DÁIL ÉIREANN

AN COMHCHOISTE UM SHLÁINTE AGUS LEANAÍ

JOINT COMMITTEE ON HEALTH AND CHILDREN

Déardaoin, 22 Samhain 2012

Thursday, 22 November 2012

The Joint Committee met at 9.30 a.m.

MEMBERS PRESENT:

Deputy Catherine Byrne, Senator Colm Burke, Deputy Peter Fitzpatrick, Senator John Gilroy, Deputy Seamus Healy, Senator Imelda Henry, Deputy Denis Naughten, Senator Marc MacSharry, Deputy Caoimhghín Ó Caoláin, Senator Jillian van Turnhout. Deputy Robert Troy, In attendance: Deputy Liam Twomey.

DEPUTY JERRY BUTTIMER IN THE CHAIR.

1 World Prematurity Day 2012: Discussion with Irish Premature Babies Organisation The joint committee met in private session until 10.15 a.m.

World Prematurity Day 2012: Discussion with Irish Premature Babies Organisation

Chairman: I welcome everyone. Our meeting this morning will be divided into two parts. The first part will be a discussion to coincide with World Prematurity Day. I welcome members of the Irish Premature Babies organisation, in particular Ms Mandy Daly, Dr. John Murphy and Ms Hilda Wall. Members will be aware that last Saturday marked international World Prematurity Day. Almost 5,000 babies are born premature in Ireland every year, equating to one premature baby born every two hours. Premature births are defined as those of less than 37 weeks’ gestation, and the most vulnerable of these children in terms of survival are those born at less than 28 weeks’ gestation or more than three months early. As someone who was born ten weeks premature and who weighed in at 2 lbs 11 oz, I am glad to say I survived and I am here. I welcome our guests this morning.

Witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if you are directed by the committee to cease giving evidence in respect of a par- ticular matter and continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against a person or persons by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice or ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I pay tribute to Ms Mandy Daly for the outstanding work she has done in promulgation and advocacy and I compliment her on it. By coincidence, Dr. Murphy and Ms Daly are both from Cork which gives them an extra benefit at this morning’s meeting. I call on Dr. Murphy to begin.

Dr. John Murphy: I thank the committee for the opportunity to speak this morning. This is a fact-finding mission to inform the committee about a group of patients that one may not come across in one’s everyday work, although at the far side of Merrion Square there is a large unit in the National Maternity Hospital. Newborn babies are defined as those in the first month of life. Believe it or not, often this is when the greatest problems occur for small babies. It is a difficult hurdle for children to get through the first month.

As the Chairman noted, we marked World Prematurity Day on 22 November. The idea of World Prematurity Day is to highlight the issue of prematurity for the stakeholders, including doctors, nurses, paramedics and health care professionals who look after these babies. How- ever, it is also a matter for the public because most members of the public have been touched either directly or indirectly by prematurity, whether in the case of a brother, a sister, a father or a grandchild who was born prematurely. I will discuss the issues that affect a large number of babies.

One year ago I was appointed as the national clinical lead in neonatology. Clinical lead programmes are a collaboration between the HSE and the Royal College of Physicians of Ire- land. The purpose of a clinical lead is to set standards and then to implement strategies to allow

2 Joint Committee on Health and Children these standards to be brought into being throughout the country. On my left is Ms Hilda Wall, a nursing manager in the hospital in Holles Street and a clinical lead for neonatal nursing. Ms Wall will discuss some aspects of neonatal nursing later on, including the complexity of the speciality. On my right is Ms Mandy Daly, who represents the Irish Premature Babies associa- tion and who is doing a great deal of work to help families who have had pre-term babies and to highlight the issues for pre-term infants.

The first slide on prematurity will give the committee a flavour of the speciality. Our spe- ciality is different from others in that it is rather visual with small babies and the things that are done. One can see in the top panel the remarkable amount of intensive care provided to these babies, who are either pre-term or term babies who are very sick. The lower panel shows the more human side. There is a picture of a mother who is giving a baby skin-to-skin kangaroo care, which is an effective way of interacting with the infant and keeping him or her warm. There is also a picture of a baby with a mother and father. That is probably the smallest baby I have ever brought out of hospital, born at 23 weeks’ gestation. There is also a picture of pre- term twins and slightly older children. There is a complexity to the intensive care involved but these children emerge as normal children.

The next picture shows a map of Ireland. I decided to use it as a challenge for the commit- tee. There are approximately 75,000 births annually in the country. There are 4,800 premature babies born, a total of 19 neonatal units used to look after these babies and 300 neonatal cots. These are the figures for the country. In the North of Ireland there are approximately 25,000 births and, therefore, on the island of Ireland there are approximately 100,000 births. This is equivalent to the number of births in Sweden, which has a population of 9 million. Therefore, clearly we have a large number of children born, thankfully so, because they will grow up and be part of a young population in the country.

The Chairman referred to the definition of prematurity as being less than 37 weeks’ gesta- tion as well as the associated issues. A term baby is one of 40 weeks’ gestation. The more pre-term the baby, the more troublesome the case. Members will note from slide 5 that the in- cidence of prematurity in Ireland is 7%. The percentage in other countries is much higher. For example, in the United States it is 12%, which is a big problem. During World Prematurity Day, an international speaker pointed to the real problem in the United States in terms of prematurity. We are fortunate in that the percentage in Ireland is a little lower, although overall it is rising. Members will see from the slide that some babies, although pre-term, are relatively big in size and others are relatively small and vulnerable. As such, the care required varies.

Slide No. 6 deals with one of the most important issues we would like to discuss this morn- ing. Not all units in the country are the same size. As shown on the slide, there have been more than 8,000 births in four particular units, which is a large number of births by international stan- dards, a smaller number in four others and 2,000 births between the remainder of the units. This is important in the context of the delivery of care. Level 1 care involves basic care of babies, in- cluding resuscitation on a needs basis. Level 2 care, which takes place in more regional centres, involves the provision of supportive or intensive care. Level 3 is intensive care for infants. It is important to be able to interact these three levels, using them quickly and effectively. This is where the term “network” comes in. In this regard it means professional connectivity. We have been working on how to make connectivity happen and on getting all of the units in the country to work together, in terms of the management of premature babies, in a cohesive fashion.

In trying to determine best practise, we visited all the units in the country and met with all the doctors in all the hospitals. We learned about what is being done on a daily basis and of the 3 World Prematurity Day 2012: Discussion with Irish Premature Babies Organisation main problems being experienced. It is important all these hospitals, in terms of the provision of care of infants, work effectively and cohesively. I will comment further on that issue later.

Slide 8 shows how successful the speciality has been. The reduction in mortality rates has been divided according to birth weight panels. In some cases, there has been a drop in mortality of up to 28% or 36% over ten years. It would be a challenge to any group in society to achieve a reduction in mortality of patients of 30% over ten years. It has been a great success. Mem- bers will note that the diagram contains information in regard to babies weighing 500 and 750 grammes, which is 1lb to 1.25lbs in weight. These babies are the new challenge for us. These are very much wanted babies of mothers who have undergone IVF treatment and have difficul- ties around getting pregnant. The challenge over the next five to ten years will be trying to get a better outcome for this group of infants.

Slide 9 relates to the benchmarking report of last year, which was mentioned at the first World Prematurity Day event last year. While many medical services in Ireland have in the past developed in an ad hoc fashion what is needed now is a much more planned approach to neonatal services. The structure of these services needs to planned and implemented. When there is a structured system in place new developments can be applied rapidly. Where there is not a structured system in place and new developments occur they are not quickly implemented countrywide. This is important for the future.

The second last sentence of slide 10 states the philosophy of the lead programme, namely, bringing expertise to the baby or bringing the baby to the experts. In other words, we want these babies to be cared for as locally as possible, by their local doctors with their families as close by as possible. They should only be moved to a bigger centre where necessary and as soon as possible after they have received that care they should be returned to the local hospital. The next slide highlights the importance to neonatal care of a seamless transfer across the sys- tem from level 1 to level 3 care and back to the local hospital as soon as possible. We are trying to eradicate post code disadvantage and want every baby in the country to get the service they need in the time they need it.

Slide 12 deals with my final point, which is on one of the most important issues in this area, namely, transport. We are lucky to have a neonatal transport system in Ireland. It oper- ates from 9 a.m. to 5 p.m. However, no service is available after 5 p.m. The service includes a dedicated ambulance and specially trained doctors and nurses, who collect babies from any unit in the country and take them to whatever facility is selected for the treatment they require. This service needs to be developed further. We would like to have a 24/7 service. Babies are regularly born outside of office hours, with some born in the middle of the night and requiring transfer by a dedicated team of staff. During our visit to hospitals around the country the need for a 24/7 service was highlighted. My main priority is to make this happen. A 24/7 transport service would be life saving.

Ms Mandy Daly: I would like to reiterate what has been said by Dr. Murphy. We are here as a united front today to outline the current situation and to put forward proposals to tackle some of the blockages in the system. With respect to the neonatal ambulance service, money has been ring-fenced for the provision of a 24/7 service. To have it implemented will require a lifting of the moratorium on recruitment. That is one of our key issues today. As a parent organisation we are privileged to work with the medics. Huge strides have been made in the past number of years by the medical community who cater for our children. One of the biggest challenges we faced is the lack of understanding of pre-term birth in the broader community, including among the stakeholders in the field. For every child born, there is a journey for an 4 Joint Committee on Health and Children entire family. As stated by Dr. Murphy, whether we bring the expertise to the children or the children to the expertise, it is vitally important this is done where appropriate and in time so as to prevent life long disabilities which have social impacts on the family and can have a finan- cial burden on the State in general. By adopting the guidelines of Dr. Murphy’s working group in relation to the structure of the neonatal system in the country we alleviate the financial and emotional impact on families. We also ensure that each unit has the appropriate skill set to care for the children in their care.

Ms Hilda Wall: As a manager in the National Maternity Hospital in Holles Street one of my biggest concerns is the availability of space. We want to ensure we provide the best possible care. This requires that babies be managed by skilled personnel, namely, nurses who are del- egated to the transport team and dedicated physicians. The bottleneck in the service is returning babies, following care, to their local hospital because often the local hospitals have to get nurses in and arrange for special ambulances, which delays the whole process.

I agree with Ms Daly that transport is a huge financial and emotional burden on parents. A mother who is breast-feeding would be required to travel every day to do so. This involves huge costs in terms of travel, car parking and overnight stays. The logistics behind doing so are huge.

Chairman: I thank the witnesses for their presentations. I had the pleasure of meeting you all at the launch of the Born too Soon report in Ireland last week. I have one question before I invite Senator Van Turnhout to engage with the witnesses. Am I correct that the funding for the transport service is in place and that what is at issue is staffing of it?

Dr. John Murphy: Yes. Additional staff are required, including three nurses and one senior doctor. The money has been ring-fenced through the national plan for last year but we under- stand the moratorium hinders final release at a control level.

Chairman: The committee will do everything it can to advance that cause. The issue of transport is vital in prematurity.

Deputy Denis Naughten: Ms Wall pointed out that it is one thing to get babies to the spe- cialist centre but another challenge to bring them back. Is there not a third leg to the stool in terms of getting them out of the local hospital and back to their own homes? This in itself is a huge challenge, particularly for premature babies with life limiting conditions. Sadly, we face that problem this time every year. Parents with children in ICUs and SCBUs are anxious to bring them home for Christmas but the current funding structure makes it impossible for them to do so. For some children, this will be their only Christmas and the system is falling down if they have to spend it in hospital rather than at home.

The rate of prematurity in Ireland is 7% on average, compared to an average of 5% across Europe.

Dr. John Murphy: It goes to 5% as one goes to northern Europe.

Chairman: We will take questions together before asking the witnesses to answer them.

Deputy Denis Naughten: Why does this differential exist? I presume part of the reason is our genetic mix resulting from being on an island. We have a higher incidence of certain rare diseases for the same reason. What steps are being taken to deal with the prematurity rate?

5 World Prematurity Day 2012: Discussion with Irish Premature Babies Organisation The statistics on perinatal mortality rates are positive for every category of children except those over 4,500g. Why does the mortality rate increase by one fifth among children in that cat- egory? I note the cohort is relatively small but 20% is a significant jump over a ten year period.

Senator Jillian van Turnhout: The report, Too Little, Too Late?, states that we do not have a national neonatal health policy and criticises the fragmented implementation of policy and the significant disparities across the country. I ask the witnesses to elaborate on this geographi- cal lottery. This brings me to the issue of the transport service. I am trying to understand the precise nature of the obstacles. I see that the service is available on a nine to five basis, seven days per week but logic tells us that babies do not always arrive during office hours. What are the obstacles to a 24 hour service?

I ask for more information on the other supports available to families. I have been working on the issue of pre and post-natal depression, which affects between 10% and 20% of women. They are being told that they have to wait nine months before they can get the appropriate ser- vices but this is a critical time for bonding with their children.

Senator Colm Burke: I thank the witnesses for their presentations and for the tremen- dous work they have done over the last few years. Given that the birth rate has increased from 54,000 to 75,000 per annum without a significant increase in staff levels, we have achieved great success in reducing the perinatal mortality rate. I understand smaller units are experienc- ing problems in regard to availability of junior doctors. Consultants in smaller units may be on a one in two call or one in three call rotation and if they are not assisted by good junior doctors they are put under further pressure. Is anything being done to increase co-operation between smaller and larger units in regard to training programmes for junior doctors? For example, a junior doctor could work for two years in Dublin followed by a year in one of the smaller units. In fairness to the big units in Dublin and Cork, they are very supportive of the smaller units and are on call on a 24-seven basis to provide assistance.

Senator Marc MacSharry: What are the weakest regions in terms of geography and to what extent are premature children born in them at a disadvantage?

Dr. John Murphy: The main issue is distance from a bigger centre when help is needed.

Chairman: We will take questions together.

Senator Marc MacSharry: Is any region particularly exposed?

Deputy Catherine Byrne: As a mother of three healthy children who were born on time, I do not have the experience of giving birth to a premature baby but I know others who have gone through the experience and how it affects their extended families. It is difficult to manage sick children at home because we have not made the connection between services.

Is there a reason for the global trend of rising rates and is it related to the fact that women are having children later in life? Young women are working later before taking maternity leave and they are coping with more stress in work. Is it just a fact of nature?

In regard to the 300 cots that are available for 4,800 premature births, how are the remaining births managed? The numbers do not add up for me. What can be done in local communities with midwives and nurses to help people whose premature babies have passed away?

Deputy Peter Fitzpatrick: I ask for more information on the 24 hour transport service.

6 Joint Committee on Health and Children What is involved in such a service?

Dr. John Murphy: I am trying to remember all the questions but I may need to be reminded of some. Deputy Naughten asked why the rate is slightly higher among babies weighing more than 4,500g. The numbers are very small but the babies concerned are very big and I suspect it may be related to diabetes. The obesity epidemic is causing significant problems in terms of diabetes, particularly gestational diabetes, and could well be a factor. For women with a high BMI, labour is more difficult and that may also be a factor. A high BMI is a warning sign and a real concern for obstetricians is women with a high BMI when they become pregnant.

A question was asked about what happens after the baby goes home.

Deputy Denis Naughten: I asked about getting the child home.

Dr. John Murphy: Getting the child home is the challenge. “Discharge planning” is a term that is coming more in all aspects of medicine. Up to now it has been the other way around. When a patient is admitted to hospital there is a lot of fuss. Charts are filled and everybody is looking at and examining the patient. Going home is often a much quieter affair and may not receive the same degree of emphasis and attention. The newer concept is that the discharge of the patient is planned almost as soon as the patient arrives in hospital. On the very day the patient arrives, plans are made for what will happen when he or she is going home. Perhaps Ms Wall would like to comment on discharge nurses.

Ms Hilda Wall: We have one whole-time equivalent in the hospital in Holles Street dealing with this. When we have very premature babies or full-term babies who are ill or babies with a life-limiting condition, we plan their discharge from the day of admission. We walk the parents through the process and through what they can expect and try to link them into the services. We have a very good palliative care team in Dublin to work with them. We also help link them to the Jack & Jill foundation, Sunshine House and the LauraLynn House. We make those connec- tions for them and have meetings with them. Before the babies go home, we have multidisci- plinary team meetings so that we link them into the services as well as possible.

Deputy Denis Naughten: That is grand for the children in the Dublin catchment area, but I am talking about children transported from places like Portiuncula and Sligo to Holles Street and about getting those children back to their homes.

Ms Hilda Wall: The first step is to get them back to their local hospitals and the local hos- pital will try and link them into the services. Our problem is that if we discharge babies from Dublin, they can be lost in the services. However, if we try to get them back to the local hospi- tals, they can be linked in with the local services, the local paediatrician, social worker, public health nurse, etc.

Deputy Denis Naughten: The network is pretty much okay in Dublin, but my point is that when children get back to their local hospitals, they are stuck in them for Christmas because the funding is not there to help them get back into their own homes.

Dr. John Murphy: The Deputy is making a valid point. Some of these babies may be so premature they cannot feed themselves properly and must be tube fed. Obviously a nurse is needed then to go out and help replace the tube. The Deputy mentioned babies with life- limiting conditions, which is where palliative care comes into play. A service is beginning to be developed in this area. A paediatric palliative care consultant has been appointed, mainly for Crumlin, but an effort is being made to roll out a national model of palliative care. We have 7 World Prematurity Day 2012: Discussion with Irish Premature Babies Organisation what we call champions in this area, in other words consultants with a special interest in the area, around the country and the hope is that these will become an integral part of the service and provide the necessary support for families who take home babies with life-limiting condi- tions. This is being developed as a model of care programme, but it only started in the past year or so.

Chairman: Will Dr. Murphy deal with the questions from other members?

Dr. John Murphy: Will Senator van Turnhout repeat her question for me?

Senator Jillian van Turnhout: I asked about neonatal care and the fact there is no national policy. What is the position in that regard? I also asked about the obstacles in the area of trans- port.

Dr. John Murphy: There has not been a national model of care for neonatology and it has been my role to develop that. On foot of visits around the units, I have produced a review report on paediatric and neonatal transport in collaboration with my colleague, Professor Nicholson. That report will be published in approximately two weeks. It is a 200 page report and deals with the units, the services they provide and overall principles of the model of care. The report has gone to the HSE for a final review before publication. It will set out some ideas for a model of care programme for neonatology and how we see the development of services on a more formal basis for the future.

On transport, everybody is agreed transport should be available 24/7 and as far as we are aware, the money has been set aside for that.

Chairman: For what specifically has the money been set aside?

Dr. John Murphy: It is set aside for the services for the hours not available. The service is already funded and staffed from 9 a.m. to 5 p.m. The extra money was required for the service from 5 p.m. to 9 a.m. seven days a week.

Chairman: Is it correct the ambulance service is based in the three Dublin maternity hospi- tals and can go nationwide within 45 minutes?

Dr. John Murphy: Mobilisation is very fast and with the good roads it can get to most places in the country within three or four hours. Therefore it has a fast turnaround. The team goes and if the baby is in a serious condition when they arrive, they will continue resuscitation on site with their added expertise and help and then get the baby to a bigger centre as quickly as possible.

Chairman: What happens outside of that specific time?

Dr. John Murphy: Outside of that, the local team and doctors working in the hospital will have to arrange to do the transport themselves. Sometimes the consultant may have to leave with the patient, which makes things difficult for the local hospital because that consultant was on call on the rota, but is now travelling in an ambulance to Dublin. This is the reason they are so keen on our programme to be developed.

Ms Hilda Wall: Also, some nurses from the country would be very uncomfortable with having to travel with a premature baby on ventilation who is very ill.

Dr. John Murphy: Science has moved on and one of the other big issues that has emerged

8 Joint Committee on Health and Children is that for the first ever we have possible treatment for brain damaged babies or babies who lacked oxygen at birth. This is termed therapeutic cooling. What happens is that the baby is cooled to 32° centigrade for 72 hours. This is a very effective treatment and one in four or five of babies treated in this fashion will be normal. We have had some great results with this treat- ment in the past two to three years. However, the problem is this treatment must be instituted within six hours of birth. What we get people to do locally is to turn off the heaters and keep the babies cold. Then we collect the babies and keep them cool during transport. This is the opposite of what one might think. It is not a good idea to wrap these babies up when they have suffered asphyxia.

We have had some wonderful success stories in the past two years with therapeutic cooling and one in four or five of babies who would have gone on to have significant cerebral palsy are normal. This treatment can only improve, now we have the first breakthrough in preventing this. Oddly enough, the damage from lack of oxygen to the brain does not happen immediately, but over a period of time and if we get within that window, we have the opportunity to reverse the damage. The committee can, therefore, see why we are so keen to be able to transport pa- tients and teach and train people around the country not to put on the radiant heaters but to keep these babies cool so that we can collect them and transport them cold as quickly as possible.

Deputy Denis Naughten: How many births would fall into that category on an annual basis?

Dr. John Murphy: I looked at the figures for 2010, as I have not got all the figures for 2011 yet because we are always a year behind with data. There were approximately 40 such babies cooled in 2010, but I expect that figure to rise.

Chairman: Given the tracking and research, is there a reason that number will rise?

Dr. John Murphy: I expect the number of babies we get to access in time and treat will rise. The identification of babies who may suffer from brain damage from lack of oxygen will increase and we will be able to get to more of them and, hopefully, prevent damage occurring. Unfortunately, we cannot prevent damage for every such baby. That will take time, but a certain percentage of them can benefit. The national experience is very encouraging for this. Cooling has been the subject of a large number of trials and is probably the biggest breakthrough we have had in neonatology in the past 25 years.

Chairman: How would Dr. Murphy rate our public health system on dealing with the issue? How are we doing?

Dr. John Murphy: We are doing quite well overall and have good connectivity. We have a great opportunity for a world class neonatal service because Ireland is a small country, we have great roads and good quality hospitals around the country with high standards. However, they need that professional connectivity so that the babies in need can be moved around to the best place. We should have a neonatal service we can be proud of nationally and internationally.

Senator Colm Burke: I also asked about the level of co-operation between the hospitals on the junior doctor issue.

Dr. John Murphy: I think Senator Burke is right in this regard. Unfortunately, there is a global shortage of doctors. This is happening everywhere. I suppose doctors tend to go to the bigger centres to participate in training programmes. We are trying to implement training pro- grammes for the regional centres so that those involved are trained in all the basic skills before 9 World Prematurity Day 2012: Discussion with Irish Premature Babies Organisation they start their jobs. Ms Wall might like to comment on the availability of advanced neonatal nurse practitioners who can perform as senior house officers.

Ms Hilda Wall: There are four advanced neonatal nurse practitioners in the country, all of whom are in Dublin. They were slow to come on board because they had to go to England for their training. They commenced training this year in the Royal College of Surgeons in Ireland, in combination with the three Dublin hospitals and the Cork hospital. These practitioners will have the same skills as junior hospital doctors. They will be able to cannulate and intubate babies. They will be able to manage babies who are very ill. This will alleviate much of the pressure in the system. It will also extend the role of nurses, who are obviously keen to be more involved in the care of babies.

Dr. John Murphy: This approach is along the lines of the American model, which has con- sultants, senior doctors and highly skilled nurses doing many of the jobs that are done by junior doctors here. When the junior doctors are reduced in numbers, they do more in training posts. The nurses in question are experienced and know all of the practical procedures and skills that are needed. They are taking a significant amount of pressure off the system. I think that is the way forward. It will lead to a better service.

Senator Colm Burke: A junior doctor in the UK can get a three-year contract with a num- ber of different hospitals.

Dr. John Murphy: Yes.

Senator Colm Burke: He or she might do a year in each of three different hospitals. The three-year contract gives certainty to junior doctors. They do not have to worry about going for interview a month after starting a new job. I wonder whether we can develop that here as a national policy. Someone who

gets a three-year contract could spend two years in Dublin and a year in a regional location. That would give certainty to junior doctors. I wonder if we could try to move that on. We are going nowhere with it. We are losing a huge number of junior doctors. I learned from a survey of medical students who graduated in 2012 that fewer than 35% of them intend to be working in Irish hospitals by the end of their internship years. Part of the problem is the uncertainty with contracts.

Deputy Catherine Byrne: I was interested in Dr. Murphy’s suggestion that cerebral palsy can occur over a period of time, rather than during the birth.

Dr. John Murphy: It is caused by the effect of a lack of oxygen on the brain. It was thought that it was like a road traffic accident in the sense that the injury occurs at the point of the im- pact, but that no longer appears to be the case. The way the brain works means that the injury that takes place as a result of a lack of oxygen happens over a period of hours, rather than in a single moment. That gives one an opportunity to move in and cool the body down to 32° or 33°, which is approximately 4° lower than normal, thereby allowing the brain to rest and recover. That seems to be the way it works. We cool the body down to 33.5° for 72 hours. It is quite complicated, but the results are very promising.

Deputy Catherine Byrne: I thank Dr. Murphy.

Senator Marc MacSharry: Is it possible for me to stray off the point?

10 Joint Committee on Health and Children Chairman: Not really. I will indulge the Senator a little.

Senator Marc MacSharry: I appreciate that the Chair might rule this out of order. Given the unique expertise of Dr. Murphy in this area, and the current public debate on the matter, I would be interested to hear his professional view on the Savita case. How does he believe the investigation should be brought forward?

Chairman: To be fair, that would not be appropriate to the discussion we are having this morning. It would place Dr. Murphy and the members of the committee-----

Senator Marc MacSharry: Is the Chairman speaking from a Government perspective or from a committee perspective?

Deputy Catherine Byrne: That is not fair.

Chairman: I remind Senator MacSharry that the Chair is independent and always acts in- dependently. We are dealing with world prematurity day. Dr. Murphy is here in that capacity.

Senator Marc MacSharry: I understand that.

Chairman: I am not allowing the question to be asked or to be answered.

Senator Marc MacSharry: We might as well take advantage of Dr. Murphy’s expertise while it is available to us.

Chairman: I am not allowing this committee to engage with this matter at the moment. We had a discussion on it on Tuesday at the quarterly meeting.

Senator Marc MacSharry: At least that is consistent with the Government response.

Chairman: The Senator’s comments are wholly inappropriate and out of order.

Deputy Catherine Byrne: They are totally out of order.

Chairman: He is being very unfair. He is trivialising the matter, which is very wrong.

Senator Marc MacSharry: I was simply making the point that in light of the expertise available to us today, we might as well ask Dr. Murphy some questions about his opinion on the matter.

Chairman: The Senator is doing a disservice to everybody by pursuing this line of ques- tioning.

Deputy Peter Fitzpatrick: The Senator and his colleagues did nothing about the matter for the past 14 years.

Deputy Denis Naughten: I will return to what Dr. Murphy was saying about the cooling of babies. Is he saying that in the cases of between eight and ten babies a year, the effects of a lack of oxygen at birth, which leads to profound disability for a child over his or her lifetime, can be addressed by putting an ambulance service in place 24 hours a day, seven days a week? If that is the case, and perhaps I am not great on the maths, is it not a no-brainer to suggest that the savings which could be generated from not needing to pour substantial health and medical resources into families, over the lifetimes of the between eight and ten children who would lead normal lives, would immensely outweigh the cost of running an ambulance that is already

11 Youth Issues: Discussion with Comhairle na nÓg available? As things stand, it would be a matter of providing out-of-hours staffing for that ambulance. Surely it makes financial and economic sense to proceed along these lines, even if we dismiss the human aspect of the significant quality of life implications for the families, the children and the communities involved.

Dr. John Murphy: As doctors, we always place an emphasis on reducing the suffering and the handicap for the child and the great burden on the family. That is what drives us in these cases, first and foremost. More indirectly, it is clear that if one can avoid disability, one will bring about substantial cost reductions overall. That is certainly right.

Senator Colm Burke: I would like to return to the question of whether there is a relation- ship between drugs, drink and smoking and babies being born prematurely. Has any research been done on that?

Dr. John Murphy: Smoking is the issue that needs to be addressed by society because it affects the size of the baby. If the baby is smaller than it should be, it tends to get more dis- tressed and may well deliver prematurely. There is a direct relationship in the case of smok- ing. Obviously, alcohol is completely not recommended in pregnancy. The number of cases of alcohol-related pregnancy problems that we encounter seems to be quite small. It is not a feature. Young women who are pregnant do not seem to do that. I have not noticed it to any great extent. I am sure Ms Wall agrees.

Ms Hilda Wall: We do not really see a lot of alcohol-related problems.

Dr. John Murphy: We see some problems that are associated with drug abuse, for example when we encounter girls who are in methadone programmes. Babies who have drug-withdraw- al symptoms have to be kept in hospital for a number of weeks. It can take them six or eight weeks to withdraw from the symptoms of their mothers’ drug addiction in pregnancy. During that period, the babies often need narcotics until they have recovered.

Senator Colm Burke: Each year, approximately 40 babies who are born in the Rotunda Hospital go into withdrawal symptoms after being delivered.

Dr. John Murphy: Those cases would be drug-related.

Chairman: I thank members for their participation in this section of the meeting. The second section of the meeting will follow immediately. I thank Dr. Murphy, Ms Wall and, in particular, Ms Daly, who was a huge advocate of the establishment of this organisation and who travelled around the country in her advocacy role while publicising the publication of the book. It is important to recognise the work she does on a voluntary basis. I thank her for being here. I also thank Dr. Murphy and Ms Wall. Today’s meeting has been a valuable exercise. As a result of this discussion, the committee will follow up the transportation issue with the Department of Health and the HSE. I remind members that the delegation from Dáil na nÓg that will address the committee shortly has prepared assiduously for this meeting. If members could wait for the delegation to arrive, it would be appreciated.

Sitting suspended at 11 a.m. and resumed at 11.05 a.m.

Youth Issues: Discussion with Comhairle na nÓg

12 Joint Committee on Health and Children Chairman: I remind people to turn off their mobile telephones if they have not already done so. It is a great pleasure and privilege for me, as Chairman of the Joint Committee on Health and Children, to welcome to the meeting members of the Comhairle na nÓg national executive, namely, Jamie Wiggins, who is from County Donegal, Mairead Coady, who is from County Kilkenny, Éamonn Ó Briain, who is from Limerick city, and Gerard Maguire, who, like Deputy Fitzpatrick, is from County Louth.

Before we begin, I draw the attention of the witnesses to the position on privilege. Wit- nesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and they con- tinue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling and parliamentary practice to the effect that they should not comment on, criticise or make charges against a person, persons or entity outside the Houses or an official either by name or in such a way as to make him, her or it identifiable.

I ask our guests to relax and to enjoy participating in the meeting. I remind them that they will be appearing on television and that the nation and the world will be watching and listening to them. Our guests are most welcome. We are delighted to have them here. I compliment them on taking the time to come before us and I commend them on the work they are doing. I call on Jamie to lead off the discussion.

Mr. Jamie Wiggins: My name is Jamie Wiggins and I am from the Donegal Comhairle na nÓg. I am going to be telling the committee about Comhairle na nÓg, which is the local child and youth council for each county development board. Comhairle na nÓg is funded and over- seen by the Department of Children and Youth Affairs. It consists of young people between the ages of 12 and 18 years of age. Each Comhairle na nÓg holds an open annual general meeting, AGM, at which local young people decide the issues on which their comhairle should work.

Ms Mairead Coady: My name is Mairead Coady and I am from Kilkenny Comhairle na nÓg. I will be telling the committee about Dáil na nÓg, especially in the context of what it did 2011. Dáil na nÓg is an annual national youth parliament for young people. Some 200 del- egates are elected through their local Comhairle na nÓg. The top recommendation for Dáil na nÓg from 2011 related to the need to find ways for young people to influence decision makers in the Dáil, Seanad and local authorities.

Mr. Éamonn Ó Briain: My name is Éamonn Ó Briain and I am from Limerick city Com- hairle na nÓg. I am going to briefly discuss the Comhairle na nÓg national executive. Each Comhairle na nÓg elects one delegate to become a member of the national executive. The role of the executive is to follow up on the recommendations made at Dáil na nÓg and at local Comhairle na nÓg AGMs.

Mr. Gerard Maguire: My name is Gerard Maguire and I am from Louth Comhairle na nÓg. I will be telling the committee about our aims. We are here today to strengthen the voices of young people through showcasing the work that is done by the different comhairlí through- out the country. Currently, there are 14 comhairlí working on various mental health initiatives and seven working on matters relating to social, personal and health education, SPHE, and relationships and sexuality education, RSE. We are here to discuss the topics of sexual and 13 Youth Issues: Discussion with Comhairle na nÓg mental health and to represent the work of the different comhairlí throughout the country and make recommendations to the committee on their behalf. As already stated, seven comhairlí are working on issues relating to sexual health, SPHE, RSE and sexual health services and a further 14 are working on the various mental health initiatives.

Mr. Jamie Wiggins: On sexual health, the key issues raised by Comhairle na nÓg are that majority of comhairlí feel that the teaching of RSE and SPHE is both inadequate and incon- sistent and that more sexually transmitted infection, STI, testing clinics are needed for young people. A number of comhairlí are currently working on the quality of teaching in respect of RSE and SPHE.

In the context of sexual health education, young people in Comhairle na nÓg are of the view that the teaching of RSE is inconsistent and that the quality of teaching varies from school to school. There is no SPHE course for the senior cycle and it is at the discretion of the individual teacher or school as to what topics are covered in class. This is a matter which was also worked on by a former Dáil na nÓg council.

On young people’s research on sex education, the 2009 Dáil na nÓg council carried out a survey on the implementation of SPHE and RSE in secondary schools. Some 94 schools in 13 counties took part in the RSE survey and it emerged that: 63% of students surveyed said they never had an RSE class; in 50% of schools surveyed RSE was timetabled into religion classes and 91% of young people felt that learning RSE in school was either important or very impor- tant to their education.

The Donegal Comhairle na nÓg has worked on the topic of sexual health in schools. It recently compiled questions to be put to survey students in the Donegal schools in order to dis- cover the extent to which the sexual health element of RSE is being taught in Donegal. It was examining the best way to circulate the surveys to the students to get an honest answer without an influence from teachers and principals.

Ms Mairead Coady: Several comhairlí are currently working on making STI testing clinics available to young people and providing educational leaflets for them. Roscommon Comhairle na nÓg has been working on sexual health for the past year. It has developed a leaflet which contains common facts and fictions relating to STIs. This leaflet should be released within the next few months. Roscommon is also campaigning for funding for a mobile STI testing facility.

On solutions in respect of SPHE and RSE, young people need a consistent relationships and sexual education curriculum that is the same in every second level school. This can be achieved if social, personal and health education teacher training is made mandatory in order to ensure an acceptable teaching standard. Leaving cycle students need more relationships and sexuality education.

In the context of STI clinics, young people need information about services and require ac- cess to such services locally. In addition, more services are needed.

Mr. Éamonn Ó Briain: This year 14 comhairlí are dealing with topics relating to mental health. Mental health is an issue discussed regularly by all comhairlí across the country. The issues that continually arise in this area are: the lack of mental health services; and the lack of awareness among teenagers about mental health services. The Comhairle na nÓg national ex- ecutive met Mr. Martin Rogan, the HSE’s national direct for mental health, to discuss such ser- vices. After meeting him it was clear that although there are mental health services for young

14 Joint Committee on Health and Children people, they do not know about them or how to access them. Various comhairlí are working on this issue, including comhairlí in County Louth and in Limerick city. The Comhairle na nÓg mental health initiatives are described in the national showcase programme.

The Limerick city Comhairle na nÓg is working on the promotion of positive mental health. It plans to develop a resource pack for young people, including information on local services and coping mechanisms to deal with stress. Its members surveyed 200 young people to find out what stresses them, how they deal with this stress and their knowledge of local services.

Mr. Gerard Maguire: The County Louth comhairle is also working on promoting positive mental health. To combat this issue, it has developed a mental health smartphone application, which gives hints and advice on dealing with mental health issues. It is the first phone app of its kind for young people in Ireland. It is quick, easy and free to download and share.

What we would like to achieve at today’s meeting is to stress that while services are in place, these are not distributed evenly across the country. There is a lack of services in some areas. However, we regard a lack of awareness as being a more significant issue. We ask for an increased effort in publicising the available facilities for young people.

We want to make the committee aware of the work of Comhairle na nÓg and of the impor- tance of these issues to the young people of Ireland. We ask members to contact their local comhairlí in order to learn about the work being done on these issues. I ask them to take the opinions of young people into consideration when making decisions.

Mr. Jamie Wiggins: We thank the committee members for listening to our presentation. We will answer any questions from members.

Chairman: I thank the members of the delegation for their very informative, enterprising and sound presentation.

Senator Marc MacSharry: I thank the delegates for taking the time to attend this meeting and talk to members. I commend the excellent presentation. I congratulate Mr. Maguire on the app, which I will download as soon as the Chairman allows me to turn on my phone in a few minutes.

Chairman: I will do the same.

Senator Marc MacSharry: The app is an excellent idea. I have a question about the stig- matisation associated with mental health issues. Do young people shy away from other young people with mental health issues? If somebody has a mental health issue, do people say, “Oh my God, we don’t hang around with that person” or “That person has something wrong with them”? It seems to be a significant problem in this country. Two years ago, in an anonymous survey of all Members of the Oireachtas, which was not specifically about the issue of adopting or having children, more than 50% of people surveyed replied that someone in the Oireachtas with a mental health issue should not have children. Is that not unbelievable? It showed us how stigmatisation is a serious issue. How can the Oireachtas and the Legislature help Comhairle na nÓg in its efforts to destigmatise mental health issues so that having a mental health issue would be regarded as being as commonplace as having a cold?

Senator Jillian van Turnhout: I thank the delegates for packing so much into their presen- tation. I refer to the issue of sexual health. I think the presentation emphasised sexual health over sexual relationships. My husband is Dutch and in the Netherlands much time is devoted

15 Youth Issues: Discussion with Comhairle na nÓg to relationship education and awareness. Is it the case in schools that the word “sexual” makes everybody wary of dealing with this matter? Should the emphasis not be more on young people developing relationships of which sex is one aspect? I note the point about access to STI clin- ics. Are there issues with regard to parental consent for children and young people to access information? Is there a role for youth cafés or other spaces to allow services to be provided in a more informal setting?

I was privileged to attend the showcase organised by Comhairle na nÓg and I applaud the work of the comhairlí on the issue of mental health. I refer to the various media campaigns about youth mental health issues. I ask how awareness can be increased, because we are all agreed this is necessary.

Deputy Peter Fitzpatrick: I welcome the national executives of Comhairle na nÓg. The age range of comhairlí members is between 12 and 18 years. Some of the topics listed are about sexual health and mental health. I would like to attend one of the meetings. Although this age group consists of young teenagers, these are very serious topics. Who attends the meetings? Are doctors and nurses and other professionals invited to speak at them?

Mr. Maguire did a survey of 200 people on the issue of mental health. What was the feed- back from the survey? What types of person completed the survey? I have been a Deputy for 18 months and this delegation is definitely one of the most impressive delegations I have met here. In my view, the delegates are beyond their years, so to speak. I am very impressed.

Deputy Catherine Byrne: I thank the delegates for their opening presentation. I am a mother of teenagers. They tell me that as a politician I should get my head around issues. They have other sayings but I could not repeat them here. Mental health and sexual health issues have been taboo subjects for a very long time. I remember a teacher in my school handing out a book in the classroom about sexual education matters. She told us to bring it home and read it. In my view, it should not be part of a teacher’s job to teach classes in relationships and sexuality education, RSE, or social, personal and health education, SPHE. This work should be done by specialists such as doctors and other professional health care workers who could come to the schools for as little as half an hour a week. This would be preferable to asking teachers to deal with these matters in religion class or as part of the SPHE programme. Young people today have very different views from mine. I have four children at home who are constantly on my shoulder. They think differently about things. They look at the space differently, whatever that means.

I note that 91% of young people surveyed think that participating in RSE at school is either important or very important. If nothing else comes out of the presentation, we should take note of that survey result and the number of young people who regard this programme as important. Qualified people who can speak openly and honestly to young people should be teaching these classes. In the case of my teenagers, they had no intention of discussing anything about them- selves or their friends with a teacher who was also teaching them maths or religious knowledge.

I used to give talks to transition year classes in my local schools. The previous Government introduced a science education policy. A bus used to travel around the country to introduce sci- ence subjects to schoolchildren. I suggest using a bus which could travel to both primary and secondary schools and would be staffed by qualified personnel. I suggest it would only need half an hour’s class time during the week for students to use the resources on the bus and to ask questions. Booklets are available in doctors’ surgeries and in maternity hospitals - such as in the Coombe in my neighbourhood - which describe sexually transmitted diseases. Young people 16 Joint Committee on Health and Children are very aware of these dangers but they need to be educated about them.

The duty of the Government is to consider changes in educational programmes. The SPHE and RSE classes are past their sell-by dates and need to be replaced. I suggest that professional people should be involved rather than leaving it to the teacher who teaches religion.

Mr. Éamonn Ó Briain: On the question of whether the stigma features throughout the country, I was at a presentation on Tuesday delivered by a member of Headstrong, which is planning on starting a Jigsaw initiative in Limerick. The organisation surveyed young people across Limerick city on mental health, and on the simple question as to what constitutes mental health, the majority of answers referred to drugs, alcohol, depression, suicide and schizophre- nia. There was not one positive answer; they were all purely negative. It is difficult to state directly what can be done about it. In Limerick, we are trying to put a pack together promoting positive mental health. At our annual general meeting, we focused solely on what one can do to deal with stress and stay positive. It is a question of going out to promote the fact that there are ways of coping with problems. It is not a question of showing the various illnesses or their symptoms. While doing so is important, it is more important to educate people on how to stay positive at school and deal with stress.

Chairman: Does Mr. Ó Briain believe his peer group is listening and prepared to offer sup- port and have people look after one another?

Mr. Éamonn Ó Briain: Definitely. If one puts something negative to young people, one will only receive a negative reply. We found that when one presents young people with positive things to do, including workshops that are based purely on positivity, they work together better and support each other. Everyone supports the idea of promoting positive mental health.

Chairman: What is the response to the other questions?

Mr. Gerard Maguire: Deputy Fitzpatrick is more than welcome to come along to our next meeting, on 3 December, and speak about mental health. It will be in the county council’s premises and is to start at 7 p.m. and end at 9 p.m. The elections are held on that day also so it will be a fun meeting to attend.

At our 2011 Comhairle na nÓg AGM, mental health was the main issue, mainly because it is still a taboo subject. That was according to the feedback we received. This year, mental health arose again, and it also arose in 2010. It has arisen for three years in a row. It is obviously still a prominent issue.

Chairman: Why?

Mr. Gerard Maguire: There are wider topics related to the issue of mental health. The concept of mental illness includes depression and suicide. There are many sub-topics, includ- ing exam stress. This is the main reason, but perhaps if we focused on one aspect, we would have to eliminate the others. The problem is so considerable that it will take years to solve. At Comhairle na nÓg level, a different topic will have to be taken every year.

Senator Jillian van Turnhout: Reference was made to positivity and the fact that young people will react positively if something positive is put to them. Is this because the initiatives emanate from young people rather than the State or adults? The showcased initiatives are by and for young people. Does this make a difference?

17 Youth Issues: Discussion with Comhairle na nÓg Mr. Éamonn Ó Briain: Yes, it makes a big difference. The model is much more interactive than others, and that makes a difference. Our AGMs and the pack, for example, are designed for and delivered by young people. By contrast, in school one receives a sheet and must cat- egorise each mental illness, for example. In my school, the teacher has not been in for two weeks. Pupils just received a sheet and were told to bring it home, read it, fill it in, or do what one wanted with it. They were told that if they wanted to study, they could do so. Focusing on a topic makes all the difference.

Senator Jillian van Turnhout: Maybe young people should design the programme.

Chairman: What about Deputy Byrne’s questions?

Deputy Catherine Byrne: They were observations more than anything else.

Mr. Gerard Maguire: Kerry Comhairle na nÓg had a bus-based youth café that travelled all around the county. Perhaps we could use such an idea but, instead of having a youth café, there could be a sexual health bus. We have worked on such ideas in the past. Perhaps we could talk to those responsible.

Ms Máiréad Coady: In Roscommon, the authorities are trying to obtain funding for a mo- bile STI testing clinic. This initiative could be run in conjunction with an initiative to improve the outlook on sexual and mental health. The two could be combined if run properly. If proper funding and supports are provided, there could be a very good and effective service. The prob- lem is obtaining the funding and staff.

Chairman: On Deputy Byrne’s point, I used to teach religion, RSE and SPHE. Is the Deputy correct that a teacher may not necessarily be the best person to discuss the matters in question?

Ms Máiréad Coady: At the Comhairle na nÓg national executive showcase day, I was pres- ent at the sexual health talk. A girl stated two individuals visit the fifth and sixth year classes in her school every year to talk openly about their sexual experiences and problems. This de- velops a conversation. It may have been in Donegal but I am not sure. Where two people talk about their problems, it makes others more likely to open up and talk about theirs.

Mr. Jamie Wiggins: I agree that there should be an individual other than the teacher. At the last AGM in Donegal, there was a discussion on this matter at which students admitted they ask awkward questions on purpose just to make the teacher feel more uncomfortable or to try to be funny. If people were specially trained to deal with awkward questions, they would be more equipped to respond to students of this mentality.

Chairman: That is a good point. Is the recommendation regarding STI testing clinics made universally? Will the services be made available in specific areas? Why was this solution rec- ommended as opposed to another?

Ms Máiréad Coady: There is no STI testing clinic in Kilkenny. The closest is in Carlow or Waterford. For a young person who does not want to go to her mother to state she may have picked up an infection, getting to Carlow or Waterford is a big deal. She must make up an excuse. It is a considerable issue. If there were a clinic in Kilkenny, one could say one was just going shopping for the day with the girls. This would be easier. It is a problem getting to clinics.

18 Joint Committee on Health and Children Chairman: Do legislators and others need to take more account of levels of sexual activity?

Mr. Gerard Maguire: There is a significant report on RSE. I presume that if there were improvements in teaching in this regard, the incidence of STIs would decrease.

Chairman: That is a good point. Have the delegates got views on bullying, including cy- berbullying on Facebook? Have they discussed this subject?

Mr. Éamonn Ó Briain: Many people-----

Chairman: I should have said social media rather than Facebook.

Mr. Éamonn Ó Briain: My view is probably in the minority. Many people like to play the blame game when it comes to cyberbullying. They blame Ask.fm, Facebook and other websites for what occurs rather than examining what really causes the problem. If, for example, one has 1,000 friends on Facebook and does not know any of them, and if one opens an Ask.fm account on which one can be asked anything, it will lead to problems. If one opens an Ask.fm account but has only 100 Facebook friends, whom one knows, one will not have a problem.

Chairman: Could Mr. Ó Briain explain Ask.fm to members and other viewers?

Mr. Éamonn Ó Briain: I do not believe Ask.fm is part of Facebook. One opens an account on the website and creates a link to Facebook, at which point anybody on Facebook can ask one a question.

Senator Jillian van Turnhout: One can be anonymous.

Senator Marc MacSharry: On the Internet generally, including Ask.fm and other chat fora, is anonymity important? Should people have to use their names?

Mr. Éamonn Ó Briain: Ask.fm is a website that is purely designed for being anonymous while Facebook gives a member’s full details.

Senator Marc MacSharry: Would it be better if we all had to use our names?

Mr. Éamonn Ó Briain: Yes.

Ms Mairead Coady: People can hide behind a computer screen.

Mr. Gerard Maguire: I would be more in favour of educating people of the dangers of the Internet because one cannot censor Internet sites. Doing so would eradicate some of the problems.

Chairman: Are the majority of teenagers aware of the dangers of the Internet?

Mr. Gerard Maguire: I think they would be. However, for example, some people might not know what Ask.fm is all about. If they were more educated, they might be more cautious. Education is the way out of it.

Chairman: That is a good answer.

Deputy Catherine Byrne: What Éamonn Ó Briain said about how one uses Facebook and other sites is important. I have two teenagers at home and I am very conscious they are on Facebook. They know who they should invite as friends. They also tell me exactly what was said here today. We cannot always blame the Internet for people making choices in their lives. 19 Youth Issues: Discussion with Comhairle na nÓg This is very relevant in light of some young people committing suicide in recent weeks. It is important parents can talk with their teenagers about who they are friends with on Facebook. I have an open mind about this. I do not stand looking over my teenagers’ shoulders when they are on the computer. If I went into their room, they would actually invite me to see some of the comments, as I would know their friends, rather than switch off the site. We tend to blame the Internet for problems in our lives. However, if there was proper education about it and people had better self-worth, it would leave people more confident in saying “No” to cyberbullying.

Chairman: To be fair, the most important point is that the term used in social media is “friends”. In a politician’s case, a social media follower may not be a friend at all. Many of them post messages which are objectionable.

Deputy Robert Troy: As well as derogatory.

Chairman: If we learned nothing else today, Éamonn Ó Briain’s comments about Facebook should be promulgated across the whole of society.

Senator Jillian van Turnhout: My point is to build on that. There is also a role for adults. We are giving one message to children about Facebook and Twitter. When adults do not act appropriately on these sites, however, we deal with it differently. We have to take on our re- sponsibility as role models in how different social networking sites are used.

While I agree on the point of the importance of education, there is also a huge power in young people telling their peers how they deal with being trolled and that it is okay to ignore it. It can give young people solidarity that they are not alone in being trolled. When one is in a difficult situation in life and realises one is not on one’s own, it makes it easier to get through it.

Deputy Robert Troy: It is appropriate the delegation is here today because later on in the Dáil the Minister for Education and Skills is taking statements on the proposed new junior certificate. In light of that, perhaps the delegation could give us suggestions on the teaching of SPHE, social personal and health education, and relationships and sexuality education, RSE, in the new junior certificate.

A constitutional convention has been established and I feel it is unfortunate younger people do not have a greater role and say in it. I have requested the Minister for Children and Youth Affairs to engage with the executive of Comhairle na nÓg on constitutional changes. One of the proposals is to reduce the voting age to 17 yet no one under the age of 18 can partake in the convention.

Mr. Jamie Wiggins: What was said before was that it might be better to have someone from outside the school and who would be more equipped to teach the RSE course.

Chairman: Should that be an anonymous person?

Mr. Jamie Wiggins: Perhaps it should be a youth worker, a person with whom students would be friendly.

Ms Mairead Coady: There was a woman who had a sexual health talk at the Comhairle na nÓg national day. She goes to different schools and spends a double class with them. Students told me they got so much more from her as they she and they tend to be more open with one another.

Mr. Gerard Maguire: From our research we realised there are not many problems with the 20 Joint Committee on Health and Children curriculum. The problem lies in the approach to teaching it. Different teachers teach it different ways. Some teachers leave out bits that they feel uncomfortable about teaching. The approach needs to be more consistent.

Mr. Éamonn Ó Briain: It really is at the discretion of the school. One colleague informed us that his school changed the title of the course to religion and sexual health education rather than relationships and sexuality education. There is no managing of how the teacher teaches it. If there were more guidelines on this it would better.

Chairman: I thank the delegation for its refreshing presentation and ability to answer the committee’s questions. This was a valuable exercise and a great experience for us. I hope the delegation enjoyed attending this meeting and found it worthwhile. As somebody who will be on the constitutional convention we can bring Deputy Troy’s point on talking to young people about the younger voting age to the convention.

I thank the witnesses for appearing before the committee. We want to engage with them. This part of the Oireachtas is concerned with children, youth affairs and health and they have a right to come in here and voice their concerns and views. They have done so this morning in a clear, cogent and emphatic manner. We have been enriched by their presence and I hope they will appear before the committee again in the near future.

I remind the members that the Select Sub-Committee on Health will meet next Tuesday, 27 November 2012 at 6 p.m. to discuss the Health Insurance (Amendment) Bill. The Select Sub-Committee on Health will also meet next Thursday, 29 November at 9.30 a.m. to deal with the health Estimate. The Select Sub-Committee on Children and Youth Affairs will meet next Thursday, 29 November at 11.15 a.m.

Deputy Catherine Byrne: Is the Chairman sending those to us?

Chairman: It will be sent, yes.

A Member: Do we have an ordinary meeting scheduled?

Chairman: Unfortunately, there will not be an ordinary meeting next week. The next joint committee meeting will be at 9.30 a.m. on Thursday, 6 December. We will adjourn until that date. Go raibh maith agat.

The joint committee adjourned at 11.45 a.m. until 9.30 a.m. on Thursday, 6 December 2012.

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