Apologies have been received from Deputy Ward and Senator Byrne. Members are all very welcome. I remind all those in attendance to ensure their mobile phones are on silent mode or switched off.

As witnesses are within the precincts of Leinster House, they are protected by absolute privilege in respect of the presentation they make to the committee. This means they have an absolute defence against any defamation action for anything they say at the meeting. However, witnesses are expected to not abuse this privilege and it is my duty as Cathaoirleach to ensure this privilege is not abused. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are also reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person or entity outside of the Houses or an official of the Houses, either by name or in such a way as to make him or her identifiable.

The agenda for today's meeting of the committee is an engagement with our witnesses to discuss Traveller health. Our witnesses are Mr. Jim Walsh and Ms Siobhán Hargis, both from the Department of Health; and Ms Martina Queally, Ms Aisling Heffernan and Mr. Tony McCusker of the HSE. I invite Mr. Walsh to make his opening statement, followed by Ms Queally. We will then proceed with a question-and-answer session.

I thank the Chair and the committee for the invitation to discuss progress made in relation to the national Traveller health action plan, the report on the Traveller and Roma mental health working group and other related matters. I am the principal officer responsible for Traveller health in the Department. I am joined by my colleague Ms Siobhán Hargis, who is the principal officer responsible for mental health policy.

The Department attended the committee in November to discuss health inequalities and mental health issues affecting Travellers. For today, I propose to maximise the benefit of this second appearance by concentrating in my opening statement on the public health response to the health issues facing Travellers.

Public health is focused on protecting and improving the health and well-being of the population, ranging from disease prevention, healthy lifestyles and, critically, addressing the social determinants of health. While the Traveller population is relatively small - at 33,000 people, it is the same size as the population of Navan – it is a minority ethnic group experiencing significant health inequalities. Public health policy can support and enable Travellers to have healthier lives.

A key indicator of public health is life expectancy. In Ireland, life expectancy is now 82.6 years, which ranks us fifth among EU member states. By contrast, previous data suggest that the life expectancy for Travellers was up to 15 years less than the norm. Recognising this, the Department’s statement of strategy for 2025 to 2028 identifies measures that improve life expectancy for Travellers as a priority for public health. The goal here is to level up Traveller life expectancy to this high national standard.

The main policy instrument for improving Traveller health outcomes, including life expectancy, is the national Traveller health action plan, which was published jointly by the Department and the HSE in 2022. I am sure members are familiar with it. The action plan was developed in consultation with Traveller organisations and is delivered in partnership with Travellers.

The action plan is a landmark document that recognises the right of Travellers to the highest attainable standard of physical and mental health, as is the norm in Irish society. It is based on a policy of progressive universalism, whereby Travellers have the same entitlements to health services as the wider population, while recognising that targeted measures are required to ensure timely and equitable access delivered in a culturally appropriate way. The HSE leads on the implementation of the action plan, overseen by a national monitoring group with representation from the Department and Traveller organisations. The HSE has recently completed a mid-term review of the plan and HSE colleagues can provide details of this review.

A central component of the targeted approach to Traveller health is the HSE-funded and Traveller-led network of primary healthcare projects. The Department and the HSE allocate significant resources to these projects, including an additional €1 million since 2023. To ensure this critical infrastructure is effective in delivering the action plan, the Department has asked the HSE to carry out an evaluation of the impact of these projects.

There is a related process for addressing Traveller mental health under the national Traveller and Roma mental health working group. Its recent report draws together initiatives being delivered under the various mental health policies and identifies relevant strengths, challenges, gaps and barriers. This report will inform current and future development. HSE colleagues can talk a bit more about that report.

The Department is committed to a fair and equitable approach to funding healthcare services for Travellers under the action plan, based on a population-based resource allocation model. The new health regions in the HSE will have devolved funding and decision-making in this regard. The Department provides the HSE with a ring-fenced annual budget of €16 million for the provision of Traveller-specific health services, including €2.3 million for mental health. Further resources of €1 million are provided in budget 2026. In all, this represents an increase of 70% in funding since the action plan commenced.

Returning to the public health response which the Department is leading on, we recognise that health services alone cannot address the health inequalities that Travellers experience. We must also address the social determinants of Traveller health, such as education, quality accommodation, fair work opportunities, adequate income, acceptable living standards, access to transport and a sustainable environment. These are reflective of the social and economic disadvantage and discrimination experienced by the Traveller population.

The national Traveller and Roma inclusion strategy is the whole-of-government response to these disadvantaged needs of Travellers. The vision for the strategy is a safe, fair and inclusive Ireland where Travellers are supported to lead inclusive, healthy and fulfilling lives. It includes a strategic objective to address the social determinants of Traveller health through a comprehensive public health response providing tailored and affirmative measures to promote health and reduce inequalities.

To meet this objective, the Department has developed three additional public health measures to drive health equity for Travellers. These complement the Traveller health action plan. The first measure is a two-year programme, with dormant accounts funding of €710,000, for five local projects to address the social determinants of Traveller health. This is run in conjunction with the Sláintecare healthy communities programme. The aim here is to address the societal factors that impact Traveller health, such as living conditions, social activities for Traveller men, school supports and access to employment.

The second measure is a pilot programme focused on supporting the health and social needs of Traveller women at risk of homelessness. This is under the women’s health action plan. Initial funding of €500,000 was allocated to the pilot programme. In budget 2026, a further €120,000 in recurring funding was allocated to mainstream a model of care that has been shown to be successful.

The third measure is a prevention and early intervention initiative focused on Traveller child health. The initiative, run through the HSE, is called "Brighter Beginnings", and it is being rolled out on an incremental basis across the HSE health regions, with annual funding of €1 million at this point. The aim of the initiative is to develop a model of best practice for delivering the national healthy childhood programme with Traveller children. It links Traveller children to routine public health interventions, such as screening and vaccinations and early interventions where issues arise, and supports Traveller families in the crucial early years of life. Brighter Beginnings reflects a life-course understanding of Traveller health that aims to give Traveller children the best start in life and to build a foundation for lifelong health and well-being. It is linked with the Government child poverty and well-being programme, in particular the priority to consolidate and integrate public health, family and parental supports for children in poverty.

I emphasise the Department’s commitment to working collaboratively with the HSE, the health regions, Traveller organisations, local government and other State bodies to promote the health of Travellers. It is definitely a whole-of-government response. We appreciate the committee’s focus on the key issues facing the Traveller community. We look forward to discussing with the committee how we can continue to make tangible and lasting improvements in Traveller health and well-being.

I thank the Chair and members of the committee for the invitation to attend today's meeting to discuss the implementation of the national Traveller health action plan and the work of the national Traveller and Roma health group. I am the regional executive officer for the HSE Dublin and south east. I am joined by my colleague Ms Aisling Heffernan, integrated health area manager for Dublin south and Wicklow, who chairs the national Traveller health implementation group. I am also joined by my colleague Mr. Tony McCusker from HSE mental health services.

I wish to begin by affirming, in the strongest possible terms, the HSE’s continued commitment to tackling Traveller health inequalities, and sustaining long-standing partnerships that have shaped Traveller health initiatives over the past 40 years. These partnerships, which include primary healthcare for Traveller projects, Traveller health units, the national Traveller health advisory forum and the national Traveller health implementation group, are essential to ensuring that the lived experience of Travellers continues to inform and shape health planning and service delivery, while also ensuring their direct participation.

We remain acutely aware of the significant challenges before us. Traveller health outcomes, as outlined by my colleague from the Department, continue to fall far below those of the general population, with higher rates of infant mortality, suicide, chronic disease and remarkably shorter life expectancy. The national Traveller health action plan, the development of which I oversaw, sets out an ambitious vision and comprehensive set of actions to address these inequalities over a five-year period. The plan is grounded in the principles of partnership, community development and social inclusion, and focuses on the social determinants of health. We are now past the midpoint of implementation and have made good progress across many areas. Mechanisms are in place to plan, monitor and track Traveller health actions and budgets across the HSE, and research has been commissioned to strengthen how we organise and resource Traveller health work. This includes a midterm review of the national Traveller health action plan, and evaluations of both primary healthcare for Traveller projects and the Traveller health units, as was referenced earlier. We are also finalising a framework for Traveller cultural awareness and anti-racism training to support the delivery of training to HSE staff and ensure that HSE mainstream services are inclusive and responsive to the needs of Travellers. The final phase of the plan will focus on implementing the findings of these reviews.

I would like to highlight the role of the national Traveller health implementation group, NTHIG, which was established in 2023, to oversee and drive the implementation of the plan. The membership includes representatives of HSE senior management, Traveller health networks, Pavee Point and the Department of Health. Recently, a representative from the Department of Children, Equality and Disability, which has responsibility for the national Traveller and Roma inclusion strategy, also joined the NTHIG and this will strengthen the work in the area of the social determinants of Traveller health. Furthermore, NTHIG aims to standardise best practice and embed Traveller-focused work across HSE systems. It is also advancing the introduction of an ethnic identifier in HSE data systems to inform policy with robust, evidence-based data.

I acknowledge in particular challenges in relation to Traveller mental health, as discussed at the committee’s November meeting and to outline the HSE’s co-ordinated response. The national Traveller and Roma mental health group, which is leading the mental health actions detailed in the national Traveller health action plan, is supporting the establishment of a dedicated structure to ensure Traveller mental health is addressed across all relevant policies, such as Sharing the Vision, the national Traveller and Roma inclusion strategy, Connecting for Life and this committee's report. This dedicated group will operate under the national implementation and monitoring committee of Sharing the Vision, and will work directly with Travellers in shaping and delivering a co-ordinated action plan.

I acknowledge the support provided by Government and the Minister, Deputy Butler in the area of Traveller mental health. This will enable the HSE to support existing and new mental health initiatives, including Traveller counselling services, suicide prevention initiatives and suicide crisis assessment nurses, SCAN. While mental health remains a pressing priority, we also recognise the continued importance of improving Traveller physical health, particularly given most premature deaths in the community are linked to physical illness in terms of communicable and chronic diseases. These include cardiovascular disease, cancer and respiratory disease. Optimising our screening services and utilising access to enhanced community care programmes will support us in helping to address these issues in a competent manner.

On a positive note, a recent UCD report on cancer awareness and attitudes among the Traveller community found that there were higher rates of awareness around breast, bowel and cervical cancer, and higher screening rates compared to the general population. This is very welcome, as it has been a strong area of focus for our primary healthcare for Travellers projects. It also found strong levels of health literacy. It demonstrates the value of these projects in supporting access for Travellers to mainstream health services and in delivering critical health messaging.

While good progress has been made under the national Traveller health action plan, the HSE recognises and acknowledges that there is a lot more to do, and we remain deeply committed to working with Traveller organisations and communities as partners to advance this plan and deliver lasting improvements in Traveller health and well-being.

I thank Ms Queally. We move on to the questions. I appreciate Deputy Rice is under time pressure, so I call him first.

I thank the Cathaoirleach and I apologise as I have to head to another meeting. I hope to come back if I can. I am deeply concerned about the statistics regarding Traveller life expectancy, which is more than a decade shorter than that of the general population, as well as the suicide rate and levels of poverty, exclusion and discrimination. These are some of the highest statistics of any ethnic group in all of Europe. I have a deep concern, as do other committee members about those. That is why we have the Department and the HSE before us again. We will continue to press these issues until the outcomes improve. The officials should expect further invitations. I would also like to see us engage with the Ministers responsible and have them before us because we do need to improve outcomes here and looking at the evidence, I do not see outcomes improving at any real scale. That comes back to funding.

I am frustrated to hear the Department official say significant resources are being spent. When we have outcomes that people are dying a decade earlier, there is not enough money being spent, and there are not enough resources in this area. Until the outcomes start to improve, we need to invest far more. It is like dropping a pebble in an ocean. What I would like to the Department to provide, and if the officials cannot today they can write to us, is the historic spend on Traveller health and not just over the past number of years. What I want to know is, from the early 2000s until today, what has been the total budget and how much of that has been core funding and how much is reoccurring or once-off funding. We often get a breakdown of funding over recent years, but it fails to take account of austerity and the huge cuts that were done to the most marginalised communities in this country during the austerity era;. Communities have not recovered from those cuts. I would like a breakdown from the Department and for that analysis to include how much inflation has increased in that time and how much, in real terms, we are now spending compared to what we were spending in 2000. We will be surprised by the results. I would be interested in the analysis on that.

In particular, we are not spending enough on primary healthcare projects. We need real investment in those. Pavee Point published a report entitled Beyond the Poverty Trap, which sets out a roadmap for sustainable Traveller primary healthcare projects. I am also interested in the response of the Department and HSE to those recommendations. Perhaps the witnesses could write to us with a detailed response to each of the recommendations and how they are going to respond to them. It might be good in the future to hear directly from Pavee Point about those recommendations, and how it sees things changing on that front as well.

I want to touch on a number of issues in the national Traveller and Roma mental health working group report. Actions 26 and 27 in particular identify key challenges relating to staffing and vacant posts Where there are staff shortages, is that a funding issue? Where there are vacant posts, are these posts that have previously been filled and are now vacant or are they new posts that remain vacant? There is also an interesting note there about the varying levels of leadership support.

I would like to hear a bit more explicitly about that issue in particular because we know that leadership and leadership support are key in progressing any of these issues.

I would also like to touch on the issues around the funding structures and multi-annual funding. I note one of the comments that came back in the survey referred in particular to the need for projects to be co-designed and co-managed. There is an interesting note there from the LGBT action group. It refers to the lack of services and a need to co-design and co-manage appropriate services so the actual referral pathways exist when LGTB Travellers and Roma present in crisis. The action group has a plan for this co-design but it needs dedicated human resources to make that plan a reality. There is a clear call there for additional human resources so people can co-design and deliver those services. I always remember speaking to a gay Traveller man who said he felt excluded from LGTB spaces because he was a Traveller and from Traveller spaces because he was LGTB. We need to create dedicated spaces and resources to tackle the mental health concerns, in particular, in that part of the community. I will be interested to hear the responses on those issues.

I might start. I note the Deputy wants written documentation back on funding and budgets from the Department and ourselves, so we will take that away.

In terms of leadership support, I would like to take the opportunity to say the Deputy is right about these matters in terms of Traveller health. We are very concerned about the levels of inequality experienced by the Traveller population. We have leadership right across the six regions and there is representation on the national Traveller health action implementation group from across the country. We are working very steadily to try to develop our Traveller health units now in line with our new regions. That will be a core area of work so we can continue to support that infrastructure development. As the Department outlined, there was investment in 2023 to develop two new primary healthcare projects and they are up and running in Limerick and Louth. My colleagues might want to say a bit more about that aspect. That infrastructure is important.

We mentioned the evaluation and Ms Heffernan will talk a little more about that. It is not just about setting the projects up but about continuing to develop them and understanding how we can support them to work effectively. We know they are a really good methodology for working with disadvantaged communities and for building that community development and supportive environment, but we do need to continually support and strengthen them in their work. Where we have high levels in the population, we must make sure they have bespoke services. That is really important and it is a key area of focus in the plan and in our actions.

Mr. McCusker might speak more about the specific mental health questions.

There is a relatively small cohort of HSE staffing dedicated to Traveller supports. A lot of that staffing comes through our community partners, section 39 organisations, and other voluntary and community agencies. I suppose it is a reflection of the requirement for funding for those community agencies. As was seen in the document, in taking feedback from the Traveller community, we have realised that a community development approach is the best way to work in partnership. We are trying to work with our community partners to source funding for those, and I suppose this brings us back to the key thing about sourcing funding. As it is a community development approach, it will probably extend beyond the HSE as well and into other funding streams.

Just on the big picture in terms of funding, how much does the HSE need to do this? Is the Department allocating enough money in this area?

I am always going to say it would be good to have more money. We are very grateful to the Minister of State, Deputy Butler, for the ring-fenced funding mental health receives. However, under the auspices of the Traveller health action plan, there is a current exercise under the evaluation to see how much the full implementation of that plan would cost. Linking in with the Pavee Point report, it is obvious that there is a bit of a shortfall currently. The difficulty we have, and the Deputy has highlighted it too, is that because we do not have an ethnic identifier at the minute, it is quite difficult for us to produce a set of KPIs. It is hard to know who is a Traveller within our services and it is hard to measure outcomes when we have not set a baseline. A lot of the work we have done with the primary care aspect and, indeed, with our own group is to look at how we measure activity and what our outputs and outcomes actually are. I think over the coming year we will be in a better position to say what that shortfall is and what our expectations are for delivery.

In terms of the national Traveller health action plan, we talk about mainstream and targeted approaches. It is really important that our mainstream services be appropriate and sensitive to the needs of particular populations, including Travellers. We must also have targeted approaches that bridge the gap where we know people are not accessing services. In my reference, therefore, to our enhanced community care services around chronic disease management, for example, we will frequently have to take bespoke measures to ensure Travellers access those services in the same way as the general population. If Travellers have higher levels of need, we will have to take assertive and deliberate action to bridge that gap. That is the area of work. We might get an opportunity to talk about some really good examples later. I think the UCD findings are really important because we spend a lot of time ensuring messaging and communication are culturally appropriate and sensitive. Working in the way we do with Traveller health primary health care projects and the Traveller health units can ensure that communication is correct, accurate and sensitive to the needs of the population. I suppose it is reassuring to see some of those findings from UCD, but I am not resting on my laurels by any sense or means. Mr. McCusker is right. We are progressing with an ethnic identifier and that will give us greater levels of information in terms of the outcomes for the Traveller population.

I appreciate that and thank Ms Queally and Mr. McCusker very much.

From the Department's perspective, we completely share the Deputy's concerns about the dire situation facing Travellers. I think this is why the National Traveller and Roma Inclusion Strategy, NTRIS, as a whole-of-government response, is critical. Unless we have a whole-of-government response, we are fighting a losing battle here. We are very much part of that, but we recognise that a lot of the social determinants of health are within the wider society. They have got to be addressed to turn the tide of health inequality.

With respect, we understand that and our intention is to examine each of the elements of NTRIS, but today we want to focus on health and the outcomes there. We will examine the other elements as well; it is not just the Department of Health.

Yes, and on the funding issue, as the Deputy knows, the budget for the health services this year is €27 billion. We have increased that dramatically over the last ten years. I think it has almost doubled. We have, therefore, put an incredible amount of resources into the health system, which should benefit everyone. The approach of the Department is progressive universalism. We want to build up universal services and then tailor them to the needs of Travellers. I will give the Deputy the example of the HSE healthy childhood programme. It is a universal programme for every child in the country. Through Brighter Beginnings, we are working to ensure Travellers get access to that programme and benefit from it. We need to use-----

With respect, Mr. Walsh, I would say the progressive element is not there if we look at the outcomes based on life expectancy and suicide rates. The Department has not been delivering.

Turning the tide of life expectancy will take a number of years. This is why we are prioritising Traveller children at the start and building good foundations, so that over the years their health will not deteriorate the way it happens at the moment. We create the building blocks across Government to ensure Traveller children have the best start in life. This is how we will turn the tide of health inequalities.

I want to note the Pavee Point report mentioned. We might have a session on that.

I think that would be worthwhile.

That would be a good idea. I thank the Deputy for that.

There was the question on the LGTB aspect as well.

I am sorry. I apologise.

I am well over time, so we can come back to it.

That is fair enough. I call Deputy Maurice Quinlivan.

I thank everyone for the presentations. Deputy Rice said a lot of what I was going to say concerning some of the issues.

We see Travellers living an average of 15 years less than the general population. Death among Traveller infants is estimated at 14.1 per 1,000 live births compared with 3.9 for every other 1,000 live births. The study shows that deaths from respiratory, cardiovascular diseases and suicides increased in the Traveller community compared with the general population. Then there is the whole issue of mental health. Will Mr Walsh tell me what he feels more positive about this year than he did this time last year? What is better for Travellers in respect of health this year?

The mid-term review, which is an independent review, of the Traveller health action plan was produced recently. It has been widely welcomed by all stakeholders. It is a much-needed strategic resource providing clear direction and renewed momentum for improving Traveller health. Its development has fostered strong national commitment and tangible progress. These achievements provide a solid foundation for building on successes and addressing the challenges during the remaining years. We have had a very positive mid-term review of Traveller health action plan which tells us the progress.

Specifically in terms of the Department, I spoke about the brighter beginnings programme. We have allocated an additional €500,000 to this in the budget to extend it from two health regions to two more health regions and this is being rolled out. This is how we will build a better future for Travellers. It will be through intervening in Traveller children's lives from an early stage and making sure things progress. My colleague will add more on the mental health side.

From the perspective of mental health policy and policy progression compared with last year, this year we are establishing a specialist group for Traveller mental health under the national implementation and monitoring committee of Sharing the Vision. This is being established as a result of a request from the Minister of State, Deputy Butler. The working group has been in formation for a couple of years and has done a lot of very detailed and specific work in terms of surveying the resources out there at present with regard to what works and what does not work. The specialist group will be very important for drawing out the work of the working group and looking from a policy perspective at what can be done to improve the mental health of Travellers. What will really stand to the group is that we are very much building in lived and living experience, and we will have a panel of lived experience members from the Traveller community who will support the work of the specialist group. This is being convened with the support of our colleagues in Exchange House Ireland and the National Suicide Research Foundation.

From a mental health policy perspective we will have a very good grounding by the end of this year not only of the work and outputs of the working group but also the specialist group under Sharing the Vision. It will give us great structure and a facility to be able to measure the demands of the Traveller community and be able to meet them also. My colleague, Mr McCusker, will speak on the Traveller mental health action plan.

One of the recommendations from the Oireachtas committee previously was to look at a Traveller mental health action plan specifically for mental health. Part of the output of this special interest group will be the mental health action plan. There are a number of recommendations in various strategies and a lot of them are very similar. We will continue to work on what we have at present but with a dedicated Traveller mental health action plan, we will be able to progress it across a whole-of-government approach.

I thank the witnesses but I am still struggling to see where there has been an impact. Can the witnesses show me any health area, such as cardiovascular health, in which issues have reduced for Travellers since this time last year?

I welcome very much the intervention with children but I hope it is not at the abandonment of the rest of the Traveller community. I say this because I represent CHO 3 and we had €128,000 less in the budget than in 2024. Will the witnesses explain what this was about? They might also explain whether there a specific reason for this. We would not expect budgets to go down when the amount of money going into the health services is being trumpeted and the witnesses have said we should expect it to benefit everyone.

Earlier, Ms Queally mentioned the report on cancer awareness. This is a tangible thing that has just been published.

This is with regard to the UCD findings on cancer awareness. As I said, I would not sit on my laurels on account of one report and it is only when we have an ethnic identifier that we can really track and see where we are making a difference. I might go to Ms Heffernan to speak about some of the detail of the work. The integrated healthcare area, IHA, manager, Maria Bridgeman, was before the committee in November and there are some fine examples from Limerick of some of the work being done through the Traveller health unit and the primary health care teams in the area.

At the same time, the Department was cutting Limerick's funding and it received €128,000 less than the year before. How can more work be done with less money?

We can have a look at that. I am not sure about the actual reduction in the budget. I know-----

Too many departments.

I might go to Ms Heffernan on Deputy Quinlivan's key question. The mainstream and targeted approach to addressing the health issues is very important. Ms Heffernan might want to speak about some of the chronic diseases.

One point I want to raise, and I know it is difficult because it does not translate into outcome data, is that we have started doing work across the projects on collating the activity of the projects and the reach they have. For example, we did this for 2024 and we could see that the projects reached 4,034 contacts in respect of national screening services and providing information. We can then see this translating into the uptake in screening rates. I know it is not exactly outcome data, and it does take time and investment to see the outcomes, but at least we are seeing the activity and the reach we are having. It shows the importance of the projects and investing in them, which I have acknowledged.

I am chair of the national Traveller health implementation group and we spoke about the mid-term review. We have just completed our review of the Traveller primary healthcare projects. There is a lot of overlap between the recent Pavee Point review and our review. It is incumbent on us to implement the recommendations of the reviews. We have ours finalised and it will be done by the end of January. I see this as my mandate to drive the recommendations of the review.

Some of the on-the-ground work happening in my IHA includes a steering group in the Dublin area and another steering group in the Wicklow area. These have HSE representatives and Traveller representatives. The Traveller representatives identify the issues they experience on a daily basis in accessing our services and some of the lovely project work that has come out of this includes, for example, that we are improving home support services for older Travellers. There was lovely work done between Holles Street hospital and the Traveller projects on antenatal information. Very practical sessions for Traveller women were held. We have a dedicated psychologist in our social inclusion team who provides direct support to the Traveller workers. We know they deal with very difficult situations on a daily basis with regard to domestic abuse and suicide and she provides very targeted support to them. These initiatives are happening on the ground. I am speaking about my IHA but they are replicated across the country.

We might get response, if not now then later, as to why there is a difference between the 2024 budget and the 2025 budget for the CHO 3 area.

We will take a look at it. As I said, there has been no reduction in our funding in the Department of Health. We have increased funding.

Yes but CHO 3 has been-----

I will follow up on this and come back to Deputy Quinlivan. We will be very happy to share the mid-term review with members of the committee if it is helpful.

I welcome all of the witnesses. I am a small bit frustrated. I hear a lot of acronyms, reports, reviews, working groups and special groups. It can be a bit confusing, if I am to be honest, to try to decipher where services exist, where there is a high level of service and where there are gaps in services. This is what we need to get to. It is about where there are gaps in services and how we plug them. Last October I asked the Minister about the mental health services available specifically for members of the Traveller community. A number of national services were mentioned, and some of them have been mentioned today.

Can Mr. McCusker confirm whether these are nationwide? Exchange House Ireland was here some time ago. My recollection was it said the resources did not allow it to provide the service nationwide.

Exchange House runs the national Traveller mental health service. I cannot speak to its resourcing across the various counties but it has a remit for the national provision of service.

Okay, maybe I am wrong and it does. It certainly said it was stretched.

Yes.

There is a culturally inclusive Traveller counselling service run by qualified counsellors who understand Traveller culture and experience. Again, is that nationwide?

The Traveller counselling service was a Dublin-based service. We received extra funding in 2024 to roll it out into a national service. We have gone from providing a service in Dublin to providing it in five hubs across the country, including Cork, Kildare, Mayo and Wicklow, with a view to expanding further. They have ramped up. They have seen a 37% increase in the number of people they have seen over the past year. We are continuing to support them to expand further out.

And that is all coming out of the €2.3 million which Mr. McCusker mentioned.

The expansion of the Traveller counselling service came out of the ministerial priorities funding for last year and this year.

Is that separate to the €2.3 million?

It is part of the €2.3 million now.

The other service I was advised of has been mentioned a few times, namely the Traveller mental health initiative. My sense of that is that it is not universally applied consistently across the country. It seems that whatever CHO has a project or potential project it could roll out seeks funding through that budget. Some CHOs seem to be very proactive. Others do not seem to have availed of any resources through that fund.

The previous structure was the community health organisations, CHOs, and there were nine in the country. In the Dublin area the three CHOs came together and ran one Traveller health unit across three areas because it made more sense but there were Traveller health units in each of the other areas. Equally, in the mental health divisions which existed in each of the CHOs there was a specific, bespoke Traveller health project worker working with Travellers. That was funded in each of the nine CHOs so there were nine of those. At the moment, part of what we are doing is looking at the new regional structures. That is part of what Ms Heffernan mentioned. We are going to look at those Traveller health units. I apologise for all the acronyms. Some of those structures are really important. The Traveller health units are the mechanism by which we work in partnership with Traveller health organisations and the Traveller communities to ensure that any of the areas of development are appropriate and culturally appropriate to the Traveller population we are serving and that we have community buy-in and support for those projects. There are very high levels of distrust between the Traveller community and the health services - this has been established. Therefore, part of what we are trying to address is that level of trust with the Traveller population. The Traveller health units are key to that, as is having really strong partnerships with the Traveller communities themselves.

The UCD research kind of shows we are overcoming that -----

We are building.

----- so it is positive. In terms of the two services Ms Queally mentioned, are the primary healthcare projects for Travellers consistently available throughout the country?

They are. We need to continue to support and grow them but they are consistently available throughout the country. As I said, in 2023 two new ones were developed – one in Limerick and one in Louth. Through the national project we will be looking at the population of Travellers. We were very deliberate about where they were placed. We knew there were high populations of Travellers and they did not have a project. It takes a while to develop the capacity and to bring together the partnership to support it in order that it can be sustained so it is not an overnight thing. However, with partners like Pavee Point and the Traveller health projects around the country we develop those strong partnerships because they are the foundation of it.

What is the difference between the primary healthcare projects for Travellers and the Traveller health units?

The Traveller health units are almost a management construct, as it were. We have Traveller organisations and HSE staff who work in the Traveller health units to take the funding, agree where it is going to go, look at service arrangements and look at what projects they are going to prioritise and deploy to support the primary healthcare projects to deliver their projects and to evaluate or assess the needs of the population. They do a variety of actions. They are a management construct but they are a partnership between the Traveller organisations and the HSE. Traveller health units will always have HSE management, Traveller organisations and Travellers sitting on them.

Between both of those, where is the service provision?

There is the mainstream service provision and the primary healthcare projects. For example, we have a cardiology programme running in Bray. At the Traveller health unit somebody said none of the Travellers access the cardiology programme; why is that? The primary healthcare project workers in Wicklow went out, spoke to Travellers and asked them why they were not going. We addressed that by setting up a specific project - Ms Heffernan might want to talk about this - where the Travellers were supported by the primary healthcare project workers to attend. Fear is a big part of access. If you are really fearful of going into a service, you need someone to support you to do that to allay that anxiety. I have to acknowledge the clinicians and cardiologists. Ms Heffernan might want to say something.

That is a great point. The team in Bray actually travelled to the Traveller communities. They travelled out of the clinic to meet them and the cardiologist was playing football with the kids. We also built on the programme. Once we had built that trust and there was good uptake of the services, we weaved in health promotion and improvement programmes on the back of that and we have ongoing further work. For example, there is a lot of work now on smoking cessation, targeted sport activity and even sun smart campaigns as well. It was a really good initiative.

We are just saying the programme is there. It is available to everybody. It will not fix it. The primary healthcare project workers were key to building that trust and our own team understanding the fear experienced by Travellers in accessing services.

I want to focus on mental health services for a moment. In reading the biannual report, there was one paragraph which I thought was quite positive around defining a structured service level provision throughout the country. It said the national Traveller and Roma mental health group is leading on NTHAP’s mental health actions and is supporting the establishment of a dedicated structure to ensure Traveller mental health is addressed across all relevant policies. Where are we with that?

It was recognised by the Department 18 months or two years ago that there are a number of recommendations across a number of policies and they were very hard to keep track of; they sat in different parts of the HSE and were reported to different Departments and different parts of the Departments too. A rationale for establishing the working group within the HSE was to task it with bringing together all the various actions under the Traveller health action plan, under the NTRIS, under Sharing the Vision and under Connecting for Life, asking them to map it out and then reporting on it. This is the first report that works to bring all of that together. It is the first structured approach. Mr. McCusker has been leading out on that group in mapping out what all the actions are and were; how they get reported in; and where the money sits for the different actions. It is the first real systematic approach to bringing together a myriad of historic policy pieces under one group. It is beneficial that we now have this biennial report which is the first time all that has been reported on in one place which allows us to ask further questions and dig into that. Mr. McCusker might want to add to that.

The working group is working very closely with the partner agencies about what is happening at very local levels. The Deputy has picked up on the theme that it is hard to measure against various projects because they all have very specific local outputs. The new thing that refers to is actually the group that will sit on the national implementation and monitoring committee for Sharing the Vision, the mental health strategy.

That will look at a strategic level about where we bring those various recommendations and actions together.

Can we bring it to a point where we say, "Here is the service"?

Yes, but there is more mapping to be done. What I am trying to say is that a lot of the community organisations and Traveller organisations have developed out of the situations that they have themselves. They reach out to us saying they want our help to make their lives better. We try to reach in and assist those groups to grow in a community development approach. However, it may well be that one area has a very strong group and other areas perhaps do not have very strong groups or there is a variance of population sizes of Travellers within the various towns and cities. What we are trying to do is to ensure that there is equity of access to services across the entire State. In doing that, we need to map out what exists where, what is working well and how we can replicate that going forward.

One of the things we need to do is ensure that there is that governance structure that reaches into those community projects through us. Obviously, the primary healthcare projects are there and there is primary mental healthcare, but when we look at mental health generally, we tend to think about secondary and tertiary care, especially around suicide reduction. That sits with mental health rather than primary. We are working alongside the primary partners, but we want to have our own structure to ensure that we can have that level of information flowing from people in their own homes up to the Department and various other Departments.

Did A Vision for Change propose a specific mental health service for the Travelling community?

A Vision for Change is the older strategy. Sharing the Vision is a global and generic approach to things. It talks about developing services and a population-based approach. I do not have it in front of me, but I can almost confidently say it does not specifically state that.

I believe the Deputy is asking whether it would be completely separate. I do not know whether that would be a wise or useful use of resources.

Is that what the document stated?

In terms of Sharing the Vision, it is a whole-of-population approach, but it lists out a number of priority groups that may require specific interventions to be considered. The establishment of a specialist group under Sharing the Vision allows for that specific focus on Traveller mental health. There is a whole-of-population approach. There is a number of specialist groups under Sharing the Vision. There was one for women, for example, that carried out a piece of work and has now been stood down. Now there is the Traveller specialist group. It does get confusing. There is a working group and a specialist group, but the specialist group is specific to Travellers. The policy itself is a whole-of-population, universal mental health policy that recognises the needs of priority groups as well.

Recognising that need, have we progressed that to the design of a specific service?

We have recognised it in the design of standing up the working group within the HSE and now designating a specialist group. The output of that specialist group by the end of 2026 will be an action plan for Traveller mental health under Sharing the Vision.

In very practical terms, there is an absolute recognition that Traveller mental health needs a specific focus. Within our services in mental health in the community, there is a very deliberate understanding and action around addressing those needs. Even though it is not a separate service, nor do I believe it should be, we need targeted interventions that work closely with the community around promoting mental health, supporting people's mental health and intervening when they are in distress.

I suppose "targeted" is the more appropriate term. How close are we to the ethnic identifier's implementation?

A paper has come to the regional executive officers in the HSE. That is under their consideration at the moment. It will go to the senior leadership team within the next couple of weeks for its approval.

I have a comment. As Deputy Rice said, we need to maintain a focus on the whole area.

Absolutely. That is one of the pillars of this committee's work. I call Senator Noonan.

I thank our witnesses. The issue of the ethnic identifier is critical. What this committee has focused on since its inception in this Dáil has been looking in granular detail at various issues around education, employment, health outcomes and mental outcomes. While there are no shortage of plans and programmes in place, anecdotally and from speaking to Traveller organisations here in committee and out in our communities, trends do not seem to be going in the right direction. There is a collective frustration. I know the witnesses share that frustration. From our perspective as a committee, we are tasked with coming up with a set of recommendations on how we can point a way forward, taking in the evidence that we have taken in over the last couple of months. It is hugely important.

A point that Mr. McCusker mentioned on a few occasions was the community development approach. From the evidence we heard from the Irish Traveller Movement in particular, we would have had a very good community development project, CDP, infrastructure in Ireland. I think 2009 was the first cohesion process when they started disbanding that approach. A number of pilot CDPs were rolled out between 2020 and 2025. If we are looking at a whole-of-government approach, is that being advocated for, particularly with Traveller organisations? It really is the most proven way forward in terms of Traveller communities self-advocating and having the ability not just to critically evaluate but also to be active participants in programmes that are being run with them rather run for them. Should we be giving consideration to rolling out an infrastructure involving that radical community development approach again?

I believe that the community development approach is the best. The Senator is right, and it is backed up by a lot of evidence. From my experience, it takes time. Sometimes, people have to be patient because it takes time. When you are looking at a very disadvantaged population like the Traveller community, it is the only method to change the rhythm of that experience.

Similarly, we are here representing health, but the social determinants of Traveller health are varied across other branches, including benefits in justice and housing. It would be great to get to that forum where there could be joint discussion around that. Through the likes of NTRIS and the new Traveller mental health specialist group, we have an opportunity to forward that a little bit.

I was interested to hear of the work with Holles Street. That is vital. I have previously mentioned postnatal care in terms of breastfeeding support for Traveller women. Is that something that the Holles Street project is working toward?

I know that breastfeeding is an important component of it. They have done a lot of work in terms of supporting Traveller women to breastfeed.

It was a component of that specific project. We know that the low breastfeeding rates among Travellers is a complex issue. It is underpinned by the social determinants of health. However, there are a lot of targeted work being done across the country. It is looking at that antenatal education. It goes back again to the ethnic identifier and that data collection. It has improved access to breastfeeding education and early expression of breast pumps for Traveller mothers. The HSE is working very closely with the projects. It is all about that co-design about the resources and information. Pavee Point has a report in relation to breastfeeding rates.

Another key piece of work that was done was the HSE's "My Child" booklets. The nought-to-two-year-old booklet has been adapted for Traveller babies. There is breastfeeding information for Traveller beoirs. The HSE is also working to improve the timeliness of the Beutler test results. I am probably not pronouncing that right. Currently, the Rotunda hospital is conducting a pilot in partnership with Pavee Point to offer carrier testing for galactosaemia.

A lot of work is being done. Even in 2025, there was an excellent webinar for maternity and public health nursing, PHN, staff across the country where over 100 staff attended. It was facilitated by Pavee Point. It is about how we collectively can optimise our support to Traveller mums and babies.

The committee discussed with the Heritage Council its plan to launch a Traveller heritage strategy. I am sure the witnesses are aware of it. We are talking in the area of mental health. I believe it is a very exciting opportunity in celebrating Traveller culture that will have positive health determinants for the Traveller community as well.

I attended a meeting with the Kilkenny Traveller Community Movement, which is our local Traveller organisation. Certainly, from that meeting it seems there is quite a high level of trust with the health services locally and a good partnership approach on many issues. It might be worth looking towards where things are working well.

I want to raise the consistency of the inconsistency. We get a lot of small projects up and running, such as €1 million in funding for that Better Start initiative. We get small pilots that are up and running for a year or six months and are then discontinued. There is a high level of frustration around that. If we can develop a programme that is working well, or programmes which work well that are replicable in other communities, we need to run with them and keep them running. Deputy Rice made a point about multi-annual funding and supporting things that work well. At times, that inconsistency is very frustrating for organisations on the ground.

I recognise that. One of the recommendations from our mid-term review around the implementation of the national Traveller action plan is around sharing the learning. We are not as good at that as we could be. Again, take that experience in Kilkenny. Are we sharing that learning across the country? We had an event last year with the Traveller health units where we brought everyone together to share their experience around implementation of the plan, but we need to do an awful lot more around that and in a variety of methods.

Another key thing I acknowledge is around that once-off funding. Ms Queally and I had a meeting with the HSE CEO in December where he gave a commitment that if there is that type of once-off funding and it is a programme that really is working with good outcomes, we will mainstream that service.

Just to be clear, the programme we are doing with children is not once off. This is recurring funding. The idea is to develop a model of best practice which can be applicable across the country. We are rolling it out incrementally but it is recurring funding. We want to measure it and evaluate if it is working but this is the future. We are committed 100% to delivering that future working with Travellers because that is where you build the future.

I thank the guests today. I also thank the Chair. I am not a member of this committee but I am delighted to be here so I appreciate the opportunity to speak.

I come from a constituency that has one of the highest percentages of members of the Traveller community per capita. I have a load of questions and many more since the witnesses' previous contributions. I am trying to work out how I am going to take what I am hearing back to my Traveller constituents. I am hearing about plans and I am hearing about implementation. There is a lot of busyness going on somewhere. I know in my bones that my constituents are going to tell me they do not see it and they do not feel it. What needs to happen? This is a big question, but we need to get to the point where there is a plan, there is a budget, there is an implementation and there is the delivery of services, particularly when it comes to mental health because the longer that process takes, the more Traveller people we are losing. We are losing them to suicide. We are losing them to a substandard life and they are not being the best person they can be. I think that is hugely regrettable and desperately sad.

I have heard about equity of access, specific focus and targeted interventions but without having an actual identifier, how do the witnesses plan to get there? How long is this work going to take? If I speak this evening about these plans to a Traveller mother who had a baby last month, should I say they will be in place by the time the child makes their communion, by the time they are in sixth class, or by the time they are becoming parents themselves?

I am delighted to hear of the cardiologist out playing football because that, to my mind, is what is actually needed here. In my experience, the disengagement and the lack of trust from the Traveller community is not misplaced; it is learnt. It has been inflicted on them for generations and for decades. There is an onus on the apparatus of the State that caused that to go that little bit extra. If it is the cardiologist playing football, happy days. If that is what it takes and it works, that is what needs to be done.

I have a specific question. With the HSE transitioning to the regionalisation of services, in terms of the Traveller mental health spend, how will the delivery of services be scrutinised under the new regions?

Regarding the new regions, all of the regional executive officers work to a performance and accountability framework. That is an established mechanism. Under that, all of the areas under our responsibility, whether they are in acute hospitals or in community, are assessed in terms of accessibility, waiting times, etc.

Perhaps my question was badly phrased. I am trying to ascertain if, in each new region, there will be a certain amount of money available for mental health. If so, how much of the money available for mental health will be spent on Traveller mental health? Where will the results of that go to? Where will they be fed back to ensure there is accountability for all these plans and implementations, etc., that are very busy on the other side?

I might pass this to Mr. McCusker. I apologise for all the acronyms and management-speak, but those constructs are important because that is how we understand whether the things we want done are being done. The National Traveller Health Group oversees the implementation of the plan and the mid-term report will show where we are with those actions being delivered. On the mental health side, we track and monitor things like waiting times, access to child and adolescent mental health services, CAMHS, and access to adult services. I will go to Mr. McCusker for some of the Deputy's specifics because they are important.

The one key thing to note this year is that the Minister for Health actually ring-fenced the mental health budget for 2026. Unlike other programmes of care, we at the HSE centre have had a bit more input into what posts are required and where we can direct any supports. Through the group that I chair, which includes representatives from the regions, from the Department and from the Traveller organisations, we try to see what we can support nationally going forward and what themes we can look at. For example, this year we are going to try to focus on Traveller men's health. In the past couple of years we tried to focus on Traveller youth mental health. We will link in through the Traveller health units that Ms Queally was talking about before and through the organisations and national organisations such as Pavee Point and Exchange House to see what the wishes and wants of the communities are. We will try to enable those.

Through that report from our own group, we tried to understand how community groups measure their own success. We realised that a lot of people measure success by the number of people coming through the door and not necessarily by whether somebody feels better at the end of the month. We are going to try to work on how we improve that. There are various things we can look at into the future; something like the health app can use a scale to ask somebody how they feel now or how they feel when they finish. The key thing from a community development approach, and trying to work in partnership, is patient-related outcome measures. We need to ask people where they are now, how they will know when they are in a better place and how we get from here to there. Through our group we are trying to invest in identifying what those patient-related outcome measures are and perhaps even some provider-related outcome measures. In CAMHS, for example, we can measure waiting lists, presentation times and the time it takes from a referral to a person being seen. However, we need to focus on what the actual outcome is.

On the issue of CAMHS, there was a 200% increase on CAMHS waiting lists in five years and a 250% increase in children waiting over a year, with 40% of referrals rejected over a ten-month period last year. What percentage of that are children from the Traveller community?

That comes back to the lack of an ethnic identifier, unfortunately.

The ethnic identifier is a really important component in terms of being able to check.

How are the officials going to assess progress and define success if they have not even got the foundation? I do not mean this as personal to any individual but how do you track progress and success if you do not have the foundations in order to do so?

To explain it, with the National Traveller Health Action Plan 2022-2027 each local Traveller health unit, of which there are seven around the country, developed its own local plan in line with our 45 actions. We engage with them twice every year to get their updates on where they are. We then consolidate all that to show where we are nationally with implementation of the plan. That was the update we provided to this committee. We can recirculate it. It will show the 45 actions and the red, amber or green, RAG, status and it gives a summary of where we are with each of the actions. We then have the backup to say Limerick might be doing really well in one area but struggling in another and this is where we need to support that team more. That is really how we are-----

Without that identifier it is almost self-identification.

Yes.

Okay. Earlier Mr. McCusker spoke about the counselling services that started as a pilot scheme in Dublin and moved to five other areas. There should be universal access to counselling. It should be in every town, every village - everywhere. If there is a primary care centre, it should have a counselling service. I say that because my next question is to ask how the other five areas were determined. Was it census statistics? Was it demand that came from the groups up?

It is a mixture of both. It is a mixture of readiness to actually provide a service and-----

What does that look like?

The national counselling service is trying to provide a consolidated service so the counsellors have the right supervision and the right access and support from the HSE. A lot of the various community organisations already employed counsellors or had counselling sessions for Travellers. We are trying to corral that and make sure it is linked in so we can measure and identify how many are using the service. As we are growing - and it is only 18 months into the development of this - a lot of it is those areas that are ready reaching out and saying they want the national counselling service to come and build a hub there because they have the supports to build this. Also, if there is for example, God forbid, a suicide cluster and there is an area where there is a high need, then obviously we will target that as well. I should say that is the Traveller counselling service. There is obviously a universal counselling service available.

It was just the Traveller counselling service I was asking about.

Each primary care centre would have access to counselling through the primary care scheme. The Traveller counselling service is beyond that for Travellers who feel they possibly do not want to use the counselling services that are available. It is recognising we do not want to replicate an entire service. We want to make sure our services are friendly and open to Travellers while recognising that in some instances there is a need for specialist services.

It is really critical to get that balance because there is the build-up and the tailing down. If I was to go back and speak to a young Traveller parent this afternoon what they would hear when I said that would be "Everybody else before us" when really it should be "Nothing about us without us".

Absolutely, yes.

Ms Heffernan mentioned breastfeeding rates within the Traveller community. We have an atrocious level of breastfeeding in all our communities, to be frank. Are there any specific areas around that or any other groups? There are plenty of the La Leche League breastfeeding support groups that happen in towns and villages anyway. Is there any additional support with an eye to the cultural aspect of the Traveller community? Are there additional supports that should be looked at to specifically target new mums in the community?

What we have been doing is that local work through the Traveller primary healthcare projects, looking at what the need is in that local community and codesigning resources. I am thinking of the point I raised earlier about sharing the learning too and making sure that if we have that developed in one area that we are really good at sharing it across the country. That is definitely a piece of work we need to do better on. We work closely with Pavee Point in particular on developing resources. There is a lot more work and I probably cannot give the Deputy any more specific answers about that.

On that area, take for instance GPs and maternity units understanding that Traveller women may be a bit more reticent about accessing antenatal clinics and working with the primary healthcare projects to support Traveller women to access antenatal clinics to help them work with public health nurses and others to just allay that anxiety and fear and bridge that gap. We have a lot of postnatal support groups and breastfeeding support groups around the country but it is about understanding and trying to work with our primary healthcare projects so Traveller women feel comfortable accessing those and that our staff also understand the challenges for Travellers accessing them.

Exactly.

That cultural awareness is really important for that work.

But also just for a mum's postnatal well-being.

Yes.

I have one last question. The Chair has been incredibly generous. Go raibh míle maith agat. The question goes back to mental health and the most severe of mental health crises. With the data the service collates or the information it has available to it, does it have any statistics on presentations of members of the Travelling community to emergency departments due to mental health crisis?

Again, without the ethnic identifier we have anecdotal evidence on that but it is really hard to definitively say what the numbers are. Mr. McCusker or Ms Hargis might want to come in on that.

What we have invested in is the identification. We are using Exchange House to try to see - it is postvention unfortunately - how many deaths by suicide were in the Traveller community, which is reactive and not proactive. We have a programme there through the suicide crisis assessment nurses, SCANs. We have two dedicated to the Traveller community already with a further two coming on board. That is in a network of I think over 20 SCANs across the country. Those nurses will link in with the other SCANs so we can build a picture, but the key thing will be the ethnic identifier.

There was a paper, which we can share with the committee, produced by the National Suicide Research Foundation on self-harm and suicide-related ideation among the Irish Traveller population that collected data on Travellers presenting in crisis to emergency departments. That data is gathered through the clinical programme for self-harm and suicide ideation.

Okay. Just to round up, what are the next steps with the identifier? If we do not have good quality information we will not have good quality delivery of services.

There are three key components in the identifier. The first is the having the technical infrastructure to switch on, like the fields for the ethnic identifier are in the data systems. The second part is that people ask the question and the third is that people understand how they answer. Those are the three main components. We are priming our systems so we have those fields in them. The training occurs with staff on how to ask about ethnic identification to make both staff and the public comfortable with those questions. As I said, that paper is with the REOs at the moment. Once they have approved it, it will go on to the senior leadership team in the HSE to approve the programme and they will consider it.

On that, I am a member of the health committee and we have spent a significant length of time looking at digitalisation in the HSE. How does that link if we do not have a digitalised HSE? Even if I am asked the question and the service gets the answer is that answer stuck in Ms Queally's section or will it transfer, without digitalisation?

There are a couple of elements to that. We have Community Connect going live in the HSE at the moment. That will be helpful because it will connect our data systems. Even though it is not an electronic health record it will connect your data from one element of the system to another. I think the ethnic identifier is already on some of the mental health systems we have and on some of the maternity systems-----

Yes, depending on the hospital.

-----so we have it in some areas. Obviously as we introduce an electronic health record that will be the most comprehensive form of an electronic system, but that will take a number of years. It is not going to be automatic.

With Community Connect, we would like to capture some of the information that would help us with things like understanding mental health outcomes and, at the very least, where our patterns for access are.

It really important to have it built into the new national immunisation system. That would be a really good win in the context of looking at outcomes.

Although we might not have a full electronic health record, having information in our maternity or mental health systems or immunisation records would all be helpful to us in fully understanding outcomes for patients.

I echo Deputy Clarke’s appreciation to the Chair and the committee for allowing-----

We have our slot, so we will let it flow freely as opposed to having specific seven-minute sections.

I thank the Chair. I thank the witnesses for the opportunity to speak with them this afternoon. I do not have the words in my vocabulary to offer a comprehensive testimonial regarding the benefits of the primary healthcare services and the projects and the work undertaken, other than to say that my experience of getting to know some of the amazing workers over the years has been a privilege. Ms Queally captured it. She said two things. The first was that we need to increase the number of services. Second, when she spoke about the case study in, I think, Blackrock relating to healthcare, she said that the key to accessing the service in question was that the primary healthcare workers were there to build trust. How do we grow the services?

We are looking at support overall. It is not just about inviting some Travellers to be involved with primary healthcare projects; it is about recruiting Travellers to be primary healthcare project workers and then supporting them in their education and training. It is tough. I really have to acknowledge the primary healthcare workers, because they step up. They are the leaders in their community. Any success we have had has been built on leaders within the Traveller community, not by the HSE or external parties. The Traveller health workers have built and led it. They are the true leaders in this system. We need to support them with education and training. The Traveller health groups are key to that. Some of the Travellers have gone on to Maynooth and some have obtained degrees and diplomas. It has been phenomenal. In November, we made an invitation to some members of the committee to, if they wanted, come out and meet those involved with the primary healthcare projects. I offer that invitation again, particularly as it is very powerful to hear from young Travellers about their experience.

I have had the privilege of working with Pavee Point and the Traveller health unit in the Dublin area for a long time. I have seen at first hand the difference those projects have made. It is truly transformational. It is not immediate or overnight but it is transformational. My ambition is to support and strengthen them. Workers are getting credentials and going back to education. Sometimes they are microcredentials or smaller elements of education that build towards a bigger component of their experience. We need to look at the structure in terms of supporting that. We have primary healthcare projects at entry-level grades. We need to support the Traveller health projects so that they have incremental steps in that journey including co-ordination grades. We have an administrative grade, namely grade 7, which is largely relates to development workers in all of the mental health teams throughout the country. In the main, those workers are from the settled population; they are not Travellers. When they are being recruited, I would like to see that Travellers are able to take up those positions. That is the journey, and it is where I would like us to get to. I have been really proud to be part of the journey with Maynooth University where a lot of the Travellers been involved up to degree level. That was phenomenal. To hear their experience and excitement at being part of that journey was great.

In Ms Queally’s experience and that of the Department, when the outcomes of the work in the projects is reviewed, is it based purely on health outcomes or is it acknowledged that it is the community work approach - relationship building, trust building and advocacy? Is it weighted in a certain way? How does the dynamic play out?

I am going to find it hard to answer that. It is sometimes difficult to evaluate the broader parameters because what is involved is very qualitative in nature. When people read reports, they sometimes want hard outcomes and quantitative data that will signal that something is successful. We try to capture the qualitative experience in any of the reports we do because that is what changes things.

From my professional experience as a youth worker, measuring impact is often that dance between qualitative and quantitative. It is very difficult. From the Department’s perspective, is that shared? How often are primary healthcare projects evaluated? Is there an ongoing review? Will the Department elaborate on that?

After we allocated €1 million to expand primary healthcare Traveller projects under the Traveller health action plan, we asked for an evaluation to be undertaken to assess the impact, identify if there were weaknesses and outline how they could be improved. Impact is open. It is about impact in terms of health but also people’s growth and development. That is a gap but it is being met at the moment. I think there is a review happening. The HSE can answer that. It got an independent consultant to do that. I think it is due this month.

We have the review of the projects completed. It is in final draft form. It is to be presented to our implementation group at the end of January. I do not think I am speaking out of turn when saying that there will be a lot of overlap between the recent Pavee Point report and our findings in the review. It will be a key feature of our group to implement the recommendations of that review. Much of it will involve looking at the future sustainability of the projects and at how we keep all of the projects going. The recruitment and retention of workers can be an issue, so we have to look at how we address that. It is also about how to grow them because although we have 31 projects and a good presence across the country, we know there are particular areas, for example, Monaghan that could benefit and be ready for a project. It is how we grow that, how to have consistency across them and how we measure. It will involve a lot of work over the next few years. I will lead on that. The CEO of the HSE has committed to carrying out a specific review in respect of the Traveller community health workers, particularly in the context of terms and conditions and the career structure relating to them.

Is there a timeframe for that?

This year.

That will happen this year. Has a business case ever been submitted to the Department of public expenditure? From my research - it is not conclusive - and from speaking to people over time, the average contract of employment is about 12 or 14 hours a week. There is a lack of access to pensions, for example. It is hard to wrap up such a broad job description. The work is so varied. Is there a pathway down the road for full-time employment in these positions and access to pensions?

We would like to look at those. We will be informed by the findings. We will be happy to share them with the committee. That will inform our work. We have been looking at it. We have been looking at it since the outset, even when we were drafting the national Traveller health action plan. We would like a stepped model for people when they become primary healthcare project workers.

The really good thing is sometimes, Travellers become primary healthcare project workers and go off into other employment. That is success. That is great. That is all part of what we are trying to do, which is providing opportunities for people. I would like to see a more stepped model. We have co-ordinators and primary healthcare project workers but I would like to see a more graduated approach in order that people know there is a pathway and a structure, if one likes.

I will ask one last question if the Chair does not mind. Is the Department's vision for the future of primary healthcare projects married with what the representatives of the HSE are saying here, in that we are very sure of what the future looks like for these services and that they are only going to grow and develop? Is it the case that the outcomes are so impactful that what we are looking at here is something that is ultimately very positive going forward for those workers?

That is what the evaluation is about. That is why we have asked for it – to give us the evidence base so we can continue to grow these projects. That is really important. We have to show the impact, just like we have to show the impact across any aspect of health policy. There is clearly an issue to do with pay and conditions. These are low-paid workers. That needs to be looked at from a low-pay perspective and what mechanisms are there to support workers on low pay. There is the working family payment. We have brought in auto-enrolment now. That should benefit them in terms of access to pensions. There might be a threshold on the number of hours, but I hope that we would look to ensure that all of the 400 workers would be able to access pensions. This is the group that needs to benefit from auto-enrolment. We are completely supportive of that.

What Ms Queally talks about is career progression. We must allow people to enhance and develop their skills and eventually they could perhaps go on to more formal medical nursing grades like social care workers, nurses, or whatever else. We need more nurses so why can we not have Travellers in those roles? Having a wider healthcare workforce perspective is a big issue for us in the Department. Let us imagine the potential benefits of that in terms of the whole issue of trust, engagement and understanding. It is just like the police or anything else: we need to have public services that reflect the population we are serving. We have more work to do in that regard. There are opportunities to do that in terms of the healthcare professions.

I thank the witnesses.

I am watching the monitor behind the witnesses because I am speaking relatively shortly in the Dáil Chamber. I was on Wexford County Council for 20 years. I am concerned about the general health and mental health implications of the current lack of housing accommodation and Traveller-specific accommodation. Has the Department interacted in any way, shape or form with any of the local authorities on the impact inadequate housing is having on mental health in particular but also the general health of the Travelling community?

The intersectionality between being a Traveller and not having good quality accommodation is a hugely important issue. It really speaks to the social determinants of health. We have taken two initiatives in the Department in this area, working with local authorities. One is in conjunction with the Sláintecare healthy communities programme to provide a funding programme to specifically address the social determinants of health. Those projects are in conjunction with the local authorities. They explore the factors, including accommodation. We do not have responsibility for housing but we recognise that it is a problem.

But it does have a huge impact on the general populace anyway.

Yes. We have developed these five projects, one of which is in Waterford city.

Wexford.

I beg your pardon, Chair. I am getting my w's wrong.

A different province even.

Yes. I beg your pardon. Let us hope that they extend it. This is just an initial approach.

The second area on which we have done a specific project is Traveller women at risk of homelessness, again, recognising another area of intersectionality – gender, Traveller and housing. We have been supporting a number of projects, again, on a pilot basis, through the women's health fund, to see how we can support the health needs of women at risk of homelessness. Again, that is a massive issue and a concern. We are pushing out the boundaries and engaging with local authorities to see how we can address this issue but we recognise this is a big factor, especially for female Travellers.

On the mental health side as well, Mr. Walsh spoke about the wider social determinants of health impacting everything that impacts on mental health. Within the last six months we have established an interdepartmental steering group for mental health. We have representation from all Departments at that, including the Department of housing. We work very closely with the Department of housing to increase opportunities for secure, independent tenancies for those with severe and enduring mental health difficulties. We have a very good working relationship with the Department of housing. As the specialist group stands up and starts to bring its recommendations as part of the action plan, and any recommendations coming out of the working group as well, that interdepartmental group, where there is representation from the whole of society within that room, is somewhere we can bring the recommendations and see what are the levers, enablers and barriers to progressing actions and making tangible changes in this regard to housing. That is going to be a very important mechanism for bringing those wider social determinant issues to the fore.

I have one other quick point to make. Mr. Walsh mentioned at the start that the Traveller population is 33,000. Is that an estimation?

It is from the census.

In Wexford, I know that the numbers on the census differ greatly to the numbers we felt were in the Travelling community. There is a shyness about declaring yourself to be a member of the Travelling community on an official form. Is that a difficulty that is being found across the country? That figure should probably be greater.

We estimate it could be up to 48,000.

That has serious impacts on the resources that are being made available. That message needs to get to the Travelling community as well: that we really need the facts and the figures to ensure that the resources are provided. You can bet your bottom dollar that the Department will go on the figures that are made available to it, as opposed to the actual figures. That is an important piece of work that needs to be done. I presume the identifier will help.

One of the big areas of work in the new structures in the HSE is that each of the six areas has a regional director of public health. They are working very closely as a group with the Department of Health and the national system in the HSE to adopt a population health approach. We will have much better population data going forward. They have started that work already. The Chair is correct about people understanding ethnicity identifiers and the public being comfortable filling in ethnic identification is really important for whole-of-government planning, whether it is education, housing or health.

I have to leave. Would Deputy Connolly mind stepping into the Chair? I have to speak in the Dáil. I thank the witnesses very much for their presence here today. It was a very informative meeting.

I would like to ask two additional questions. I apologise if they were covered already. If that is the case, just let me know and I can read the transcript. If not, I am interested in the witnesses' answers.

In the first set of questions, Mr. Walsh talked about the importance of the ethnic identifier. Could he give us an update on that and where it is at? How is the Department of Health in particular doing at implementing the ethnic identifier?

We had a good discussion on it.

If it has already been covered I will turn to my second question.

Ms Queally will give the state of play on that. She has a very good update on it.

The national Traveller health implementation group has prepared a paper on the ethnic identifier. That has been sent to the six REOs and is under consideration by those. Then, we will go to the senior leadership team in the HSE. There are three main components. First, regarding infrastructure, we will turn on key fields in our systems so that we have the ethnic identifier as a field in any electronic systems we have. Second, we will undertake training around filling out that field. It is no good having a field unless it is completed. This will be staff training around the importance of completing the field and sensitivity about asking questions around ethnicity. Third, we will support communities like the Traveller community in understanding the importance of completing that. That was touched on in the earlier point around the census.

Are there members of the senior leadership of the HSE and the Department of Health on the national Traveller health implementation group? Are some of those senior leaders Ms Queally spoke about represented on that implementation group?

Yes, they are. The Department of Health is represented on the national implementation group.

At what level or what seniority? Who represents the Department?

Who from the Department is on the national implementation group at the moment?

I am asking about the senior leadership. We talked about this in terms of going to the senior leadership.

No, that is in the HSE.

Sorry, excuse me. It goes to the CEO and the senior leadership team of the HSE. That is where it goes next.

Are some members of that senior leadership on the implementation group that Ms Queally mentioned?

The national implementation group is chaired by Ms Heffernan, one of the IHA managers, which is at national director level in the HSE. Therefore, it is a very senior level of leadership.

Is the Department of Health represented as well?

Yes, it is.

Who from the Department of Health is there? Is it the Secretary General?

I would have to check with the Secretary General.

Will Mr. Walsh check with-----

Yes. Is the Department represented at senior level?

The question is on the seniority of the Department of Health representative-----

On the senior leadership team of the HSE?

On our group, that is, the national Traveller health implementation group.

I am getting confused here. Is the Deputy talking about the senior leadership team in the HSE?

No. I am asking about this national Traveller health implementation group. Who from the leaderships of the Department of Health and the HSE is on that group?

We have a senior official from the Department. Either an assistant principal officer or I would attend.

Am I correct in understanding there was a recent review of the primary healthcare projects under way?

Yes.

Will Ms Heffernan tell us a bit more about that, if she has not already?

We have covered it but I will say that the HSE has conducted a review and we are finalising the report. It is going to our national Traveller health implementation group at the end of the month to be ratified and then we will go to implement the recommendations. I was saying that there was likely to be a significant overlap with the recent Pavee Point report as well.

My concern is that these projects are already quite stretched in terms of resources as well as the level of work that needs to happen. Does the scale of the review put them under additional strain and stress? Is that taken into account in the scrutiny that is applied to smaller projects and part-time workers? I am referring to how much time and resources it takes, from doing the actual work to getting to the outcomes I mentioned about life expectancy? It is about a balance between them. I know these audits and reports have to be done but is the balance right?

It is true. We have had a number of reviews under way that we were drawing on the same people to respond to. We did our best to stagger them. We are hoping now, that once we have this review done, we will also have a framework of how we can, over the next few years, monitor on an ongoing basis without it being such a significant ask so that it is much easier to check in.

It is about being conscious of that, particularly as to how stretched resources are and the level of need and the scale. I used to manage a small community project working with the LGBT community. It was quite a small-scale project but sometimes the reporting requirements from the HSE, the Charities Regulator and others could take up a chunk of time and leave you with less time to do the actual work you are funded to do. Sometimes, there is an onerous burden placed on front-line workers in under-resourced projects. Sometimes, we need to give them more money and resources if we want them to do the level of reporting that is required.

An issue that has been identified in the mid-term review is that we are probably over-reliant on primary healthcare projects for reporting on Traveller engagements. We should be capturing more of that in the mainstream health system because that is where the responsibility lies. That is where the ethnic identifier would help us. We will be able to say how many people participating in all the programmes in the mainstream health system are coming from a Traveller background. That is probably where we will see the full accountability. I take the Deputy's point, though. In terms of KPIs, there is probably too much onus placed on the projects rather than the wider HSE.

To clarify my question on the national Traveller health implementation group, is Mr. Walsh saying he is a member of that group? Is that correct?

It is either myself or the assistant principal officer in my department. There has been a change there.

I thank all of our witnesses for coming in and for their contributions. They can see from the range of Members from outside our committee who attended the interest in the well-being and health of the Travelling community and the concern about the statistics that highlight the challenges that are there. I expect we will be meeting frequently to discuss these issues.