We now move to Leaders' Questions. I ask that all Members adhere to the rules laid down regarding the time allocated for each question.

Ardóidh mé inniu an úinéireacht atá beartaithe don ospidéal náisiúnta máithreachais agus atá molta ag an Rialtas agus ag an Aire Sláinte. In ainneoin na himní tromchúisí atá curtha in iúl ag go leor ban agus go leor dochtúirí faoi athlonnú an ospidéil go dtí suíomh Ospidéal Naomh Uinseann i mBaile Átha Cliath, tá an Rialtas ag leanúint go dícheallach leis an rogha léas a bheith aige ar an talamh ar a dtógfar an t-ospidéal in áit a bheith ina úinéir air. Ní dhéanann sé ciall ar chor ar bith go mbeidh píosa iontach tábhachtach dár mbonneagar sláinte a thógáil ar chostas thar €1 billiún ar thalamh nach mbeidh úinéireacht ag an Stát air.

I wish to raise the proposed ownership model of the national maternity hospital being pursued by the Government and the Minister for Health. Despite serious concerns being voiced by many women and many prominent medics about the relocation of the hospital to the site at St. Vincent's University Hospital in Dublin, the Government is relentlessly pursuing the option of leasing the land on which the hospital will be built instead of owning it outright. It is very concerning that the deputy chairperson of the HSE board, Professor Deirdre Madden, a leading medical law scholar, and Dr. Sarah McLoughlin, a patient advocate on the board, both dissented from the board's decision to recommend the legal framework.

Everyone in this House agrees that a new national maternity hospital needs to be built and become operational as soon as possible but expedience cannot be at the cost of rights in any way. The full range of legally permissible services must be available in the hospital to any qualifying patient. The minutes of the HSE board meeting of 14 March show that Professor Madden and Dr. McLoughlin expressed concerns at the "legal ownership of the site and building, and the governance and control of the proposed new maternity hospital" and felt that these concerns were not adequately addressed in the revised legal framework.

It does not make any sense that the Government is going to build a vital piece of health infrastructure at a likely cost of approximately €1 billion on land the State does not own. The Taoiseach said yesterday that the lease would only cost €10 per year but that does not change the fact that the new hospital will have a private landlord. The question must be asked once again, because no answers were forthcoming on this issue yesterday from the Taoiseach, as to why the Sisters of Charity and St. Vincent's University Hospital cannot simply gift the land to the State. It is a simple question. What is the answer? Why is the Government accepting this convoluted, messy ownership model that is stoking unease and worry? What we need is a publicly built maternity hospital on publicly owned land delivering public healthcare services for women at a standard of excellence. Sin é. That is what is required. This would protect the State's investment and address the concerns of so many who fear that religious dogma could compromise the delivery of healthcare at the hospital.

We understand from media reports that, among others, the Minister for Tourism, Culture, Arts, Gaeltacht, Sport and Media raised concerns about this model at Cabinet. It is incumbent on the Minister for the Environment, Climate and Communications to give a full answer as to why the Government continues to pursue a model of ownership that does not enjoy the confidence it should. Will he outline his position? Is he satisfied with this model of ownership despite the fact that the land will not be owned by the State?

The Minister for Tourism, Culture, Arts, Gaeltacht, Sport and Media was asked these questions yesterday. As she rightly stated, what we decided at Cabinet on Tuesday is that it would be very good for us to have this debate in order to have full scrutiny and transparency with all the legal documents because people on all sides and from various different parties are concerned. It was right and appropriate for us to make the decision that the Minister for Health would go before the Joint Committee on Health and answer every question in order that every possible angle of this matter might be examined. I fully agree with the Minister for Tourism, Culture, Arts, Gaeltacht, Sport and Media in this regard.

There are very different medical views on this matter. The Deputy quoted one medic versus another. The vast majority of medics and the wider public recognise that the existing situation in the National Maternity Hospital, as good as that facility is in terms of medical care, is intolerable and that we cannot delay. The Master of the hospital attended our parliamentary party meeting yesterday and said that even if we went out and commenced work tomorrow, it would be 2030 before we would see a new hospital in operation at St. Vincent's. Any further delay that would put matters back five, ten or whatever number of years, as we started to look at alternative options, would give rise to real controversy.

My view is that the legal documentation and the various structures show that there will be no religious interference, which was one of the main concerns I have heard over the years in respect of this matter. This is clear and transparent. A good article in The Irish Times today states that legal experts think that if religious interference were allowed, those responsible would rightly be accused of medical negligence. There are legal structures in place to give reassurance in that regard.

The issue of how this hospital will operate is a much wider in nature and relates to our voluntary health and voluntary hospital systems. All three maternity hospitals in Dublin are voluntary hospitals, with structures that in some cases go back over 200 years. There is a debate separate to the religious issue as to whether we should engage in compulsory purchase of those hospitals and move away from a voluntary hospital system. There is an argument to be made in that regard, but it has not formed part of the debate to date. Another article in today's edition of the Irish Independent refers to the fact that the voluntary hospitals are the ones that are currently providing the full range of services, whereas not all public HSE-run hospitals do. This is a complex and difficult issue in terms of the strengths and benefits of voluntary hospitals versus HSE-run hospitals. Our voluntary health system has real benefits.

My view is that the national maternity strategy should be central to this because it provides the guiding direction. The strategy gives me real reassurance and we need to apply it because it recognises that even with the voluntary hospitals, hospital group CEOs will ultimately be accountable to the national director of acute hospitals for all services delivered within the maternity network. That is an important point. This is where the actual direction comes from. What is that direction? It is for a woman-centred system that is midwife-led rather than consultant-led, with much more care in the community. This is what we need to focus on delivering at St. Vincent's, Holles Street, the Rotunda, the Coombe, Limerick and every other maternity hospital. That is the guide as to where we should go and how services should be developed and delivered.

The Minister did not answer my questions. I asked why the Sisters of Charity and St. Vincent's cannot gift this land to the State. It is as simple as that. From what the Minister said, it seems that he supports the idea of spending €1 billion of taxpayers' money building a hospital that we all agree is needed on land that is not owned by the State. Does he agree with the statement that I have not heard a single dissenting voice from anyone who does not believe that the hospital must be in complete public ownership? That should involve not the creation of a lease arrangement but, rather, the transfer of ownership of the site to the State so that there is no uncertainty or lack of clarity regarding ownership. These were the Minister's words in opposition. The difference is that now he has some power to do something about it. It should not involve the creation of a lease arrangement but rather the transfer of ownership of the site to the State so that there is no uncertainty. The Minister previously said that the State needed to step up. It is time for him to step up. Deputy Hourigan was on the radio yesterday saying that this is an incredibly serious issue. She said it went to the core of why people voted for the Green Party. Has the Minister abandoned the position he held, which was that a lease agreement was not acceptable and did not provide the certainty or has he now rolled over to the tune of Fine Gael and Fianna Fáil?

The original approach in terms of how this would be structured was set out in the Mulvey report in 2016. The Government has changed what was set down somewhat. The lease arrangement was originally for 149 years; it is now for 300 years and will cost €10 a year. It is my understanding that the Sisters of Charity were asked if they wanted to sell the land. Their response was that they did not want to do so. My understanding is that they are no longer in the business of healthcare. The St. Vincent's Healthcare Group has decided, as is its right, to retain its voluntary hospital status and operate this co-located model. The change made by the Government is that rather than just St. Vincent's and the National Maternity Hospital having board members, there will be three public interest members, and the Minister will appoint the chair. As stated, we have changed some aspects of the arrangement.

It is still a lease.

The underlying argument in favour of co-location remains. There are good reasons for this, including ensuring the provision of good medical care for women. Patients should be able to go from one ward to the another; from the maternity hospital to the general hospital.

Will the Minister answer a question? Why is it beyond the capability of this Government - and why was it beyond that of the two previous Fine Gael-led Governments - to countenance a State-owned and controlled national maternity hospital, built on State lands and through the use of State funds? The Minister once agreed that this was the only credible outcome. In 2017, he told the Dáil that the new maternity hospital "should involve not the creation of a lease arrangement but rather the transfer of ownership of the site to the State so that there is no uncertainty or lack of clarity on the ownership". Has he changed his mind in that regard? Does he, like the Taoiseach, believe that a lease agreement is practically the same as ownership, so what is the big deal? It is only the future of women's healthcare services that is on the line and, of course, a €1 billion investment of public funds. The Taoiseach made a big thing of the €10 annual rental charge yesterday. Tellingly, he failed to mention that the actual rent stipulated in the lease agreement is €850,000 per year. It will be reduced to €10 as long a list of six conditions are complied with, including that the landlord, St. Vincent's Holdings, retains a controlling stake over the use of the hospital. If these conditions are breached, the rent will revert upwards. If St. Vincent's Holdings is magnanimously offering an annual rent of €10, can the Minister explain why this punitive penalty clause exists? It is especially bizarre that a separate legal document - an options agreement - specifically countenances the State purchasing the site. If everyone agrees that it is legally feasible that the State could buy the site, and that outcome is expressly provided for in legal documents, why is the State not just buying the site?

There has been a lot of talk about conspiracy theories in recent days, with those who have genuine concerns about this deal being vilified and equated almost to anti-vaxxers or Covid deniers. This is something I personally find pretty reprehensible. If we want to talk about conspiracy theories, I have a better one. An article in The Irish Times today suggests that the Minister of Health has 100% guaranteed that terminations and sterilisations will be available in the new hospital, a guarantee which, as reported by the media, could be relied on in legal proceedings as evidence of the Government's intention concerning the hospital. That is nonsense. The only thing that a court will have regard to is the legal documents underpinning the deal. A Minister's guarantee, unless it is contained in the legal documents, is worthless.

I have two questions. Why, when the Minister, Deputy Ryan, once insisted that the State should own the site, is he apparently happy to go along with this deal? Second, is the rest of his party in agreement with him?

As I said in my response to the question from Deputy Doherty, my understanding is that the Government and that which preceded it did approach St. Vincent's to see if it would be possible to purchase the land outright. The hospital group decided that it, as a voluntary hospital, wanted to run with the arrangement involving Holles Street and the new board . That arrangement has changed, with public interest directors being added to the board. With St. Vincent's saying "No" and with real benefits in a co-located system, the question that arises for the Government is what to do. Do we look for another hospital or another co-location facility, recognising that we are probably going to have the same issue with the Coombe and Rotunda in time, because the strategy is to move towards the model where our maternity hospitals are co-located? There are benefits in that regard. We are agreed on that. Therefore, the choice for the Government is whether to turn down a 300-year lease at €10 a year, which is akin to ownership. There is not a material difference between outright ownership and a 300-year lease at that rate. It is better to progress with that, because there is an urgency around delivering combined health services, rather than going back to the drawing board and waiting the five, ten or 15 years that it tends to take this State, unfortunately, to deliver principal health systems. We have not built a new maternity hospital probably since the Coombe in the 1950s or Holles Street in the 1930s. I cannot think of another instance of one being built since then.

The Mercy hospital in Cork was built after that.

Sorry, the Mercy hospital in Cork was built. We do not build a lot of maternity hospitals, and we are incredibly slow at delivering them. We need to deliver. A 300-year lease gives us the reassurances that we need. The legal structures give real assurance against the risk of religious interference, which, I understand, has been a real concern. I believe that matter has been addressed. In my mind, doing nothing, walking away and deciding not to take that option would not be the right approach.

We look forward to the debate at the Oireachtas committee this week and to hearing what the alternative approach is, how we can avoid delay and how we might move forward in another way. I do not see another way. It is important that we act.

Going back to the key point - and I hope the Deputy, as one of the people involved in bringing forward the Sláintecare report, agrees with this - I see the national maternity strategy as being centrally connected to it. Does the Deputy agree that the focus needs to be not only on who owns the hospital but also on how we get a midwife-led, woman-centred maternity system in place? I do not believe that we have delivered the maternity strategy with the pace and the ambition that is required. That is where the focus needs to be. It is not just about whether a 300-year lease constitutes effective ownership. That is not the key issue for the women of this country. We need to focus on the care.

The Minister is being quite disingenuous. This project has been delayed for almost a decade. Four successive Ministers for Health were incapable of delivering the project in a way that would satisfy the public in terms of the independence of the hospital and the protection of a massive public investment. The Minister referred to co-location. Nobody argues about that. This is about so much more than co-location, however. It is about a takeover. Does the Minister realise, because I do not think he does, that the new national maternity hospital is due to become a wholly owned subsidiary of St. Vincent's Holdings? Its status is to change completely. Furthermore, we all know that the Vatican had to approve the nuns' transfer of their shareholding to the new holding company. When asked what terms and conditions were attached to this transfer and whether any documentation exists spelling them out, the Minister of Health flippantly responded that we would have to talk to the Vatican about the matter and that the Government does not have any such documents. Is the Minister, Deputy Ryan, seriously telling us that that question has never been asked in the context of that delay? If it has not been asked, why is that the case?

With regard to the status of the institution, the other people I have listened to, including women friends, colleagues, those who are connected to the hospital and clinicians-----

Did the Minister read the document?

Please, Deputy. The Minister is responding.

I am trying to read every single document.

Is it acceptable------

Can I just make the point-----

Is it acceptable that it will be a wholly owned subsidiary?

Deputy, let the Minister answer the questions already asked.

She is not interested in answers; she never has been.

I wish to make the point that it seems to me that the vast majority of clinicians in the existing hospital are arguing very strongly that we should proceed.

Of course, because they want a new hospital.

If the Deputy is saying that the institution is deeply worried about the loss of its independence or that St. Vincent's will be taking it over, I do not hear that from the clinicians in Holles Street.

Did they have access to the legal documents?

I will get back to the key point I want to make. It is not just the conditions. Under the national maternity strategy, it is the national director of acute hospital services who will have ultimate accountability and that is important to remember.

It is St. Vincent's Holdings that will control the national maternity hospital.

It is the State-----

Read the documents.

-----and State policy that will decide how this is run.

The current documents; not those from a few years ago.

Can we please let the Minister who is asked questions answer without interruption?

The Deputy is not interested in answers; never has been.

I am, you know.

You are not.

I am. I would love it if you were.

You are interested in controversy; that is all.

It would be helpful for us on this side if the questions were answered and with a little less heckling from the colleagues to the right of the Minister, Deputy Ryan. I am not one bit reassured. I welcome the pause, but I am deeply troubled that at the same time there is a pause that will allow the committee to look at it, we have reports in The Irish Times, a newspaper of repute, telling us that the Government has no intention of changing any of the documents. It is as if the Government is seeking to calm the masses. I will look at the Minister's point on the existing hospital. The conditions are intolerable but I ask the Minister to please not use up the reply telling me that. On this side of the House, we have repeatedly called for the hospital to be co-located on a site owned by the public and run by the State. What is equally intolerable is the failure of the Minister, the Taoiseach, the Tánaiste and the Minister for Health to deal with any of the issues we are raising today.

Deputy Shortall raised the issue of rent and the Minister conveniently ignored it. Even with my background, I am struggling to read through the documents we got. I look at those documents and I see there is a 299-year lease and a provision for rent. As has been alluded to by Deputy Shortall, the documents set out the position regarding rent. The Minister might explain that further and outline what will be the default position when the higher rent comes into being if the conditions are not met. The Minister might apologise for saying that the delay is on our side when the delay has consistently been on the side of the St. Vincent's Healthcare Group and the Religious Sisters of Charity. The Minister might explain how the gift we were going to get never materialised. He might also explain, as Deputy Doherty asked, why we cannot have the site given over to us in our name.

I have struggled with these documents. I can see no reason for all this complexity. If we look at the senior counsel's opinion that was commissioned by Uplift, it states: "Insofar as ownership of the lands are not obtained, the proposed arrangements are Byzantine in their complexity, almost Kafkaesque". In 2020, Dr. Peter Boylan, in the context of the ownership, was informed by the National Maternity Hospital's lawyers that there would be a plethora of different structures and ownerships and a complexity to the legal documents. The Minister is telling us today that the situation is intolerable in the hospital. I agree. What is equally intolerable is the Government's failure to deal with the serious concerns we are raising, that Dr. Boylan has raised and that the two dissenting and very distinguished members of the health executive board raised. That is not to mention the women and men of Ireland who are concerned and the three motions overwhelmingly passed by this Dáil asking for public ownership of the hospital.

Hear, hear.

In the context of the report on the front page of The Irish Times today, the Cabinet decided on Tuesday to: open up all the documentation; make sure it was fully transparent; allow the Oireachtas committee to examine, question and investigate; and for the Minister for Health to come back to the Cabinet with observations from that process. That is what was decided at Cabinet. We will have to wait and see what will be decided at Cabinet in two weeks' time. It is not decided on the front page of an Irish newspaper.

No one on our side, in our party or, certainly, from what I have heard, in government is casting blame for the delay or saying it was one side or the other. From listening in recent years, it seems that the central concern relates to religious interference in procedures in a new institution. One of the outcomes of the delay that has occurred in recent years is that there is a clear legal certainty that this will not be the case and that those concerns can be allayed and addressed.

Where is that certainty?

In the constitutional arrangement, the framework and all the legal analysis and documentation. I refer back to another article in The Irish Times today which states that various independent legal experts were asked if they think there is still a concern in that regard. From what I read, the vast majority of those with expertise in the area of medical legal matters stated that should no longer be a concern. It was important that this was addressed.

This matter is complex. It is complex because the charters and rules of governance of Holles Street and the Rotunda Hospital date back to when they were founded 200 or 300 years ago. Trying to bring together one of these institutions with a voluntary hospital organisation is difficult. Our voluntary structures are strange. Let us be honest about that. If you were designing a system from the start, would you design it along the lines of our complex Irish health system which has these effective, flexible and capable voluntary hospital systems? Probably not. We have those systems, however. What would happen if we were to compulsorily purchase the entire voluntary health sector or another sector?

Maybe debate that first.

I am just asking the question because it would involve is a debate on a wider matter. Catherine Day carried out her analysis and compiled a report on how we might manage that. I am of the view that it can be managed and that we can retain a voluntary health system that will be a public health system that will Sláintecare-based and that puts communities first. It should not all be led by and centred on hospitals and consultants. That change needs to come.

This new institution will not answer, solve or change all of those issues. We need it to be built. We also need to ensure that its buildings, etc., will be much better than those in which people in Holles Street are operating at present. For that reason, I look forward to going back to Cabinet in two weeks to hear what has been said at the committee and to make a decision on the matter. Further delay would not be the right choice.

Let me try to clarify the position in 60 seconds. The Government is open to change; is that what the Minister said?

I did not say that.

So the Government is not open to change. That is very good. We have that clarified. My concerns are in respect of the documents I have read and the absence of some extremely important documents, such as, for example, the constitution of the St. Vincent's Healthcare Group. Mr. Menton tells us that the group is evolving into a secular organisation. Evolution is slow and I would like to know where we are in the evolutionary process of the St. Vincent's Healthcare Group. Where is it as a secular organisation?

The Minister mentioned complexity. There is no complexity here. This is the 21st century. On the basis of what has happened in our history, which I do not have time to go into, we have to have a national maternity hospital on a public site.

On the documents that are missing - in addition to the constitution I have mentioned - I would like to know on what basis the Religious Sisters of Charity was finally happy to give over its share. How did the Vatican allow the order to do that and still comply with its ethics and so on? It is difficult to get that information. This matter needs to be the subject of proper debate here in the Dáil.

I am familiar with St. Vincent's University Hospital. It is my local hospital and many of my family and friends have been treated there.

I am asking the Minister for specifics.

Can I answer the question?

Certainly. Please do.

The Deputy asked me about the nature of its secular values or its-----

I asked the Minister if the Government is open to change, and he said it is not.

How can the Deputy say we are heckling?

I will try to answer if I can.

I apologise.

The Deputy asked me how we can be sure that the ethos of St. Vincent's is secular. That is one of the questions she asked. One of the analysis documents I read today looked at its objectives or mission statement. Whether they are religious or secular, the values referred to in that document are ones we would all agree on. They are not two separate or completely different worlds. The values the hospital wants to deliver - I have seen it deliver them - relate to valuing and protecting life, the Hippocratic oath and treating patients with fairness and equity. As I understand it, that is outlined in the hospital's mission statement.

No birth control.

It is secular, but that does not mean it is completely divorced from the past because it has often done a lot of that.

I have seen first hand the incredible care that it provides to the patients. We need to make sure that the skills it has are also available to the women in the national maternity hospital not an ambulance ride away but in a corridor beside it. That is why this approach is being taken.

For the information of the House, the Business Committee agreed this morning that there will be a debate in the House next week on this matter. Next week also, the Oireachtas Joint Committee on Health will hear a presentation from the Minister at which we hope all the questions Members have will be dealt with.