Michael McNamara (Clare, Labour)
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This issue concerns Shannondoc, which is a general practitioner, GP, co-operative based in County Clare that provides out-of-hours services to cover what GPs normally do during office hours in the evening and at weekends. It is an important service but there have been repeated rumours throughout County Clare of various reductions in Shannondoc services in west Clare, Shannon and elsewhere. Thankfully, this has not come to pass and it is important to state there has been no reduction in the Shannondoc services thus far but nevertheless, it also is important to acknowledge there is a great deal of pressure on the services Shannondoc provides because of GP shortages. When the present Government was elected, there were 20 GPs operating out of north and west County Clare but that number has now fallen to 15 and therefore, the number of GPs Shannondoc can pool and put on a roster in the evening is reduced. While this might not appear to be so important, the ambulance service is already at breaking point or at least is at the very edge of what it can achieve, and likewise the accident and emergency facilities in Limerick. While I thank the Minister of State, Deputy Coffey, for coming into the Chamber, I appreciate he is not a Minister in the Department of Health and consequently may not be aware of the overcrowding situation in the accident and emergency unit, but it is at an unacceptable level.

If people are unable to get a doctor to call out to them at night time, they have no alternative but to call an ambulance or make their way to an accident and emergency department and join the lengthy queues there. It is a serious issue which arises not as a result of a lack of HSE funding of the service but owing to a lack of doctors practising as GPs in the area. Many of the GPs currently working in the area are elderly and are, understandably, less inclined to work long hours. Very few of the GPs coming on stream these days are going into rural practices across County Clare.

Doctors and graduates of medicine in Ireland generally earn a lot of money. They earn what would appear to me to be a great deal of money and it would certainly be a huge amount in comparison with the earnings of most of the people I represent but it is still a lot less than they can earn in Canada and in other countries across the world. For young doctors who are not tied to any particular place and do not have a family of their own, the option of going to work in the health service in another country is very attractive and that service is probably better funded. There is little this Government can do to stop that happening. It would be wrong to try to stop anybody emigrating. We had a referendum a long time ago, the aim of which was to stop certain people leaving the country, which would be a preposterous proposal to most.

Older doctors also earn a lot of money. Many older GPs were encouraged by the HSE to set up GP practices in which they invested very heavily in terms of equipment and so on and in respect of which they received funding from the HSE. However, that funding has been reduced. Every backbencher has a constituency office. I assume Deputy Coffey, although a Minister of State, still maintains a constituency office. Constituency offices are funded by the Exchequer such that Members are not required to pay for them. While GPs were encouraged by the HSE to invest in their facilities and in that regard took out mortgages and so on, they now find that the funding they receive is a lot less than they anticipated when they took out loans and so on. There is a real problem in relation to general practitioners in this country. If there are not sufficient GPs, people go elsewhere with their health problems. They clog up accident and emergency departments and inevitably rely on the ambulance service, which is already over-stretched.

Paudie Coffey (Waterford, Fine Gael)
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I apologise to Deputy McNamara on behalf of the Minister for Health, Deputy Varadkar, who is unavoidably absent today. However, I am happy to take this important matter on the Minister's behalf.

Shannondoc is a GP co-operative funded by the HSE. It provides a valuable urgent out-of-hours service to the population in the mid-west region. Operating out of 11 treatment centres, spread across the region and a fleet of mobile doctors, Shannondoc had 110,000 patient contacts last year, with 90,000 receiving treatment. At the heart of the operation is the call centre. Based in St. Camillus' Hospital, the centre processes all patient calls, with nurses assessing and managing concerns or directing patients, where necessary, to a treatment centre or assigning a home GP visit. It is acknowledged that Shannondoc is facing a resource challenge in relation to the availability of doctors, especially in west and north Clare, as indicated at the start of the summer period.

A review of the out-of-hours service has commenced to ensure that a safe and appropriate GP out-of-hours service continues to be available to all people living in the mid-west region, which can be accessed as and when needed. In the meantime, the HSE has advised that Shannondoc is providing the same service and is continuing its consultation with GPs in County Clare to meet the current service needs. The HSE remains focused on ensuring out-of-hours service will continue to be delivered for all throughout the country.

In relation to the Shannon treatment centre, Shannondoc has confirmed that this will not be closing. In addition, there has been no diminution in the level of service being provided at the Shannon centre. When required, patients will be seen at the centre. Last week, 112 patients attended the Shannon centre for treatment. Patients who require treatment at the centre are assigned appointments during the time when the doctor is on-site. There are occasions when the Shannon centre augments the busy Ennis centre. Normally at weekends, the Shannon treatment centre experiences a low level of patient appointments between the hours of 9 p.m. and midnight - averaging two per night, compared with the higher throughput at the Ennis centre. When there are no further scheduled appointments at Shannon, one of its GPs relocates to Ennis during those hours. However, should an appointment be required at the Shannon centre, and if the patient is unable to travel to Ennis, a GP will travel back to Shannon to ensure the patient receives an appropriate service. This system has been in place since 22 September 2015 and has run seamlessly. House calls continue to be provided in the Shannon area as normal. This level of co-operation between treatment centres allows Shannondoc to provide a more effective service to the patients in the mid-west region while making the most effective use of its resources.

The HSE has stated that Shannondoc wishes to reassure the Clare community and the people in the mid-west that they will continue to be able to access and receive a GP out-of-hours service in the area.

Michael McNamara (Clare, Labour)
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I thank the Minister of State for his response and I welcome the fact there is no diminution in services. I also welcome his acknowledgement that the problem is one of resources and is related not to funding provided by the HSE but the availability of general practitioners. This problem is exacerbated by the lack of locums, for which there are two reasons. Many locums come from outside of Ireland. Many are what might be termed third country nationals and do not come from within the European Union. The visa regime with regard to locums has changed such that they are now required to leave Ireland for a portion of every year.

I previously worked in the area of immigration law. I have always thought there was a particular discernible attitude within the Department of Justice and Equality towards third country nationals, non-EU citizens in particular. It is almost as if we are saying that these people are good enough to come here and save our lives but we would not want them to get too comfortable lest they might decide to stay. That is appalling. If locums come here and provide essential services, the least we can do is ensure we have in place a visa regime which enables them to remain here if they so wish. A similar problem arose in the context of the shortage of junior and senior house doctors at the time when this Government came to power. While those brought into the country at that time were deemed good enough to be junior and senior house doctors, they were unable to access training programmes. Many of those involved were from India, Pakistan and other countries. They were well qualified and good doctors but they were unable to access training programmes, which was akin to saying that they were good enough to provide some services but we would not want them to get too comfortable, lest they might decide to stay, which is an appalling attitude but not one that surprises me because that is how our immigration system works. It is a problem that not only creates a further problem for these excellent doctors and their families but for ordinary people across this country in terms of not being able to access as good a medical service as they might otherwise get if this visa regime did not exist. This issue needs to be addressed.

Another problem is the high wages paid to locums in the UK. I understand there are Irish doctors going to the UK to work as locums because they know locums there are paid more. As I said at the outset, doctors earn a great deal more money than many of the people I represent. Many of our doctors are going to other countries where the wages are higher because they are under financial pressure here.

Paudie Coffey (Waterford, Fine Gael)
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It is important to put on the record that GP services and primary care in general in this country receive substantial State support, although an argument can always be made for more. I accept the Deputy's genuine concerns in that regard. This is a priority area for Government, one in which we will continue to invest.

As stated, the HSE and Shannondoc have asked that the Deputy be assured that the people in Clare and the mid-west region will continue to be able to access and receive a GP out-of-hours service, which I am sure the Deputy will welcome. In terms of the topical issues raised today, recruitment and attraction of professionals into our health service remains an ongoing challenge. The Government and HSE is committed to ensuring that we have a successful recruitment programme. The Minister and Department of Health will continue to monitor and evaluate that programme and respond accordingly.