanner in Cork. I go back to the fact Cork University Hospital has hired 233 people. Why has it not prioritised resources for that CT scanner? Beaumont has. I went into Beaumont one Saturday morning and there were 60 people in the emergency department. Six or seven of them needed a CT scan. I went in and saw a CT scanner that was not being used. The lights were turned off. It was a brand new investment not being used. The region recognised the problem and prioritised investment and resources to make that CT operational, which it now is. It is about strategic, intelligent decision-making by everybody. It cannot just be about growth. The health budget has doubled in ten years, and in the last five years, we have had a 52% increase in taxpayers' money going into the health system. There has been a 33% increase in the number of people working in the health system, but only a 16% increase in the actual activity in the health system, including when accounting for complexity. The most expensive part of healthcare are inpatient day cases, not emergency departments. Activity there has increased by only 2%, notwithstanding a budget increase of 6%. We plan based on demographics; that is what we do. We plan to grow based on demographics, because we have already invested in so many people but we are not using them in the correct way. We have not been using the integration that should happen in all the different regions. I have demonstrated this repeatedly throughout the year when talking about Mallow and CUH, but I see it happening in other regions, particularly HSE Dublin and North East, where that integration has been much more successfully achieved and where recruitment has been strategic and planned. It is important now that the Oireachtas see where the strategic recruitment plan is for next year. It is important now that everybody has transparency, including the REOs, about how they will use the additional 3,000 people that may go into the health system next year, on top of the 3,000 that went in this year. That 3,000 was contingent on reducing agency spend and overtime by reorganisation, redeployment and making better use of resources. That has to happen, too.

I think we are in parallel universes here. Directors of hospitals tell me they are being blocked from recruiting their graduate nurses, and the Minister is saying something very different. We need to get the truth. The Minister talks about demographic growth but she has not mentioned once the rising complexity of care within our health system, which is driving the increase in admissions and the issues within our hospitals. The reality is we have a serious crisis in our hospitals right now with regard to delayed transfers of care. For about 215 days this year, we have seen over 500 people stuck in hospitals. They no longer need to be there but have nowhere else to go, and the Government has no answer to that. I do not use names lightly but I am thinking about a man today, Christy Murphy. He is in a nursing home because of the benefit of one-on-one care through the HSE. He was in St. James's Hospital for many months because they could not find a nursing home for him and then they found a nursing home in Finglas. The family, who are from Dún Laoghaire, are so grateful but they have been told that the one-on-one care has been pulled and that patient will end up back in St. James's Hospital. That is wrong. I am hearing nothing from the Minister about prioritising community care and ensuring we get people out of our hospitals when they no longer need to be there, and ensuring that those graduates are actually recruited.

It is so important to prioritise community care, which is why the challenge in here is articulated in terms of acute hospitals and not always in terms of community care. Let us look at that because the acutes have always pulled from community, as the Deputy is aware, but the resources need to go into community. That is why we are trying to focus on making sure there are beds going into model 2 hospitals like Mallow and Bantry. The Minister of State, Deputy Kieran O'Donnell, opened a community nursing unit with 50 beds in Midleton last week, an area the Deputy is very familiar with. We will be opening community nursing units in Donegal and Kerry for the same purpose. All of these are facilities to try to get people out of the hospital, and that investment is just as important. What I find challenging is the conflict between the articulation that hospitals need more money but we also need to get people out. When we put money into other hospitals and facilities, they have to be used. Those beds cannot lie idle. People need to move out of those hospitals, so it has to be both. However, it also has to be articulated as both. It cannot always be more money for CUH but not recognising how much has gone into that region. I am thinking of Mallow, Bantry, the South Infirmary beds, the additional private beds and the new community nursing unit. It has to be everything, and it has to be articulated that way too.

Recently, I was shocked to see a bizarre advertisement on the issue of consent, funded by the Department of justice. The advertisement featured an elderly couple greeting their grandchildren with a hug at a family event and suggests that they, the grandparents, should have sought consent first. This is totally wrong in how it demonises elderly grandparents and in the shocking waste of taxpayers' money. Consent is very important when it comes to sexual relations between people. However, equating these types of relationships, with a granny giving a hug to a grandchild is completely inaccurate. It is wrong to conflate these two issues of sexual violence, on the one hand, and affection exchanged by a grandmother to a grandchild, on the other. Why is the State asking grannies to second-guess themselves when it comes to hugging their grandchildren? Why is the State planting a seed in a child's mind that it is somehow dangerous to receive a hug from their grandmother? Grandparents do a tremendous job in this country. They have raised one generation and, in many cases, they are helping with childcare for the next generation. Why is the State in this space at all? This is family relationships. It is not a criminal issue either, and it represents an incredible overreach by the State into the private lives of our citizens. It is not sinister for a grandparent to greet their grandchild with a hug at a family event. During the Covid years, we saw how grandparents were deprived of contact with their grandchildren. We know from Alone and many other organisations that loneliness has such a tremendously damaging impact on grandparents, the elderly and senior citizens. It is bad for mental and bad physical health. How much taxpayers' money did the Government spend on this advertisement? Will the Government apologise to grandparents? The Government needs to get its priorities right when it comes to spending. Spending in relation to sexual violence and gender-based violence is very important but it is clearly being mismanaged in this regard. When it comes to priorities, a few days ago The Irish Times led with a story about Tusla having no special-care place for a 14-year-old girl. This girl has a learning disability. She travelled across a county, was brought to a house, was continuously fuelled with drugs and was repeatedly raped. Of the 26 special-care places, 11 of them remain closed as a result of staffing shortages. That is a priority. When will the Minister get her priorities straight?

I want to be very clear that this is not a Government campaign and that is not the view of Government. It is not the view of the Minister for justice, who made his view very clear this morning. The Government does not support that advertisement or that campaign. There is a broader question around consent, which is important, and that is highlighted and targeted. As the Deputy said, it is important that we are having a consent conversation. That is partly why the SPHE programme in schools has been updated to have broader conversations than we had previously about consent and what is appropriate and what is not. That does not extend to this advertisements or to grandparents in any way. Grandparents are an incredibly important part of family life and every child's life. The advertisement was inappropriate and demeaning to grandparents. It has been removed by the Dublin Rape Crisis Centre, following the Minister for justice's engagement with officials. It goes without saying that having loving grandparents in somebody's life is an incredibly positive thing and is not something to be campaigned against. It does not represent the views of Government in any sense. If we set aside that advertisement on that basis, it is still important that there is a broad body of work, which I know the House agrees with, around domestic, sexual, and gender violence more broadly. That work is being led by Cuan and it is important that it continues. It is also important that we clearly distinguish this video, which was an error and does not represent the views of Government, from that different body of work that is being carried out. I acknowledge what the Deputy said in relation to Tusla. Special care is a very difficult working environment. It is an incredibly important part of our response to protecting the most vulnerable children in the State. Difficulties recruiting and retaining staff have been the main limiting factors on the number of beds that are currently open in the different available units. As a consequence, a new special-care worker grade was introduced in January 2025. This offers an improved salary scale, with 20% higher pay at the top of scale compared with the other Tusla social-care worker grade. That is in addition to recruitment initiatives for special care, including Tusla's new children's residential services training college. The reason for that is due to the particularly sensitive, difficult, and important work that is necessary to support some of Ireland's most vulnerable children. Of course, it is important that we discuss this here, and the Deputy is correct to highlight it. The response of the Government is to try to recruit and retain more people and for them to be recompensed appropriately for doing that most special and particularly difficult work.

This Government funded the advertisement campaign. This is taxpayers' money spent by this Government. The utter contempt the Government has shown to older people and grandparents is unacceptable. It is a Government-funded campaign, and the advertisement suggested that when it comes to sexual abuse and violence in this country, we need to be looking at and investigating our grandparents. How much did the advertisement cost? Will the Government apologise to grandparents? When it comes to the issue of Tusla, it is in contempt of court in relation to the lack of care for vulnerable people. This is happening in real-time. This is not a past scandal. It is happening today. There are 13 children missing from State care for more than six months. That is still happening. Meanwhile the Government is presiding over spending on the most ridiculous advert, which is trying to demonise grandparents.

I thank the Deputy. I reiterate that this is not a Government campaign. There was no question of it being sanctioned by the Government. The Government has service level agreements with many different entities to deliver services on their behalf and this ad was funded without consultation with anyone in government. I want to be absolutely clear that no person in government viewed or sanctioned this ad.

What about quality control?

This is not representative of the views of the Government.

There are no checks on taxpayers' money.

It is not representative of the views of the Government. We have service level agreements with a range of different entities across the health, justice and housing systems that deliver services on behalf of the Government. That does not mean we have oversight of every single thing they do. I am saying clearly that the ad has been withdrawn and does not represent the views of the Government. That is crucial.