Wednesday, 18 December 2019
Ceisteanna ó Cheannairí - Leaders' Questions
The insurance crisis is having its most immediate and telling impact on the childcare sector. Up to 1,300 providers have been left without insurance cover following a letter from their broker, Padraic Smith, who said that he had spent the past six months trying to find alternative insurers through intermediaries and so on. Providers now have only weeks to find an alternative. Many quotes they have received represent a dramatic increase on their existing premiums, from €1,500 to €4,500 in some cases and in others from €3,500 to €9,000. Without question, this is causing real stress and anxiety not just for providers but also for many parents who simply will not be in a position to find alternative places, as was revealed on last evening's edition of "Prime Time". The sector is in crisis for a number of reasons. There is a shortage of places, the goal posts relating to regulatory burdens have been changed and there are questions regarding the credibility of the career pathways for many working in childcare. It must now have to deal with what is potentially an existential insurance crisis. The Government's response to date has been very confusing. It was slow off the mark and the degree to which it seems to have been caught by surprise is incredible. Different Minsters have also been dismissive. Yesterday, the Taoiseach stated that childcare services are mostly private businesses and are expected to cover their costs by the income they receive, and that seemed to be it. Equally, the Taoiseach indicated that the Department did not know about this until 6 December. I find that extraordinary, particularly in view of the fact that the Minister for Finance, Deputy Donohoe, said that he was aware of the impact on various sectors in June. Mr. Peter Boland of the Alliance for Insurance Reform went before the joint committee in April and told it that many sectors, including that relating to childcare, faced existential crises in the context of insurance. I would like clarity on when the Government discovered all of this.
This morning, the Minister of State at the Department of Finance, Deputy D'Arcy, stated that the new, increased rates were essentially reasonable and that the childcare providers should get on with it and take them on board. He stated that what is involved would amount to €60 per child, which he said should be reasonable. He must know that the cost of childcare in Ireland is much higher than the OECD average in terms of its impact on net income. Affordability is a big issue and an additional cost on parents is not sustainable. The Minister for Children and Youth Affairs, Deputy Zappone, stated that she was shocked and stunned and indicated that something would have to be done. Deputy Darragh O'Brien put forward a constructive solution in respect of this matter to the Minister in April whereby any childcare provider that operates an early childhood care and education, ECCE, scheme would be able to access insurance via, for example, IPB Insurance, which is capitalised to the tune of €1.5 billion and has €600 million in a retained income. An approach like that or else a subvention will be required to resolve this matter. Why was the Government so unaware of the issue of insurance in the childcare sector? The Taoiseach must be concerned about that lack of awareness. What does he intend to do to ensure that crèches can stay open in 2020?
I thank the Deputy for raising what is a very important issue at the moment. Many parents are worried their crèche or childcare provider might not be open in the new year and that they may see a steep increase in fees in the new year. The Government is working very hard to make sure neither of those scenarios arise. I met the Minister for Children and Youth Affairs, Deputy Zappone, and her Secretary General yesterday to discuss a number of matters relating to children and youth affairs and this was one of them. We are working together with the Minister of State, Deputy D'Arcy, the industry and others to make sure we have a solution.
The vast majority of childcare providers, close to 100%, are now registered for next year so people can be given the reassurance they will not find out when they go to their crèche or childcare provider in the early new year after the holidays that they are not open. They will be open. That is not to say there will not difficulties finding insurance in the next few weeks. As things stand, only one underwriter, Allianz, is currently providing insurance to childcare providers following the exit of Ironshore from the market. Up to 1,300 childcare providers have been affected by Ironshore's exit, with most of their policies due to expire on 31 December. Allianz, through its broker, Arachas, has stated it is willing to consider quotes for all affected services. Quotes are being processed within 24 hours of applications in the vast majority of cases. As of today, the majority of the providers impacted by Ironshore - 869 of 1,300 - have been given quotes. The balance can be processed within a short timeframe and, therefore, reports of thousands or even hundreds of the services closing appear to be inaccurate. There may be a very small number of high-risk services which may not receive quotations.
Providers are reporting increases in premiums that range from 10% to significantly higher than that, but it is understood the majority of services will experience an increase at the lower end. It is worth pointing out that the provider that is exiting the market had been offering insurance at much lower rates. The average cost of insurance from Allianz, the insurer that is staying in the market, for full-time childcare is €60 per annum per child and the average cost for sessional services, such as the early childhood care and education, ECCE, scheme, is €25 per annum per child. While parents pay an awful lot in childcare fees in Ireland, only a very small proportion of it is required to cover insurance, roughly €60 a year on average and less is some cases.
The insurer has said that premiums of over €450 per annum can be paid monthly by direct debt, reducing the immediate impact on providers' cashflow in the new year. This is an issue we are seized of and on which we are working, and I am confident that parents, when they bring their children back to their crèche or childcare provider in the new year, will find the crèche or childcare facility will be open.
I asked the Taoiseach why the Government was caught so unawares and why the Minister expressed the view that she was shocked and stunned at what was transpiring, given that in June 2019, the Minister for Finance, when asked a question regarding difficulties crèches were having in accessing insurance, said: "I am very conscious of the difficulties being experienced as a result of the cost and availability of insurance to certain types of businesses." The Government must have been aware that this was a looming crisis within the childcare sector. The response has been very lethargic since then. Likewise, Peter Boland of the Alliance for Insurance Reform raised an existential crisis facing sectors, including the childcare sector, at the Joint Committee on Finance, Public Expenditure and Reform, and Taoiseach in April 2019.
What the Taoiseach seems to have said here this morning is that everything will work out fine and there will be no difficulties. Is that what he is saying or does he acknowledge that many crèches will be facing significantly higher insurance costs as a result of the exit of one insurer from the market? The OECD average for childcare costs is 12.6% of net family income. In Ireland, it is 27.4% so there is a real affordability and cost issue in Ireland. The additional costs will find their way to the parents and they will have to pay the additional childcare fees.
Can the Taoiseach explain why the Government seems to have been caught so unawares? He has said the Government was working behind the scenes. Can he bring more clarity to what that means in terms of helping crèches to ensure their viability and continuance into 2020?
I thank the Deputy for those questions. I do not agree with his assessment. We have all been aware for a very long time that there is a general issue regarding the cost of employers' liability and public liability insurance. We set up an interdepartmental working group to deal with those issues a very long time ago and we have been implementing its recommendations as recently as yesterday, with the establishment of the Judicial Council.
In relation to the specific issue of Ironshore pulling out of the market, I only became aware of that in the last couple of weeks and I think it is the same for others. As to where we are now, one insurer, Allianz, is still in the market. It is a good and reliable insurer, which has been there for a very long time. It is willing to offer quotes to those childcare providers which were insured with Ironshore previously at an average rate of roughly €60 per child. Ironshore was offering very low cost insurance. Allianz offers insurance at a premium of about €60 per child per year. Work is ongoing to see if we can get another insurer into the market. As good as Allianz is, it would be better if there were two or three insurers and a degree of competition.
In terms of the general issue of affordability, the Government absolutely acknowledges that the cost of childcare is a huge burden on very many families. More so than any other Government in the history of the State, we have been active in improving that. We brought in two years of guaranteed preschool provision for children.
We have also bought in the national childcare scheme, which means increased subsidies for hundreds of thousands of children and also that people on middle incomes will qualify for the first time. We brought in increased and longer maternity benefit, parental benefit and paternity benefit for the first time. This is very much a Government that is building a society with the family at its centre and that is trying to make life easier for families.
We all agree that manners need to be put on the insurance industry in this country. Insurance companies have been exposed for charging customers extortionate premiums, despite the fact that claims have fallen significantly and those same companies' profits continue to soar. There was general outrage when motorists discovered the extent to which they were being ripped off. There is an ongoing issue for every festival, playground, community organisation and GAA club with their insurance costs but now, disgracefully, our childcare services have fallen prey to the same greedy arrogant insurance industry.
At the core of this problem is the fact that we rely on private provision for early childhood education and for childcare. That is the nub of it. The root of this problem is that childcare providers have no option but to rely on the vagaries of market forces and market providers which can decide whether they will open their doors. All of that needs to change and it is my strong belief that we need to move towards making early childhood education and care a public service. That is the answer to this but that will take considerable work. However, in the here and now, all those childcare providers, parents and childcare workers - who not alone do not have a structured career pathway, as Deputy Micheál Martin would have it, but are very low-paid, are in very insecure work and, for the most part, are women - want to know that the doors of the crèches will open in January. I am alarmed to hear the Taoiseach, on the one hand, speculate about the concern - it is actually panic - that families are feeling about all of this and, on the other hand, move to give a reassurance that registration of these crèches is in order and that they will open in January. The fact is if they do not have insurance cover, they will not be opening in January. The Taoiseach speculates that the new quotations and premiums will be reasonable but that is not the evidence we have heard from any number of providers. One in Tallaght, for example, with which Deputy Crowe has been working, has had a €1,000 hike in its premium. It provides for ten children, one of whom has special or additional needs. Other premium hikes range from €600 to €2,800. These are breathtaking additional costs and if they can be met by the provider, which is not a certainty, they will come out of the pocket of parents.
We need Government intervention. The Taoiseach needs to give solid assurances to parents, childcare workers and providers that they will be able to operate in January. That means the Government has to step in.
Simply to recommend to those families that they cross their fingers and hope the market will be good to them is frankly not good enough.
I thank the Deputy. I am not entirely sure what she means by stepping in, but perhaps in her further reply she can outline exactly what she would do if she was in my position. Whether it is a public provider or private provider, insurance is still needed, and whether it is a public or private, a provider can still be sued. That applies to schools, hospitals and community centres. Anybody is at risk of being sued and almost any concern needs insurance, whether it is public or private. There is still an insurer in the market, namely Allianz SE. That insurer is willing to offer cover to crèches and childcare facilities at an average rate of €60 per child per year.
Ironshore had been offering very low-cost insurance to some providers. That firm is now out of the market. Allianz is still there, offering insurance to childcare providers at an average cost of €60 per child per year. It has already offered insurance to 869 of the 1,300 providers formerly covered by Ironshore, and is willing to make offers to others within 24 hours. I am confident that this situation is under control and will be resolved. I totally understand that parents are worried, as I acknowledged earlier. As the Deputy said, some of them may even be panicking. It is our job not to cause them to panic or add further worry. That is why we should be factual in our comments and not add to parents' concern, anxiety and worry at this time of year. This is being dealt with.
Neither I nor previous contributors have said anything that is not factual. The facts of the matter are that very many childcare providers believe they will not be able to meet additional insurance costs and therefore may not be in a position to open their doors in January. They are the only facts we need to face. The last thing I want to do is cause panic or anxiety to any parent or childcare worker. Therefore, they have to have a more concrete response from the Government rather than the Taoiseach, with the greatest of respect to him, sounding like an advertisement for Allianz and say what a great provider it is. Perhaps it is, and perhaps its premiums will be reasonable, but that is a considerable gamble. It is a considerable statement for the Head of Government to make given what we know about insurance costs and the behaviour of insurance companies in this State.
The Taoiseach asked me what he needs to do. He needs to give assurance to providers, parents and childcare workers that where those premiums are extortionate or cannot be met, the State will step in on an interim, one-off basis to assist those providers. That is not ideal, but as I said earlier, it is not ideal that we regard childcare and early years education as a matter for the private market. We need to fix that, but in the here and now the absolute priority is that people have complete assurance that their children will have a place in care in January and childcare workers will have jobs to go to. That is how serious this is. I will ask directly. In the event that Allianz does not meet the Taoiseach's high expectations and the premiums cannot be met by providers, will the State step in with a subvention or emergency fund to make sure the doors open in January?
I am grateful that the Deputy has at least made a suggestion, but I contend that it is a rather reckless one. If an insurer is unable to provide cover for a particular facility, be it a crèche, a childcare provider or anything else, there may be a good reason for that. There may be a very high risk in insuring it, for a particular reason. For the State to wander in blindly, no questions asked, and offer to cover the bills of a private company or even a public body would be an entirely reckless thing to do.
I will move on to a topic that the Taoiseach does have some control over, since he seems to have no control over childcare facilities. In one of the last Leaders' Questions put to the Taoiseach in 2019 before the Christmas holidays, it is apt to mention the deplorable state of the health service. In particular, I refer to Letterkenny University Hospital and the legacy of this Government to date.
This week the HSE published its national service plan for 2020, following approval from the Government. While it includes several measures, the plan will not specifically address bed capacity or staffing issues at Letterkenny University Hospital and it does nothing to end the current HSE embargo. The plan for 2020 has been allocated a budget of €17.4 billion by the Government. This is a record-breaking budget, the largest in the history of the State. While this represents a 6.3% increase in funding compared with 2019, it is clear that the plan will do nothing to alleviate the effect of the current HSE embargo on the quality of healthcare in Letterkenny University Hospital and across Donegal.
The embargo, or, as the Taoiseach continues to call it, the interim control measures, was introduced in April and was supposed to last for only three months. As we enter 2020 with the HSE service plan in place for next year, this embargo is no longer a so-called interim measure. It has been reported that as part of the Government's official directions to the HSE when drawing up its service plan, the Department of Health sought to maintain the employment restrictions. That means hospital overcrowding at Letterkenny University Hospital will continue, as will the staffing crisis at that hospital and the resulting decline in patient safety. Letterkenny University Hospital has some of the highest numbers of patients on trolleys this year, with 47 people waiting when I last raised this issue with the Taoiseach in November. This problem is not confined to Letterkenny University Hospital but also applies to community services right across the county. In Donegal alone, more than 100 posts lay vacant despite being approved by the national recruitment service. The embargo is here to stay, and if this Government returns after the next election, it will continue.
What is worrying is that the HSE has indicated that it will need an additional €420 million to address demographic, technological and other pressures and to tackle unmet need. An extended and more intense recruitment embargo will continue as a result. This vicious cycle will remain in place if Fine Gael and Fianna Fáil continue with it. It is up to the Taoiseach to break this cycle. Will the Taoiseach signal an end to the HSE embargo or interim control measures in 2020?
I thank the Deputy. Following Government approval, the HSE published its service plan for 2020 yesterday. The budget for the HSE next year is €17 billion, the biggest ever budget for our health service, and an increase of more than 6%. While the Deputy rightly points out that we have a growing and ageing population, a 6% increase is more than what is required to meet the resultant demographic demand. A lot of that money, roughly half, will go into additional pay and pensions for our healthcare staff. We stand over that. We want to be able to pay our staff better and pay them more, and that is why so much of next year's budget will go into pay and pensions. Roughly half of the increase will go directly to staff in pay increases, pensions and the hiring of additional staff. I thank the HSE, the new board and the new CEO for the professional and collaborative manner in which the service plan was drawn up this year. It was so much more professional and collaborative than in previous years. We have seen a dramatic improvement in financial planning and management under the new CEO and board, and I am grateful to all of them for that.
Regarding the Deputy's question about the embargo, I know he has read the service plan and knows it provides for an increase of 3,000 in the total number of staff in our health service. Increasing staff numbers by 3,000 does not constitute an embargo. This time next year 3,000 more staff will work in our health service than today. However, managers are no longer permitted to hire staff for positions that are not funded. That is the norm across the public service. It was not the norm in the health service for a very long time. Now it is, as it should be. Because normal public service rules now apply and staff cannot be hired for positions that are not funded, the deficit for the HSE is dramatically lower than in previous years. Principals cannot hire teachers that are not funded and Garda inspectors cannot hire gardaí that are not funded. We now have a normal set of rules in our public service and health service when it comes to the hiring of staff. There will be 3,000 more staff in our health service next year.
There will also be additional funding for community services and extra home care hours. For the first time, the budget for disability will exceed €2 billion in one year, which will mean more places for school leavers with disabilities, more autism services, additional respite care, more personal assistant hours and more residential places for people with disabilities who are no longer able to live at home.
Often they have ageing parents who cannot look after them anymore. There are additional palliative care beds: 55 in Kildare, Mayo, Waterford and Wicklow following the opening of the new hospices. I do not think so many hospices have ever been opened in one year. There is additional funding for the primary care reimbursement service, PCRS, to widen eligibility and reduce prescription charges, to extend free GP care to six year olds and seven year olds and make it easier for people over 70 to get a medical card. There is funding for the maternity strategy, the cancer strategy and the trauma strategy. There is €1 billion for mental health for the first time, additional funding for the fair deal scheme to make sure that waiting times do not exceed four weeks, or at least stand at an average of four weeks, additional funding for the voluntary hospices such as Marymount Hospice, St. Francis's Hospice and others, to begin to equalise their funding with the statutory hospices and additional funding for winter capacity. By no means will the extra staff and extra money solve all our problems in the health service, but it does give us a fighting chance of making some real improvements next year.
The Taoiseach gave a great rundown of the HSE's proposals for next year but the HSE will still be €420 million short of addressing what it calls demographic, technological and other pressures. Even with what the Government is doing, we will still be here next year talking about a deficit in the HSE.
Why did we not get the service plan before budget 2020 so that we could see what it was intended to do? The reality is that we will still be in crisis early in the new year, as the winter bug hits, and right throughout next year. While the Taoiseach says there will be extra funding, the Cleary Centre will still not have a new building. Seaview House respite home, Lifford hospital, iCARE and the Bluestacks centre will still be looking for funding. St. Joseph's in Stranorlar and all those other hospitals right across Donegal will all be in need because of the Government's inaction and its lack of recognition of the fact that health services need more than just money and highlighting the extra money the Government is spending on health.
Everyone writes the service plan after it is known how much funding is available for it. However, I do not disagree with Deputy Pringle. Of course we will have problems and challenges in the health service next year, just as we have had in every previous year, and just as every other country does too.
As Deputy Pringle pointed out some of the difficulties we will face next year, it would be remiss of me not to point out some of the positive things that will happen next year. We will see two new hospitals open in Ireland next year: the National Rehabilitation Hospital in Dún Laoghaire and the national forensic mental health campus in Portrane. We will see three major extensions open: the Dunmore wing in Waterford, the new wing in Limerick and the new wing in Clonmel as well. We will see healthcare become more affordable for many more people. Seven and eight year olds will get free GP care. More people over 70 will get a medical card and prescription charges will go down for everyone. We will see patient outcomes continue to improve. More people will survive stroke next year. More people will survive a heart attack next year, and we will continue to see improvements in cancer survival, which are already better now than in the NHS, and I believe in the next couple of years will exceed the European average.
We will also see waiting lists continue to fall. We have seen the waiting lists for outpatient appointments fall for four months in a row. It took years of investment and effort to get there but we have got there. The waiting times for people waiting for operations have been falling for approximately two years. The number of people waiting more than 12 weeks for a hip replacement or a knee replacement, or for cataract, angiogram, vein and tonsil appointments is half what it was when I became Taoiseach. We will have lots of problems and we will deal with them, but we will also see lots of improvements too. Let us acknowledge them because at the very least we should be respectful to the staff in our health service who work so hard to deliver those improvements.
I wish the Taoiseach a very happy Christmas from County Clare in particular. I wish to raise with him a Bill that was discussed in this House on 26 November, the Thirty-ninth Amendment of the Constitution (Right to Health) Bill 2019, which I introduced. An amendment was accepted by this House that a report on the Bill would be produced within six months. However, it will be due on 26 May, which most likely will be beyond the lifetime of this Government. I want to keep this issue alive on the floor of this Thirty-second Dáil. I would like to get the Taoiseach's views on the principles of the Bill. I believe it is a bold and ambitious Bill, a constitutional proposal that challenges the current thinking on health policy and health provision. It would place a socio-economic right to health into the Constitution.
The Bill reads:
i The State recognises the equal right of every citizen to the highest attainable standard of health protection; and the State shall endeavour to achieve the progressive realisation of this right.
ii The State shall endeavour, within its available resources, to guarantee affordable access to medical products, services, and facilities appropriate to defend the health of the individual.
iii The health of the public being, however, both individual and collective, the State shall give due regard to any health interests which serve the needs of the common good.
The Government did not accept that proposal and, as I outlined, it tabled an amendment. The two objections the Government made is that the amendment would be justiciable and it wanted to know how it would defend and put a limitation on rights in terms of taking cases to court.
The second ground on which the Government opposed the Bill was the separation of powers. The fear was that courts could dictate Government policy and it raised the question of what enforcement powers the courts would have concerning the provisions within the constitutional amendment.
Health inequality kills, and we certainly have health inequality in Ireland at the moment. Our two-tier system is a blight on the public service, in particular for the marginalised within the community. We continue to export our graduates due to the poor state of the health service. That results in gaps in the service and indefensible delays in the delivery of care, notwithstanding what the Taoiseach has just said. Such an amendment would place the implementation of Sláintecare on a constitutional basis rather than as a leisurely option. There would be no excuse for the Government to delay the implementation of Sláintecare. The amendment would act as a driver of health reform and new health policy. One of the strengths of the amendment is that failure to provide health services that are necessary, reasonable, proportionate and rational can be judged by the courts and, if found wanting, they could direct the Government to act to remedy its failings. In my view, courts would not decide policy, but could direct the Government to formulate policy and to vindicate a right to health. The failure of the Government to deliver on our health needs provides a powerful imperative for this amendment. I would like to get the Taoiseach's views on it.
I had a chance to read the constitutional amendment Bill introduced by Deputy Harty and we had a chance to discuss it at Cabinet. We were all very much of the view that it should not be dismissed out of hand and that it is something that deserves proper consideration by the committee, as has been proposed, if not in this Dáil then certainly in the next one. I have always had an open mind on including socio-economic and cultural rights in the Constitution, whether it is housing, education or health, but I also think we need to be realistic about it too. All of us in this House know that rights may exist in law or they may be put into the Constitution, but that does not mean that they are realised on the ground. Eighty-three countries have a statutory right to housing but every single one of those has homeless people. Just making something a right in law or in the Constitution does not necessarily mean that it happens on the ground in the real world. It does not provide resources or money when money is not available. It does not help one to find staff if the staff are not available. It does not build buildings that do not exist. Governments have to do that, in particular by running an economy well to produce the resources to allow them to do that. No constitutional provision can change that reality or that fact of life.
The second thing we must bear in mind as well is that we need to be cautious not to create new rights and new legal obligations that may put people in a position whereby they can sue the State and receive compensation for not having those rights vindicated. None of us wants to see hundreds of thousands of euro being paid in compensation payments to people who did not get healthcare when that money could have been spent on healthcare, or hundreds of thousands of euro being paid to people because their right to housing was not vindicated when that same money could have been spent building a house. We need to be smart about these things. If we are going to put something into the Constitution, we must fully tease out the sequelae and the unintended consequences. That is the reason I think we are taking the right approach by referring it to the committee for detailed consideration either in this Dáil or the next.
This is not an abstract proposal that can be dismissed or deferred. For instance, we have a constitutional right to primary education. That is a socio-economic right that is already within the Constitution. This amendment would oblige the Government to act to provide health services to meet the needs of citizens.
Only if it failed to demonstrate that would there be a right to appeal to the courts to have it vindicated. The wording in the Bill, to the effect that there would be a progressive realisation of rights within available resources, gives sufficient protection such that there would not be a sudden march to the courts if the provision were introduced. No longer could the Government say that it is doing its best. If this measure were introduced, the Government would be obliged to do much better than its best. It would be obliged to vindicate a right to health. It would occur in respect of cases such as that of Alex O'Shaughnessy, who has had his chemotherapy deferred on several occasions. Ninety year old patients are sitting on chairs rather than lying on trolleys in our accident and emergency departments. An average of 600 patients are on trolleys. The number is only 552 today, which is a pretty good day, but there are 74 people on trolleys in University Hospital Limerick. If what I propose were introduced, it could no longer be said we are sorry we cannot meet the targets for the provision of scoliosis services. The Constitution would oblige the Government to meet them. Failures such as those I have mentioned and myriad others would be unconstitutional. The provision would mean the courts could direct the Government to improve the health services. Failing to do so would be justiciable.
I understand from where the Deputy is coming. I have an open mind on this but I do not believe that his suggestion is the panacea he may suggest it is. A constitutional right and a court judgment cannot build a hospital that does not exist, hire specialists who are not available or create resources that are not available. The Deputy mentioned that he has included in his terms a caveat such that provision be made within available resources. It should be borne in mind that it is only two years since we have been able to balance the books in this country. We had an IMF programme before that. It is only in the past two years that the amount of money we have got in revenue has exceeded the amount we are spending on public services and other matters. Up until two years ago, the courts would presumably have said the resources were not available, and that would have been of no benefit to anyone.
I agree with the Deputy on something, namely, that the two-tier system within our public hospitals is wrong. The Cabinet approved a proposal on Tuesday that the Ministers for Health and Finance will outline later today. It is to offer a new contract to hospital consultants, including new consultants who want to become consultants in our system or existing consultants who wish to move to the contract. The new contract will provide a salary scale to hospital consultants of between €180,000 to €222,000 now, rising to €250,000 per year in 2020, on the proviso that the consultants taking up the contract commit to work in our public hospitals only and dedicate themselves to our public health service. This is a major change. Linked to that is a Government commitment to increase the number of consultants by a net 1,000 over the next ten years. We will press ahead with this. This is Sláintecare happening. We have done a good deal with the general practitioners, of which the Deputies are aware. Progress is being made in that regard. We are now willing to make a deal with consultants and offer them €250,000 per year provided they commit to our public hospitals and public health service alone.