David Cullinane (Waterford, Sinn Fein)
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I welcome the Minister of State to the House. This Bill presents welcome amendments to the Health and Social Care Professionals Act 2005, the Medical Practitioners Act 2007 and the Regulated Professions (Health and Social Care) (Amendment) Act 2020. I and my party will support the Bill. These amendments will address barriers which prevent holders of British medical degrees from taking up interim training posts in this State. This is essential for attracting more internationally-trained doctors into the HSE and for increasing and deepening all-island co-operation in training medical professionals.

However, we are currently experiencing a shortage of interim posts despite the increase in recent years from 727 in 2016 to 854 intern posts this year. While all-hours graduates are entitled to one, many international students who want to stay and work in Ireland cannot get one and we also need to increase the number of medical graduates in the coming years.

The Bill also makes other registration-related amendments required to ensure the continued provision of a route to registration on the general division of the Medical Council's register for certain cohorts of internationally-trained doctors. These amendments are vital to ensure that internationally-trained doctors can continue to register and practice in this State. Many issues of unfairness are also faced by international doctors in assessing medical specialist training posts which this will not resolve. That is an issue of capacity.

The Bill will also ensure that social care workers who must register with CORU are subject to the same relevant standards as other regulated health and social care professions. This Bill, while welcome, speaks to a weakness in Government policy when it comes to the medical profession. For a number of years, the HSE has been overreliant on international recruitment to fill posts. The Medical Council's medical workforce report 2021 published over the summer illustrates this significant reliance, with more than twice as many international graduates as Irish graduates first registering with the Medical Council in 2021. Likewise, we have a significant overreliance on international recruitment to fill nursing posts. In 2021, 62% of first-time registrants with the nursing and midwifery board were non-EU workers. Migrant workers contribute vitally to the Irish health service and are the only reason that staffing levels have not collapsed. However, we must develop a sustainable supply of domestic graduates and retain those we train. The problem we face is illustrated in the fact that by the end of May, Australia alone has already issued 402 visas to Irish doctors, compared to 272 in 2019.

Not only must we train more Irish doctors and make it easier for internationally-trained doctors to come to work here, but we need to stem the bleed of Irish graduates abroad. It is a disgrace that again, we are seeing considerable numbers of doctors and nurses leave, not because they want to - many do want to go to develop skills and some will come back and some will not - but, unfortunately, my experience of dealing with some junior doctors and people who would want to come to work in the Irish healthcare system are opting to emigrate out of necessity and because they feel that the public system is not delivering for them in the way that they would like.

To address all of that will take serious work, to address working conditions as well as the housing disaster and the cost-of-living crisis which is driving talented graduates from our shores. The ongoing dispute with non-consultant hospital doctors is not growing confidence in the ability of this Government to deliver on health. Speaking at the medical professionalism conference 2022, the CEO of the Medical Council, Leo Kearns, stated that the council's 2021 medical workforce intelligence report, "will definitely highlight the need for a workforce strategy for healthcare".

I have been talking about this for some time. We need a comprehensive workforce strategy that gets real about training more graduates and about retaining and recruiting more and dealing with the myriad industrial relations issues, contract issues, capacity issues in the system which make it difficult for medical professionals to work on the frontline in healthcare and, of course, the cost-of-living and the housing crisis do not make it any easier.

I will also discuss a matter which this Bill does not address; the regulation of homecare workers. This is important from a safeguarding point of view, as well as for employment standards and pay. There is a dire need for greater regulation across the homecare sector, which has been highlighted by HIQA time and again. The non-regulation of homecare as a profession does a disservice to care workers in my view, as it means the State does not truly value the work that they do as a professional career. It is also a disservice to those in receipt of homecare and their families who should have confidence that the care worker delivering their care is a fully-regulated professional.

Homecare workers are, more often than not, caring for people who are at a higher risk of abuse or neglect. Anyone who is working so closely with people in a vulnerable position should be a regulated professional. This lack of recognition for homecare is at the root of the shortage of homecare workers. There are many different reasons, but I think we will all accept that working conditions and pay in this sector are among the main reasons we cannot recruit the numbers that we need to fill the million of hours that are made available every year under the Estimates process.

It is not recognised, unfortunately, as a valuable, meaningful career by the State, which is evidenced in the HSE's outsourcing of homecare to private providers. They are not given the secure, well-paid employment which they deserve and their employment conditions often leave them with little or no pension, unreliable hours and insecure employment.

I welcomed, a number of years ago, as I imagine most Deputies in the House did, the considerable number of additional home-help hours that were made available in the budget a number of years ago. Unfortunately, many of those hours were not delivered, simply because we could not recruit the staff. I also know that we have the same problem with children's disability networks teams. We have the same problem in many different areas of healthcare. On paper, people are entitled to a service. We are being told the funding and the money are there but we cannot get the staff.

There was a big announcement in the budget again last year and big numbers from the Minister. The Government said it would recruit 10,000 staff. Five and a half thousand were recruited but it is way behind what we should have recruited. Critically, they are in those areas of primary care and community care which are very important for staffing and the network teams which are supposed to working on the ground to provide for people in the community, care for people in the community to take pressures off our acute hospitals.

It really is about time that we got serious about workforce planning and healthcare. It really is about time that we looked at fully implement the safe staffing and skills mix framework. It is about time we deal with all of the contractual issues which have bogged down recruitment and retention in the health service for so long.

It is about time we treated healthcare professionals and people who work in the public or private sector delivering healthcare better. One clear example I can give, which I raised directly with the Taoiseach earlier, is the pandemic bonus payment, PUP. It affects people under the Minister of State's brief given she has responsibility for older people. I listened intently to Tadhg Daly of Nursing Homes Ireland this week. He quite rightly challenged the Government on the failure of the HSE to deliver the pandemic bonus to all the staff in nursing homes. We talk about Covid and the huge pressures staff were under, which was absolutely the case in acute hospitals, but nursing homes bore the brunt in the first couple of months. It was traumatic for people working in nursing homes. It was beyond belief what they had to go through to ensure people were kept safe. Despite this, they are the very workers who still have not got the pandemic bonus payment. Bizarrely, and in a failure of governance on the part of the Government, we hear now that the State is going to employ a consultancy firm to find out or figure out how to pay non-HSE staff. Some consultancy firm is going to be hired and it will be paid well, as these firms are. I do not know how long this will take but it is beyond a joke that this is where we are at nine months after this bonus was first announced. Members of the Defence Forces, fire service workers, cleaners, security staff and, as I said, people who work in nursing homes and agency staff still have not been paid. That is unacceptable.

This Bill does a number of good things, which I welcome. We must properly regulate the healthcare sector. Regulation in staffing is important and professionalising healthcare is something we should always strive to do. The removal of barriers, as provided for in the Bill, is welcome but the bigger challenge is convincing the people who are training to come and work in the public system. This Government has much to do if it is to win over graduates to come and work in the public system. That is deeply unfortunate.

Patricia Ryan (Kildare South, Sinn Fein)
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This is a welcome Bill despite its technical nature. It addresses a number of registration-related issues affecting certain registrants with the Medical Council and CORU. The Bill makes a small number of amendments to the Medical Council's complaints investigation process and to liability in civil proceedings for specified persons. It makes a number of amendments to support the performance by the Medical Council of its triage, investigation and adjudication of complaints functions under the 2007 Act. It also seeks to ensure social care workers applying for registration with CORU are required to meet the same safe standards as all other CORU professions. In addition, it provides that the Minister may vary the qualifications to be listed in Schedule 3 to the Health and Social Care Professionals Act 2005.

The Bill will remove roadblocks to people who hold a British medical degree from availing of medical intern posts in this State and ensure a route to registration on the general division for international doctors. These are small but important steps that will help us attract more doctors from abroad. However, it is no replacement for addressing the fact that Irish doctors have been emigrating in their droves over the past few years. The Government must speak to newly-qualified doctors and ask them why. I accept some choose to travel but in my experience the vast majority are leaving this State because of our health system. They are leaving because of the housing situation, their inability to buy or even rent an affordable home and the spiralling cost of living in a country where people are choosing between food and fuel. This is a country where people are waiting until they have two or three medical issues to see a GP because of the cost. That is not to mention the difficulty of getting an appointment to see a GP.

This Bill is a missed opportunity because it does not provide for regulation of the home care sector. This sector is in desperate need of professional regulation. The Minister of State should not take my word for this. HIQA has called for regulation of home care services and so too have unions and workers in the sector. It is vital we have adequate regulation in home care to prevent unregulated workers intimately caring for vulnerable people.

Other issues such as low pay, non-recognition of the vital service that home care and home support workers provide and the HSE's overreliance on private home care providers must also be dealt with. The HSE spends €20 million a year on home care support. It should be directly employing these carers and ensuring they have good pay, good conditions, pensions and a clear career path.

In the past few weeks, I met the National Community Care Network and Family Carers Ireland. They are both saying we have a recruitment crisis, as are service users. The Government is doing very little to address the matter. Sinn Féin in government will work towards a sectoral industrial relations solution for pay and conditions to provide a basis floor with standards that will attract or retain the workers in this sector. We will make home care an attractive career opportunity and provide training. We will add home care sector workers to the critical skills list for employment visas and permits and prioritise direct public sector service provision in the sector.

Approximately 35,000 home care hours per week are not being delivered, with more than 4,500 people who have been granted funding on waiting lists for carers. We need to make this sector an attractive career. We need to move away from nursing home care to care in the home. Recently, I met Alone and last week I met Age Action Ireland. Everyone favours our older people ageing in place, that is, in their homes and communities. Older people deserve better and Sinn Féin in government will ensure that.

The Minister of State has sat in on many a meeting with me around our older persons' advocacy groups and everything else. She is well aware of how difficult it is for these people to attend to people who are in that sort of need. This sector needs to be looked after much better and our old people certainly need to be looked after much better.

Johnny Mythen (Wexford, Sinn Fein)
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Sinn Féin welcomes this Bill, which we see as a positive initiative that should create a more professional and protective system for the public and staff alike. We also welcome the removal of the bureaucratic anomalies that prohibit people who hold British medical degrees from availing of medical intern posts and establishing a route to registration for the non-consultant doctors on the general division of international doctors. However, I encourage the Minister of State to address the outflow of our own qualified doctors who are, worryingly, emigrating in large numbers. For example, by May of this year, Australia had issued 402 work visas to qualified Irish doctors.

In my region, 25% of GPs are destined to retire within the next five years. We have five locums in place and these circumstances are replicated throughout most other regions. Many urban doctors are not able to take on the numbers of patients presenting, many of whom are elderly people who are left without access to family doctors for weeks due to the retirement of neighbouring GPs. Many rural areas are left without any doctors at all. I ask that immediate action be taken by the Minister on this alarming public health issue before it becomes a national emergency.

I welcome that the title of "social care worker" will become legally protected on 30 November 2025. It is only right and fitting this should happen. As we know, social care work involves work with the most vulnerable people in our society, from people with disabilities and the homeless to women in prisons and their children and those living in poverty. I am glad these workers will finally be recognised as a cohesive professional partner with their fellow social workers.

This Bill should also provide professional regulation of the home care sector. This part of the sector is fundamentally connected and in many cases overlaps with the work carried out by the social workers and care social workers of Ireland. Some 35,000 home care hours are not being delivered. At the start of the year, 600 families were waiting for home supports in County Wexford. I ask the Minister to establish a national database on respite availability that would give a comprehensive practical view on the age, details and specific requirements of each region. The key public aim of the registration of medical, health and social care professionals is to protect the public by promoting high standards of professional conduct, education, training and competence through statutory registration structures and processes. Professional regulators are important and part of the reason we have such a high and well-regarded standard of healthcare professionals in Ireland.

There is no doubt that the level of professionalism experienced in care provided by our healthcare professionals is outstanding and we saw this in particular during the Covid-19 pandemic. It is for this reason that the pandemic employment bonus is so bitterly disappointing. Nine months on, workers are still waiting on their well-deserved reward. The complete lack of a controlled and planned roll-out of the bonus by the Minister and Government is unacceptable. Will the Minister of State outline a definite timeline setting out when all front-line workers will be paid?

Sinn Féin welcomes the Bill and sees it as a vital part of protecting the public interest, especially in the sphere of social work and care workers having to meet the same safety standards as all other CORU-registered professionals.

We welcome the new route this Bill provides for registration of international doctors and plead with the Minister to accept the importance of the points raised on the emigration of our doctors and the significant numbers of our family doctors who will be retiring in the not-too-distant future.

James O'Connor (Cork East, Fianna Fail)
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I thank the Minister of State, Deputy Butler, for being here today and recognise the seriousness of this legislation. Although it is quite prescriptive, it is very finite. There is a lot in it but it will make a significant difference collectively across other work the Government is doing in the area of health. It will address a lot of issues around trying to get foreign medical professionals involved in our health service. I do not need to tell the Minister of State or any other Deputy in the House about the challenges facing the healthcare service. We have a swiftly growing population as is indicated by the results of the most recent census. There is significant pressure being placed on the health service, with significant growing pains. It is important that we do absolutely everything we can to ensure we have an efficient healthcare service, including trying to get people from a multitude of different countries to come here and work. Many other developed countries of the same standing as Ireland from an economic point of view have been doing so for a long time.

There is one area I would like to highlight and in which I would like to see a little bit of work being done. I have encountered a number of people who came to Ireland to become pharmacists from countries such as South Africa. I understand that a significant portion of them are still encountering difficulties. They were told there were delays as a consequence of Covid and they are still waiting for further information. I believe it is under the remit of the Pharmaceutical Society of Ireland, PSI. Perhaps that is something the Minister of State could check with the Secretary General of the Department of Health and the Minister in their respective capacities. It needs to be looked at. I am sure the Minister of State will agree it is remarkably unfair that people who have been here for three and four years are not able to work in the capacity in which they came here. In the cases to which I am referring the people came here as pharmaceutical technicians. I am very familiar with the pharmacy sector in general as I have two siblings who work in that profession. I am kept well briefed on the issues pertaining to it. I look forward to meeting the Irish Pharmacy Union, IPU, next week at its budget briefing. Those provisions are very welcome.

The other point we need to get serious about, and Mr. Watt as Secretary General of the Department of Health is better placed to do this than anyone else, since he did it for himself, is pay for our healthcare professionals. It is exceptionally important that we look at the substantive issues when it comes to paying consultants whom we desperately need to bring down our waiting lists. There has been Trojan work done by the Government in that area but we need the medical professionals to do that work, whether it is children with spina bifida or multiple other long-term illnesses that need serious surgeries. We need the surgeons to be here in Ireland and we are competing with countries that are paying far in excess of what surgeons can be paid here. That has to be said. Every citizen in this country wants to ensure when making contributions to the State that we will have a health service that is fit for purpose and can deal with the challenges in the event that people fall ill.

It breaks my heart a little that we have so many people who come to Ireland to study medicine but do not stay here. It costs hundreds of thousands of euro to train people to become doctors, which we do exceptionally well. We have centres of excellence such as the Royal College of Surgeons in Ireland just down the road from Dáil Éireann, Trinity College, University College Cork, the University of Limerick and the National University of Ireland Galway. There are fabulous schools of medicines in those universities. It is important that we look at the exodus of young doctors, people who go as junior doctors to travel abroad. I understand that it is compulsory to get training abroad in order to become a consultant. That is not what I am necessarily saying but I am aware of that. It is a shame that we lose so many people. Quality of life is a factor but pay is also a factor. In Australia and Canada, for example, they earn multiples of what they can earn here.

I recognise Deputy Mythen's point on rural GPs. It is the same in east Cork. The doctors' surgeries cannot take on any more patients. A growing population is a factor and we have a slightly higher growth rate than the national average in east Cork. I know the Minister of State, Deputy Butler, is very familiar with my area. This is a major concern for rural Deputies. When people move into an area, they struggle to get in to see a general practitioner. This shows why this legislation is needed, if it is going to help us bring in those medical professionals. We certainly need to pursue more legislation in this area.

On home help, home care assistants and carers in general, a serious amount of work done has been done in this area throughout the pandemic, often in very difficult circumstances. That has to be recognised, as the Minister of State has done. I agree on backlogs. When it comes to the Covid payment that was made to healthcare professionals, I would like to see outstanding issues resolved and I know the Minister of State and the Minister are working on that issue.

The legislation is welcome, as is recognised by all sides of the House. We need to look seriously at pay. My message to the Secretary General of the Department of Health is that if he could address that, it would make an enormous difference to the quality of healthcare on this island and build upon the health service we have. It is a profound concern that many people have. The Minister of State and the Minister are acutely aware of that challenge.

Réada Cronin (Kildare North, Sinn Fein)
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I welcome many aspects of the Bill and am happy to speak on it. Unfortunately, it does not do anything for the appalling conditions under which our non-consultant hospital doctors are working in terms of the gruelling hours and careless, slapdash and sometimes downright insulting institutional approach to their pay and conditions. That they have to take to social media to highlight this is shameful. It is no wonder doctors are emigrating in their droves or planning to do so, as are swathes of medical staff generally. Deputy Mythen has already outlined a 45% increase in the number of work visas Australia has issued to Irish doctors. This is a brain drain of the highest order.

I am also concerned that the Bill fails to deal with the regulation of the home care sector. This failure is bad for the superb people we have working in the sector. It leaves them unprotected when they are working in other people's homes, certainly in the area of intimate care. They have been calling for such regulations, as have HIQA and their unions. We have a major problem when the HSE is spending over €20 million a year on private healthcare providers when it should be providing home care directly and providing decent pay, conditions and pensions for workers. This is vital as we move away from the nursing home care model and facilitate older people to stay in their own homes. We need people to be able to happily choose careers in the home care sector and we need the public to be able to depend on the system for the quality of service and availability of workers. I know people in north Kildare who are desperate for carers and home care. It is no surprise given that 35,000 hours a week are not being provided and more than 4,500 people who have funding are waiting for care while their quality of health and life and their independence deteriorate.

I do not know what obsession the Government has with profiting from and monetising the basic essentials of life such as housing, energy, childcare, healthcare, elder care and now home care. We need public funds to directly benefit the public and to be used for the public benefit. Instead, public funds are having to wrangle their way through middlemen and middle women so they can cut their slice of the profits. This will be a priority for Sinn Féin in government. It really should be a priority for this Bill, too.

Róisín Shortall (Dublin North West, Social Democrats)
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I am happy to support the legislation. It is overdue in many respects. There is no denying the importance of regulation, particularly in the health and social care area. As we know, the legislation dates back to 2005 in respect of the inclusion of social care workers. At the time, that was highly significant. The work of dealing with children, older people and some of the most vulnerable people in our society is very important. It is essential that the people working in that sector are properly regulated. We have to ask why there has been such a delay.

It is very important that the State has a regulatory system that we can have confidence in and that we legitimise the profession, protect the public and provide a structure for appraisal and approval of training and qualifications.

However, as I said, the progress has been painfully slow. I do not know why that is the case. We are just moving at a piecemeal, slow pace when there are several professions that need to be regulated. I do not know why we could not have done that by statutory instrument on an ongoing basis and why the progress could not have been quicker than has been the case. I do not know why that is. Is it a funding issue with CORU? Is there a problem with CORU? Why is it not able to move through the professions more quickly? Alternatively, is it the case that it has requested the Minister to move on different professions and the Minister or, perhaps, successive Ministers have been slow to do that? It is important we know the reason for what would appear to be a completely undue delay in regulating the professions. As I said, health and social care professionals should all be regulated. Why is it taking so long and why is it so slow?

On social care workers, clearly the register is still not operational. We are told that it is set to open in November 2023. However, there are other requirements in terms of experience working in the sector. Therefore, it is likely that with qualifications and experience, people will not be able to register until 2025. Was this not foreseen? Why was provision not made for this? People have been working in this sector for years on end. Are we talking about post-qualification experience? What is it? There is huge confusion about how one actually qualifies in this area. Why have we not sorted this out before now?

It is undoubtedly a complex environment for a couple of different reasons. The previously unregulated status of social care work has been a problem in respect of new regulation. The range and diversity of titles, practices and routes into the sector has been diverse and wide and all of that needed to be brought into line and streamlined. Again, why that is only happening now?

In 2018, a Social Care Ireland survey regarding registration awareness noted that respondents indicated 80 different job titles in that sector. There have been some tangible developments in recent years. In 2015, the social care workers registration board was established with CORU. That was a certain amount of progress. More recently, the code of professional conduct and ethics and the standards of proficiency in education and training were published. However, there is still no clear pathway for fully regulated and recognised roles within social care.

Obviously, serious problems arose in relation to those students in the Dublin Business School. That was very bad practice all around. It was a devastating blow for the students. This course was established four years ago in 2018 and it is still not accredited by CORU. Why was there not clarity about that? The Dublin Business School has serious questions to answer in relation to that. Students must now be provided with clear options to strengthen their qualifications. The Minister raised the issue of refunds for students. I do not know if that has happened, but it should happen. However, more important than getting refunds is having a clear pathway to early recognition of the academic work that they have done and, indeed, for many of those students, the previous work experience they have had in the sector.

There is no doubt that an acute shortage of social care workers is looming now. Despite a relatively strong supply of graduates in this area, there is a shortage. That is because the importance of social care was not recognised in this country until relatively recently. There have been debates on this in the UK for the past 20 years. We are very much fixed on the idea that we are talking about expensive healthcare and very highly qualified people. We talk about consultants, GPs and nurses. However, actually a huge amount of care in the general health area relates to social care. That is where the big demands are. We hear all of the publicity around long hospital waiting lists, and they are a scandal. However, the reality is that most people who contact us as public representatives with regard to waiting lists are asking about older people, in particular, but also about young children and people with disabilities. Effective and well-resourced social care is needed in all of those areas. That is where the big demand is. Very often, if people cannot access social care locally in their community, they are left in situations where their condition inevitably gets worse and they inevitably end up having to go to a consultant or be admitted into hospital. A whole range of services needs to be properly recognised and resourced at community level.

That, in many ways, is what Sláintecare is about. It is the lowest level of complexity. People start off with different conditions that are not complex and need care and support. That is the whole social care area. If that is addressed, it has downstream effects. It slows down conditions getting worse and becoming a bigger burden of demands on the health service. We need to get back to early intervention, early diagnosis of conditions and providing appropriate staff in the appropriate place. We have not been good at doing that in this country.

In 2019, 14 educational providers were providing 34 social care programmes or pathways into social care. This was happening. The educational systems, particularly post-leaving certificate providers, were gearing up for that. However, unfortunately, there was not the necessary recognition of those qualifications, which are very often level 5 qualifications, and then clear pathways provided into higher level qualifications, recognition of that and regulation.

Between 2015 and 2019, Tusla experienced a 30% increase in referrals, but only a 1% increase in the social care workforce. The austerity period brought very significant challenges with cuts, embargoes and moratoriums. Of course, many of those cutbacks and austerity measures were very short-sighted because they resulted in even more serious problems and a lack of an adequately qualified and available workforce in this very important area. The cost of living and spiralling rents, of course, added to that.

This is a predominantly female profession. Some 86.7% of respondents to a Social Care Ireland recruitment and retention survey in 2021 were female. Increased privatisation and the use of agency workers to bolster the service provision has undoubtedly been a factor in this. In many ways, we are seeing creeping privatisation in the social care area. That is largely to do with the fact that at HSE level and at Department of Health level there is no recognition of the importance of social care. It is seen as some kind of afterthought that should be farmed out to the voluntary sector. People were doing it on a voluntary basis for a long time.

That sector cannot operate on a shoestring, which is what the expectation was. It was not professionalised and put onto a proper financial footing. We are paying a big price for that now. Due to the lack of recognition of the importance of social care, we ended up with a very expensive model of care in this country. Services were dictated, in the main, by consultants, when we should have been looking at services at local level led out by social care professionals.

Sláintecare recognised that healthcare and social care are inextricably linked. That has to be recognised.

Services and facilities have been disconnected or competing for far too long. We should be operating a system of integrated care. There has been recent recognition of that and I very much welcome the integrated care hubs that are being developed. They make absolute sense. They take work out of hospitals and they recognise the importance of health and social care professionals and the fact that they play, and are capable of playing, a key role in the delivery of health services and that can happen at community level.

The current disconnect between healthcare and social care is very evident in waiting lists. The health system waits until conditions become serious before intervening and that inevitably ends up with long waiting lists for hospital services. On 5 July, there were 102 people across the acute system awaiting a discharge home, with 61 of them waiting for a carer to be assigned. I do not have the up-to-date figures in that regard but what we have seen through the years is that there have been several hundred people in very expensive acute hospital beds ready to be discharged but there was insufficient funding at community care level to provide the kind of home supports they needed. That issue, more than any other, typifies the dysfunction within the health service. There are people using hospital beds who want to go home and are ready to go home and it is in their healthcare and other interests to do so. It is a much cheaper model of care yet there is that disconnect between the acute hospital sector and social care. It is the way we should be going. There is no justification or defence for a situation where there is not an adequate budget for home care and then people end up staying in hospital beds which, in turn, has an impact on waiting lists. More important, at the end of May there were 4,720 people waiting who had been assessed and approved for home support but were awaiting a carer to be assigned.

Mary Butler (Waterford, Fianna Fail)
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We have the funding.

Róisín Shortall (Dublin North West, Social Democrats)
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I know that. That is what I am saying, however - they were assessed. The bar is quite high to get approval for home care. These were nearly 5,000 people who were approved for home care but the staff were not available. This has been raised with the Minister of State. In fairness, I know she is very committed to her portfolio but this has been raised with her on umpteen occasions. One has to ask why this issue is not being addressed properly and why are we still in this indefensible situation. From an organisational and financial point of view, it is indefensible. The key thing, however, is that there are 5,000 people in their own homes, many of them in their late 80s and 90s and many very infirm, left in dangerous situations on their own at home. It is inevitable that many of those people will end up going into nursing homes because there are not basic supports available to them at home. That issue has to be addressed as an absolute priority. When is the Minister of State going to resolve this? It is dragging on far too long. She promised a statutory right to home care. When will we see that? When will the staffing shortages be addressed?

There is an issue there relating to the disparity in the contracts and the terms and conditions of employment in the community, voluntary and private sector home care areas. The HSE funded and employed home care workers are on a regular and relatively decent salary. They have security and all the other entitlements that permanent workers have. People employed in the community sector or, more important, the private sector, however, are getting far less than they would as HSE workers. The terms of the contract do not even recognise things such as travel time. That can all be addressed by the Department. It seems that the most recent tender was specifically designed to drive down the cost. It represented a race to the bottom, essentially, and we are now paying a price for that. In the new tender, the Minister has to address those issues and equalise the pay. Ideally, far more of the home care staff should be employed by the State because it is a key area of health and social care provision. We should seek to have those staff employed by the State. I am concerned about the privatisation that is going on in this area in particular and the downgrading of that work. We are paying a price for it now because of the staff shortages. There is also the issue of the need for an employment regulation order to cover this. I would very much welcome such an order.

The same issue pertains in the disability sector, of course, in terms of the dire shortage of staff. I refer to the children's disability network teams. More than 17,000 children with disabilities are still awaiting their first contact in what was supposed to be a new system that would address their needs. Of them, 8,000 are waiting more than a year. The vacancy rate in the teams across the sector is approximately 28%. That has to be dealt with as a priority.

In the few minutes I have left, I note that the Medical Council's medical workforce intelligence report was published this month. It lays bare major problems relating to non-consultant hospital doctors, NCHDs. This issue has to be addressed. There has been really good research done on this whole area, led by Dr. Niamh Humphries in the hospital doctor retention and motivation project that has been running in recent years. Dr. Humphries and her colleagues appeared before the health committee earlier in the year. I raised the matter with the Minister for Health on umpteen occasions. That research sets out clearly why the majority of Irish-trained doctors are leaving our shores as soon as they can. I raised this issue earlier today. NCHDs are leaving Ireland in their droves. They are leaving as a result of their poor treatment in their training. Career structures are very poor and they have to move every six months. Imagine doing that with a family and the crisis in housing. How would one do it? Some 25% of NCHDs are breaching the European directive on working hours. They are forced to do that and cannot avoid it because hospitals are insisting that they work over the 48-hour limit. Some of them do not even get paid for that work. Imagine having that kind of gruelling regime and not even getting paid for it. They complain of burnout, bullying within their profession and a general lack of respect. They are leaving our shores in droves. Is it any wonder that is happening? There are currently almost 900 consultant vacancies. Attention was drawn to this yesterday, particularly in the context of the impact of those vacancies on emergency departments, EDs, and the shocking conditions and waiting times that exist there. That comes about largely as a result of major levels of consultant vacancies right across the board. One can imagine the impact of those 900 consultant vacancies. Is it any wonder that the health services cannot recruit to those posts, given the experiences of NCHDs early in their careers? In addition, only 50% of the internationally trained healthcare graduates have access to a training programme in hospitals. We are hugely dependent on them but they are being treated extremely badly.

This is at the centre of the problems within the health service. There are major problems in respect of recruitment and retention of staff and unless the Minister gets serious about this, sets up an urgent task force, ensures adequate placements in the health service and ensures adequate training places in colleges, the health service will continue to deteriorate.

Thomas Gould (Cork North Central, Sinn Fein)
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The Bill has several important components that will remove unnecessary barriers in terms of registration with CORU, particularly for social workers. Removing the requirement for two years of continuous work will be a big benefit.

As we know, life gets in the way and sometimes it can be hard to source two continuous years of employment. However, given the huge shortages of therapists, social care professionals and other important health care professionals, I hoped the Bill would be even more ambitious in speeding up the registration process for those seeking CORU registration from overseas. Figures released to me recently via parliamentary questions show that the average processing time for registration has increased from 8.8 weeks last year to 9.6 weeks this year. More worryingly, since 2020 some 697 qualified people, including occupational therapists, speech and language therapists and physiotherapists, have waited for more than three months for registration. These people are ready to work and want to do so. They are able to work in complex fields but are being delayed. We leave them waiting for months, unable to contribute in their chosen professions. This is particularly the case for those coming from other countries. I note there is provision for UK degrees. We should examine the possibility of extending these provisions for people who are properly qualified and accredited in other countries. The reality is that children’s disability network teams, CDNTs, in particular are scandalously understaffed and this understaffing has a huge knock-on effect. Existing staff are facing burnout, or have burnt out. Last year the CDNT in my area had one occupational therapist for 893 children. How is that acceptable in this day and age? The pressure that person is under is unimaginable. At the same time children fall through the gaps due to a lack of therapists, social workers and so forth. Their chance of early intervention is lost because it takes years to have them assessed, to have the school places and to get them to therapies they desperately need.

This Bill has the potential to impact positively on staffing levels for disability services. I want the Minister to liaise with the Department to see what improvements can be made. I am on the ground meeting with families and groups like Families Unite for Services and Support, FUSS, that are campaigning nationally for children with disabilities. They are begging the Minister. We need more action now, especially for families and children with disabilities.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I am sharing time with Deputy Boyd Barrett. We welcome and support this Bill. It is amazing to think that the Brexit referendum, which led to many anomalies, happened six and a half years ago. As a consequence of Brexit, there has been a correction in regard to medical interns studying in Britain or the North of Ireland to come back here. That is a good thing. If we can attract professionals back into the Irish health system, it is a good thing. There is also a downside to this. I am probably preaching to the converted because the Minister of State knows the downside with regard to keeping people in the Irish public health system, which is the most important thing. If graduate doctors, nurses and other allied professionals who are qualified at the highest grade in the world feel compelled to leave the country at the end of that process, we have a big problem. We have to challenge that.

At the moment, there is an enormous number of vacancies. For example, there are vacancies for 900 medical consultants. Such a void has consequences in regard to health care. Other Deputies alluded to the junior doctors who issued an extraordinary statement a number of months ago regarding their conditions. If doctors are saying that their working conditions in certain environments are unsafe, we should be concerned not only in regard to their own well-being but also patients’ well-being. We are talking about life and death in some circumstances. If they say these circumstances are extremely stressful and detrimental to the profession, this is a serious problem. Like many other Deputies, I have said on several occasions that this issue has to be addressed immediately. That is down to retention, recruitment and respect in regard to workers who have graduated and want to play their part, but circumstances go against them.

I would like to refer to a statement that Dr. Fergal Hickey, who is the president of the Irish Association for Emergency Medicine, made on a radio show yesterday. He painted a stark picture of emergency departments this year and beyond. He stated that we need a plan for the whole year, and not just a winter plan, for sudden surges of influenza or Covid-19. The Irish health system is not prepared for any sudden shocks. It seems we were lucky a year and a half ago in regard to Covid-19. If there had been a situation where there was an absolute oversurge in relation to emergency beds and acute beds, the Irish health system would have been in serious trouble. Happily, that did not happen but it is still a possibility.

My final comment relates to overall recruitment, retention and respect. There are a number of reasons people stay in a country or in a job. People are motivated to help their fellow human beings in the health system. That is why they go into healthcare jobs, and stay in them, but there is a huge issue in regard to staff retention. The reasons that people leave the Irish health service have to be addressed. They are passionate about their jobs but they look at the related issues of cost of living and burnout. I have friends who are nurses in the Irish health system. They are motivated but find it difficult to stay in the system, particularly due to the cost of living. It is detrimental to the Irish health system if we cannot keep these people. If we cannot keep them, other health systems get them, to the detriment of Irish society. We cannot afford to lose people like that. We must recruit them, look after them, respect them and retain them.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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We support the Bill. As I understand it, the Bill essentially deals with one of the outworkings of Brexit by trying to recommence a situation that was the case before Brexit whereby medical graduates from the UK and the North can do internships here. That would be beneficial for the health service here. We support what the Bill is trying to achieve. As others have said, it highlights the fact that we have a more general problem in recruiting and retaining healthcare professionals in multiple disciplines across the health service to the point that it is fair to say our health service is creaking at the seams. Many people in the health service are demoralised and burnt out, and are leaving the public health service to work in the private sector. Alternatively, they leave the country entirely or leave the health professions because they simply cannot bear the pressure, stress and conditions they face across much of the health services. Indeed, a family member of mine has been in hospital for several months. He sings the praises of all the staff who look after him but every time I go to see him he tells me that the nurses and health care assistants are run off their feet.

They are burned out, are dealing with too many patients and they just cannot cope quite a good deal of the time. We have a problem. In broad terms, as Deputy Gino Kenny has said, we have to listen to the people on the front line as to what they think is necessary in order to resolve the situation and we are not doing that. I am not going to list all of the different groups of healthcare professionals that we should be listening to but I want to speak up for just a few that I have been talking to recently.

The first of these groups is physiotherapists. I hope that the Minister is aware that physiotherapists are making what seems to me to be a very reasonable request and it may be something that could even possibly be dealt with by amendments to this legislation. It certainly seems to be a very easy legislative change that could have a significant impact in addressing some of the waiting lists that we have in our health service. The Chartered Society of Physiotherapy is saying that physiotherapists need to be included in the list of people who are allowed to refer for X-ray. I did not know this until up they informed me of it but physiotherapists cannot refer people for X-ray. As a consequence, they have to needlessly chase after other people who are on the legislative list, because it is set down in law, of either doctors or certain grades of nurses - there may be some other groups - who are allowed to refer for X-ray.

This is wasting the time of those doctors and nurses who could be doing other things when the physiotherapists know that somebody needs to be referred for an X-ray. This is adding unnecessarily to the stress on other healthcare professionals and it means longer waiting times for people to get the treatment they need. The simple measure they are requesting is that they be allowed to refer people for X-ray, as is the case, they inform me, in many other health jurisdictions and I believe it was in fact committed to as part of Sláintecare. That is very elementary stuff and I would appeal that this might be done.

The legislation that is referred to is a statutory instrument, SI 256/2018, that needs to be changed to simply include physiotherapists, as a group, who along with others - I believe dentists are among them - who are allowed to make such referrals, and so on. Physiotherapists should be allowed to do this. That seems like a good measure and I recommend that the Minister of State might read their submission on this because the figures are quite stark. It says that the numbers that this could potentially deal with and the impact on waiting lists could be very substantial. I will not go through all of the details but this is about joined-up thinking and having the most efficient use of the skilled people that we have in our health service and not unnecessarily burdening others who are already overrun with demands on them, in particular, doctors and nurses. I hope that the Minister of State will listen to this request, please.

The second group I would like to speak up for is one I have spoken up for on many occasions. This has been well-aired and the Government should be aware of the issue of psychologists. As we know, we are in dire need of a great deal more psychologists to do assessments for people with disabilities, children with special needs, in particular, and then to provide services for children with special needs, and so on. There is a whole range of other areas, indeed, where there is a shortage of psychologists. We need them and the paradox and irony of this is that there are many young people who want to be psychologists but there are totally unnecessary obstacles being put in the way of these people who want to study psychology, who want to work with children with special needs, with people with mental disabilities, mental health issues, and so on. As we know, we have absolutely dire waiting lists where people are not getting their assessments in the time that they are legally entitled to get them and are not getting the services. We know in our mental health teams, our child and adolescent mental health services teams and community mental health teams, that there is a very urgent need for more psychologists. Yet, if one wishes to do a doctorate in psychology, one has big obstacles if one is doing this in the area of education or counselling psychology. Clinical psychologists who are doing their doctorates will get a salary for the placement work they do and will get a very substantial amount of the very high fees that they are asked to pay. These are fees of up to €15,000, which is extraordinary.

Many, and I have talked to these young people who want to be psychologists, if they are not being paid on placement through the counselling psychology doctorate, and if they have to shoulder fees of €15,000, as some of them have put it to me, if they are working class, on a low income and do not have the money, they cannot be a psychologist. They will be forced to drop out and it is just too much. Why do we have a situation where we fund some - not enough I would suggest - clinical psychology doctorates, to some degree, by giving them a salary and paying most of their fees and we do not do the same for educational and counselling psychology? It makes no sense.

Again, I refer the Minister of State to the Psychological Society of Ireland’s budget submission and is not the first time-----

Mary Butler (Waterford, Fianna Fail)
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I met the society.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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The Minister of State has met the society. To me it is a slam dunk that we should do this. I am coming across a considerable number of young people who are very interested in the area of mental health, they want to go into this area and we are putting obstacles in their way which makes no sense. The society says that the figures for extending the salary and the assistance with fees for education and counselling psychology is a derisory €1.7 million. It is nothing. It says that an additional 50 trainee psychological posts across the professional doctoral programmes for a five-year period would be an extra €2.45 million. That is €12 million over five years. That, again, is buttons compared to the wider health budget but would have a very serious impact. It is also saying that in order co-ordinate the management and placement of current and increased numbers of trainees, the Government should fund with immediate effect the establishment of a national psychology placement office, as the HSE has recommended, which would require the funding of just a measly €770,000 per year. Again, this is buttons but could have a very real impact.

Incidentally, when one thinks about the sort of mental health issues, and so on, that we have in our schools, I believe that we should have psychology departments in every single school in this country. It would be a great assistance to our young people. who are significantly impacted by all kinds of mental health issues and need support. There are many young people out there who want to do this kind of work, to work with other young people, but we need to make it easy for those who want to do this, to get the qualifications and placements they need, and then to move into working in our health services.

One other group which I will quickly give a shout out for is the graduate entry level medical students, that is the people who have previous degrees, graduate entry level students. I believe there is a particular name for this group which the Minister of State’s officials, I am sure, will know the name of. These are people who have done other degrees and now want to move on to medicine. They have not done a primary medical degree, have done another degree, and then go on to do medicine. There is a pathway for them to move from whatever other degree they have done into medicine but, again, they are faced with completely shocking fees. This is crazy. When we have such a shortage of doctors, why are we putting obstacles in the way of people who want to study medicine and who want to work in our health service?

The other broad point I would make on recruitment and retention, which came up with regard to the student nurses, could apply to a lot of healthcare professional areas where there are real difficulties in people just surviving day to day, whether they are studying nursing, midwifery or in other areas. The people I have mentioned often have real day-to-day cost of living and accommodation issues. Because they are studying, they are not paid properly and they cannot afford accommodation so they drop out. There are all sorts of pressures on them. We should introduce bursary schemes to incentivise people, essentially to fund them in these areas of healthcare where we have a dire shortage of people, whether it is in nursing, midwifery, psychology or elsewhere.

The quid pro quocould for such bursary schemes is that if people get a decent bursary, they would then commit to working for a few years in the health service after they qualify. We assist them in getting through their qualifications so they are not struggling, they are not paying shocking fees and they get some sort of proper stipend to sustain them and allow them to pay their accommodation costs and, as a quid pro quo, they commit to giving a few years in the health service, rather than leave the country, as so many do because the situation is so difficult for them. Those are a few practical suggestions.

We are theoretically committed to this under Sláintecare. We have a lot of the capacity we need in the health service but the problem is that a significant section of that capacity is privatised because we have a two-tier system. That is just crazy. I am infuriated when I hear the ads for private emergency departments and private hospitals. The implication of these ads that we hear on the radio every day is that if people go to the public emergency department, they will be waiting for half a day, a day or two days in a war zone, but “Come to us, if you can afford to pay, and you will get treated straight away.” The capacity is there but it is only there if people can pay. There is significant additional capacity in the private system but only available to people who can afford to pay very expensive private health insurance. That speaks to the obvious need to integrate and to have a single-tier, universal, publicly-run system, rather than the two-tier system that we have. We were forced to recognise the need to do that during Covid so surely we should make that a permanent state of affairs by having an integrated, single-tier, universal public health system.

Pa Daly (Kerry, Sinn Fein)
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We support the Bill and some of the amendments, which are worthwhile. I want to take this opportunity to raise a number of issues. No dentist in County Kerry will take on medical card patients at the moment. There was one in Killorglin but the staff were so overwhelmed with requests from across the county that they had to stop taking new patients. I was particularly struck by the case of a man who came to me. He had been working abroad for approximately 30 years. He came home needing to have a crown fixed and he expected the same level of healthcare that he had in the country from where he had come to retire. He was staggered that even though he had a medical card, he was not able to get that service. He was searching around the Ring of Kerry, looking for a dentist, and he could not get one. He came to me and I had to pull a favour from a dentist I knew to get him the treatment he so urgently needed. That is not acceptable.

As the Minister knows, there has been a haemorrhage of dentists from the dental treatment services scheme because the services covered are insufficient to provide dental care and the reimbursement rates are so low that dentists are losing money and it is costing them more to keep the practice going than they receive for treating a patient. The number of dentists holding these contracts nationwide had been in excess of 1,000; it declined from 1,600 in 2017 and now only 600 dentists throughout the country are actively treating medical card patients.

Primary school dental check-ups are running two to three years behind schedule, which means children with orthodontic needs are delayed getting on the waiting lists. The dental clinics in Kerry have treatment waiting lists that are five years long and orthodontists are coming into the county to provide treatment. The physical and emotional harm being inflicted on young people as they wait while their teeth get worse during puberty is unacceptable. What is the Government doing, in particular for Kerry, to ensure there is at least one dentist taking on medical card holders in each local electoral area, LEA?

Earlier this week, I met with members of the INTO regarding their pre-budget submissions and one of their four main demands stood out, which related to mental health support for pupils. Other speakers have mentioned the necessity for therapies and psychological services to be made available in primary schools, where children can be seen without having the stigma of having to leave the school or the classroom to go to see a psychologist or speech and language therapist on the other side of town, if they eventually get that service. I was informed that the number of primary schools referred to CAMHS and other services rose 40% during the pandemic. Special education teachers are trying to act as a stopgap to perform the task. Early intervention therapies in schools are working but more help is needed.

With regard to the pandemic bonus payment, staff are still waiting ten months on from when the promise was made who are working privately in the public system. It shows the level of two-tier unfairness in the system that they are still waiting at this late stage for their payment. What is being done to sort that out?

Peadar Tóibín (Meath West, Aontú)
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I am aware of a number of the issues that relate to this Bill, especially the case of the Dublin Business School, and I have been in contact with many of the students in that regard. The school has hugely failed the students regarding their particular qualifications. Many of these students have spent big money and many have taken time out of their own jobs and have changed careers. Many have spent a lot of time on placement so they could qualify with the Dublin Business School, and they are now left in limbo without the proper, clear commitment that their issue will be fixed for them. I welcome any legislation that potentially helps their situation in the future.

I want to raise a couple of other issues that relate to this Bill and to look back on the historical nature of social care and how problems have existed with that. We need to make sure we have good legislation with good, strong regulation as well. I previously raised issues in the House regarding the internal case reviews and the practice assurance and service monitoring, PASM, reviews conducted by Tusla. In particular, I raised the case of Alice and I was shocked to discover at that time that the Government was not aware of the Alice report, despite the fact Alice had emailed and telephoned the Minister, Deputy O'Gorman's, office on many occasions prior to my raising it in the Dáil. He also stated that he was not aware of the 13 other internal case reviews that were completed. Surely, given the gravity of these reports, they should be shared between the Department and Tusla. I can only presume that the Minister has sought them from Tusla since I raised them here.

I know he met with Alice a few months ago, along with my parliamentary assistant, Luke Silke, and I want to thank him for that meeting with her. Alice is obviously a pseudonym that Tusla ascribed to this woman, who was abused in foster care in the State, physically, emotionally and sexually, in the 1980s and 1990s. There are a number of other issues with the Alice case that I would like to raise. I have already raised issues specifically regarding whether the other 16 foster children who lived in the same home with Alice and her siblings were interviewed. This question has not been answered and it is a key question that has to be answered, either by gardaí or social workers. It has been some time since I raised the questions and I am incredibly frustrated that they have not been answered. I would also like to know what happens currently if a child makes a disclosure to a social worker or to other children in homes. Again, I asked that question of the Minister a number of months ago and it has not been answered.

Second, when Alice's sister, Ms H, made a disclosure of sexual abuse within foster care, the Tusla report notes that the alleged abuser was interviewed, confessed to the abuse and a file was sent to the DPP, but the DPP decided not to prosecute.

Again, I cannot comprehend this. In recent months, Ms H applied for her files under the general data protection regulation, GDPR, and the Garda wrote back to her to say it had located a PULSE record number but the file was empty. It appears that no file was sent to the DPP. There remains confusion and mixed messages over exactly what happened to the file. This has caused untold hurt to Ms H, who is now an adult. Her wounds have been reopened. Will the Government trigger an investigation to determine where these files have gone and to ensure they are located and returned to Ms H? A PULSE file that has potentially been emptied is a very serious matter, as I am sure the Minister of State will agree.

In the case of Alice and her family, the State completely failed them. Alice was taken from her parents, where she had been abused, and was placed by the State in a foster care home in which she and her siblings endured further abuse. It is a nightmare scenario for any child to have gone through. Her birth mother wrote to the social workers about this abuse prior to her death in 1989 but, despite this, Alice continued to reside with the foster care family until March 1992, at which point she left the home with £10 in her pocket, bought a bus ticket and applied for a job in a nursing home. She built a life on a ten pound note. It is important to flag that she was never removed from that home. The only way she could escape it was by running away from the abuse. There were multiple case conferences and multiple occasions on which disclosures or additional information were made available to social workers and the Garda but no investigation was conducted for decades.

This case and the reports I have examined lead me to believe that either we have a cover-up in which the Garda and the social workers conspired to protect the foster parents from the allegations being made against them by the children, or else we have a country that loudly, clearly and collectively said it does not believe children simply because they are children. This report appeared to adopt an attitude of not believing any of these children. The problem is that since we have divulged this information here, the response of the Minister for Children, Equality, Disability, Integration and Youth will be that the Government shall ignore it until it goes away.

In recent years, Alice triggered a Garda Síochána Ombudsman Commission, GSOC, investigation into the Garda station that failed to act on her abuse disclosures in the past. During that investigation, the Garda station wrote to a local authority and falsely told it Alice had committed an offence. I believe this action had a negative effect on her housing application. I will repeat that to ensure we all understand what is going on here. Alice triggered a GSOC investigation into a Garda station that failed to act on the abuse disclosures she gave in the past and, as a result, the Garda station wrote to a local authority falsely accusing Alice of an offence she had not committed and this caused difficulty for her in applying for a council house.

These are some of the hurdles Alice has faced in her campaign for justice. They have been extraordinary. I believe she has been actively persecuted by the State for speaking out against the system. In recent years, for example, Alice was referred for counselling and psychological assistance free of charge after Tusla took charge of this historic case. At the mental health unit to which she was referred, Alice spoke about the social worker who had failed to disclose what happened to her. She found out that social worker is actively employed by the HSE as a mental health worker. One can imagine the pain for Alice of not being believed in a scenario where she is with a psychiatrist and being told the lady in the room next door was the social worker who wronged her in the past. This is just another example of how she has been wronged. Alice was later to discover, through her incredible and comprehensive detective work, that a social worker from her past is currently married to a GSOC officer. I do not suggest for a minute this had any bearing on the GSOC investigation but for a woman who has gone through at least five or six wrongs by the State, it is another incredible situation to arise.

One of the saddest things about this story is that when Alice brought the information to us, she told us she had found out her birth mother had died. She found this out simply from being at mass and hearing the priest tell the congregation who was recently deceased. One can only imagine finding out in this manner that one's birth mother had died. This story highlights the difficulties so many children go through in this State. It also focuses on how important it is to have social workers who are of the highest standard and are governed by the best regulation.

I refer to another internal case review conducted by Tusla. Again, I have the permission of the victim, to whom the pseudonym Karen was given. Like Alice, Karen was left in an abusive home, with the knowledge of the social workers, and had to take it upon herself to run away from that home to escape the abuse. The time period was the same, that is, the late 1980s and early 1990s. In Karen's case, the alleged perpetrator was never prosecuted, despite a file nearly a foot thick being sent to the DPP. Like Alice, Karen received a small settlement from the HSE in a very secretive and questionable manner outside the courts. Like the Alice report, the report on Karen's case has discrepancies in what the Garda has said. I will focus on a couple of extracts from the report that I believe are important.

Karen first disclosed sexual abuse in 1984 at the age of nine. In a video I have seen of Karen as a child in 1986, in which she outlines to social workers the nature of the assaults on her, she describes how she was sexually assaulted repeatedly by her mother's partner. She was also sexually assaulted by the next-door neighbour. The Tusla review states that the neighbour was fined £75 for that incident. It is incredible that this was the level of justice achieved by Karen in that circumstance. Astonishingly, after the abuse disclosure, of which the local hospital, the local child guidance clinic, CGC, and the Garda were aware, Karen was sent back to the same home. In February 1985, she made further disclosures of sexual abuse. The local GP visited the home and Karen was admitted to the local hospital. When she was released after a short period and referred to the CGC, which was the equivalent of CAMHS at that time, she was released home again.

Karen escaped the abuse in 1986. The Tusla report states:

Karen had made numerous attempts to run away from home. On 31st August 1986, it was recorded that Karen ran away, stole a bike and travelled about a mile from her home before it rained. Cold and tired she saw a light on in a nearby house and when given access broke down and disclosed to the household owner about the alleged abuse.

One would hope this was the end of it but, no, it was not. Karen was put in the care of the State and after a brief spell in foster care, she was placed in an institution. In this State at the time, if you were a victim of sexual abuse, in many cases, you were placed in an institution. The review notes that Karen ran away from the institution and slept rough in Dublin, where she was exposed to prostitution and heavy drug use, although she did not partake in either.

This is the way children were treated in the past in this country. Every time we raise these questions, we are assured things are different now and that policies and safeguards have been strengthened. The legislation we are discussing must do right by the students of the Dublin Business School who have suffered, but it also must ensure we have the highest level of regulation of, and the best level of investment in, these resources and that we protect the children who currently are in the care of the State. That is not the case. I know this is not necessarily the Minister of State's particular area of authority but I ask that she or the Minister, Deputy O'Gorman, meet with the two women I have discussed today. They and others like them have done their best to achieve a certain level of justice for themselves and, in many cases, after contacting Departments and State agencies and organisations, they were rebuffed and sent back home. In many cases, the only level of justice they might receive is that their case is discussed as a pseudonym case on the floor of the Dáil. That is wrong.

We must ensure we meet and speak to these adults. Equally, we must ensure that all the different hurdles they had to surmount and the wrongs they suffered, as well as those instances where the State let them down and An Garda Síochána, GSOC and Tusla did not do their jobs, are investigated and justice is provided for them. That should be the baseline standard for people in this State.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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I call Deputy Mattie McGrath next. We must adjourn this debate at 5.42 p.m. in accordance with the Order of the House from earlier today. If the Deputy is still speaking at that time, I will have to call on him to propose the adjournment.

Mattie McGrath (Tipperary, Independent)
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I thank the Ceann Comhairle. I thought there was a Sinn Féin speaker before me. I am delighted to be able to speak on this subject.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Gabh mo leithscéal, Deputy Ward is here.

Mark Ward (Dublin Mid West, Sinn Fein)
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I have only trí nóiméad, so I will not be long.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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I am sorry about that.

Mark Ward (Dublin Mid West, Sinn Fein)
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I will speak on the regulation of counsellors and psychotherapists under the auspices of CORU. The Minister of State will be aware these regulations were made by her predecessor in 2018. Members were appointed to the Counsellors and Psychotherapists Registration Board in May 2019. The board has 12 very experienced members and it met three times in 2019, four times in 2020 and seven times in 2021 and it has met six times so far in 2022. Therefore, the board has met 20 times since 2019. Four years after the Minister of State's predecessor initiated this process and after 20 meetings of the board, we still do not know when counsellors and psychotherapists will be regulated through CORU. I have met representatives of groups, as I am sure has the Minister of State, such as the Irish Association for Counselling and Psychotherapy and Therapists for Change. They are not able to tell their members when they will be regulated in respect of their concerns.

In fact, I sent an email to the Minister of State earlier this month on behalf of the Therapists for Change group, which I will now read. It states that the author is writing to the Minister of State as a member of Therapists for Change, that she may remember that the organisation wrote to her in June 2021 and April 2022 to ask if she could meet with its representatives and that, in good faith, the Minister of State responded with the suggestion that Therapists for Change contact CORU, which was appreciated. The email message continues that when the organisation wrote to CORU on 25 April 2022 seeking a meeting, CORU responded with a generic letter and did not address the request. The email points out that Therapists for Change wrote to CORU again on 10 June 2022 and notes that no response has yet been received.

It will be appreciated that counsellors and psychotherapists have many concerns about statutory regulation and how that will effect them, including whether the courses they are undertaking or have completed will be eligible for registration. As discussed already, we heard about the situation with students in the Dublin Business School who were sold courses for social care roles and now find they may not be eligible for registration with CORU. Some counsellors and psychotherapists find themselves in this situation too. Concerns also include how and if a grandparent scheme will be put in place. Psychotherapists need to make plans to ensure that what they are doing now meets the criteria for future registration.

A meeting with CORU to answer these questions would allay the fears of Therapists for Change and make the transition as problem free as possible. It would also be a gesture of goodwill. The group is writing to the Minister of State to see if she can meet with them or intervene with CORU to see if a meeting with its representatives can be arranged. The group would very much appreciate the Minister of State's advice and help with this matter so some clarity can be brought to the situation for the great many counsellors and psychotherapists who are anxious about their future. I note the Minister of State probably cannot answer now, but will she agree to have this meeting or could she intervene with CORU in respect of setting up a meeting?

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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That is much appreciated. I now call Deputy Mattie McGrath.

Mattie McGrath (Tipperary, Independent)
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I am pleased to be able to speak on this legislation. This Bill seeks to bring some decorum or measure of change and adjustment to what is needed. This whole area needs massive change. We can have all the regulations and Bills like this and all the grandiose titles and amendments, memorandums and everything else, but people want services. The Minister of State knows that. A Teachta Dála living in any constituency knows this about the services having the required healthcare professionals to deliver these services in a professional and timely manner.

In most cases, the services are not timely. In some cases, unfortunately, there are questions about the profession too. We heard An Teachta Tóibín's contribution. This is not the first time I have heard his point and I have discussed it with him. We all have heard of cases where people are languishing on waiting lists for professional therapy and help, from the cradle to the grave, literally. It is most troubling when we see young people trying to get assessments in respect of special and particular educational needs, language needs and all kinds of therapies. Yet they cannot get them. This is where the real problem is. We can have all the legislation, aspirations and flowery words and sentences and acronyms we want, but that is all pointless if we cannot get the services.

Nothing is more frustrating for a family, whether there is one parent or two or a whole family with siblings, than when a child with special and additional needs does not have those needs determined because the family cannot get access to the professional services required. The lives of the children concerned and their families could change if it was possible to get a diagnosis and additional supports. Is mór an trua é sin. We can go on to the areas of autism, dyspraxia, dyslexia, attention deficit hyperactivity disorder, ADHD, etc. My late brother was a paediatrician, and quite a good one from what I hear from his patients. He had a keen interest, God rest him, in children with learning difficulties and any kind of needs. He travelled the world and gained expertise. I still meet families today, and it is nice, who come up to tell me they miss him so much some 11 and 12 years later. The crucial thing is that the patient, whether young or old, must be at the centre of our healthcare system, but unfortunately that is not the case.

The system has seriously regressed since the dreaded Covid-19. Many people are not back to work in places and there are skeleton services and people working from home or whatever. I am not here to undermine or challenge the staff. Some great people are working in the HSE and other care areas, including in mental health. There are, however, some amount of cracks in the system, and needs, trauma and anguish. We saw people lobbying today, with music and entertainment on the street. I met a special lady, whose name eludes me, who gave us a rendition in the audiovisual room and a bit of a recital. Why are people like her punished and why is the system cruel to them? We must praise their ability rather than remarking on their disability. Mol an óige agus tiocfaidh sí. Indeed, mol na daoine agus tiocfaidh sí. It is our abilities and what people can do that we must praise, and not our disabilities. There is a major opportunity here for learning and brushing up on what we do, instead of the slippage we have experienced.

I recently met a retired person who used to look after home care hours and applications. She told me she was delighted to be gone because there was no bother getting home care hours and packages now, but there was nobody to fulfil the hours. We have a flight of experts in this area. Home carers are experts in their own right. Many of them do not have degrees as such, but they have degrees in understanding, care, passion and supporting people who are sick. Ní neart go cur le chéile. I refer to carers as well. I always wear a carers' badge, but it is covered up by the mental health badge this evening. We have questions about the mental health budget as well.

I met the people lobbying downstairs as well. In a proper system, these people should not have to lobby but, unfortunately, they have to. Maybe it is the big organisations, the more powerful ones, that can lobby strongest that will get the best outcomes.

Unfortunately, as regards carers and home care packages, the approach is so short-sighted. It is easy to announce all the money. The Taoiseach, when anybody questions him, the Tánaiste and the Minister state there are so much in additional budgets but they are not there. Carers are run ragged and they are tired, with the distance now travelled, the cost of fuel and everything else. I am conscious of the impacts they make and the joy that they bring to people in their homes on home care visits. They keep them out of hospital and accident and emergency departments. A complete overhaul is needed to put more funding into community services. This Bill should be about enabling that but it is not happening.

Recently, a nurse told me that 67% of her class were in Australia. They have done so much learning here and done so much to join the wonderful and noble profession of nursing only to emigrate. The grá is there for some people and they will emigrate anyway because they want to travel.