Stephen Donnelly (Wicklow, Fianna Fail)
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I welcome the opportunity today to contribute to Dáil statements on safe staffing in our hospitals. Safe, in hospital terms, means much more than numbers of staff - it refers to safety for both patients and staff. It refers to the environment in which patients are treated and where staff deliver care.

Of course, maintaining adequate staffing levels is an important factor in making sure we have safe staffing in our hospitals. Safely staffing our hospitals is a top priority for the Government and for me. The Government has fully supported the continued expansion of staff numbers working in our health service, including working in our hospitals. This expansion has been made possible by successive, large increases in the health budgets, which Governments have proposed and the Oireachtas has voted through.

I will give an overview of the increases in staffing in our healthcare service over recent years and outline where improvements have been made. I will also talk about other important aspects of safety. There are almost 18,500 more people working in our public health service than there were when Covid arrived. It is an expansion of 15%, which is the largest increase in the workforce since the establishment of the HSE. We now have almost 5,700 more nurses and midwives and 3,000 more health and social care professionals. We have 1,800 more doctors and dentists. We have more to do, but this level of hiring during a pandemic is something of which we should be proud.

In order to maintain and increase these staffing levels we need, amongst other things, to make sure a sufficient number of graduates is entering the workforce. Since 2014, the number of students graduating from healthcare courses such as medicine, pharmacy, nursing, midwifery and others, has increased by nearly a third, that is, 30%. Back in 2014, there were approximately 4,800 graduates from healthcare courses. By last year, the figure had gone from 4,800 to 6,200, which is a significant increase. We are continuing with this work. We have additional places coming this September.

In addition, the Minister, Deputy Harris, and I, with our Departments, are engaged in a plan to increase radically college places in the coming years. Colleagues will have heard me say previously that we need to double the number of healthcare college places in our country. We need more doctors, nurses, midwives and health and social care professionals, including dentists, pharmacists, medical scientists and many other people across the system. We have to set Ireland up, not just for the next two or three years, but for the next ten, 20 or 30 years. In doubling the number of healthcare college places, that is exactly what we intend to do. I have had the opportunity to meet with senior academics within some of the universities and colleges who are running some of these healthcare schools, be it in medicine, nursing or other areas. I have to say the level of enthusiasm and the positive engagement I have found has been very encouraging. All of the universities and colleges I have met have been very keen to engage with the Government about a significant, radical increase in college places.

The nursing and midwifery workforce accounts for approximately a third of the overall workforce in the HSE. Ireland has the second highest number of nurses per capitain the EU. We are second only to Finland, according to official figures from the OECD. We have 12.8 nurses per 1,000 population. The EU average is much lower than that, at 8.3. Our nursing and midwifery workforce is highly skilled, educated, motivated and professional. While nurses and midwives demonstrate their professionalism and skill as clinicians, at all times, we all appreciate the extraordinary additional work, skill and professionalism shown by these healthcare professionals throughout Covid.

The development and implementation of the framework for safe nurse staffing and skill mix accounts for a significant portion of our investment in the workforce. Two related policy documents have been published. Phase 1 focused on general and specialist medical and surgical care settings. Phase 2 focused on emergency care, that is, ensuring there are sufficient numbers within emergency departments. The framework provides us with an evidence-based approach to ensure we have the right safe staffing levels and skill mix levels for nursing and healthcare assistants. The framework determines nurse staffing levels based on care requirements, rather than ratios. This is an important innovation in Ireland, whereby the level of nursing staff we deploy on a ward in an emergency department is not based on a national ratio. It is based on the level of care required by the patients in the ward at that time. It has been a positive innovation.

Since the start of Covid, more than €31 million has been allocated to the framework, with €25 million of this investment allocated to implementing phase 1, with regard to hospital wards. This funding provides for an additional 470 whole-time equivalent registered nurses and healthcare assistants across large hospitals. I am pleased to be able to share with colleagues that 85% of those posts have been filled. The balance of €6 million is providing for an additional 101 nurses as part of phase 2, that is, increased staffing within the emergency departments. Positions are being filled for this, as well.

The framework is an agreed part of the overall strategic workforce approach. The budget for this year provides an additional €24 million for workforce measures, including the continued implementation of phase 1 to model 3 and model 2 hospitals, as well as an additional 80 advanced nurse and midwife practitioners. This is very important, because the largest hospitals were targeted at the start of phase 1. The Irish Nurses and Midwives Organisation, INMO, and others said that was great and they fully support it, but they wish to see the same framework rolled out in the smaller hospitals, that is, the model 3 and 2 hospitals. They are absolutely right in calling for that. It is being funded and rolled out.

The framework is positive and continues to demonstrate real impact for patients, staff and the organisations where it is in place. We see reduced length of stay for patients, increased overall job satisfaction for our healthcare workers, a reduction in staff intentions to leave and efficiency gains through reduced agency usage, which I think we would all support. As part of my commitment and the Government's commitment to full implementation of this framework, a national safe staffing unit has been established in the HSE. It is responsible for oversight of the national implementation of the safe nurse staffing and skill mix framework and is led by a director of nursing.

Deputies will be aware that I established a national taskforce to look at the situation for non-consultant hospital doctors, NCHDs, last year. We have had positive feedback on it from front-line clinicians who have been engaged with the taskforce and are looking at what is being rolled out. The purpose of the taskforce is to put in place sustainable workforce planning strategies and policies to improve the NCHD experience, work-life balance and training opportunities. Our aims are to develop and foster an even stronger culture of education and training for NCHDs. It is worth saying that Ireland has a very strong reputation globally for the training of our NCHDs and the quality of the consultants coming out of Ireland. They train longer and, in many cases, harder and more intensely than in some other countries. This is recognised around the world. However, I know, and colleagues will be aware from their own conversations with NCHDs, that in far too many hospitals, this is simply not sustainable. NCHDs are being asked to work unsustainable work patterns and have not traditionally been supported in moving around the country. They have been dealing with a nightmare of repeated emergency tax and many other issues. There are basic facilities that they should have in hospitals and have not had. I have spent considerable time engaging with NCHDs and this taskforce is focused on making sure we deal with those issues.

I thank colleagues for their support for the new public-only consultant contract. It was launched recently, following intensive negotiations. We wish to remove private practice from public hospitals and make sure patients in our public hospitals are treated on one basis, that is, the basis of clinical need. I recognised the importance of making this contract as attractive as possible to both future and currently serving consultants. The contract involves a significant expansion in consultant availability and the provision of consultant-delivered care and consultant decision-making over an extended day, from Monday to Friday, and on Saturdays. The contract also facilitates more flexibility for consultants who wish to opt for different work patterns.

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The Government is committed to continuing to build our consultant numbers to provide a better service and faster access for patients while also improving the work-life balance of consultants. Colleagues will be aware that many consultants quite rightly say we need to have more. Our ratio of consultants per capitais far too low. We have a little under 4,000 whole-time equivalent consultants in the country and we need approximately 6,000. That is something we are absolutely determined to fund. We are determined to make sure that the consultants are put into the right places, that the non-consultant hospital doctors, NCHDs, coming up through their training want to take these posts and that a lot of consultants around the world, many of whom are Irish trained, see Ireland as a very attractive place to come to work. As we expand those consultant numbers from a little under 4,000 to closer to 6,000, we really are going to see a big difference, first and foremost, for patients but, second, in the consultants' workload, their ability to treat their patients, their ability to spend the kind of time they want with their patients, and their ability to engage in research, clinical trials and local innovation on behalf of patients.

The contract does not result in an increase in working hours for consultants. For most consultants, including on-call, it will be approximately €300,000 for a 37-hour week. I acknowledge that many consultants work much longer than that on a voluntary basis anyway but the rostered week is a 37-hour week. The rostered hours are more flexible but the actual hours worked do not change. What does this do? It helps us have a health service that can manage timely and effective patient flow in the evenings and on the weekends, enhance senior decision-making presence on site and rosters, reduce waiting times and waiting lists for patients, and reduce the number of patients on trolleys. It was very evident in January when there were three particularly bad days. The issues went on for longer than three days but three days were very bad. The HSE implemented a much more flexible rostering approach and within a matter of days the number of patients on trolleys fell by approximately half. We know how effective it is but we cannot ask the same doctors to keep working more and more hours. We have to build the workforce to make sure we can roster that on a sustainable basis. We have to make sure that the other facilities they need, including access to diagnostics, outpatient clinics, other consultants, discharge teams and health and social care professionals, are available as well.

Last night we debated universal healthcare in the context of the Bill to remove hospital charges for adults. Ultimately, universal healthcare is about putting people at the centre of our health service. W are all working towards a health service people can access when they need it, in which there is always high-quality care that is either free or affordable. Despite significant challenges, important reform and innovation is being delivered through increasing beds and critical care capacity, improving primary and community care, developing new models of care designed to work for the patient as opposed to being designed to work for the system with the patient having to navigate their way through it. It has been supported by unprecedented investment and funding for our national clinical strategies, including the national cancer strategy, trauma strategy, maternity strategy, mental health, stroke, dementia, women's health services and many more. I want to acknowledge the work of healthcare professionals throughout the system who are rolling these services out and who are putting really important new models of care and services in place for patients. I was talking this morning with some clinicians about the impact that the oncology bypass nurses are having. Up until very recently, for anyone going through treatment, if they crashed during treatment a lot of the time they had to sit in an emergency department. It is completely inappropriate, particularly for somebody who might be very sick and might be immunosuppressed. That is now being changed in all of the hospitals. There are bypass nurses who will bring those patients directly to the oncology services, bypassing the emergency department. It is not 24-7 yet but that is what we are staffing up to do. There are improvements like that, the see -and-treat gynaecology clinics and the new specialist menopause and endometriosis clinics. There are new services like that being rolled out in all of our constituencies that are beginning to make a difference to patient care and to families.

Waiting times for scheduled care were far too long for patients before Covid and we know they got a lot worse during Covid. We are working with the HSE and the National Treatment Purchase Fund, NTPF, to find ways to cut these waiting lists and, critically, progress is being made. As we discussed last night, last year saw the first fall in patient waiting lists since 2015. This year is going to be the second year. From the Covid peak, there are 150,000 fewer men, women and children waiting beyond the agreed ten- and 12-week targets than there were at the end of last year. Hundreds of thousands are still waiting. The goal is to bring it down to no one waiting longer than the ten- or 12-week agreed times but a reduction of 150,000 is a good start. The number of patients waiting longer than the 12-week target for inpatient and day cases fell by about a third from the pandemic peak, which is very welcome as well. Colleagues will be aware that we published the waiting list action plan recently. Some €363 million is being allocated across the HSE and to the NTPF as well, into hospital waiting lists, community waiting lists and diagnostic waiting lists to increase the speed at which patients are getting care. As I said, last year for the first time in a long time we saw the waiting lists fall. We are going to see them fall again this year. We are taking a multi-annual approach, something colleagues here have rightly called for many times.

I would like to turn in the last few minutes I have to recruitment and retention. The HSE has increased retention efforts right across our health service. It has contributed to record staff increases in recent years, which I referenced a few minutes ago. We are heavily invested in the ongoing education of healthcare staff to support recruitment and retention. My Department and myself are engaged on an ongoing basis with the HSE to make sure there is sufficient professional development, mentorship programmes and opportunities for our healthcare professionals. The HSE has commenced a recruitment reform and resourcing programme to lead out on the development of a resourcing strategy, which is an important innovation. A core element of this will be enhancing the HSE's ability to attract, develop, retain and engage with the workforce on an ongoing basis.

We have all spent quite a bit of time in this Chamber over recent weeks and months discussing patient safety legislation and other policies to improve patient safety. Patient safety initiatives enable the support of safe, high-quality care and incorporating patient safety within health professional undergraduate and postgraduate education with an emphasis on inter-professional learning is a vital tool to supporting the ongoing improvements in patient safety. Retaining experienced staff in our healthcare system, providing strong leadership, governance and regulations are other ways we can improve and maintain patient safety as well.

Significant evidence on safety in our system stems from nursing and midwifery. Throughout the system, every patient interfaces with a nurse but it is no longer one profession that defines or delivers patient safety. The WHO's global patient safety action plan 2021-2030 identifies healthcare worker education, skills and safety as an important strategic objective. The plan recognises the need to inspire, educate, skill and protect nurses and all healthcare workers to contribute to the design and delivery of safe patient-focussed healthcare services.

The HSE's national health and safety function has reported that incidents of assault across the public service, that is, the HSE and section 38 organisations, have reduced from approximately 11,700 five years ago to 9,100 last year. The reduction is welcome but I know we will speak with one voice in saying there is not a single assault or abuse on any healthcare worker that is ever acceptable under any circumstances. It is important that we are seeing a reduction from nearly 12,000 down to a little over 9,000. It is very positive and encouraging to see but it is still 9,000 too many. Ensuring the safety of employees and services users is a priority for me, the Department, the HSE, the Government and all of us here in the Oireachtas. I am advised that the HSE is now prioritising a review of the policy on managing violence and aggression in the workforce.

I am fully committed to putting in place sustainable workforce planning strategies and policies, improving the NCHD experience, continuing to deliver reform and innovation towards universal healthcare, focusing on waiting lists, staff safety and continuing to roll out and complete the nursing and midwifery safe staffing framework.

David Cullinane (Waterford, Sinn Fein)
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I welcome the opportunity to have a discussion on safe staffing in our hospitals. Last summer was the first time we had a serious problem in our hospitals, namely a summer trolley crisis. Before that summer trolley crisis arrived, people working in our healthcare systems throughout primary, acute and community care were flat out during Covid. There was a cyberattack and long before Covid they told us they were burned out. Along came the summer with some hope of relief for those on the front line, which did not come. In fact, we had serious overcrowding in hospitals for the first time in a significant way last summer.

That continued into the autumn, as the Minister knows. It became worse into the winter. We had what was possibly one of the worst winters on record, exacerbated by the lack of capacity in the system as well as the mix of illness circulating in the community which put enormous pressure on our front line healthcare system.

Over the past number of weeks we have had, on average, 500 patients on trolleys every day. Last week, there was not a day where the number was less than 600. It seems to many people who work on the front line in healthcare that this has become the new normal. It is now acceptable that every day, week, month and year we have to tolerate that level of overcrowding in our hospitals. There are a lot of reasons for it.

We have had many discussions on why we have the levels of overcrowding we have in our hospitals. Part of the reason is that there are not enough staff in our hospitals, primary care centres, out-of ours GP services, community care infrastructure and so on. We know there are a lot of reasons we end up with the crisis we have in our emergency departments.

Unsafe staffing is one of the problems. If we talk to any hospital manager - at this stage I have spoken to most of them - they will say surgical theatre, diagnostic and bed capacity are all important, but none of that is possible without staff.

Over the past number of months we have had threatened strike action from the INMO. The Minister has spoken at length about all of the things he and his Government have done. While additional staff and beds, a movement towards universal healthcare, a new consultant contract and many other positive developments have been put in place, which I have of course welcomed, the backdrop to this discussion is that we have seriously overcrowded hospitals and record numbers of patients on trolleys. People aged over 75 waited, on average, 40 hours in one month last year in our acute hospitals in Cork. That is the backdrop to this debate.

People who are waiting for access to care on healthcare waiting lists and all of that is a product of a system that does not seem to be working despite all of the resources and capacity Minister spoke about. The system does not seem to be delivering the levels of care at speed that need to be delivered. He will accept that the waiting times and the length of time people are waiting in emergency departments is too long.

In the early days of January when we first came back and had a discussion on was happening in hospitals, I said to the Minister that we have to take what happened from last summer onwards as a watershed moment in healthcare and, once and for all, we as an Oireachtas were going to say that we are not going to tolerate those levels of overcrowding in our hospitals. It simply cannot be accepted as normal. The only way we are going to be able to deliver on that promise is to put the capacity in place. Part of that is staffing.

I listened to what the Minister has said over the past number of months. He spoke about doubling training capacity so that we can train more healthcare professionals. I support that. It should not be a competition about numbers, where he refers to doubling the numbers and I say the figure should be more or less. It has to be based on what we need.

We need a new workforce plan and strategy underpinned by what the health care system needs. We have the science. The safe staffing and skills mix framework should tell us what we need in terms of staff across wards, hospitals and emergency departments, and we should then roll that into community services and primary care in terms of HSE and public sector staff.

The INMO has, justifiably, asked the Minister and Government to underpin that framework by legislation. That would mean the State and Minister would be legally obliged to provide safe staffing levels in hospitals. That is something that I am committed to. I can clearly say in the Chamber that if I were sitting where the Minister is and I was Minister for Health I would introduce legislation to underpin the framework. That is the science. That tells us what we need. That will change based on demographics and the additional capacity we put into healthcare. It will not deal with all of the problems or tell us everything. It is only based on what capacity we have in the system. At least it would be a starting point and should be underpinned by legislation. Unless we have a workforce plan that is of substance, talking about more beds or capacity in the system or all the other capital investment and any other investment we want to put into healthcare will come to nothing because we cannot open beds and put the capacity we need into our hospitals without staff.

At its core, healthcare is about people treating people. It is about healthcare professionals and front-line healthcare workers treating sick people, and we need more of them. We will not have more of them unless we train more and have more placements, which is important. We cannot increase the number of training places and not have placements in healthcare settings so that we can make sure people can get training as well as placements. We need investment to make that happen.

Seán Crowe (Dublin South West, Sinn Fein)
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Staffing levels in the health service have been a problem for decades and successive Governments have failed to get to grips with the fundamental issues of recruitment and retention. At the core of these issues is the working conditions our healthcare professionals, in particular nurses and young doctors, are forced to face every day. When gruelling 24-hour shifts or the threat of violent abuse or assault are the reality, is it any wonder that our young graduates are heading to Britain or Australia?

Since the beginning of 2021, more than 3,400 nurses have been assaulted in our hospitals. If we consider all staff, that figure goes up to 5,600 incidents of physical, verbal or sexual assault. A nurse described an accident and emergency department as a pressure cooker with aggression causing junior nurses to quit. She no longer feel safe in the workplace. None of us would put up with that if there was an alternative. I was shocked to hear recently that there is a two-tier system whereby a doctor gets longer than a nurse or other staff member to recuperate if he or she is assaulted in the workplace. This does not make sense.

The worse the staffing crisis gets, the worse the overcrowding and so on gets. It is a vicious circle. The Government and HSE must put measures in place as a matter of urgency to ensure the safety of all our nurses and hospital staff. The obvious tension and pressure cooker atmosphere in accident and emergency departments, in particular, must also be relieved.

A plan needs to be brought forward to tackle waiting times and overcrowding. Part of that has to involve alternative pathways to care and a greater emphasis on care in the community. Thousands of people experienced unnecessary delays in discharge from hospitals last year due to a lack of step-down beds and care packages in the community. The pressure a lack of focus on issues such as home care puts on the hospital system is enormous.

Home help is one area where we will see greater demand as time goes on.

Our population is ageing. Our population aged over 65 is one of the fastest growing in the world in fact. Many families have gotten smaller as time has gone by. Where there may have been three or four siblings to look after an ageing parent, there may only be one or two now. This means that home help will be more crucial as we move forward. We can see clearly the issues caused in our hospital service when elderly patients are medically discharged but have no supports once they leave, so they are stuck on a hospital bed.

We call it a health system because it is made up of many moving parts. When one breaks down, the whole system suffers. A lack of home help or step-down beds means that patients are not discharged and someone on a trolley in the accident and emergency department cannot be moved upstairs to a bed or an ambulance sitting outside the door cannot discharge a patient into the hospital because there is no space inside. That, in turn, means that ambulance is not responding to the next call, which is why our emergency response times are way outside the targets set for them.

We need to examine options that will alleviate pressure in areas where we need to build up staffing numbers. Let us consider GPs. We do not have enough GPs, which is putting further pressure on our emergency departments as people feel they have no other choice but to go to hospital if they cannot see a doctor. This is yet another example of one part of the system breaking down and causing problems down the line.

Irish Pharmacy Union representatives were before the Joint Committee on Health two weeks ago and they spoke about the enhanced role that community pharmacies can play in providing capacity in our health service. By operating minor ailment clinics, they could triage a great number of people who may not need to see a doctor or go to a hospital. This would free up appointments in GP surgeries, which would then allow people to see their doctor rather than go to the accident and emergency department.

We need higher levels of staffing in our hospitals. Everyone accepts that and that is a given. The pressure and unfair working conditions that our healthcare professionals are subject to are simply unacceptable. We are creating pressurised situations in our hospitals that are jeopardising the safety and welfare of patients and workers alike. We need, however, to look beyond the simple arithmetic of more workers equalling greater capacity. We need to innovate and be proactive when it comes to treating people in our community and preserving our hospitals for those that need to be there.

Programmes such as Pathfinder, which aims to have ambulance personnel treat people in their homes where possible and prevent a hospital visit are invaluable in that respect. We need, however, to see that value sooner and roll out these programmes throughout the State far sooner. By creating and strengthening these alternative pathways to care, we can alleviate some of the pressure on our hospital network and allow ourselves breathing room to both improve the working conditions and build staffing levels.

Imelda Munster (Louth, Sinn Fein)
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In all seriousness, how long has the Minister been saying that safe staffing levels is a top priority? I wish that we could see the real results coming from that. The question is: when is a priority actually a priority? It has been five years since the final report of the task force on safe staffing and skill mix in Nursing. The Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Ireland was published in 2018. It is five years then since it was published and we have seen nothing of any improvement whatsoever. In fact, many would argue that the situation is a great deal worse.

How many times have we heard of problems in the health service caused by lack of staffing and lack of capacity? It was only in December that there was what was described as a scene of "total chaos" outside Our Lady of Lourdes Hospital in Drogheda hospital as 11 ambulances queued because there were no trolleys and no beds to take patients into the hospital.

Stephen Donnelly (Wicklow, Fianna Fail)
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They all arrived at the same time.

Imelda Munster (Louth, Sinn Fein)
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In December, I also stood with staff and protested with them as they highlighted what they described as a third world service caused by lack of resources and capacity in the hospital and I listened to their pleading for more resources. At that time staff told me that there were 60 health and social care professionals vacancy deficits as it is, never mind bringing Our Lady's Hospital in Navan on board. There are 15 to 20 current deficits in clerical and approximately seven in emergency departments alone. There are times where there are only two staff members to cover the night shift. The staff told me that they cannot go on breaks, go for food and, at times, they cannot even get to the bathroom. That is the stage at which they described the service they are providing as a Third World service.

Those same staff are so stressed and overworked that, if things do not change, it could end in industrial action. They are the last people who want to see that. Such are the stress levels, the staff shortages and the shortages of resources that they may have no choice.

It is not just nurses but it is health and social care professionals, together with clerical and administrative grades across the hospital group. When there is a problem in staffing levels in one area there’s a knock-on effect in others, as the Minister knows well.

When those staff talk to their college friends or former work colleagues who emigrated overseas and hear of the much better conditions there, who can blame some of them for packing it in and leaving?

Duncan Smith (Dublin Fingal, Labour)
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I will pick up on the Minister's comments on recruitment and retention and the efforts he said that the Department and the HSE are making. We are hearing from the unions that one of the key reasons we are struggling in this country not only to recruit but to retain staff is housing and the cost of it. I am aware that this is outside the Minister's remit but this is a fundamental reason and I know that the Irish Nurses and Midwives Organisation has done some research among its own members on this. Graduate nurses in Dublin and Cork are paying upwards of 77% of their income on rent. That is totally unsustainable and someone cannot live on that. Directors of midwifery stated that in exit interviews carried out by the INMO, 59% of young nurses who are leaving are going abroad for better pay and conditions and cheaper and more available living standards. Unless we resolve the housing crisis, this issue will prove fundamental to also resolving the recruitment and retention crisis.

I do not believe we would be having statements in the Dáil this week, which I am very thankful for, if the motion on safe staffing had not been tabled by Senator Hoey of the Labour Party in the Seanad a number of weeks ago. It is vitally important that we are having another opportunity to debate this issue.

The one issue I would like to focus - and I would like to the Minister to response to the letter writer in SIPTU, and the health spokespeople - is the serious physical assault scheme and the disparities within it. SIPTU health division wrote to the Minister on 14 March and copied in the Chair of the Joint Committee on Health and Senator Hoey in respect of removing the inequity within the treatment of the serious physical assault scheme to support grades within our health service.

The support grades are porters, receptionists, cleaners, healthcare assistants, paramedics and household staff, all of whom are front-line staff and have been victim to assaults, be they physical, sexual or otherwise. At the moment, given how the scheme is set out, they are not entitled to the same benefits under the scheme as other officer grades. This is unsustainable. The HSE has responded to the SIPTU health division to confirm that they are supportive of its claim, which was lodged in October 2021, but it would require sanction from the Department of Health to address the concerns raised. This claim has remained within the Department ever since. It is unacceptable that support staff who suffer such assaults should be subject to the lesser terms of support from their employer than other grades within the same service. Where two staff members may be victims of the same assault, one may qualify for greater benefits under the same scheme than the other. That is not equitable and has to change. I imploring the Minister to address this issue. We could talk about many different aspects of the health service but this is the one issue on which I would very much like him to come back to me in writing. It has been going on for far too long. The inequity has to change and it cannot continue to languish within the Department. The results of this inequity is that the support workers who are subject to serious physical assault in the workplace are afforded only 25% of the terms that can be provided to another grade even, as I have said, if both are assaulted in the same incident.

The delay by the Department in removing this tiered system of benefits that is available to healthcare workers continues on a daily, weekly and monthly basis to treat support staff as if they were of less value than other grades of staff. We are discussing safe staffing and equality within our health service.

We could talk for hours or days about it but we need to fix this scheme and remove the inequity in it. That is what I want to leave the Minister with today. Could he please respond to the SIPTU health division, let the health spokespersons know the position and end the inequity in the scheme?

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I welcome the opportunity to examine the issue of safe staffing levels in Irish hospitals, which are fundamental to delivering safe health services to the highest standards. It is important to acknowledge the programme for Government, which commits to the large-scale expansion of the health and social care workforce. This expansion has been significantly accelerated since the beginning of Covid-19. Record levels of capacity have been added to our public health service. Increased funding is supporting community intervention teams, GP supports and out-of-hours services to reduce the need for attendance at emergency departments.

In November, our total public healthcare workforce stood at 137,220 whole-time equivalents. Thanks to successive large increases in the health budget, there are 17,403 more people working in our health service than there were at the beginning of 2020. That is an expansion of 15%. This includes 5,169 nurses and midwives, 2,870 health and social care professionals and 1,801 doctors and dentists. Funding has been secured in 2023 to continue this considerable expansion of the workforce, with an additional 6,000 staff to be added this year.

Recruitment capacity is also expanding to ensure that ambitious workforce targets can be met and maximise the number recruited. I understand this has included the expansion of international recruitment markets, targeted recruitment campaigns and streamlined recruitment processes.

Record funding has been provided to permanently increase capacity in our healthcare service. This year's budget is over €24 billion, up from €14.8 billion in 2018. This is the largest allocation ever. I welcome the confirmation from the Minister that he has secured funding to continue this considerable expansion of the workforce, with an additional 6,000 staff to be added this year across all service areas and in key staff categories. Included are medical staff, nurses and health and social care professionals.

However, challenges obviously remain. While the consultant number has increased significantly, by 254 to 3,837 during the year ending in October 2022, it is still low by international standards, as the Minister is aware. We need about 6,000 consultants.

I welcome the new consultant contract and also the ongoing efforts of the task force that has been working closely with representatives of non-consultant hospital doctors, NCHDs, to improve conditions and opportunities for NCHDs and resolve unacceptable issues around placements and taxation. Equally, Deputies from across the House will be aware that there are significant challenges over the provision of GP care in the community and the provision of dental services. We have all seen these at first hand in our constituencies. More needs to be done, and I welcome the confirmation that the Higher Education Authority is working with higher education institutions to scale up capacity in dentistry, pharmacy, medicine, nursing, and veterinary courses. I understand recommendations on capacity are due to be submitted to the Minister for Further and Higher Education, Research, Innovation and Science shortly.

It is critical to have enough nursing or midwifery staff with the right knowledge and skills, in the right place and at the right time, to provide safe and quality care to patients and service users.

There are 18,516 more staff in our health service now than at the beginning of the pandemic, including 5,742 additional nurses and midwives. The years 2020, 2021 and 2022 have seen the biggest staff increases since the HSE was established. Ireland now has the second highest level of nurses per capitain the EU, at 12.8 nurses per 1,000 of the population, contrasted with an EU average of 8.3, and 8.5 across the water in the UK. These statistics are useful for comparison but the real indicators should be the levels and standards of care being provided.

Waiting lists for outpatient appointments are too high and the waiting times in emergency departments are too long.

I am aware that the Minister and his Government colleagues are making significant structural changes, including by establishing a safe staffing framework, to ensure safe care standards for patients. The framework has worked well in large hospitals and I welcome comments from the Minister that it will be fully implemented, particularly in smaller hospitals.

It is important to acknowledge the challenges and issues and deal with them, but it is also important to acknowledge the fantastic work being undertaken by the entire medical community. In my constituency, Dún Laoghaire, I have seen at first hand the wonderful care provided in St. Vincent's, St. Michael's and Loughlinstown hospitals and, of course, the newly expanded National Rehabilitation Hospital on Rochestown Avenue, which we got a chance to view. All of these hospitals are supported by the work of practitioners in the community, from GPs, community nurses and meals-on-wheels providers to home care assistants, pharmacists and, of course, carers. We are all grateful for their efforts.

I thank the Minister for his update today and look forward to the response.

Ruairi Ó Murchú (Louth, Sinn Fein)
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Had I realised I had this slot, I might not have dealt with quite as many issues yesterday; however, in fairness, I may revisit some of them. I hope we can get an answer on some of them.

Like everyone else, I am very glad we are dealing with the issue of safe staffing levels in hospitals. We all know the issues that we had, particularly in December and January. We know of the chaotic scenes in a considerable number of hospitals and the issues that continue to arise in the likes of University Hospital Limerick. Obviously, the issues are having a huge impact on patients across the board. We know of the difficulties that have arisen for elderly patients, who are under considerable pressure. My party colleague Deputy Munster was speaking about the particular issues that we faced in Drogheda. We all know there was a huge ambulance backup. We all know the issues relating to staff being under incredible pressure.

I welcome some of what the Minister has said. Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Ireland was published in 2018, so it is just a matter of ensuring we do the entire piece of work that needs to be done in regard to it as soon as possible and deal with the issues concerning working conditions. Obviously, such issues arise for a large number of people. We are aware there are wider issues concerning accommodation and other matters that impact on many people, who are deciding to move from the Irish health service to Australia and Canada. This is not working for any of us at this point.

Could I get an answer on neurorehabilitation teams in each community health organisation, CHO? Is there an update on the Minister's engagement with the Irish Dental Association on the specific issue of dental care for those on a medical card?

Rose Conway-Walsh (Mayo, Sinn Fein)
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The HIQA report on Mayo University Hospital, published a few months ago, showed a 10% deficit in medical staff, a 14% deficit in nursing staff, a 15% deficit in healthcare assistance staff and a 23% deficit in pharmacy staff across the hospital. The shortfall was even more acute in the emergency department. That department is just not capable of supporting the needs of Mayo as it is. Dedicated and very hardworking staff are under immense pressure and sometimes barely able to cope. They are not getting the support they need. This weekend, the emergency department at Mayo University Hospital simply did not have the required capacity. Elective surgeries had to be postponed as staff were redirected. Saolta University Health Care Group was forced to issue a statement urging people not to go to the emergency department unless it was absolutely necessary, as if people just rocked up when it was not necessary.

People are not well placed to identify whether their symptoms are urgent and who should attend. People with medical concerns and fears should have a place to turn to.

Research shows that three out of ten people have put off accessing a GP or hospital appointment because they hear that they should not attend a hospital or emergency department unless it is urgent. We also know that 14% of cancers are diagnosed in an emergency department. How many early cancer diagnoses have we missed because people have been told the emergency department cannot cope?

Crowded emergency departments have a knock-on effect. Mayo University Hospital in Castlebar is not meeting ambulance turnaround times. Ninety percent of the ambulances attending the emergency department did not even meet the turnaround time of less than 30 minutes. Imagine waiting for an ambulance, travelling more than 50 miles on some of the worst roads and waiting hours outside an emergency department.

The problem is that community beds have been closed in the district hospitals. The people who made the decision to close them across the board for years and who were adamant that it had to be done have not been held accountable. This must be looked at and those beds must be reopened. We need to look at each county and area in a joined-up way with a bit of common sense around this to make sure people get the healthcare they need.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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We have an unusual situation in that Deputy Louise O'Reilly is taking the Social Democrats slot.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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Is that agreeable? I do not want to be awkward.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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I do not think anyone here will object to it but it is unusual.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Unusual but agreeable.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Deputy O'Reilly is doing it but it is not setting a precedent.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I do not wish to set a precedent and I will not take all of the time because I do not want to be in other people's way when they want to make their contributions. I thank the Ceann Comhairle and everyone else for indulging me.

I noted the Minister's speech in which he referred to the need for patient safety, which is extremely important. However, when we consider the issue of staffing levels, we must also consider the issue of staff safety. In many of our hospitals, staffing levels are at crisis point and our nurses, doctors, porters, cleaners and all our healthcare workers are used to operating in a semi-warlike environment, which is really tough for them. When staffing levels get low, there is a consequent increase in levels of violence because it makes the hospital unsafe and not just for patients. From a patient safety perspective, short-staffing is a grave issue. When staffing levels are low, violence against staff increases. If we look at our nursing and midwifery workforce, we can see it is predominantly female. They are the ones who bear the brunt of these assaults. As recently as February, the INMO was pointing out that there are ten assaults per day on nurses. That is really shocking.

As shocking as that figure is, and I am shocked by it, we also know there is a significant issue with under-reporting. I represented nurses for nearly a decade. They have a great way of just getting past it and getting on with their work. They are coming back into work the next day but I want to impress something on the Government because it is important. There has been a lot of talk in this Chamber, and rightly so, about threats made against parliamentarians and working in an atmosphere where we feel our safety might be slightly compromised. Many female Members have said it makes them somewhat fearful to come in to do their job. That is a fact. If people are worried about violence, it makes them fearful to do their job but our nurses, porters, cleaners, doctors and physiotherapists work in an environment where staffing levels are low and they run the risk of an increase in levels of violence yet they still come in every day. There is no "Prime Time" special about this. Nobody is doing lengthy one-to-one interviews on "The Late Late Show" about this. It is just par for the course for them. I urge members of the Government to put themselves in the shoes of those men and women who are coming back into work after an assault. It is really tough. They know the pressure is on them. Because they are short-staffed, they know they have to come into work because if they do not, they are letting their patients, colleagues and the health service down and they just do not do that. However, it is really tough to get up and go back into work to the same place where an assault occurred. There are ten assaults per day on nurses and midwives and that is just one grade. It is a big grade but it is just one grade within the health service. That is replicated throughout the health service. They come in every day when they can and it is really traumatising. They are driven back into work because they do not want to let their patients and colleagues down. We are asking them to do something that is traumatising and re-traumatising them.

The answer to this is fairly simple. We need a 24-hour security presence in our accident and emergency departments. We also need advanced risk assessment to find out where there are dangerous situations and situations where staff safety could be compromised. They need to be risk assessed and then staffed appropriately. When we talk about safe staffing, it is incredibly important from a patient safety perspective but it is also extremely important from the perspective of the health, safety and welfare of healthcare workers. As it stands, I imagine the Government and the health service are failing in their obligations to these people under the Safety, Health and Welfare at Work Act. These people are not failing. Ten nurses per day are assaulted and the figure is going in the wrong direction, yet they come into work the next day. They are coming back to the place where that trauma and violence occurred. They are getting up, coming back in and going back to their workplace. We owe them great gratitude for doing that but we also owe them proper staffing and a safe place to work.

Emer Higgins (Dublin Mid West, Fine Gael)
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I am glad to contribute to this debate. As a Dublin Deputy, staffing levels in the hospitals in our capital are a massive concern to me and my constituents. This is because they are far from safe. I know of one hospital whose accident and emergency department has almost 50 nursing vacancies and where, when there should be 18 nurses working on any given day, there is often half that number. As few as nine nurses sometimes run the accident and emergency department. On a good day, that number might increase to 11.

This continuous understaffing has become the norm for people in these hospitals, which is leading some healthcare professionals to feel sick at the thought of having to go to work and face another shift in appalling working conditions and then dreading the day when they themselves actually feel sick and have to call in sick. We all know politics can be a stressful job but it does not begin to compare with the stresses facing our healthcare workers right now.

My main concern, which I know is shared by many nurses, doctors and healthcare staff, is safety. Healthcare settings are simply not safe. They are not safe for patients or staff. The fact that more accidents and deaths do not occur is a credit to the staff in our hospitals but the point is that staff and patients should not be in that position. Patients should not be waiting up to 20 hours to see a doctor and hospital staff should not be pushed to their limits day after day. Staff should not have to put up with unsafe working environments. It is not sustainable and we all know it contributes to the numbers leaving the profession.

Travelling and seeing the world is a very common career move for young people in general, including young people in healthcare professions. However, whereas every year, there is usually a group leaving and a group coming back to balance that out, all of the people who were prevented from travelling in the past couple of years due to Covid are now leaving and this is compounding an already worrying problem. They are not necessarily leaving for Australia, New Zealand or Dubai. In many cases, staff are leaving just to go to tertiary hospitals outside Dublin where conditions and staff levels in some cases are better. We are losing senior nurses and doctors in our major hospitals to burnout.

One thing we can do to boost staffing numbers and support staff is to iron out existing visa delays.

We have large numbers of healthcare staff who are looking to come to work in Ireland but many are being delayed by visa issues. I am in favour of prioritising those people for visa decisions given the major shortage we are facing in healthcare in our front-line workers. For a long time our health system has relied on nurses, doctors and other healthcare professionals from outside Ireland to keep us functioning. Our hospitals would not survive without these people. We need to ensure that process of applying to live in Ireland and work in our health service is as quick and seamless as possible.

We also cannot ignore the impact of housing. There is no sector that is not impacted by the cost and shortage of housing. That is particularly acute in Dublin. Healthcare professionals I meet say that colleagues outside Dublin and from rural Ireland are leaving in their droves to move back home because they as if one is not from Dublin what is the incentive to stay here. If they could work in a smaller hospital in a more rural area where housing is cheaper than Dublin why would they not do that? That applies to people coming from abroad to work here too. Many foreign nationals coming to work in the health service stay in Dublin for the length of time that they are contractually obliged to. It is usually a couple of years. Once that is done, because they have no ties to Dublin, they move on to somewhere else. We need an incentive to keep our healthcare workers in our capital city whether it is a Dublin grant or bursary towards housing. We need to look at it because the cost of housing in Dublin and the staffing issues in our busy city hospitals are incentivising no one.

We also see it on the ground. We see it in Newcastle and Lucan in particular where there is a lack of service due to a lack of public health nurses in my community. That is impacting families of young children, and babies in particular. In my community, there is also a shortage of GPs. I know we have invested in recruiting more GPs and in more GP college places but we need to incentivise more GPs to establish practices in our community.

While there is really significant investment planned, and ongoing in some places, in primary care centres in Dublin Mid West, Lucan Esker and Lucan village are being underserved and they need proper primary care centres with access to all of the primary care services.

The number of people presenting to hospitals is back to well above pre-Covid levels. It is fair to say that in many hospitals staff morale is at an all-time low. While they continue to provide the best care they can, the stress and the burnout is unsustainable. In many cases it is looming. That will not change until staffing is at a safer level and conditions are improved. That is what we as a Government need to prioritise.

Paul Donnelly (Dublin West, Sinn Fein)
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I commend Deputy Higgins for her damning indictment of 12 years of Fine Gael in power. It was pretty powerful.

I commend all the staff who work in hospitals and in our community care services. Just this afternoon, we attended a tree-planting service for those who died during Covid. Some of those were our doctors, our nurses, cleaners and other staff who worked on the front line in the direct firing line of Covid. We can never fully understand what they went through during that period. That really tough and difficult time was preceded by a time when there were already massive problems in staffing and resources. This experience made those seeking help, very sick people looking for care, being forced to wait for hours and sometimes days in emergency departments, in absolutely horrendous conditions, leaving staff to deal with angry and frustrated patients.

We have a mental health crisis with people trying to access urgent and emergency care. It is not a service that any Minister or government could stand over. I know of individuals who have waited ten to 20 hours on multiple occasions for help and support to be simply given an appointment as far away as three weeks to see a psychiatrist. Mental health care is in crisis with community and voluntary therapeutic service providers talking on the radio today about filling in those gaps in the service.

Just yesterday we heard a nurse and other mental health professionals talking about leaving the country. They are on their second eviction notice and cannot find anywhere to live. That is not to mention the cost of a property if they do manage to find one. They said that they love Ireland and that they love working and living here and they love the people but they cannot find a safe, affordable and secure place to live. Our own student nurses, doctors and health professionals are leaving en massebecause of the housing crisis. We can provide all the workforce planning in the world but if they have nowhere to live then they will not stay here and we will not encourage others to come into our health service.

Réada Cronin (Kildare North, Sinn Fein)
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Naas general hospital is in my constituency in Kildare North. In a reply to a recent parliamentary question on waiting times across the State tabled by an Teachta Cullinane, I was horrified to find that waiting times in the emergency department in Naas were among the top three worst times for people over 75 years and the top five worst for patients generally. Last December, general patients were waiting 21.5 hours for admission to Naas general hospital. For those over 75 years, they went from waiting 21 hours in 2019 to an absolutely disgraceful 30.5 hours last December. We know people waiting longer have poorer outcomes. I was so worried about why those aged over 75 years were waiting so long that I wrote to the Department. I got a load of gobbledygook back from the HSE about testing and processes involved in the care of those over 75 years. Families who have contacted me in Kildare North are telling me they are afraid their parents are just left there while exhausted and overworked staff are tripping around them. This is no reflection on the fantastic staff we have in Naas general hospital, many of whom I know or have met. I want to pay tribute to them here because they feel so overworked and so undervalued by the Government.

Delays in care in our hospitals comes down to safe staffing levels. Staff in our hospitals do not feel valued. They have told me that they do not feel valued in Naas general hospital either. I want them to know that Sinn Féin will value them. We have a multi-annual plan to tackle staffing levels in our hospitals. We intend to treat our non-consultant hospital doctors so much better so that they will stay in Ireland.

According to the British Medical Journal, 62 out of 77 medical graduates in the UCC class of 2021 left for Australia. It is no wonder when they are treated so badly here with the constant problems around rostering, getting paid and being made to work awful hours. This Government has to let them know in word and in deed that we do not want to lose them. Not only can we not afford to lose them but we need to keep more. The Minister has said that we need to double student training capacity in healthcare but my comrade, an Teachta Conway-Walsh, constantly brings this up with the Minister, Deputy Harris. He says that he cannot provide more places at third level because we do not have the clinical placements. It goes to the disconnect in the Government. It is not working together. I could speak on this all day but I am out of time.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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It is good that we are having this debate. There are serious issues around staffing levels in some of the hospitals in the State and particularly in emergency departments. This has been exacerbated by overcrowding and the inadequate bed capacity. The environment is not conducive to safety for the staff or the patients. There is something fundamentally wrong when nursing staff from emergency departments say the situation is dangerous. It is around staffing levels and where people can sometimes wait for days in emergency departments.

This is a very wealthy country. This is not rocket science. We are talking about a system where people would be treated in time and with respect. This has a knock-on effect on staff morale and retention and recruitment. The new HSE CEO, Mr. Bernard Gloster, was before the Joint Committee on Health during the week. He said in his opening statement that one of the most important issues in his tenure is staff recruitment and retention.

4 o’clock

It is extremely important - I cannot overemphasise it - that we retain the staff we have right now. If we do not retain them, there will be a spiral whereby highly motivated and educated staff who want to stay in the Irish health system will not be able to do so because of the housing situation and because of being burned out. They want to partake in this environment but the situation is not conducive to this. That is a very important point. The new CEO said he would make it one of the most important elements of his tenure.

As to the framework for safe staffing and skill mix, it is a good concept but it needs to be fully implemented. I have worked in hospital environments before and I know the most fundamental part of working in such an environment is having the proper skill mix, whether you are a healthcare assistant or a nurse. Everybody needs this. However, once that is out of kilter - it happens on a regular basis - people will die. There will be situations where people cannot be attended to. This is how serious it is. The framework is a very good concept, but it is kind of arbitrary in its implementation.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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There is a big disconnect between what we are being told by those who work in the health service, and those who use the health service, and the tone and content of the Minister's narrative. He painted a very rosy picture of the health service and the success of the Government in addressing the staffing crisis - that is what it is. Every single report we get from people using the health service, from those trying to get into accident and emergency departments or from patients in hospitals refers to this unsafe and understaffed situation. This is what the healthcare workers are also saying. It is unsafe for the staff and the patients. That is a pretty damning indictment.

The INMO did a survey of several hospitals last year. I will pick St. Vincent's University Hospital because it is near me. In terms of its findings, 70% of nurses and midwives stated they felt pressured to work extra shifts; 73% said they had worked additional unpaid hours over their contracted hours in the previous 12 months; 36% said they had been asked to defer annual leave or work during annual leave in the previous 12 months; 65% said they had considered leaving their current work area due to workplace stress during the previous month; 67% said their work environment was emotionally exhausting to a "high" or "very high" degree; 82% said they "always" or "often" felt worn out by the end of the day; 69% said they "always" or "often" felt exhausted at the thought of another day at work; 25% said they had to attend their GP or another healthcare professional as a result of work-related stress in the previous 12 months; and 65% said they had experienced verbal abuse or threatening behaviour in the previous 12 months. There were similar figures in Blanchardstown, in addition to another category. Some 91% stated that based on their professional judgment, the current staffing levels and skill mix in their area was not appropriate for meeting clinical and patient work demands. Of these, 81% felt that patient safety was put at risk "often", "very often" or "always". That is shocking stuff.

To cut a long story short, I was talking to Phil Ní Sheaghdha today. She said that the framework on self-staffing and skill mix needs to be underpinned with legislation. It must not be a standard or a recommendation. It must be a legislative requirement. The HIQA and the Health and Safety Authority, HSA, need powers to regulate to ensure the implementation of the framework. The framework is on a scientific basis for patients and staff safety. That is what it is; therefore, it needs to be legally implemented. Patient safety legislation must be accelerated and brought forward and must become a legal requirement of our health service. The HSA and HIQA need to be given the power to regulate to ensure we have safe staffing levels in our hospitals.

Verona Murphy (Wexford, Independent)
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The next slot is a Sinn Féin slot. I call Deputy Martin Kenny.

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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Listening to the Minister’s speech earlier is in stark contrast to the experience of the vast majority of the public out there who attend our hospitals and, indeed, the staff who work there. In my constituency, Sligo University Hospital has been in crisis for many years because of understaffing and under-resourcing. Last September, the INMO industrial relations officer, Neal Donohue, said that the conditions in the department were so concerning that they had no choice but to call on the HSA to intervene and conduct an urgent inspection. It was claimed that there are real issues of risk of fire, injuries, and additional infections in the hospital. These issues are ongoing. I spoke to a man whose wife was taken to hospital and stayed overnight on a trolley in the emergency department while waiting to get a bed. That is the normal experience of so many people because the staff are not there to provide the service.

On 8 February 2023, the Irish Medical Organisation warned that the ongoing capacity crisis in our health system is directly leading to sustained and critical risks to both patients and healthcare staff on a daily basis. Everybody else except the Minister cannot be wrong. We seem to be hearing everyone other than the Minister - all of those who have experience of being in hospital, all of those working in hospitals and every professional body that represents staff in hospitals - saying there is a crisis and a huge problem with understaffing. When the Minister comes into this Chamber, however, he tells us that there is no real problem, that we have recruited more staff than we have before, and that there are little bits of teething problems but everything is okay. That is not the case. The experience of people is that we have a crisis and we need to deal with that crisis.

The crisis expands beyond the emergency departments and into all aspects of our hospitals. There are huge problems due to the staffing crisis in our mental health services, in particular. Child and adolescent mental health services, CAMHS, are under huge pressure, as are adult mental health services. I know of a case involving a man who has been a mental health patient for many years. He was suicidal and had to go to an accident and emergency department because there is no emergency service in mental health services. This serious problem needs to be dealt with across the country.

We also have problems with diagnostics. Diagnostics in most of our hospitals are working on a 9 a.m. to 5 p.m. basis. That is not appropriate when we have hospitals open 24-7. They should have a 24-7 diagnostic service. What happens outside of the hours from 9 a.m. to 5 p.m. is that people come in on emergency calls and it simply does not work.

The reality for the vast majority of people out there is that the system is broken. The Minister needs to acknowledge that rather than telling us stories about how great things are.

Mark Ward (Dublin Mid West, Sinn Fein)
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It will be no surprise to the Minister of State that I will talk about children's mental health, the crisis in children's mental health services and the false promises made by the Government. In May 2022, 11 crucial CAMHS beds were closed in Linn Dara. The Minister of State with responsibility for mental health and the then Taoiseach said that they would be reopened in September 2022. We are now in March 2023 and there is no sign of these beds being reopened. These were more false promises. There is an impact due to this. Because children are not getting the care they need, when they need it and where they need it, they are more likely to need the acute services or CAMHS. Of the 11,000 children who are waiting for primary care psychology services, 4,000 have been waiting for over one year to get a psychology appointment. In addition, 5,000 children are waiting for an initial assessment with CAMHS, and that has not been delivered either. Only 75% of beds in CAMHS are in operation.

Last year, 741 children went to accident and emergency departments with mental health issues because they could not get the care they needed, where they needed it and when they needed it.

Deputy Higgins talked about her constituency and community; it is also my community. I sometimes think we live in a parallel universe when I hear what is going on. I refer to the issues around primary care centres. There are none in Rowlagh or Lucan. There is not one in the whole of Dublin Mid-West. The lack of access to GPs and general health care, as well as the lack of access to housing for healthcare professionals, have happened under Fine Gael's watch. There have been 12 years of Fine Gael in government. The Minister cannot point out all the problems and say, "It is not our fault." when it absolutely is. It is time the Government got its act together because the people of Dublin Mid-West do not forget.

Verona Murphy (Wexford, Independent)
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I want to take this opportunity to praise Wexford General Hospital and all those involved in dealing with its recent fire and the very successful evacuation from the fire service to the volunteers, the staff, the management and everybody else. There were two firemen who worked on the blaze for 20 minutes and they did a stellar job. Organisations have fire plans and procedures in place but we often do not expect them to be needed. The response was swift and everyone involved put their shoulder to the wheel to evacuate the hospital and ensure the people inside were led to safety. I am sure all the patients and their families will be very appreciative of the work that went on to ensure there were no casualties.

Those involved included the nurses, doctors and other staff of the hospital, all the emergency services and, in particular, the members of the fire service, who did remarkably well considering a lot of their manpower were attending a car accident in another part of the county when the fire broke out at the hospital. Those who helped to assist the firefighters deserve special mention and their actions most likely helped to prevent the fire spreading further.

While the focus might be on the fire-damaged building, it is also an appropriate opportunity for the Government to review fire services and identify ways in which they can be better supported and brought into the modern-day realm. There are inquiries and investigations into how this fire occurred and I hope those involved are successful in establishing the cause, with a view to ensuring that a similar incident never happens again.

One of the consequences of this fire is the extra pressure it has brought to bear on University Hospital Waterford. Our emergency departments are under pressure at the best of times and, therefore, the additional pressure of having one hospital temporarily out of action will be felt by all of those working on the front line. We must recognise the way in which staff of other hospitals contributed to the emergency response in accommodating people who had to be evacuated from Wexford. We must ensure action is swift in order that Wexford General Hospital is back operating bigger and better than before.

Only a few days before the blaze at the hospital, during a sitting of the Committee of Public Accounts, I received confirmation from Department of Health officials that they had not yet received a proposal for the 97-bed ward block for Wexford General Hospital. I was told the proposal was still being reviewed by the hospital group, as part of the HSE. This is the type of process that can be drawn out and where cans get indefinitely kicked down a long road. In light of recent events and the current circumstances, there will be a need to repair and rebuild this hospital in Wexford. It would be worth not just investigating but joining the dots with regard to maximising the beneficial use of taxpayers’ money through the adding of the 97-bed unit while the restorative works are going on. That is the ask of the management of Wexford General Hospital, the people of Wexford and the CHO 5 area while Wexford hospital is out of commission. It has gone from 235 beds to 123 and although all he staff are prepared to pull their weight and be drafted to other hospitals, that is not ideal and it means their work environment will not be as familiar as it should be. Wexford hospital badly needs to have its emergency department back up and functioning fully. According to Dr. Yousif, who is the assistant director, it appears that we are at least six months away from that, but those six months could be spent planning for the 97-bed unit. It makes sense. It was to go ahead, according to the Minister of State, Deputy James Browne, so it is in the offing.

We met the hospital team last week and they say they are ready to go tomorrow with the planning proposal, if it is needed. I ask the Government today, on behalf of the people of Wexford, that staffing levels be met but also that the bed numbers be secured in the emergency department and in the rest of the hospital. The significance of the 97-bed unit is that we would have 47 extra beds if that unit was in situ. This is a hospital that came under huge pressure during Covid and last winter, and the staff have done very well to maintain the level of care. The pressure on staff in Wexford is quite well catered for by management. The manager of the hospital, Enda O'Leary, is a former HR manager. There are staffing level issues in every other healthcare setting, from primary care to children's disability network teams to CAMHS, but the hospital itself is well managed.

The most important thing happening in Wexford today is the restoration of the emergency department. I ask that the Minister of State, Deputy Naughton, as Chief Whip, arrange a meeting with the Minister for Health to cater for the public representatives of Wexford to discuss bringing forward the 97-bed unit.

Bernard Durkan (Kildare North, Fine Gael)
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I am happy to have an opportunity to comment on this important issue, which affects everybody. The standard of safety and services in our hospital facilities is all-important from the point of view of the public and particularly from the point of view of staff in situations where they may be threatened, attacked, assaulted or whatever the case may be. That is completely intolerable. It is a disgraceful situation when people are doing their work, as they do all of the time, and find they do so with the threat of violence.

I happen to have had a sojourn in one of our major hospitals in the past few weeks, which was an emergency admission as it happened, and that is the place to go if in need of emergency services. My views of the situation as presented are totally at variance with the kind of message I am getting across the floor of the House. The hospital was efficient, effective and well run. There is no doubt the staff were busy and they were on the go all of the time, but that is the nature of the business, and that is the way it is. However, they were courteous and attentive to everybody throughout the accident and emergency department, and they attended assiduously to everybody when they came in. Some people were more seriously ill than others but the standard and quality of the service was second to none. We need to appreciate that and appreciate the kind of work that goes on, day in, day out, 24-7. The same people had to soldier on during Covid. Again and again, they were tested, and they did well.

On a point I have mentioned before in the House, we tend to denigrate the health services to an appalling extent, resulting, to my mind, in a huge drop in the morale of the staff. As we should know in this House, if somebody is being criticised all the time, it eventually punches through and it does not do any good. By all means, we have to bring to the attention of the authorities any shortcomings that we find, and we need to attend to them and ensure we have the best service possible.

I want to comment on the submission of one Opposition speaker regarding Fine Gael being ten years in government when the country was broke and there were no services, and so on and so forth. They should come into the real world, go back ten years and stand where this country was then, when the country was broke and there was nothing happening. People were in serious danger then and services were threatened everywhere. There were countries all over the world in a similar position at that time, and some of them went to the wall and are still there. Yet, somebody comes into the House from the Opposition side to lecture the Members who had responsibility at the time. It is true that Fine Gael and Labour at that time had to take the responsibility, which they did in a difficult time. Everybody else opted out and nobody wanted to deal with the situation. It was not there for them; they only wanted to comment on it. Taking responsibility is a different story, and that is what the Government of the day did. It was difficult and, of course, we paid a huge price for it; the Labour Party paid a huge price and Fine Gael paid a huge price. However, when I hear some people standing up and criticising the parties in government who took responsibility and stood up to the challenges that were put in front of them at that particular time, and pretending they in some way let the country and the people down, I reject that in its entirety.

I ask the people concerned to review themselves and to ask themselves what they were doing at that particular time. Were they assisting? Were they helping out? Did they make the sacrifices that everybody made? We do not know. At some point, one gets fed up listening to the same old tune. Let us give the health service a little bit of recognition for the job it does and will continue to do. As a public representative, I gained great insight from seeing what happened at all levels in the hospitals, including procedures. There had been a massive improvement in the quality of service and the degree to which staff attended to their duties compared with ten or 15 years ago. There had been a great improvement, as one would expect.

On the issue of health and safety insofar as nursing staff are concerned, I incidentally also had experience in that area. A member of the public kicked up a row, threatened members of staff and had to be restrained. However, gardaí and internal security were there. Nobody had to send for anybody. There was no panic. It was dealt with. There were people there to inform, restrain and encourage members of the public who wanted to impress on the staff that they needed to be recognised above and beyond anybody else and to ensure that hospital services were able to continue. Of course, there was a siren going for a good long time but, as I have said, it was dealt with. Nobody's health and safety, including that of the nurses and staff or patients, was in any way threatened because of the activities of one or two people who decided to take the running of the hospital upon themselves for that particular time.

The health services will face a bigger burden in the future than they face now. That is because the population of the country is increasing. We always hear that we have an aging population. I believe people are looking at me when they mention that. I am not so sure about that. However, the fact of the matter is that the proportion of our population comprising older people is not going up nearly as fast as the same proportion in populations across Europe because an awful lot of young people are returning to this country and a lot of young people are coming into this country. They are all taxpayers and contributing to the economy in a meaningful way. We need to recognise that they are part and parcel of the delivery of the services. Notwithstanding the increasing population, everybody contributes and will continue to do so. That is a positive thing and a very helpful sign for the future. Long may it continue.

The last point I will make is about the personal attention that patients expect when going to hospital, depending on their degree of vulnerability. I had first sight of really horrendous cases right throughout the ward on which I was. It was great to see the fortitude of the patients. They are there for a particular purpose. They need to be attended to and they were grateful for that attendance. At the same time, I was amazed at the extent to which some people continued to work. They were working on computers at the same time. The general attitude was that they should continue. Whatever job they were at, they continued, and they received the services as required.

Contrary to some of the points raised, although not by everybody, I believe that we need to pay great tribute to our health service workers now more than at any other time because they have been through the mill and they carried the can of responsibility, which was big, when they had to. The Cathaoirleach Gníomhach mentioned recent events at Wexford General Hospital. I believe everybody wanted the rescue efforts to fail. That is the impression I got. However, in actual fact, what happened was a credit to the health services. Everybody rowed in at the time that was required and did the job that had to be done. There was no need for anybody to point the finger at anyone at any time anywhere throughout the operation. It was done effectively and efficiently and was a credit to the delivery of health services. If the Cathaoirleach Gníomhach wants me to go on for another two minutes, I will.

Verona Murphy (Wexford, Independent)
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No, the Deputy may please himself.

Bernard Durkan (Kildare North, Fine Gael)
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I will go on if the Cathaoirleach Gníomhach encourages me.

Verona Murphy (Wexford, Independent)
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Not at all.

Bernard Durkan (Kildare North, Fine Gael)
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In any event, that sums up what I had to say.

Verona Murphy (Wexford, Independent)
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Before I call Deputy Connolly, I note that we have some esteemed veterans of the United Nations with us in the Gallery. Deputy Ward's dad is with us. They are quite welcome. I thank them for a service well provided. I call Deputy Connolly of the Independent Group. Is she sharing time?

Catherine Connolly (Galway West, Independent)
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No, and this may be one of the rare occasions when the Cathaoirleach Gníomhach has a problem keeping me to time because I have just listened to Deputy Durkan and, while I have great respect for him, I do not have respect for what he has just articulated over his nine minutes in this Dáil. It is both dangerous and disingenuous to say that Opposition Deputies are the cause of the low morale among staff.

Bernard Durkan (Kildare North, Fine Gael)
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I did not say that.

Catherine Connolly (Galway West, Independent)
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It is just-----

Bernard Durkan (Kildare North, Fine Gael)
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On a point of order, I did not say that.

Verona Murphy (Wexford, Independent)
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That is not a point of order.

Catherine Connolly (Galway West, Independent)
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Could we stop the clock?

Bernard Durkan (Kildare North, Fine Gael)
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Deputy Connolly knows that and so should the Cathaoirleach Gníomhach.

Verona Murphy (Wexford, Independent)
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Deputy Durkan was not interrupted.

Bernard Durkan (Kildare North, Fine Gael)
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I was not interrupted but I did not accuse anybody; I made a general reference.

Verona Murphy (Wexford, Independent)
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Deputy Connolly is entitled to her speech.

Bernard Durkan (Kildare North, Fine Gael)
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No. I am not putting up with that kind of nonsense. I did not say that.

Verona Murphy (Wexford, Independent)
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Excuse me. I am in the Chair.

Bernard Durkan (Kildare North, Fine Gael)
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Fine.

Verona Murphy (Wexford, Independent)
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Deputy Connolly is going to make her speech. I ask Deputy Durkan not to interrupt.

Bernard Durkan (Kildare North, Fine Gael)
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The allegation was against me.

Verona Murphy (Wexford, Independent)
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The Deputy can address the allegation at another time, not now on the floor.

Bernard Durkan (Kildare North, Fine Gael)
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When am I going to do it?

Verona Murphy (Wexford, Independent)
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The Deputy's time is up.

Catherine Connolly (Galway West, Independent)
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I have already lost about ten seconds.

Verona Murphy (Wexford, Independent)
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The Deputy is all right. She is well ahead of time.

Catherine Connolly (Galway West, Independent)
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I appreciate that the clock was stopped. Let me put this in context. Yesterday, I praised the Minister for his efforts with regard to the consultant contracts and other matters. Today, I am not inclined to praise him because I have listened to and read his speech. I know it is no longer politically correct to say that you would sell oil to a certain group of people but he certainly would sell oil to a certain group that produces oil with what he has set out here in his four pages. He has given no context whatsoever. I advise Deputy Durkan that the daily numbers of people waiting for beds on Tuesday, Wednesday and Thursday of this week have been among the highest so far this year. On Tuesday, 21 March, the number was the third highest. Of that 665 people waiting for a bed, 56 were in Galway. As Dr. Hickey of Sligo University Hospital has not only told us, but continuously tells us, more than 300 people, at the very least, die every year as a direct result of the time they spent on trolleys.

On 17 February, the INMO sanctioned a campaign of industrial action in pursuance of safe staffing levels and that process is ongoing. Staffing levels in our hospitals are not safe. On top of that, one third of nursing posts in St. James's Hospital are unfilled because nurses cannot afford to live in Dublin any more. That is only an example; this is repeated in lots of other places, particularly in Dublin and Galway. We have extraordinary waiting lists. If I may be parochial, I will refer to Galway, first in the context of safety. Back in 2021, a HIQA report told us that the situation in Galway was an accident waiting to happen. It warned the hospital of a series of breaches of law, including at its temporary emergency department. As the Minister of State well knows, we now have another emergency department, which cost €60 million. I welcome that. I was there myself, although not for me personally, but for somebody close to me, and I can only praise it. I can only praise the staff for their extraordinary fortitude - to use Deputy Durkan's word - in persisting in a situation that is unsafe and downright dangerous. The low morale of the staff is a result of the conditions they have had to work with, the failure of the HSE to retain staff, the Department of Health's policies and so on. We are never going to change this system if we persist with a narrative that this problem exists because we speak out on it. That is utterly unacceptable.

I will refer to the waiting list for orthopaedic treatment in Galway. It should be remembered that two theatres were closed in Galway over two or three years. The delay was inexplicable and the orthopaedic list went out of all proportion. A total of 7,092 adults and 1,438 children have been waiting on that list for more than 18 months. They are the damning statistics I could go on to cover.

The spending review carried out only recently, in 2022, gave an overview of hospital performance for the years 2017 to 2021. The emergency department waiting time performance was persistent across years. They are the types of statistics I am looking at. I then ask how this happened.

This happened, just like the housing crisis, as a direct result of Government policies and the privatisation and commodification of our health service.

In 2010, almost 13 years ago, the World Health Organization raised a red alert with regard to retention problems. It specifically asked for countries to zone in on the problems with retaining nurses and medical professionals because we were relying on workers from other countries coming here and depriving their home countries of their services as a result.

I refer to the situation in respect of medical students. According to an article in The Irish Times, almost half of all medical students, who pay on average €56,000 in college fees, move away after graduating. Irish graduates are moving away. One survey in Sligo found that of 77 medical students who graduated from UCC in 2021, 62 are working in Australia.

What is happening with our public health service? We have privatised and commodified it, while financing a private system. We have failed to learn from Covid. We have failed to have safe infection policies in Galway. I received an email about the level of Covid in Galway. I understand that Covid is endemic, but there are no single rooms in the hospital in Galway. According to the emails I am getting in relation to people suffering from Covid, infecting others with it or contracting it in the hospital, we seem to have learned very little.

There is still no timeline for the planning application relating to the accident and emergency department in Galway. It would have been quicker to go ahead with the brand new hospital in Merlin Park, which was the choice made in the context of the options appraisal. That was changed two years later in order to keep developing the hospital in Galway out of all proportion. There are many other issues.

The Minister of State, Deputy Hildegarde Naughton, is in the right place when it comes to the health service. She will be familiar with many of the matters to which I refer. They did not happen by accident; they did not happen overnight. They happened as a direct result of Fine Gael and Fianna Fáil policies over a long period that put an emphasis on private medicine.

I praised the Minister last night regarding the new contracts with the consultants, which have not been finalised. It is most ironic that at the time when we move to make public hospitals for public patients, we are, by stealth, privatising primary care centres. Galway will have a primary care centre funded completely by two private companies. The HSE will lease these back, and we cannot be given any details of what will be involved. As for why that is the case, we are told it is a commercially sensitive matter, etc. That is ironic.

Hildegarde Naughton (Galway West, Fine Gael)
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I know that every Deputy in this House wants to ensure that our hospitals are staffed in a safe manner. Debates like this are important because they give us the opportunity to reflect on issues affecting the hospital sector. This debate has given us a very valuable opportunity to discuss what are, without doubt, extremely important matters when it comes to ensuring that our hospitals are safely staffed.

I take this opportunity to recognise the remarkable work of the staff in our health service, including those who have been there for many years and those more recently recruited under the initiatives mentioned. I commend these staff on their dedication, professionalism and commitment to delivering health services to patients. We will continue to invest in our workforce, we will continue to grow it and we will continue to provide to the members of our workforce additional opportunities for learning and advancement. Many of the issues discussed today are being prioritised in terms of the reviews, including those relating to safe staffing levels and ongoing recruitment and retention across our healthcare services. As the Minister indicated, the Government's objective is to ensure that patients get the best care possible through providing safe levels of staff in our hospitals. Implementation of the Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Ireland is a priority in this regard. It is acknowledged that there have been some challenges with implementation of the framework in hospitals. In order to overcome these challenges, a revised governance structure was put in place in November 2022. The Department of Health is represented on the oversight group established under the latter.

The Minister spoke about the first two phases of the safe staff nursing and skill mix framework. Phase 1 deals with general and specialist medical and surgical care settings and phase 2 deals with adult emergency care settings. I want to update the House on progress in respect of phase 3, which comprises three distinct care settings. Implementation of the framework has commenced in long-term residential care settings for older persons and will commence later this year in community care settings. Implementation in step-down rehabilitation settings will then follow.

Legislation is sometimes cited as a solution to the problem of staffing shortages, but very few countries have implemented this as a solution. Of those that have passed legislation, some are struggling to implement it. Two of the main aims of introducing legislation for nurse staffing levels would be to promote patient safety and improve working conditions for nursing staff. The Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Ireland incorporates these principles and goes beyond them to include improving quality of care. Internationally, there is limited evidence available which would justify the need to introduce legislation for safe staffing, whether as an effective solution to addressing recruitment and retention of nurses or otherwise. Recent evidence from the UK relating to tools and systems to determine nurse staffing requirements shows that there are no superior patient classification systems. Instead, the use of measurement tools that are endorsed by the UK's National Institute for Health and Care Excellence, NICE, was recommended. The patient acuity system, which has been used in Ireland for many years, is in line with this NICE recommendation. From the evidence we have, safe staffing policies, such as those used in Ireland, result in more registered nurses at the bedside and these policies have a clear and positive impact on patient and nursing staff outcomes.

Reforming our health and social care services is critical for the services we are delivering today and for the care needs of the next generation. Our ambition is universal healthcare. What this means for people is that when they need healthcare, they will be able to access it quickly, it will be of consistently high quality and it will be free or affordable. A significant programme of ongoing reform is under way and is making progress. This Government's aim is to make our health service one of the most attractive places around the world for healthcare professionals.

I will now speak about some of the improvements that have been delivered in the acute hospital sector and that have made a real difference to patients. This is despite the significant challenges faced in 2022 due to Covid-19 surges, pressure on emergency departments and other operational factors, including problems hiring staff. Some 1.56 million patients were removed from waiting lists, a further 1.53 million patients were added, there was a net reduction of 30,000 men, women and children in the numbers on the lists and the number of patients exceeding the maximum wait times in the 2017 Oireachtas Sláintecare report decreased by 11% and, since pandemic peaks, 24%.

The Government continues to invest in order to reduce the amount of time people are waiting for important hospital appointments and procedures. In 2022, some €350 million was allocated to the HSE and the National Treatment Purchase Fund to primarily provide additional public and private activity to further stabilise and reduce scheduled care waiting lists and waiting times in tandem with bringing forward much-needed longer-term reforms. For 2023, this investment has increased to €363 million. Some €123 million funding was allocated to the HSE in budget 2023. This will be made available on a recurring basis to ensure the reforms deliver sustained reductions in waiting lists and ensure we achieve the strategic Sláintecare maximum wait time targets. The Government has invested record sums in our health service. This has been used to boost permanent capacity, which is key to helping us tackle our waiting lists. Our workforce has grown by over 18,000 - doctors, nurses, midwives and therapists - since the beginning of 2020.

The Government takes the issues raised in respect of safe staffing levels in hospitals very seriously. I thank Members for their valuable contributions. We will reflect closely on Members' contributions. Many of the issues highlighted are already being addressed by means of our programme for Government commitments, our national policies and strategies and through the HSE's national service plan. We have achieved much in recent years through new developments and improvements to existing services.