Mr. Bernard Gloster:

I will take the questions relating to community health care from the last four contributors. On the Chairman's question about GP recruitment, we have two vacancies in the mid-west that we are attempting to fill in the mid-west, one in north Tipperary and one in Thurles. On anticipating those, we have a fair indication as to when people are thinking about retirement. Many of the Chairman's GP colleagues will stay on for quite some years but we have a general indication. On what the system is trying to do about that, nationally, last year, the HSE's target was to have 187 GP trainees. The actual out-turn was 170. That gives an indication of the transition in respect of filling some of the places. This year's target is 198.

In the mid-west, one thing we have tried to do to mitigate the difficulties in recruiting is use the job-share scheme in some practices. A contractor might decide to go on reduced time in later years before they retire. Another doctor comes in and eventually takes on the practice. In the two or three cases where we have done that, it has been quite successful. It is a bit different to the assistant with a view to partnership.

The challenge in relation to GP recruitment will not become more level or ironed out until the contract issues have concluded. That is being attended to by the Minister and the Department and negotiations are ongoing.

We have tried to expand the range of supports available to GPs. The Chairman will be very familiar with the Shannondoc system in the mid-west area. It was originally intended as an out-of-hours emergency service and is effectively an extended day's service in terms of people's expectations. There are more than 100,000 contacts to that service annually. Luckily, we have been able to provide additional supports. The Chairman is a particularly strong supporter of the community intervention team. Last year in the mid-west, GPs alone made 290 referrals to the community intervention team as distinct from sending people to hospital. That is one small snapshot of its work.

That is the direction in which things are going but I would not dispute that GP recruitment is very challenged. We are probably somewhat more fortunate in the mid-west in how the numbers have fallen but we are challenged.

Senator Swanick, who had to leave, made particular reference to the use of district hospitals or community nursing units. Between us, my eight colleagues across the country and I have 7,002 public beds and 1,982 of those are used as short-stay beds. All of them, other than those used for people coming in from home for respite, are predominantly associated with hospital flow of one type or another whether it is rehabilitation, step-down, transition and so on. Some 5,020 of them are in the long-stay system. We are very committed to the community nursing unit system. The Senator might be familiar with the Government commitment to the refurbishment programme or the new build programme for which the regulations were amended to take us to 2021. There is in excess of €500 million being spent to enhance that sector. The public community nursing units are very much a feature of our plans for the future.

Deputy O'Connell asked a specific question so as not to misunderstand my intervention in respect of Deputy Donnelly's point. For clarity, I was not necessarily arguing that Deputy Donnelly's observations on international comparators were in any way out of kilter. To be fair, he was relying on the capacity review for much of it. The point I was trying to make was that in the Irish context, while we have a younger population in some respects, one must look at the health status of the older population. Life expectancy is above the EU average in Ireland because fewer people are dying from circulatory and other diseases because of advances in medicine.

It does not mean that people do not have those diseases and, indeed, they have dependencies on the healthcare system as a result. That is why this year, we will deliver very high concentrations of support to older people in hospitals and the community, such as more than 17 million home support hours. It is not as simple as noting Ireland's young population compared with other countries and asking why things are different here. The status of our population and, in particular, the fact that 65% of those over 65 years of age have at least two chronic conditions, as members are aware, creates significant dependencies on every part of the healthcare system.

On the use of primary care centres, we are always looking for ways to encourage people to utilise what is available to them in the community.

Ms Cowan will address the issue raised by Deputy O'Connell in regard to the model used in Kilkenny. I am aware that general practitioners in the mid-west are fortunate to have other routes available to them, such as an acute medical assessment unit, a surgical assessment unit, a bed bureau and so on.

On step-down facilities, Deputy O'Connell referred to Mount Carmel Community Hospital. A very successful initiative was introduced for the winter of 2016-17, repeated in 2017-18 and effectively is now an all-year-round system. It is a transition care system that allows people to convalesce or be cared for outside an acute hospital while, for example, awaiting the completion of their fair deal process. We have had some very good successes in that regard and the system now runs throughout the year. Approximately €2.5 million per month is spent on it and over 200 cases per week are approved, each of which has an average length of stay in transitional care of 22 days. Were it not for the scheme, those patients would be likely to spend that time in the acute system. Deputy O'Connell rightly referred to care plan and consent issues in that regard. Some hospitals use the transition care system more than others. Limerick is the highest and best user of the transitional care system. It is a very effective intervention and we probably will have to sustain it long into the future. To go back to Deputy O'Connell's point, we must also try to work with people on consent and care plans, which is not always easy for many reasons to do with families and choice and so on.