Róisín Shortall (Dublin North West, Social Democrats)
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683. To ask the Minister for Health if he will add endometriosis to the long-term illness scheme; if this is being considered as part of the development of the National Endometriosis Framework; and if he will make a statement on the matter. [19030/24]

Stephen Donnelly (Wicklow, Fianna Fail)
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The HSE’s National Women & Infants Health Programme (NWIHP) is finalising the National Framework for Endometriosis in collaboration with the Irish College of General Practitioners, which sets out a defined clinical care pathway for women with endometriosis. This Framework identifies how care needs to be delivered for women in this area, with this care spanning primary care to local hospital care to specialist complex care through multidisciplinary teams.

This Model of Care will ensure that women receive timely and effective treatment through 2 supra-regional specialist centres in Tallaght and Cork supported by 5 regional endometriosis hubs in The Rotunda, Coombe, NMH, Limerick and Galway. All hubs and supra-regional sites are currently operational and taking referrals.

It is expected that the framework will be published in the coming weeks following final consultations with stakeholders. Funding recently announced through the Women’s Health Action plan will see Phase 1 of the Endometriosis Framework fully funded.

The Long-Term Illness (LTI) Scheme was established under Section 59(3) of the Health Act 1970 (as amended). Regulations were made in 1971, 1973 and 1975, prescribing 16 conditions covered by the Scheme. These are: acute leukaemia; mental handicap; cerebral palsy; mental illness (in a person under 16); cystic fibrosis; multiple sclerosis; diabetes insipidus; muscular dystrophies; diabetes mellitus; parkinsonism; epilepsy; phenylketonuria; haemophilia; spina bifida; hydrocephalus; and conditions arising from the use of Thalidomide.

While there are currently no plans to extend the list of conditions, it is important to remember that the LTI Scheme exists within a wider eligibility framework. This Government has put a significant focus on improving access to and the affordability of healthcare services, advancing substantial policy, legislation and investment to deliver expanded eligibility.

In 2022, a range of measures were delivered including the abolition of public in-patient charges for children, reductions in the Drug Payment Scheme threshold to €80 per month, and the introduction of free contraception for women aged 17-25.

In 2023, further measures have facilitated better access to affordable, high-quality healthcare, including an expansion of GP care without charges to children aged 6 and 7, and to people earning no more than the median household income, the abolition of all public in-patient hospital charges for adults, and the extension of the free contraception scheme to include women aged 26-30 (extended to those aged 31 from 1 January 2024). These measures continue to create a health and social care service that offers affordable access to quality healthcare.

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 under the General Medical Services (GMS) Scheme. In accordance with the provisions of the Health Act 1970 (as amended), eligibility for a medical card is determined by the HSE. Medical card eligibility is primarily based on an assessment of means and is not granted on the basis of any particular condition.

In certain circumstances the HSE may exercise discretion and grant a medical card, even though an applicant exceeds the income guidelines, where he or she faces difficult financial circumstances, such as extra costs arising from illness. In circumstances where an applicant is still over the income limit for a medical card, they are then assessed for a GP visit card, which entitles the applicant to GP visits without charge.

Under the Drug Payment Scheme (DPS), no individual or family pays more than €80 a month towards the cost of approved prescribed medicines. The DPS is not means tested and is available to anyone ordinarily resident in Ireland. The DPS significantly reduces the cost burden for families and individuals with ongoing expenditure on medicines.

Individuals may also be entitled to claim tax relief on the cost of their medical expenses, including medicines prescribed by a doctor, dentist, or consultant. Relief is at the standard tax rate of 20%.

Róisín Shortall (Dublin North West, Social Democrats)
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684. To ask the Minister for Health the status of the National Endometriosis Framework; the timeline he is working towards for publication; and if he will make a statement on the matter. [19031/24]

Stephen Donnelly (Wicklow, Fianna Fail)
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The HSE’s National Women & Infants Health Programme (NWIHP) is finalising the National Framework for Endometriosis in collaboration with the ICGP.

This Framework sets out a defined clinical care pathway for women with endometriosis with the care pathway spanning primary care to local hospital care to specialist complex care through multidisciplinary teams.

This Model of Care will ensure that women receive timely, and effective treatment through by 5 regional endometriosis hubs in The Rotunda, Coombe, NMH, Limerick and Galway and 2 supra-regional specialist centres in Tallaght and Cork. All hubs and supra-regional sites are currently operational and taking referrals.

GP referrals for the endometriosis care pathway will be through general gynaecology services. Patients can then be referred for care to the hubs/supra-regional sites if clinically required.

The framework is expected to be published in the coming weeks following final consultations with stakeholders.

Róisín Shortall (Dublin North West, Social Democrats)
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685. To ask the Minister for Health if he will consider changes to the age and body mass index limits for fertility treatment; if clinicians have discretion to treat patients over those limits in certain circumstances (details supplied); and if he will make a statement on the matter. [19032/24]

Stephen Donnelly (Wicklow, Fianna Fail)
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As the Deputy may be aware, a commitment to “introduce a publicly funded model of care for fertility treatment” is included in the Programme for Government.

‎The Model of Care for Fertility was developed by the Department of Health in conjunction with the HSE’s National Women & Infants Health Programme (NWIHP) in order to ensure that fertility-related issues are addressed through the public health system at the lowest level of clinical intervention necessary. ‎

This Model of Care comprises three stages, starting in primary care (i.e., GPs) and extending into secondary care (i.e., the six Regional Fertility Hubs located across the country) and then, where necessary, AHR (assisted human reproduction) treatment (e.g., IVF (in-vitro fertilisation) and ICSI (intra-cytoplasmic sperm injection)), with patients being referred onwards through structured pathways.

Phase One of the roll-out of the Model of Care has involved the establishment, at secondary care level, of Regional Fertility Hubs within maternity networks, in order to facilitate the management of a significant proportion of patients presenting with fertility-related issues at this level of intervention. Patients are referred by their GPs to their local Regional Fertility Hub, which provides a range of treatments and interventions.

Phase Two of the roll-out of the Model of Care relates to the introduction of AHR treatment, including IVF, provided through the public health system at tertiary level.

Funding has been made available to support access to AHR treatment via private providers. As well as IVF and ICSI, this allocation is also being used to provide, in private clinics, IUI (intrauterine insemination), which can, for certain cohorts of patients, be a potentially effective, yet less complex and less intrusive treatment.

Referrals for AHR treatment by private providers commenced in the week beginning September 25th 2023. Criteria which prospective patients should meet in order to access fully-funded AHR services and the services to be initially funded were agreed by the Department and NWIHP and discussed at Cabinet in July 2023.

The approach adopted by the Department of Health in relation to defining clear parameters regarding clinical criteria for AHR is in line with European and international counterparts, allowing for necessary accountability for the cost-effectiveness use of public funds and the safety of patients and any consequent pregnancy that may result. More details on public fertility services, including information on the new publicly-funded AHR treatment initiative, are available from the HSE at: www2.hse.ie/conditions/fertility-problems-treatments/fertility-treatment/

The criteria were developed and finalised following engagement and consultation with experts in the field of reproductive medicine, taking into account the clinical parameters of the access criteria including the assessment of such areas as age, body mass index (BMI) and other health and well-being elements.

These clinical parameters were reviewed in the context of both the potential success or otherwise of the advanced fertility treatment itself but also the health and well-being of the intending birth mother and any resultant pregnancy, inclusive of the management of maternity care, delivery and health of any child.

In relation to the clinical parameter of age, as advised by the clinical experts in the HSE, it is important to note that age affects the fertility of both women and men. Fertility starts to reduce after the age of 30 and this reduction happens faster after the age of 35. The reason for the reduced fertility is two-fold. The first reason is related to the fact that poorer quality, older eggs are less likely to lead to pregnancy. Secondly, the chance of genetic or chromosomal abnormalities rises significantly over the age of 40.

It should be noted that age can also increase the risk of certain complications during pregnancy. This includes miscarriage, pre-eclampsia, gestational diabetes or having a baby with a chromosomal abnormality. It is for these known risks and the significantly reduced chances of successful treatment that a defined parameter regarding the age of the intending birth mother was established for the purposes of publicly-funded AHR services.

Specifically in relation to the clinical parameter of BMI, it should be noted that women presenting with high BMIs are at a high risk of reproductive health complications, as are their babies. The risk of sub-fecundity and infertility, low conception rates, miscarriage rates, and pregnancy complications are increased in women with raised BMI, in both natural and assisted conceptions. Furthermore, reproductive outcomes for all fertility treatments are poor in this cohort. Obesity may impair reproductive functions by affecting both the ovaries and endometrium. It is because of these safety concerns and poor outcome facts that it is recommended, in line with the UK, the BMI parameters for intending birth mothers are a minimum of 18.5 kg/m2 and a maximum of 30.0 kg/m2.

The approach adopted by the Department of Health in relation to defining clear parameters regarding specific clinical criteria for AHR is in line with many European and international counterparts, allowing for necessary accountability for the cost-effectiveness use of public funds, and the safety of patients and any consequent pregnancy that may result.

The access criteria and the AHR treatment scheme will be kept under review as new evidence becomes available, an understanding of how the service provision is working in practice emerges, and when the AHR legislation – currently at Report Stage in the Dáil – is finalised.

It should be noted that some of the criteria to be met in order to avail of the secondary fertility care services at the Regional Fertility Hubs have broader parameters. These Hubs can successfully manage a significant proportion of patients presenting with fertility-related issues at this level of intervention without requiring them to undergo often extremely invasive and arduous IVF or ICSI treatment.

My Department and the Government are focused, through the full implementation of the Model of Care for Fertility, on ensuring that patients receive care at the appropriate level of clinical intervention and then those requiring, and eligible for, advanced AHR treatment such as IVF will be able to access same through the public health system.

The underlying aim of the policy to provide a model of funding for AHR, within the broader new AHR regulatory framework, is to improve accessibility to AHR treatments, while at the same time embedding safe and appropriate clinical practice and ensuring the cost-effective use of public resources.