I welcome everyone. I remind all those in attendance to ensure their mobile phones are on silent mode or switched off, including my own.

As the witnesses are within the precincts of Leinster House, they are protected by absolute privilege in respect of the presentations they make to the committee. This means they have an absolute defence against any defamation action for anything they say at the meeting. However, they are expected not to 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 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 witnesses from the Irish Traveller Movement to discuss Traveller health. Our witnesses are Ms Ann Friel, primary healthcare co-ordinator, Donegal primary healthcare for Travellers project, and Ms Mary Nevin, community health worker, Longford primary healthcare for Travellers project. They are both very welcome. I invite Ms Friel and then Ms Nevin to make their opening statements. We will then proceed to a question and answer session.

I thank the Chair and members of the committee. I welcome the opportunity to speak here today as a Traveller woman. I co-ordinate the primary healthcare project in Donegal. I am also a representative of the national Traveller health network on the national Traveller health implementation group. I acknowledge the work of the committee and its focus on Traveller health.

As members are aware, the poor health inequalities our community experiences are well documented and we, as Traveller organisations, have a model pioneered by Pavee Point that has been in place for over 30 years and works. The primary healthcare for Travellers model is internationally recognised by the World Health Organization, WHO, the State, the Department of Health and the HSE. The model is underpinned by the social determinants of health, which include racism, discrimination, accommodation and education, and takes a community development approach. This means we seek to address the root causes of poor health, not just the symptoms.

The Traveller health review highlighted gaps that need to be addressed and set out nine recommendations. Some of the recommendations include proper investment and sustained funding for projects to end the poverty trap, with better pay conditions and benefits, including a medical card for workers, which we are pleased to say the HSE's CEO has approved initially for one year pending review; national standardisation, including roles and training to support workforce planning; mainstreaming Traveller health across the system with job opportunities beyond Traveller primary healthcare projects; and better data to monitor services and capture the work of the projects.

We currently have 27 well-established primary healthcare projects around the country, with three new ones established over the past few years. There are about 300 Traveller health workers, who work on average 12 hours per week with our community and our older people, younger people and families across the country. However, in most cases, if not all, these workers are working beyond their hours for on average €15 per hour nationally. We have workers who have been working in the field for over 30 years and they are on the same rate of pay as new workers and with no pensions. The pay does not reflect the reality of the hours worked or the complexity of our roles. As Travellers and Traveller workers, we work and live in the community. We go beyond what is asked of us and what our official job description says on paper. When crises arise, for example a suicide or other tragic event, Traveller community health workers are called on and are available outside nine to five. During Covid-19, we put our own health at risk to protect our communities and we know we saved lives, but we did not even qualify for the front-line pandemic payment despite being on the front line.

As I said, the Department of Health has published a national review of the Traveller primary healthcare projects with a number of recommendations, which I have gone through.

I will now pass over to my colleague Mary.

I thank Ann for the introduction and I also thank the Chair and members of the committee. I echo Ann's appreciation for the committee’s work on Traveller health and welcome the opportunity today to contribute to its work. I address the committee this afternoon with regard to one of the main themes emerging from the mid-term review of the national Traveller health action plan and emerging from the review of the primary healthcare projects published this week by the national Traveller health implementation group.

The role of Traveller community health workers has evolved and expanded considerably over the course of 30 years. Where the role might have involved solely primary care in its beginnings, we are now pulled in many directions, be they homelessness, mental health, health and well-being, or drugs and alcohol. We are the stopgap for everything in our community. We need to see proper pay and career progression and hopefully, with review, recommendations will be implemented,

We need the primary healthcare projects to be resourced and workers paid properly. We also need ambition to be realised. Traveller community health workers have given a lot and have an awful lot to give to the health services and beyond. We want Traveller community health workers to have choice and opportunities both within projects and beyond. We want to see workers thrive and Travellers as doctors, nurses and administrators and reflected across the whole system. We have seen some positive progress as workers over the past few years with the national Traveller health action plan. Thankfully, and announced only recently by the outgoing CEO of the HSE, Bernard Gloster, Traveller community health workers are now entitled to retain their medical cards when working in primary healthcare projects for one year. This was a win and we require more of them.

I welcome Ms Friel and Ms Nevin and thank them for making the journey to be with us. I am shocked by the pay. It is truly shocking. I, along with the rest of the committee, am well aware of the work done by Traveller primary healthcare workers. They have been praised roundly in this committee over the past number of months by all of the witnesses who have appeared before us. I am truly shocked by the pay. It is a disgrace. Have there been discussions about the pay and conditions of Traveller primary healthcare workers? We see that modest win in terms of medical cards but it is a very modest gain. In terms of pay parity, salaries should be benchmarked against an equivalent standard within the HSE.

There was a webinar this week and the review of the primary healthcare project was published. One of the recommendations was to look at pay for community healthcare workers who are members of the Traveller community. Nationally, that is the real figure, around €15 per hour. We met with the Minister of State, Deputy Murnane O'Connor, yesterday and she has committed to looking at the recommendations of the primary healthcare review so we hope that will be looked at, but it needs to be funded and resourced. There are community healthcare workers who have been working for 30 years in the same position for €15 per hour with no pensions.

Do primary healthcare workers meet regularly as a network to discuss these issues around pay and conditions but also to compare their work and share the work knowledge they have?

Pavee Point hosts the national Traveller health network, which is an opportunity for all primary healthcare projects to come together. There are 27 well-established Traveller primary healthcare projects, of which three were established in the past number of years. Pavee Point co-ordinates that space for primary healthcare projects to come together to learn from each other, network and discuss challenges in each area.

Are there any distinct differences in Donegal in terms of the issues facing the Traveller community in the north west compared with, say, Offaly, Kilkenny or even Dublin? Do any specific issues stand out?

A lot of the issues for the Traveller community across Ireland are similar but some issues affect particular areas. Because Donegal is situated so close to the North, it can bring challenges, such as women experiencing domestic violence not being able to get shelter and having to move to the North. We have a particular problem with mica and defective blocks in Donegal, which has affected many members of the Traveller community in group housing, the private rental sector or local authority housing. That is a massive challenge. Even getting into private rented accommodation or trying to come out of homelessness is a challenge because of racism and discrimination. Trying to get private rented accommodation is a real challenge for Travellers because of their ethnicity, the lack of properties and the level of rent that is demanded from landlords.

Are group housing schemes included in the redress scheme?

Group housing is included in the redress scheme. There is group housing in Donegal that has been badly affected by mica.

I thank Ms Friel and Ms Nevin for their opening statements. I really appreciate them. To follow on from Senator Noonan, the pay and conditions are atrocious. The hourly rate of €15 for 12 hours per week is extremely low and, as Ms Friel noted, in many cases the hours go well beyond that because of the complexity and range of issues the workers deal with on a daily basis. I have just googled this and pay for a home care support worker with the HSE ranges from €15 to €25 per hour, so even if we were to make that comparison, Traveller community healthcare workers are underpaid. I hope this issue is something we can take up as a committee because the pay does not do justice to the role these workers play. It does not recognise the nature of the role and the challenges they face daily. That is something this committee needs to act on if we can.

There are 27 primary healthcare projects across the country and some additional ones will be coming on stream. Did Ms Friel say there were three coming?

Three projects have been launched in the past number of years but there have been 27 in existence for quite a long time and are well established.

Are the healthcare workers anchored or connected to those projects?

Yes. The model of primary healthcare is such that members of the Traveller community are trained to take up roles as community healthcare workers. Many of them are community health workers working in primary healthcare at grassroots level on a daily basis with and for the Traveller community.

What level of support do the workers have? If they encounter particular difficulties and need support as a worker, where can they go? Who is there to help them?

Each organisation has a support mechanism. Mary might like to come in on that question.

It is slightly different within each organisation. A counselling service is available to all our staff where there is a crisis to make sure they are following procedure and for their own mental health and well-being.

On the figure of 12 hours worked by primary healthcare workers, it is really more because when you are working within the community, you are well known and is never out of work. You will always get someone who will pull you up in the street. You might be out doing your own business-----

It is like being a politician.

Yes.

It is very hard not to do it because it is so close to the heart, so obviously you will do your best for your community. That is right across the board at local and national levels.

I know the witnesses do not have a typical day, so it is probably not a well-framed question, but can they give us a sense of a day in the life of a healthcare worker?

It can be range to a lot of things. It could involve working with a particular homeless family with a lot of complex needs or maybe a child with complex needs who is homeless. We could be looking for support and accommodation for that family. It could involve supporting a new family that has come into the area and does not have a GP or cannot get access to a GP or a medical card. It could involve getting women to engage in different programmes that are run to meet the needs of the community. Community health worker roles vary from day to day.

There is a broad range.

It is really key. There is no other organisation or role in this country that can engage the Traveller community in the way primary healthcare workers can, and that was evident during Covid-19. It varies from day to day.

I know, and that is why when I framed the question it was to get a sense, but there is a wide range of anything and everything.

Yes. It could be health promotion, it could be applications.

I will go back to my other question on what support mechanisms are there for the workers. Counselling is fine but the witnesses come across people in homeless situations and with particular health issues. Do the witnesses have contact points with the other State agencies, for example, the local authority or the HSE? Do they find they have an open door with a lot of these agencies or could that improve?

Those in different areas have different experiences. The majority of the 300 workers who are the workforce of primary healthcare projects are women. In society, we experience challenges, but it is Traveller women who are knocking down doors sometimes and who are outside looking to get in to advocate. It depends how long the primary healthcare project has been established in that particular area as well and on having those working relationships.

It depends on what kind of a relationship has built up. So, it does vary but very often the workers are fighting for recognition.

We are banging on doors.

Banging on doors trying to get recognition and access.

We want to be taken seriously and as professionals.

Exactly, and the pay does not reflect that or give the workers that status, to be perfectly honest. Do the witnesses believe there is hope in the recommendations of the health review published this week? Obviously, it has to be backed up with action, delivery and funding. Do the witnesses believe it could potentially be a very significant shift?

Definitely. A lot of work has gone into it. Our hope is that things will come from the recommendations and that they will be implemented. We are hugely surveyed. We have done many reports. It would be lovely to see no dust gather on this one, as such, and some of the recommendations implemented in order to improve the lives of the Traveller community and the work that has been done, and to be seen as professionals, as Ms Friel said clearly. The pay says a lot, as the Deputy quite rightly said. In any role, there is always a frame of work. Being able to climb that ladder and move into different positions within and outside the organisation is hugely valuable for the primary healthcare workers if they are to continue doing their good work.

I listened to Ms Friel speak about building up trust within the Traveller community. Being Travellers, we automatically have that trust and the amount of engagement we get from the Traveller community is second to none. We are able to go in and do a lot of very important work through the HSE and through leaflets and information. We make sure Travellers are aware of all of the different elements of their entitlements and what is out there. That is a lot of the work that is done on the ground on a daily basis.

As Ms Friel said, it is community based. Our role is a community one. The community is at the heart of everything we do. Homelessness and accommodation are massive issues within the Traveller community right across the board, both locally and nationally.

Going back to Ms Friel's point about links, we have good links in some areas and are able to get in that door but it is about the progression after making those links. It is about getting to the round table talks and then implementing what has been asked for and is required. From working in this area for many years, it is not about what people want, but what they need. I make this point in a lot of the meetings I attend. It is about what we see is needed within the Traveller community.

Absolutely. The report provides a very solid foundation. This committee has a role to play in keeping the pressure on so that the report's implementation moves forward. The report probably gives us a basis for comparing progress on its recommendations on a moving basis. We need to carry out those reviews with the Department and the relevant Ministers to ensure that there is progress being made. As a committee, we have a duty to try to ensure that happens. No doubt, that is something we will take up in the coming months.

I welcome our witnesses and thank them for their work, for their time and for sharing their expertise and knowledge with us.

I know a number of different reviews have taken place. Will the witnesses help me to tease them out a bit? There was the review of primary care for Traveller projects, which was published this week and is a HSE and Department of Health independently commissioned review with a series of recommendations. There is another report by Pavee Point, entitled "Beyond the Poverty Trap: A Roadmap for Sustainable Traveller Primary Heath Care Projects", that also sets out a roadmap and makes some recommendations. There have been a lot of reviews and work done in looking at the witnesses' work and how it operates.

Looking at the two reports, is there any particular recommendation we should really focus on and highlight? What I hope to achieve from this committee is to help to progress some of these recommendations and put a bit of pressure on the Government to do these things. As the witnesses might know, the committee has had a series of sessions on health. We are coming to a conclusion on that matter and are hoping to put out a report and have a wider debate on these issues. For the committee's final piece of work, which of these recommendations do the witnesses think are the most important and we should really focus on?

Investment and funding to sustain the primary healthcare projects. There was great news about the medical cards this week. There needs to be good workforce planning to get the younger generation involved in the work. At the moment, the way primary healthcare and the funding streams are set up, there are a very limited number of hours and that is not very attractive to our younger generations to get involved in. We will not be in our jobs forever, so it is about creating the conditions for our younger people to get involved in primary healthcare projects. There should be no glass ceilings for community health workers, there should be progression and there should be funding to sustain the primary healthcare projects.

Just so I am clear, all of these primary healthcare projects are independent. Ms Nevin is from the Longford primary healthcare project, for example, and it is independent of the other primary healthcare projects. She and Ms Friel are not representing any other big organisations. The Irish Traveller Movement was mentioned, but these projects are independent and separate.

Yes. Most of the projects are under Traveller organisations but a few are based in local development companies. That is a different structure.

Each of them is separate and the witnesses are here on behalf of their own primary healthcare projects. I just wanted to be clear for the record.

Funding and pay are the main issues. Does Ms Nevin have any other thoughts on that?

We want primary healthcare projects to be an inviting space. As Ms Friel said, we will not be around forever; we have been there for quite a while. It is good for our younger generation coming up. Primary healthcare projects are a stream of employment. They are very close to the heart and the lived experience of a Traveller person. It will give momentum to the young generation coming into primary healthcare work and help them climb the ladder and move into different areas both inside and outside primary healthcare, working in different agencies in collaboration and partnership but always representing their community. That is the key point. With the racism and discrimination Travellers face, it is very hard for them sometimes to identify when there are different positions outside of primary healthcare work. We have many role models right across the board in Ireland but a lot of the young generation cannot identify as Travellers because of the racism and discrimination they face over coming from the Traveller community. For us, all of that needs to be streamlined so that when the younger generation enter the wider community to take up other jobs, they can be very proud. We are very proud of our community but because of what we face on a daily basis, it is a very difficult situation to be in. A certain job would give you the money you need to pay your bills and make some sort of life for your family, but if you identify as a Traveller, you might not get that job. There is a lot to answer for.

Another thing is the burden these reviews have placed on the witnesses in terms of reporting back and that kind of thing.

I worked on a somewhat similar project. I worked with a Cork gay men's health project, which is a small community project. I can sympathise with the witnesses never being off work when meeting people out and about and they are asking questions. Sometimes, you just want to get on with the work and not be tied up with the overburden of reporting and evaluations. It is important that that be done, too, but it can sometimes take up too much of the work and not leave enough time to be meeting people and be doing the direct health interventions. Is the balance off? Does Ms. Nevin have any thoughts on that in terms of the reporting back and accountability stuff?

Twelve hours a week is a very small amount of time to get so much work done. There is a huge amount of work to be done and if you are working full-time, you have to make sure the work is being done on a local level but also that you are part of the national framework. That is hugely important because that is where we get a lot of our guidelines from. Ms Friel spoke about the medical card. It means a lot to be able to say to a young Traveller person that they can come into the project without losing their medical card. With the amount of health issues among the Traveller community, that is a massive win for primary healthcare.

Initiatives like that are hugely important and that is why we need to look at this report and make sure it is implemented in order for change to happen. We have made a huge change over the years for the Traveller community in the area of health but there are still a lot of gaps that we are trying to close.

Given that these reports and reviews have been done, it would be a real shame if they were not now implemented. Unfortunately, that happens too often across the board, not just in relation to Traveller health. We get really good reports and recommendations but they sit on the shelf, get dusty and do not change. What we can do as Oireachtas Members and as a committee is put pressure on the Department of Health, the HSE and the Minister to now implement these recommendations in full because the work has been done, the reviews have been done and the organisations have all done the reporting back. It is now time for the Government to act on those and to make these projects sustainable in the longer term, with the recruitment and retention of staff so that we can get to the bigger goal of improving Traveller health.

I wish the witnesses all the best with their work on that and I thank them again for their time today.

I thank Ms Friel and Ms Nevin for their opening statements. It is quite depressing that we constantly have different groups from the Traveller community coming and we hear that nearly everything is the same across the country. There is so much lacking. When we look at it, some of the problems the witnesses are facing seem to be coming from elsewhere. That is very consistent.

Ms Friel talked about the 300 Traveller health workers and the 12 hours a week on average. There does not to be many, if any, who are full-time. That does not make sense to me. Many of these are obviously working well beyond the call of duty for the 12 hours. That they have been on the same pay for the last number of years is very unfair, as is the fact that there is no possibility for them to get pensions. That does not make sense and is something that is consistently coming up here.

I am curious about the healthcare workers. Are they all Travellers or are there others coming in as well? We have experienced that with other groups who said that they were not necessarily all Traveller healthcare workers.

The review of the Traveller primary healthcare project made nine recommendations. Ms Friel's submission highlighted five of them. I would have thought that suicide and self-harm would be major issues, as we consistently face high rates of suicide and self-harm in the Traveller community. It is just appalling. So is the average lifespan, but that is another story.

It has come up many times about how the workers in question were not treated in the same way during the pandemic as other healthcare workers. They did not get any sort of compensation. That is discriminatory. That is the reality. It should not have happened. People across the board should be treated in the same way. Of course, racism and discrimination are across the board. Do the witnesses find that the problems are exactly the same in the different areas they represent or are there differences? Are there differences, for instance, in the suicide rate and self-harm rate in different areas or are those generally the same across the board?

The majority of the cohort of 300 workers are members of the Traveller community. Community health worker posts are specifically for Irish Travellers. Those roles are designed for Irish Travellers.

We know that suicide is a massive challenge and a crisis in our community. However, if we look at cancer rates and rates of respiratory disease, including chronic obstructive pulmonary disease, COPD, they are also massive causes of death within our community. It is not that members of the Travelling community are not going into the services. Rather, it is normally at the point of late diagnosis. There are massive challenges in relation to getting through the door and being navigated through the system. We know that from the findings of the EU Fundamental Rights Agency, which stated that 39% of Travellers faced racism and discrimination. Suicide is still a massive issue, but there are other issues as well that have arisen in the last number of years.

Regarding the causes in each area, they are similar across the country. They are the same particular issues that I mentioned earlier on. Different issues may arise around the Border counties but we are normally working on the same kinds of issue.

Would that apply in terms of homelessness and housing? Is the local authority better in different areas? Is it better or worse in someone's area or are people facing the same problems with serious homelessness, overcrowding and so on? These problems lead to serious health issues, which is a major problem.

I will address homelessness because I do a piece on that through my work. It is a very high number. The Deputy hit on it with the hidden homelessness. As far as I am aware, it is right across the board. The suicide rate is right across the board in the Traveller community, as is the housing issue. Some areas are slightly better than others. In some areas, the council has a specific Traveller liaison officer. That can bridge some of the gaps. However, it is not just about getting through the door and sitting down at the table. It is about what happens after the talks and what is going to be implemented. You can go in and air all your issues but we would like to see outcomes from that. Does that make sense?

The Deputy spoke about our population dying. Traveller men die ten years earlier than men in the wider community. Traveller women die 12 years earlier than in the wider community. Hitting on the point made on the pensions, I have been working in the area for over 22 years. I am not getting any younger. By the time I am given a pension, I do not know if I will be around to receive it.

This also makes the point for young people to come into a job. They want the same. They have the capacity and are well able to do the job, but they want the same entitlements as their counterparts are getting. The Deputy spoke about racism and discrimination. Those are very much at the core. We want to be seen as professionals. We perform as professionals, so why not get the same pay scale? Why not have the pensions? We have given so much in the line of work we do. If we did not love our job, we would not be in it.

We have seen a massive shift. The Traveller health action plan has been fantastic for Traveller health.

We have that structure. We have an National Traveller Health Implementation Group, NTHIG, set up to drive that Traveller health action plan. However, in terms of engaging with other services - we are professionals working in this area for a long time - unfortunately, it is very often based on the personality of the individual who has the power in that service. It should not be based on that. As the Traveller community is part of the population and part of Irish society, services have a responsibility to work with, for and include the Traveller community. As professionals and Irish Travellers, it should not come down to the personality of an individual whether they are willing to work with us in different services. There are policies out there for Irish Travellers in relation to health, education, and so on. We are part of Irish society. Services need to be inclusive, and this includes for Traveller health as well.

First, I apologise for being late. I chair the Joint Committee on Disability Matters and we were out at the Acquired Brain Injury Ireland office in Dún Laoghaire and got delayed coming back. I thank Ms Friel and Ms Nevin for their presentations. Even though I did not hear them give their opening statements, I have read them. I also watched some of the commentary on my phone when I was on the way back in.

As my colleague Deputy Ellis said, we have heard a number of submissions over the last number of weeks. The statistics given by everyone who has come in here are off the scale, whether they relate to mental health, dying earlier, or cancer rates. Then there are statistics on employment, racism and all that stuff. Every session we have come to has been horrific. While I feel a bit powerless, and we are going to try to change that, we do not seem to be getting any solutions to any of these issues. What we have done in the last number of weeks is get all of the recommendations from previous reports to try to put them together and see which ones we can prioritise and then try to get the Government to prioritise them.

I thank the witnesses for their opening statements. They are very useful, as is the work they do. Ms Nevin spoke about how the role of Traveller healthcare workers has expanded and now includes dealing with homelessness, mental health and well-being while still on the same payment and with the same role. Does she think a new role should be created for a person to specifically address the issues of access to housing, education and employment? This would mean that others could focus on health. This would be a new role.

Through the primary healthcare structure, we have specific workers in certain areas that work maybe on homelessness; on accommodation, in other words. It does not happen in all the primary healthcare sites across the country, but it does happen in some of them. You might have a specific person working in accommodation. You might a specific person working on education or maybe employment, so within that remit we have different workers. However, as Ms Friel said, the community health workers are all from the Traveller community and their remit is working at grassroots level, on the ground, linking in with families. Signposting to different agencies, in order to support families and young people, is a big piece of our work. The social determinants for the Traveller community are health, education, training, employment, mental health, addiction and the suicide rate. It is very varied. We have a certain amount of people doing that, but at the same time if the hours and the pay were resolved and looked at, we could get more people to come in to battle in those areas, if that makes sense.

Yes, it makes perfect sense. I thank Ms Nevin very much. Healthcare workers respond to incidents of suicide or tragedies in the community. We are well aware that they do not all happen between 9 a.m. and 5 p.m. Do workers receive training on how to handle such emotive situations?

Yes, we do. Within the primary healthcare sector - this is nationally and not just locally - we do training throughout the year. We do SafeTalk training and applied suicide intervention skills training, ASIST. We learn one-to-one how to deal with a situation when it arises. No community health worker is left on their own to deal with it. As the Deputy said, it is probably at weekends or evenings. We are there to support the family. We do not say, "No, we cannot do it". We have a lot of training on how to support a family and how to look for local links to support the family alongside ourselves.

What supports, if any, are there for the people who have deal with all of that? If they need help, do the workers get any specific counselling?

Yes, we look to avail of the counselling service. We have it in most local areas and nationally. This is where we link in with each other. If something arises in Longford and we are not sure what to do, we can connect with other primary healthcare providers, such as Pavee Point and other national programmes. It is very important that we are involved with all the national programmes and that is why it works so well. We are not just working independently on our own in the different areas; it is right across the board. If something happens in one area, we learn from each other about how we go forward and move forward so everyone gets the support. Suicide is obviously a very traumatic piece of work to have to deal with, both for the families and for the connection within the community as well.

It is even traumatic for the worker who deals with it.

It is, 100%. We have to make sure we follow up. That is another thing. There can be gaps in mental health services for any community, but specifically for the Traveller community because that is where we work. There are gaps in aftercare in the aftermath of the suicide when people come to the realisation that the person is not coming back. We have a lot of young people dying by suicide, which is frightening. It is not a shock to us. Mental health problems in the Traveller community are very high and there are many causes. Employment is a massive piece within the Traveller community.

As we spoke about earlier, some 90% of our health is affected by outside things that are going on. We do not have proper accommodation. If you are living on a halting site where there is no running water, no toilets and maybe no electricity, that has a huge effect both on the individual and the children who are growing up in that. It has a huge impact.

If you are living in a family who are experiencing hidden homelessness, there is the impact of living with parents or grandparents. There is no structure within that, and it causes some amount of stress. We have high numbers of diabetics in the community. We have high numbers of asthmatics. We spoke earlier about respiratory illness and cancer rates. When you have family going through that, there is nowhere to go. Even during Covid-19, Travellers had to try to isolate, but it was very difficult. We were told that we had to isolate, but if you are living in a caravan with five or seven other members, how do you isolate? That was another issue that arose during that time.

We are always battling on and firefighting. We win one battle, and we are onto the next one. We are here today to highlight the work being done on the ground. You have to see it to believe it. You have to have lived the life experience to have a greater understanding of what it is like to be a Traveller and walk in their shoes on a daily basis. It is very difficult.

I can imagine. I thank Ms Nevin for explaining that. We all agree that there is an issue with access to employment and especially access to apprenticeships. We have a scheme in Limerick where Tusla are doing an access to apprenticeships course, and I know that a number of Travellers have been involved. There is an awards ceremony at the end of March and that should be good.

After what we have talked about, I do not know how we expect some workers to go out into the Traveller community and deal with all those issues on their own without wraparound support for them. I know that I can come out of my constituency clinics feeling quite stressed, not to mention the people coming into me. When people are dealing with suicides - I have done, but not as closely as the workers by any stretch of the imagination - we really need to make sure they are supported.

That is why I suggest that, if possible, we should create a different role to help that person and take away the work related to employment and housing to let them focus on health. Every statistic at this committee shows us that we need to prioritise housing, education, employment, health services and, as the witnesses mentioned, mental health services in particular, which leads to suicide. I thank the witnesses and apologise again for being late.

In terms of the mental health services and access to hospital, we have had experience where people have been turned away.

There is a certain amount of discrimination involved in it. Does Ms Nevin experience a lot of this? I have experienced it here in Dublin with the different Traveller groups where there has been suicide. There have been people turned away and as a result, they have ended up dying, unfortunately. I am not sure if Ms Nevin and Ms Friel are having the same experience or if they have a better relationship with the accident and emergency departments or whatever.

I suppose it is a difficult one to answer because a lot of the services are overstretched. When people from the Traveller community approach services, they need support to go there in the first place because sometimes people are not culturally aware of the Traveller community. You might hand them a form to fill in. They might not be able to read and write that form. I am not saying that applies to all the Traveller community. A huge part of it is being informed, having an understanding of the culture and having an understanding of the individual standing before you. I would be promoting that within the services so that they have an understanding of what the people who come into them are up against.

On the supports that are there, it is difficult to say because there are so many waiting lists at the moment. It is like everything else when you go into any service. I suggest that because the Traveller community has a high mortality rate and high incidence of health issues, Travellers should be prioritised. It is difficult enough to approach a service but when you do, it is about what you get back and how you are treated when you go to that service. That is why the role of community health workers is so important. They are able to break that barrier. They are able to step in and support that family. Once they are there, they have been trained up to have an understanding of how to advocate on behalf of the Traveller person or family, whoever it may be. It is a difficult one, very much so.

I seek clarity on the medical cards. In her opening statement, Ms Nevin welcomed the announcement from Bernard Gloster. Am I correct in understanding that is just for the first year?

It is for the first year but we are hoping that, all going well, it will be extended.

Have they only committed to doing it for the first year?

Just a year, so we are hoping.

What we ideally want is for people to be able to retain those medical cards.

Exactly, that they would be ongoing. In order to be able to get them to come in to apply for the post in the first place, because of all the underlying conditions that the Traveller community has - for example, they have higher rates of illnesses - they need their medical card. That sometimes can deter them from taking up-----

It is more of a half-step than a first step. Would that be right?

Yes.

There is a commitment there for one year and we are taking that as a win. For people who are just over the threshold and have lost their medical cards, if they take up the role of community health worker for 12 hours a week, they will lose a lot more. There is the medical card and probably the housing assistance payment, HAP, allowance. It varies in different situations. We are all different. We take that. We welcome that medical card, even for one year, and maybe it will be reviewed then.

Perhaps the witnesses, or Pavee Point or another organisation, might keep in touch with us this matters. If it transpires after a year that it is not being extended, we can look at it again and keep a watching brief on it.

Okay.

Travellers need to have a medical card. Often, as workers, we have the same health inequalities in the wider Traveller community. Even though we are employed, we still suffer. Old age diseases present at a much younger age in the Traveller community. We experience that as well as workers. To have a medical card, even for one year as a starting point, is a good deal for us.

On a related point, when we had representatives of Pavee Point here, they were talking about wanting changes in social protection around jobseeker's allowance. Have they heard any updates or any progress on any of that side of it or has the medical card been the only change?

So far, the medical card is the only change.

There are other things that can be done to make it more attractive. For example, it has been recommended here that the employment rulebook for jobseeker's allowance be amended so that it goes from a daily one to an hourly one. Similarly, the Department of Social Protection could amend the jobseeker's earning disregard from a daily one to an hourly one, and increase it. If people can retain some of the other benefits and protections that are there, it will make it more attractive for them to take up the work. As has been said, we need the next generation of people to do the work and continue these projects. It is important that all of the pieces happen.

Even at the moment, if you look at the report from Pavee Point, you will see that they are in the poverty trap. If Travellers are kept at 12 hours per week, in the current climate at €15 an hour on average nationally, they will be kept in the poverty trap. You are talking about people who have committed 20 or 30 years of their lives to work on this primary healthcare infrastructure and are still on the same bit of pay. There will be very little progression and no increase in pay and they will be kept in the poverty trap.

That certainly has to change. The witnesses have my support on that. We need to advocate for that. The pay, as other members have said, is too low and needs to be changed. I thank them for highlighting all of these issues and for their time.

The vast majority of the healthcare workers are women. In relation to interaction and engagement in the community, is there a reluctance among men to engage with them?

We have seen a massive change since the All Ireland Traveller Health Study. When primary healthcare - Pavee Point was the pioneer organisation that started a primary healthcare project in this country - started, it was all women. We have seen a shift, even before the All Ireland Traveller Health Study in some areas but particularly after the All Ireland Traveller Health Study. Now you have Traveller men taking up positions within the primary healthcare infrastructure as men's health development workers.

Where those men are in place, do you see a greater participation?

A greater participation of Traveller men, yes. Traveller men will engage Traveller men.

But not women?

Women too.

They will engage with women as well.

They will do both. I suppose the idea with the men is that they use a slightly different tool of engagement, which can be through sport or an interest in what the men are coming in for. Through that tool of engagement, we can cover many areas. For example, it will come up through some of the work that is being covered around mental health and suicide. When men are busy doing stuff - playing ball, playing snooker or playing cards - they do not realise and through that, the talks happen. Then we can see our role, we can intervene and we can do workshops. We are informing them at all the different stages. There is so much we can do. As Ms Friel said, where we have community men's health workers, it is brilliant. The uptake of the men is very high when you have a men's worker in place.

Okay.

We are able to get them in then. The women are able to get in to do their piece, which is around a lot of the health initiatives, how to mind our health and the different topics. That is hugely important as well.

Somebody once put it well to me that men often engage side-by-side as opposed to face-to-face; for example, in the car.

It is a good expression.

Are there any regions that are particularly good on Traveller health? From the statistics, there does not seem to be anywhere. Without naming it, is any region particularly better than others or is there any that is really bad?

Is the Deputy referring to health inequality for Travellers? Is he asking if there are areas that are better for Travellers to be in than others?

I am asking about the whole situation with regard to access to health. I refer to the nurses and doctors that would be there. Is there one region that is better than others?

It is similar nationally. This is the one thing that keeps coming up for the Traveller community, whether they are attending a hospital appointment or their GP service. It is broad, but is similar in all areas. Obviously, there are blocks and barriers accessing different areas. I spoke about the cultural awareness piece. If people working in these areas have an understanding of the Traveller community and being culturally appropriate, it will work an awful better and be more effective and more efficient. Does that answer the question the Deputy asked?

Kind of. Ms Nevin is basically saying that it is not great everywhere.

Exactly.

I was not trying to pretend it was great somewhere.

No.

On the issue of men being involved as Traveller healthcare workers, I am aware that there are obviously barriers for anybody being involved - the pay, the lack of progression, and the lack of a pension, etc. Is there anything that could be done, assuming we address those issues, to get more men into it? As everyone said, men will dig with men more easily and talk to them more easily in such circumstances?

I will go back to the point about the pay rise and the pensions.

A person who is going for a job, looks at the job description first. If it offers fairly decent pay and a pension and the person wants to do that job, that alone is incentive for men to come on board. Once they see that and see the outcome on the ground of what they are doing, the empowerment and the engagement, they can become role models. We want to see more of that.

It is different in different areas. In certain areas, some men might be more engaged in the primary healthcare project than others. In Donegal, we have four Traveller men with the primary healthcare project. Different areas have different numbers of men participating. We normally associate women with primary healthcare. It can be regarded as a bit menial for men who might feel it is not a male's role, but it is a male's role. Where men are employed, it is working, but different areas have different numbers of men employed.

What Ms Nevin said about having more role models is important. I come from a working-class area, and we need to have role models to show people how they can progress in life or whatever. I read Travellers' Voice; I have it sent to me. There are some great stories in there, but it does not seem to get great traction because most people do not read it. I read recently about a Traveller consultant who is working in Australia or somewhere like that. He is a really good role model, but does anyone know about him? Shane McCarthy is from Kerry. He is on Instagram every five minutes. He lives in my area at the moment. He is a good role model for kids. He does not just talk about being a Traveller; he covers mental health and other issues. Promoting those role models would help everybody.

We have a lot of those role models within our community, but they have to hide their identity to be able to secure their jobs in the specific areas the Deputy mentioned. That again goes back to the racism and the discrimination that the Traveller community face on a daily basis. That is right across the board. That is in sports, social life and medical services; it is right across the board. It is not just in one specific area. We need role models to be visible. They should not have to hide who they are. I could tell many stories. Imagine how that affects a young person or any person.

For Travellers, leaving home and going to a job outside of primary healthcare - because they can self-identify within that - they are wearing that cap. In work, they have a uniform and they change the way they are until they come out and get into their car to drive home. When they get home, they feel they are in a safe place and can be themselves once again. It is very hard for our young people to have to wear those two caps. It is also very belittling for them that they should have to hide who they are to be able to stay in their positions, even with whatever qualifications they may have. That is right from the bottom up in the different positions. It is very difficult. We see it and hear it.

I work with young people and could tell many stories about the different words used towards the Traveller community. They could be in training or in college. It is grey marks when they are not self-identifying. That hurts and can cause trauma internally. Being trauma informed is another piece that a lot of us in the Traveller community have been raised with. We have to deal with all these issues and may suppress them because we have nowhere to go with them. That is why the mental health issue is so big within the Traveller community.

I saw a letter on Instagram a few weeks ago - I read it out at the committee's previous meeting - about a young Traveller girl who left school and her experience coming home and how her mother got really upset. Her mother said she was really upset but really proud as well. The girl is clearly proud to be a Traveller, but she did not want to go to school and be different. That was the big thing in the letter.

There is nothing wrong with being different. We in the Traveller community are different. As Ms Nevin said, unfortunately, in some cases people in particular jobs have had to hide their identity. There are people from to the Traveller community who are in well qualified jobs, are doing really well within their field and are really proud of their identity. We should not judge people on whether they hide their identity. There needs to be investment in apprenticeship. It is about identity and pride. People need to know that it is okay to be a member of the Traveller community and to have higher expectations. We have people out there who are doing quite well in different fields and are really proud to stand out as individuals. They are proud of who they are and where they come from.

Even within primary healthcare, over many years we have seen progression in those roles. Many years ago, when I started, we would not see many Travellers being co-ordinators or managers within that role, whereas now that is changing. We can see the shift, but, as Ms Friel said, we need more of that. We need investment in order to move along and move forward. Looking at the younger generation, that is why we are here today, it is an investment for them to change their lives for the better, to improve their outcomes, to have fewer health issues, to be more aware, to have a better understanding and not to have a lot of trauma to carry through their lives. That is what this is about.

I would agree that there are some great role models there. I follow Shane McCarthy every day. He has 100,000 followers on Instagram, which gives him great visibility. He talks about being an LGBT Traveller and being a member of the gay community. He is a great role model. Regarding pay, I know there was engagement with the Minister of State, Deputy Jennifer Murnane O'Connor. Did she give any indication about a change in pay and conditions?

At our meeting yesterday, she said she was committed to the implementation of the findings of the review, which is very positive.

We will have to keep the pressure on her to deliver on that.

Ms Friel stated that some of the health companies are in LEADER companies and others are not. Is there any difference in the approach between the two.

The whole model of primary healthcare is driven by community development of work. A lot of the independent Traveller organisations are driven by community development. That may vary through different local development groups. There is a funding stream coming through. We would see community development as the core driver of the model of primary healthcare projects. The model is there but it could be done differently and maybe not pushed in a community development way because it is about the community working with its own community, raising conditions where the community comes and the workers pushing the work. It varies. Ms Nevin has experience of working in a local development company.

It is a bit more difficult working under partnership because within a Traveller organisation that understanding is a given, and everyone knows where they are at with it. In a partnership sometimes it is very difficult because they might not have an understanding of what exactly the Traveller community's needs are. As Ms Friel said, the core piece is community development. That is the work we do and sometimes that can be a bit difficult. In an organisation, it is a lot easier to be able to go and get a straight answer. Is that the right way of saying it?

It is indeed. We often encounter that ourselves. Does Senator Noonan wish to come back in?

Yes. I apologise; I had to go to the House to vote. Are there any training or further education opportunities for Traveller primary healthcare workers to go into mainstream medical or social care work? Have there been examples across the country where primary healthcare workers have moved into mainstream health services or other professionals?

One of the recommendations from the review was to look at standardised training for community health workers as a baseline. There has been a piece of research work looking at the level of qualifications that exists within primary healthcare. In different parts of the country, it varies from level 4 to level 7, mainly level 6. One of the recommendations is to look at standardised training. At the moment, a training initiative has been set up in the Dublin region, involving, I think, 19 women and one man, looking at the model of primary healthcare and doing a QQI level 4.

That is something to look at with workforce planning for the future. Within the organisation that I work in, professional development is key, especially in the context of community development. The organisation works on the basis of an ethos of community development where Travellers are trained and where Travellers take up leadership positions. We have workers who are doing level 7 degrees. I am in the third year of my master's degree. It is around professional development being pushed. We are looking for a standardised training. Different areas have different examples of good practice to show that.

It is about trying to define and set out career paths for primary healthcare workers to move into.

People should not be stuck in the one job - for lack opportunity - on the basis of their training for 30 years. They should be progressing. There should be other opportunities for Travellers that we feel skilled enough that we can apply for within the organisation, outside the organisation or within the HSE.

Both projects in Longford and Donegal are largely rural based. How big an issue is public transport in terms of Traveller families getting to appointments, training or education? Is it a significant issue or have things improved in that regard?

Transport is normally a massive issue for everybody in rural areas, but particularly for Travellers. If a child or an adult has to a national hospital, transport is a massive issue. Normally, where sites are located or built is normally outside town boundaries where public transport is not great. It is quite challenging even to come to Dublin. It is particularly challenging for a person who needs to get public transport to go to a hospital appointment. It is a massive issue for everybody, but particularly for people who have to go to hospital appointments nationally.

There has been some significant expansion of Local Link services. There have been pilots of some rural transport initiatives where a shared bus could be used between a number of projects, with different drivers involved. Are there any schemes like that in the witnesses' localities?

Not that I am aware of. In relation to transport, we have a really good intercultural preschool. Loads of different ethnic minority children attend that preschool, but transport is a massive issue and challenge, especially for Traveller children, to access it. This is because of the geographic spread within the county. Research papers show that Traveller children are not accessing preschool services because of fear of discrimination and racism. It is different where there is a preschool in which the value is driven and there is a mission and a vision around inclusion, but transport is a massive issue for children to access that preschool as a result of it being located in a large town or an urban area.

I suspected that. It is something that we need to give consideration to in our report. There might be novel solutions out there. This is something I have interest in. There are plenty organisations that have buses lying in the yard for half the week. Those vehicles could be shared among a number of services. This is something we are not making good use of. It is not just access to preschools or education; it is also access to health appointments, medical appointments, education, training, etc. I do not know how we frame it, but it is important.

In parts of Wexford, we have community car initiatives that are overseen by local LEADER companies. That could be a route to go down, or we could opt for community buses. An Garda Síochána operates a community bus in the New Ross area of Wexford. It is certainly something that we can investigate.

I thank the Cathaoirleach very much. I appreciate that.

I have good news for the Chair. I have an appointment at 2 p.m that I cannot forgo. That restrict my time. The Chair will not be disappointed with that news.

I welcome the witnesses. There were two shocking stark backdrops to our discussion today. The first is the difference in lifespans, with nine years for women and 12 years for men. The second relates to the suicide rate. These are two shocking backdrops to what we are going to talk about.

Because I am restricted as to time, I will ask specific questions. Are there difficulties in recruiting health workers, special workers and Traveller community health workers at present?

Yes. We are finding it hard to get staff to come in and to retain them due to the pay scales, pensions and hours. They are only working 12 hours a week. That is a real restriction. It is not a very inviting space.

That is not enough.

Yes, 100%.

It is good news that they are getting medical cards. What should be next? Would it be pay increases?

The pay increases should be the next piece following the medical card. It would then be a case of looking at the pensions. That is needed in order for it to be an inviting space that people will come into. We need to look at the hours. Once we get that, it is a setting piece. They could make a shift on the hours because they could retain their medical cards. Having a medical card taken away is a massive loss. If they have extra hours, it means that they are working within their hours rather than working and not being paid for it, if that makes sense. They are working outside of those hours to make up for the shortfall in the hours they are working.

Ms Nevin referred in her opening statement to the ambition - this is an ambition that every member of the committee would share and every sane person listening or watching would share - that Travellers would have a wider involvement in the health service. They would have administrative roles and could go up to what are called the higher professions. They could become nurses, doctors or whatever. Is the biggest obstacle to that education? Is it attitude? What is it.

There are a lot of factors involved in this.

Will Ms Nevin outline a few of them?

It is the education, training and the employment that follows that. As Ms Friel said, it is about training and upskilling for people to retain places and move forward into different positions.

There is not an opportunity to upskill.

Not really at the minute. There is to a small extent-----

There should be a progression into nursing, for example.

At the moment, we do not see that.

Obviously, there would have to be nursing education, but the progression should be there.

There are Travellers in this country who are well qualified but who cannot get jobs.

Is that as nurses?

It is not particularly nursing professionals; it is other professions. They are qualified and have degrees, including in health and social care. In different settings, there are a number who are struggling to get jobs on the basis of their surnames or addresses. We know this as a lived experienced as being members of the Traveller community. Equality is one of thing. It is important. Travellers have to have the opportunity to progress and take up opportunities. There are high rates of unemployment in the Traveller community. There are Travellers who have got the best qualifications but who struggle to get employment because of racism and discrimination.

That is a shocking indictment of contemporary society. If the witnesses want to supply the Chair or secretariat with specifics on that, it might be helpful. I would appreciate it if they could supply them to me too.

It would be helpful.

It would be very helpful if specifics could be provided. If the allegation is true, specifics or even some case studies should be obtainable. That is a horror.

When it comes to case studies, people apply for jobs, and they will not even be called for an interview on the basis of their surnames or their addresses. This is because the live on sites. We know that anecdotally in the context of local areas.

That is an indictment; it is awful. I have two more questions and I will leave it at that. The first leads neatly into the second. In the context of distrust among members of the Traveller community of health professionals, etc., one would like to think that is going away. Do the witnesses want to comment on that?

It is going away because we have Travellers working in the area. There is peer-led work happening. People are working in partnership with all agencies. We cannot work on our own. Because we are working within our community, the trust is automatically there. We have that.

It is the fact that all the trauma Travellers have historically been subjected to relates to that piece around mistrust.

This is my final question. I want to ask Ms Nevin about health education and health awareness. Before I ask the question, I want to preface it by saying that we are very aware that addiction and health difficulties are not particular to any one community. They are not particular to the Traveller community; they are in every community. Alcohol, drug and gambling addiction are in all sectors of society, but today we are discussing the Traveller community. Could Ms Nevin speak to how well addiction services are going? How available are such services? In the context of health education and addiction prevention and support and follow-up for the Traveller community, is there a lacuna?

We have seen change, and there has been a shift. We do have fairly good services that support Travellers who are in addiction. There are follow-ups in that, but, at the same time, the services are sometimes not there for the Traveller community. They might not be as local. People might have to travel. The Senator spoke about travel. That might be an issue. That might be a barrier for a Traveller to get to where they need to go. The Senator also spoke about trust. In order to have that, if people are linking in with the primary healthcare structure, it is automatically given, so they are getting the support of both.

For the purposes of this committee specifically, is Ms Nevin saying that it is available if people can get to it?

To a certain extent, but it is not widely available. It would be correct to say there are still a lot of barriers for people trying to get to that service.

I stress that this is not a Traveller-specific condition, but are there Traveller-specific courses or presentations available?

Yes, we have specific services in different areas that we can link in with and that we signpost. Again, however, they are overstretched. In relation to wider availability, there are different areas people can go to, but there is a barrier there once again for the Traveller person to sometimes get that. It might be transport. It might be the no trust side of things. There are a lot of different barriers.

That is useful information for us. With the Chair's permission, I have to leave. I thank our guests for being here. It is shocking. We were having an informal discussion with Senator Noonan on the way up, and we were saying that it is horrible that we are encountering the same issues every week.

I thank everyone very much indeed for their attendance and for engaging with the committee. This session has been very informative and useful. What we have heard will assist us greatly when we put our report and recommendations on this particular pillar of Traveller health together. We look forward to meeting our guests again, hopefully, in the not-too-distant future.