Dáil debates

Wednesday, 20 March 2024

General Practice and Local Health Services: Motion


7:15 pm

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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I call Deputy Cullinane to move the motion. He is sharing time with his colleagues and has 20 minutes.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I think I have five minutes. Is that correct?

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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You have as long as you like. It is up to Sinn Féin.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I move:

That Dáil Éireann:

acknowledges that:
— the survey of the career intentions of graduates of the four-year General Practice training programme, carried out by the Irish College of General Practitioners in mid-2023, showed that over two thirds (78.4 per cent) of recent graduates saw their future career in Ireland;

— General Practice is a vital part of our health service and needs to be supported and developed to ensure that patients have alternative care pathways to hospitals and Emergency Departments; and

— pharmacies can play an important role in ensuring patients get the right care, in the right place, at the right time;
notes that:
— many areas are experiencing difficulties in General Practitioner (GP) capacity, and this is leading to longer wait times;

— not all trainee GPs want to pursue independent practice and there is a role for directly hired GPs;

— the current GP contract is archaic and needs to be modernised to reflect the changing nature of General Practice and the need to expand multi-disciplinary Primary Care Teams; and

— pharmacies need to be supported to take pressure away from busy General Practice surgeries; and
calls on the Government to:
— establish a multi-disciplinary Working Group on the Development of Primary Care, with relevant stakeholder professions to guide strategic investment and deepen collaboration;

— increase the number of undergraduate, postgraduate and advanced specialist practice training places for Primary Care professions;

— develop a new public contract for GPs and launch a pilot programme in areas where there is a shortage of GPs for out of hours services and leave cover;

— increase the use of nursing and advanced practice therapy grades across Primary Care services; and

— invest in a "Pharmacy First" approach to minor ailments and move appropriate care from Primary Care practices to community pharmacies.

The purpose of the motion is to ensure that we provide the right care in the right place at the right time for patients. That was one of the core promises of Sláintecare. As I have said to the Minister for Health on a number of occasions, the problem we are having in our emergency departments, including again today across all our hospitals, not only in University Hospital Limerick, UHL, but in many of our major acute hospitals, is that we have had far too many patients on trolleys. We saw that again in the extraordinary numbers that were published today by the Irish Nurses and Midwives Organisation, INMO. Part of the reason is that we do not have the capacity in hospitals - we do not have the beds or staff - and it is partly because of what is happening in the hospitals. However, it is also partly because of what is happening outside the hospitals. Anyone who works in emergency medicine or any specialist who works in an emergency department will tell you far too many people end up going to an emergency department because they do not have any other option. The alternative care pathways are simply not there. If we are serious about really challenging, solving and addressing the unacceptable trolley crisis, we have to put more capacity into hospitals, but we also have to make sure people can access the right care in the right place at the right time and that is in primary and community care settings.

Much has been made in recent times - the Minister of State will have seen the commentary around it - of older patients being transferred out of hospitals. The difficulty is that many hospital managers do not have the option to transfer some patients safely because the step-down beds, recovery beds and convalescence beds are not there. We need more capacity in the community. Another big part of the problem, which is the substance of our motion, is that more and more people are waiting longer to see a GP. I attended a public meeting in Cahersiveen in County Kerry a few weeks ago. It was an area with Waterville in Kerry that had six GPs a few years ago. It now has two GPs of whom one is a locum. The other, a full-time independent GP who works there, will retire some time during the summer so the whole area of Waterville and Cahersiveen will be left with one GP. There is real concern among the population there, which has also increased in recent years, that people will be waiting much longer to see a GP. That is just one example. We can give many examples of that, not only in rural areas but also in urban areas.

We also are not making the best use of community pharmacists. I welcome that there have been some positive changes in this area in recent times. For example, pharmacists now have the ability to hold on to a prescription and extend it for a specified time without the person having to go back to a GP. That is for the good, but I have been calling for a pharmacy first model for some time that would allow pharmacies to manage and deal with minor ailments and be able to make prescriptions and better support general practice to take pressure off GPs and our hospitals.

The Government is not opposing the motion. I assume and hope this is because it agrees in principle with many of the recommendations made in the motion. It is time for the State to look at directly hired, salaried GPs. I have talked to a lot of young people who are in training colleges and want to be GPs. Some of them will want an independent practice and that is fair enough. Some of them do not, because they would end up being entrepreneurs and running busy practices which is not what they want to do. They want to be able to treat patients. In those circumstances, we could give them the opportunity to work for the State out of HSE centres and, in some cases, out of emergency departments, where that is necessary and would add value, and to provide locum and out-of-hours support. There is a whole range of options, but it is not something the Government has advanced or so far considered.

We have a crisis in general practice in some areas. We are not making enough use of community pharmacists and we do not have the care in the community, either in primary or community care, to manage older people or people with chronic conditions to the extent we should. All of that is lending itself to more and more people ending up going into emergency departments through no fault of their own because the alternative care pathways are not there. The recommendations we are putting forward with respect to general practice, community pharmacy, primary and community care are about making sure patients not only have options but also get the right care. This is also a big part of solving the problems in emergency departments and patients being on hospital trolleys. I thank the Government for supporting the motion. I want it to implement the recommendations contained in it.

Photo of Pearse DohertyPearse Doherty (Donegal, Sinn Fein)
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Every day, dedicated healthcare staff do their best to serve patients in their communities, but we can all agree that our health system is under increased pressure and unprecedented strain. This includes local services that are facing workforce shortages and infrastructure deficits. These problems are not isolated or contained. A lack of alternative and primary care options in our communities feeds through the entire healthcare system. It adds pressure to the emergency departments in our hospitals and ultimately leads to longer lists and waiting times for patients and difficult conditions for healthcare staff.

The recent budget from this Government was a disaster for the healthcare service. It was an act of deliberately underfunding our health service, calling into question its ability to even stand still, never mind to improve access to care and capacity. Remember, the CEO of the HSE himself warned the Government that the budget provided for the health service could not be delivered without significant and punitive risks to the public. That is exactly what has happened. I have seen too many instances where decisions made by the Government have caused our communities to be underserved, put untold pressure on our healthcare staff and short-changed our patients. That needs to end.

At the beginning of this year, my office was in contact with a woman who was pregnant and in distress. She was from south Donegal. She was told she needed a GP referral in order to be seen by a doctor in the maternity departments in Sligo University Hospital or Letterkenny University Hospital. However, GP practice after GP practice in south Donegal told her the same thing. They were full, at capacity, and could not add her to their books. That is the pressure GPs were under and as a result she was unable to be seen by a doctor in either maternity ward. A pregnant woman could not be seen in a hospital. It is a truly shocking state of affairs which speaks to the pressure local health services are under. After contacting the HSE and after a long wait, the lady in question thankfully now has access to a GP, but that problem should not have arisen. We are talking about the year 2024. As a rich country with billions of euro of surpluses, we are coming up short time and again on the basics, such as access to a local GP. Our communities deserve much better and Sinn Féin has a plan to improve our health service. We have practical and realistic goals that can be delivered.

That is why this Private Members' motion should be not just supported but actually implemented.

7:25 pm

Photo of Kathleen FunchionKathleen Funchion (Carlow-Kilkenny, Sinn Fein)
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I am delighted to get the chance to speak on this motion because I find increasingly that people who cannot access a GP are calling in to us. In many cases, they have been living abroad or in another part of the country and when they come home they find it impossible to access a GP. In one recent case, a person with a very serious condition who had been living in England for a long period had to come home for health reasons and then could not access a GP. Similar to the story Deputy Doherty told, they then cannot get into the hospital-based consultant service they need because everything is based on a GP referral. We know that often when people cannot access a GP they present at the emergency room. Obviously this puts pressure on that system. To be fair to people, in certain cases they do not know what else to do. Particularly in the case of a sick child, nobody is going to take any chances. It is a vicious circle effect. One of the key issues raised in the motion relates to the pharmacy first approach. We need to explore this much more because there are so many services that our pharmacists could offer. We underutilise the pharmacy service. Many people have built up a good and strong relationship with their local pharmacist. I hear that people often go to their pharmacist because they cannot get to see a GP. This puts the pharmacist in a difficult position at times. However, people really are getting desperate. It is difficult to understand that we are talking about people accessing basic healthcare, such as a GP service, but it is becoming a huge problem.

The motion also proposes some good solutions in relation to community and nursing home beds. For decades, we provided great convalescent services in this country but we have seen those dwindle in recent years. That is one of the reasons so many people get stuck in the hospital system. While I am glad to hear the Government is supporting the motion, we need to see these measures implemented.

Photo of Pádraig Mac LochlainnPádraig Mac Lochlainn (Donegal, Sinn Fein)
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I am going to raise an issue with the Minister of State, Deputy Butler. She will have been requested to meet the community in Carndonagh, County Donegal, which has lost day services in the community hospital. It is unacceptable that, rather than upgrade the facilities, the hospital has been relocated, causing serious dismay. There was a packed public meeting in recent times. On a cross-party basis we ask the Minister of State to meet the community group and find a solution. Deputy David Cullinane, who drafted this motion, has rightly put all of the services together, be it GP, pharmacy or community primary services, as a solution to what we are seeing. The scale of this surpasses anything I have seen in all my time in politics. The Minister of State will know this. So many people cannot get a face-to-face appointment with their GP. They are struggling to get one. There are people who cannot register with a GP service in their local community. I can only speak with authority about north Donegal where our constituents are telling us they just cannot get an appointment. There is huge frustration. There is no doubt the capacity is not there. We need to lean on community services. We have a very strong pharmacy service in Donegal. We need to lean on that. That is why I am grateful to our health spokesperson, Deputy Cullinane, for putting this motion together. I have given the case of day services in Carndonagh but respite and community services are just not available in County Donegal. Every time we go to the HSE we hear the Department and lack of capital being blamed for this. We need a plan to back up our community services and resource community hospitals and pharmacies. We have these new primary care centres, which are lovely, but we are not seeing substantive delivery on the ground. People are still reporting a challenge in accessing care. I hope to see improvement on the back of this motion.

Photo of Patricia RyanPatricia Ryan (Kildare South, Sinn Fein)
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I thank my colleague, Deputy Cullinane, for introducing this important motion and giving me an opportunity to raise the issue of serious pressures on GPs in my constituency. After more than a decade of chronic underfunding by successive Fine Gael- and Fianna Fáil-led Governments, local GP and healthcare services are creaking at the seams. We have staff shortages, increased workload, longer waiting times, insufficient alternative community care - the list goes on and on. The 2024 budget was a travesty. Services cannot run properly when the funding provided is not even enough to maintain an already overwhelmed service level. Providing no new funding literally rubs salt in the wound. Recruitment embargoes tell trainees and graduates not to bother staying. We are exporting our best and brightest. If this Government did its job properly, we would have proper funding and the health service would function properly. We all deserve a universal healthcare service.

Older people in rural communities such as my constituency of Kildare South deserve better. The Minister of State and I meet older people every day. We deal with them all the time. The Minister of State knows, as I do, that if people cannot access a GP, their health gets worse and if they end up on a trolley, their chance of recovery is far less. I ask the Minister of State to look into that. The healthcare needs of local communities have been ignored by the Government for far too long. County Kildare cannot wait any longer. Sinn Féin's plan is the way forward. The Government must step up to the plate by developing a public contract for GPs in order to address the shortage of GPs. It must lift the recruitment embargoes and double the recruitment target to keep our graduates here in order to provide the primary care that we need so badly.

Photo of Maurice QuinlivanMaurice Quinlivan (Limerick City, Sinn Fein)
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Local health services throughout the State have come under severe pressure due to workforce shortages, challenging working conditions, growing waiting lists and excessively long wait times. This impacts staff morale and undermines confidence in the health service. Local health services and GP services need to be improved as a priority. The lack of alternative care options in the community is placing further strain on our hospitals and their emergency departments. Nowhere is this more evident than at Limerick’s main hospital, University Hospital Limerick, a hospital in perennial crisis with its full capacity protocol in use almost all the time. Surgeries and outpatients’ appointments get delayed as the hard-working staff try to cope with the high number of presentations. Subsequently, people are treated on hospital trolleys and in hospital corridors. Already in March, 1,300 people have been left on trolleys at UHL. So far this year, 5,620 people have been left on trolleys. This is a national scandal. It is important to remember that each of these people has been assessed and deemed to be in need of a bed, yet no bed is available.

This motion calls for the establishment of a working group on the development of primary care, which much be a priority. The group would not be starting with a blank page. There are some examples of how care outside the hospital can be successful. One is the pathfinder programme, which has been rolled out in a number of counties, including my own, County Limerick. It is successful in triaging patients and in many cases avoiding emergency department presentations. The pathfinder teams respond to low-acuity 999 calls from people aged over 65. With pathfinder, the citizen is assessed in his or her home by a paramedic and others. It is a service that should be greatly expanded, not reduced. The HSE provided statistics that show it can make an impact. In the first eight months of 2023, some 2,874 ambulance calls were referred to the pathfinder teams. Of these patients, 42% were able to stay at home where they availed of alternative pathways of care, rather than going to hospital. In the mid-west region, between April and September 2023, 188 patients were assessed by these teams, 47% of whom were supported at home, avoiding an emergency department presentation. Expanding such services can make a critical difference but such an expansion needs to be matched by an increase in the number of nursing home beds and community care. I welcome the motion.

Photo of Mairead FarrellMairead Farrell (Galway West, Sinn Fein)
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The need for the provision of properly resourced healthcare at community level is clear. The ongoing crisis in our hospitals emphasises the importance of care being available to people at a community level to help relieve pressure on the emergency departments. Part of the plan to strengthen community care is the concept of primary care centres which would support the provision of a range of services in the local community. The roll-out of primary care centres in Galway west has been painfully slow. In 2014, the HSE advertised for expressions of interest for a primary care centre site in Moycullen. It opened nine years later, in 2023. In 2019, the HSE advertised for expressions of interest for primary care centres in Oughterard agus An Spidéal. I am informed that process had to be reset and there will be a new call shortly. There is currently no plan to develop badly needed primary care centres farther west in Connemara. The consistent failure to invest in primary and community care in a timely manner places a major burden on our hospital system. The lack of progress in developing the primary care centres in An Spidéal and Oughterard is disappointing and frustrating. More worryingly, the primary care centres mapped in the accommodation needs assessment for primary care teams 2011, which proposed a primary care centre for south Connemara to cover An Cheathrú Rua agus Ceantar na nOileán, are not currently on the list to be developed.

At a time when the health system is in crisis, we need to be developing and supporting more community-level health services in order that people are supported to stay living in their own homes and communities. These services have a real impact on people's lives. Although the opening of the primary care centre in Moycullen is welcome, the absence of progress in An Spidéal is disappointing. Most concerning of all is that there is no plan to develop the required primary care centres for the communities further west in Connemara.

I take this opportunity to raise the issue of Clifden hospital. I know the Minister of State is aware of the importance of the hospital and how far Clifden is from Galway city. Realistically, it takes between an hour and a half and two hours to travel from Clifden to the city. The Minister of State will be aware there was another public meeting in Clifden last week on the need to keep Clifden hospital open. The meeting was very well attended because the issue is important to local people. When the issue first came to light a year and a half ago, we were told there was not demand for Clifden hospital. Of course, the community told us a very different story. They told us how important the hospital is for the local community. Local doctors told us how important the hospital is. We were told the issues related to an industrial dispute but, again, the community and the people working there told us that was not the case. We were then told it was due to a recruitment issue. The Minister of State is aware of the importance of the hospital to the people of Clifden and Galway. We must do everything in our power not only to ensure the hospital remains open, but to heed the clear call from that public meeting to expand services at the hospital. The Minister of State is aware of the importance of this issue. We must do everything in our power to keep the hospital open.

7:35 pm

Photo of Mary ButlerMary Butler (Waterford, Fianna Fail)
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I welcome the opportunity to engage with colleagues on the important matter of the provision of primary care health services. Access to health services in the community is essential to people's well-being, with GPs usually acting as people's primary care providers and gatekeepers to the wider healthcare services. Treating patients as close to home as possible is beneficial for patients and for the wider health services as it reduces pressures on hospitals.

The programme for Government recognises the importance of expanding primary and community care. One important commitment is to strengthen general practice and increase the number of GPs working throughout the country to accomplish this. The Government has increased the attractiveness of working as a GP by significantly increasing investment in general practice in recent years. The 2019 agreement included more than €211 million in additional investment for general practice, providing for an almost 50% increase in capitation payment rates for GPs and a 10% increase in rural practice supports. Improvements to GP maternity and paternity leave arrangements were also made and a support for practices in urban areas of deprivation was introduced. The 2019 agreement also introduced the GP chronic disease management programme, which has since been fully rolled out, as committed to in the programme for Government. The programme helped GMS patients with chronic diseases to be cared for as close to home as possible, in GP clinics and community settings, and avoid the need for hospital attendance.

Separately, the 2023 GP agreement included a total financial package of €130 million. The agreement further enhanced capitation rates across various age groups and enhanced the payments for the provision of contraception services under the GMS scheme. The 2023 GP agreement also included measures specifically to support GP capacity, including €30 million to assist GPs to retain and recruit additional staff to meet patient demand.

The effect of these measures, which make working as a GP in Ireland more attractive, is reflected in the record number of 1,311 medical graduates who applied for GP training in 2024. The number of doctors entering GP training has been increased each year from 2019 by approximately 10%, rising to 286 places for new entrants in 2023. The Minister for Health, Deputy Donnelly, has engaged with the HSE and the ICGP to provide for a further increase of 22% on last year, to 350 places, for 2024.

The ICGP's recent graduate survey, to which reference is made in the motion, reports that retention of GP graduates is extremely high, with 96% of GPs surveyed who graduated between 2017 and 2022 found to be working in general practice in the State. As stated by the ICGP, the improved financial environment for general practice and the variety of career options has made general practice a very attractive career for graduates.

To increase GP numbers more rapidly, the Government has co-operated with the ICGP and the HSE to introduce the non-EU rural GP training programme. This programme recruited 112 non-EU GPs last year. The Government has provided funding to bring up to 250 more non-EU GPs to Ireland by the end of 2024. The programme targets the placement of GPs to rural and underserved areas, increasing access to services for these communities.

The enhanced community care, ECC, programme established in 2019 aims to improve patient care by delivering increased healthcare provision in the community and thereby also reducing dependency on the hospital system. Under the programme, care is reoriented towards general practice, primary care and community-based services to help enable an end-to-end home first care approach. The Government has allocated €195 million in recurring annual funding to the ECC programme for the establishment of 96 community healthcare networks, 30 community specialist teams for older people and 30 community specialist teams for chronic disease, as well as national coverage for community intervention teams and the development of a volunteer-type model in collaboration with the Alone charity. All 96 community healthcare networks are operational, as are 53 of the 60 specialist teams. In total, more than 2,800 staff have been onboarded, with 3,500 staff ultimately to be recruited into the ECC programme.

Since its commencement in January 2021, the GP access to community diagnostics programme has facilitated GPs to directly refer patients for radiology diagnostic scans at convenient locations in the community. The programme provided more than 339,000 directly referred scans in 2023. The Government has provided funding of €46.9 million in budget 2024 to continue the programme with full adult population access. Furthermore, we have provided funding of €22.7 million in the waiting list action plan 2023 for identified HSE community initiatives, with a focus on orthodontics, primary care child psychology, counselling in primary care, primary care therapies and CAMHS. Work is currently under way to develop a primary care waiting list management protocol to ensure a more consistent focus on understanding and addressing these waiting times.

The pharmacy task force established last year to support the expansion of the role of pharmacists is continuing its work. Expanding the role of pharmacists can help mitigate demand on other service providers and further move care into the community. The initial report of the expert task force was published last November and the first recommendation implemented from 1 March. The first recommendation empowered prescribers to write 12-month prescriptions for patients where clinically appropriate and following certain criteria. This reduces the demand on GPs and other prescribers for repeat prescribing. The task force is now focusing on recommendations regarding pharmacists prescribing within their scope of practice. A report with associated recommendations will be published by the Department of Health before the end of the second quarter.

The Government has taken measures to increase third level student places across health-related disciplines and thereby increase health workforce availability, including that for community services into the future. In collaboration with the third level sector, the Government has provided for more than 660 additional student places in medicine, nursing and midwifery, pharmacy and other key healthcare courses in the academic year 2023-24. This includes more than 220 student places across nursing and midwifery and allied health professional courses in Northern Ireland. Some 25 additional medical places are being made available for qualifying students from Ireland or Northern Ireland in Queen’s University Belfast in September 2024, with a further 25 places to be made available in September 2025. The number of doctors enrolled in training programmes has been increased by 25% in the past five years, with a 23% increase across basic specialist training intakes and a 26% increase across higher specialist training intakes. Some 13 higher education institutes are currently providing publicly funded undergraduate nurse and midwife education. For the 2023-24 year, an additional 259 undergraduate nurse and midwife student places were made available, resulting in an overall number of 2,332 available student places in first year of the programme across these HEls.

The Government has also invested heavily in advanced practice for nurses and midwives in line with the prioritisation of community care, including chronic disease management, older persons' care and waiting list management. Budget 2023 provided funding to recruit an additional 80 whole-time equivalent advanced nursing and midwifery practitioners during 2023. Some 69 of these have already been onboarded and further recruitment is planned for this year. As of January, there were 1,132 advanced nursing and midwifery practitioners working in the health service. These measures highlight the significant work of the Government to provide improved community healthcare and GP services.

While the GMS contract has been significantly updated through the recent GP agreement with the IMO, a strategic review of general practice is under way to examine the issues facing it and to set out the measures necessary to ensure a more sustainable general practice service. This will involve a further modernisation of general practice. The review is examining issues relating to capacity, out-of-hours care and e-health, among others. Particular consideration is being given to the suitability of salaried GP roles and mechanisms to attract GPs to underserved areas.

It is the Government's intention not to oppose the proposed motion. The Government fully recognises the important role of general practice and has provided significantly increased support for the provision of the GP services. The number of student places for health-related disciplines, including nursing, has been increased. The number of doctor training places, particularly GP training places, has also been greatly increased. Provision has been made to increase the number of advanced nursing and midwifery practitioners and consideration of how to further expand the role of pharmacists to provide community services is well under way. These measures show the Government's commitment to improving patient care at the local community level and the very real steps taken to that end.

7:45 pm

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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I thank the Minister of State very much for that comprehensive presentation.

Photo of Donnchadh Ó LaoghaireDonnchadh Ó Laoghaire (Cork South Central, Sinn Fein)
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Being able to access a GP is like having money in the bank. The security it offers a family is hard to overestimate. However, it is too often the case that people trying to find a new practice, perhaps having come to a new area, find it nigh on impossible to do so. Even if you are on a GP's books, it can be difficult to get an appointment. While it was not mentioned much in the Minister of State's contribution, this has implications for health. It has real implications for people. Very often, people do not rush into ringing the GP. They want to see whether they will be okay. However, a lot of the time now, people are worried that, if they do not ring straight away, they could be left waiting for days or weeks. I speak to GPs and they have a lot of concern about the future. When they look at the classes coming out of the universities, the Royal College of Surgeons in Ireland and all of the places that offer medical courses, they see effectively entire classes going to Australia and other places like that. In particular, there is great concern that rural areas, areas where a high proportion of people hold medical cards and working-class areas will not be adequately served. There is a real change needed. Far too few are choosing this course of action. It is a crucial piece of our infrastructure. I believe more can be done as regards pharmacies but we also need a strong GP infrastructure. Under this Government, the situation has deteriorated and people's confidence has been reduced.

I will make a final point on healthcare staff. The point has already been raised today about long Covid, nurses and their concerns about that scheme ending. I echo the concerns that have been expressed in that regard. Those staff worked very hard during the pandemic and are very concerned about what is coming next.

Photo of Johnny MythenJohnny Mythen (Wexford, Sinn Fein)
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I thank Deputy Cullinane, our spokesperson for health, for bringing forward this motion. The bottom line is that local health services are under severe strain and the situation is getting worse. People in my own constituency in Wexford, and particularly in rural areas of the county, are waiting for up to four weeks to get an appointment to see their doctor. That statement alone is shocking. Not alone is it a shocking truth, but it is neglect of the duty of care to our communities and those who require immediate medical attention.

The other area of major concern is the number of doctors retiring. It is reported that up to 25% are to retire within the next five years. This was well known and well flagged. Yet again, there was no advance thinking or planning on the part of this Government. Constituents have come to me in distress and tears because their local GP was retiring and they could not get another doctor to take them on. Medical card holders, many of whom are old age pensioners, are finding it impossible to find a replacement local GP. A growing number of people are contacting my office because they are entitled to a GP card but cannot be issued one because they cannot identify a doctor who will take them on. People's files and medical histories are in danger of being lost in the current failing system. This is a scandal. People are getting sicker. Their health is deteriorating because they cannot get timely access to a basic doctor's appointment while, at the same time, there is a forced ban on recruitment and retention. This makes no sense at all.

We are calling for an increase in the number of undergraduate and postgraduate places and for more places for primary care professionals, including in specialist practice care. The Minister needs to roll out directly-employed GPs, to increase primary care staffing in rural and disadvantaged communities and to review the current GP contracts, which are not fit for purpose. We need to ensure that the Government is supporting general practice, delivering a pharmacy-first model to relieve pressure on GPs, expanding multidisciplinary teams and providing more care in the community in general. The lack of alternative care options for our communities is putting more and more avoidable pressure on our acute hospitals and emergency departments. The Government has had four years to address the ever-growing waiting times for access to GP services but has failed to take every action available to it. I call on every TD, and especially every Wexford TD, to support this motion, which is much needed. I hope the electorate will get a chance to decide who the future Minister for Health will be sooner rather than later.

Photo of Pa DalyPa Daly (Kerry, Sinn Fein)
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There is no doubt that this motion is very relevant for the whole of the State but it is particularly relevant for County Kerry. The primary care facilities in Kerry, particularly in UHK, are under severe pressure. Before Christmas, there was a lot of talk about elective surgeries being cancelled for three days in Limerick. Elective surgeries in UHK have been postponed since 15 December last. There has been a lack of surge capacity in that hospital for years. Whenever there is a winter flu or the hospital comes under any other pressure, such as the Covid pandemic, it is the elective surgeries that are put back. However, it is totally unacceptable that they have been out of action for the last three months. Kerry is a county in which there is a high degree of isolation and many small towns and villages are struggling when it comes to recruiting and retaining GPs. Elective surgery services are being offered in Cork and Limerick. That is also totally inappropriate and is going to lead to suffering for other patients and a diminution of services in UHK.

Tough questions need to be asked. I have been speaking to staff and they have told me about the crucial points that must be addressed. Staff in the hospitals are concerned about the services. They are working very hard but see what is happening around them. Are there any plans to provide protected beds for elective surgeries? Even in UHL, which is rightly receiving attention, the interruption to surgery was only temporary. In Kerry, it seems to be semi-permanent. Some 100 new beds were promised in a previous review by HSE management but these plans have now been abandoned.

The solutions are there and this motion gives a good account of our stances and policy positions. We must free up GP appointments. There is no doubt but that the GP system is broken. All around the county, from Milltown to Ballyduff, I hear of GPs coming in but being asked to run a business. Supports and services should be put in place to attract GPs to rural areas.

Photo of Dessie EllisDessie Ellis (Dublin North West, Sinn Fein)
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My constituency of Dublin North-West has a large urban population of approximately 90,000 but it has a severe lack of medical facilities. This area has been neglected for many years and has been badly served when it comes to the provision of health services. For example, there has not been a single GP in the north and west of Finglas for more than 20 years. This alone should make the provision of a primary care centre all the more urgent. It has been more than a decade since Finglas was promised a primary care centre. A comprehensive study was carried out by the HSE and this identified an urgent need to deliver a primary care centre in the north and west of Finglas. Finglas was considered a top priority for the provision of a primary care centre yet areas such as Cabra and Blanchardstown had theirs built years ago. A new primary care centre is needed to deal with minor injuries and to provide social care, mental healthcare, GPs and other services for the local community.

One of the most pressing issues in my constituency is the assessment of children with autism and special needs and the delivery of supports for these children. The Minister of State knows that early intervention is crucial but children have been failed in this regard and many are waiting years before being properly assessed.

Many parents who come to my constituency office who have children who have been assessed are frustrated and in despair because they are finding it almost impossible to find school places for their children. These children are being left behind. Their parents have nowhere to turn. That is unacceptable. The Government needs to invest more in the provision of special needs assistants, child psychiatrists, specialised therapies and in an increase in the expertise available across the disability services, which is currently severely lacking.

7:55 pm

Photo of Matt CarthyMatt Carthy (Cavan-Monaghan, Sinn Fein)
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The crisis we are encountering is staggering. We see it every day when dealing with constituents who are just seeking to access the most basic healthcare services. What we are discussing first hit home with me a number of years ago when Fine Gael's health policies really started to impact. A family returned home to County Monaghan and contacted me to say they could not get a GP to take them on. It was the first time I became aware of just how bad the situation had become. I became aware of GPs working way beyond their desired retirement age. They were doing so because they believed they had an obligation to the community and understood what would happen if they were to retire suddenly. These GPs were picking up the slack for Government failures.

What we are discussing also hit home with me on many occasions when people tell me about the child who might have what is considered a minor cough. The parent has to ring their GP service every day as that cough becomes worse and as a virus or an infection takes hold. Then days or possibly weeks later the child needs treatment he or she would otherwise not have needed if he or she had had speedy access or if the local pharmacist was in a position to treat the child, which many pharmacists tell us they can do. We are dealing with a situation that is the result of the other crises within our health and disability services and that this Government is overseeing. Our GPs are burdened with a huge number of asks that should not necessarily be their responsibility. If disability services, mental health services and other services were working as they should be, GPs would not be burdened with producing referral after referral in the hope of progressing people's care.

Local services are challenged as a result of workforce shortages and the working conditions in which GPs are expected to operate. The root cause of this is a failure on the part of the Government to implement a vision. I am so grateful that Sinn Féin has a spokesperson for health in Deputy David Cullinane who has such a vision and that Sinn Féin has a plan to realise that vision to deliver the changes in our health services that are so badly needed and that this Government is clearly incapable of achieving.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Hear, hear.

Photo of Alan KellyAlan Kelly (Tipperary, Labour)
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I am glad the Minister of State, Deputy Mary Butler, is in the Chamber to take this motion. I thank Sinn Féin for bringing it forward.

The issues around general practice and primary care are obvious to anyone who is a public representative. The burden on GPs is so enormous that we need an all-encompassing contract for them whereby they would be provided with all the services they need. The stop-start, haphazard primary care roll-out needs to be dramatically changed as well, particularly in the context of the impact this has had on the overspend relating to the new national children's hospital.

The Minister of State will have no doubt about what I am going to talk about. I am going to talk about Nenagh community nursing home. I want the Minister of State to listen because I doubt I could be any more passionate about a particular matter. This issue is very close to my heart. I have been working on it for years. Many of my family members spent their final days in St. Conlon's Community Nursing Unit in Nenagh. There was major upset the weekend before last about the delay relating to the new unit. This is the new unit we got built, and for which I had sought funding in 2015. This is the unit for which we helped to get planning permission in 2019 beside the hospital. This is the state-of-the-art unit on which we spent €23 million and which I campaigned to have opened. I campaigned to get the unit opened in order that the people of Nenagh and surround areas would have access to this 50-bed unit.

Almost 14 years ago, HIQA stated that the building in which St. Conlon's is located was not fit for purpose. There are fantastic staff and a fantastic manager, Elaine Flynn, there, but the building is not fit for purpose. They were excited about moving to the new unit. The residents and their families in particular were excited about moving. Just under two weeks ago, we had a situation whereby, on social media, Deputy Lowry announced what was going on and Deputy Cahill indicated that he had gone to the Minister and asked for him to intervene. I find that incredible. This is how the residents, the staff, the public and I found out about what is happening. It cannot be allowed to happen.

The Minister of State has responsibility for older people. I admired her when she spoke up on the issue of the fair deal, and I believe she was right. I know all about dementia and its impact on people. I know all about the decision-making that is necessary and the consequential issues that can arise. I want the Minister of State to do something that I believe she can do. I hope she will see sense. Some €23 million of taxpayers' money has been spent on this project. We all know that what is going on at University Hospital Limerick is a disaster. I have all the figures in that regard. I have been on about this for more than a decade. Reconfiguration never happened.

On the Thursday before last, Bernard Gloster stated that the HSE was going to do three things, namely: have medical assessment units open at St. John's in Ennis and in Nenagh for 24 hours, which is a brilliant idea if they can get the staff; have profiling at the point of entry to the accident and emergency department in University Hospital Limerick to discover why people had or had not gone to their GPs - a heat-mapping measure for which I have been calling for years; and reprofiling of the 96 beds versus the Nightingale wards to create more beds. I agree 100% with all three of those measures. We then have this bombshell about a delay of this community nursing home for 50 people that is so badly needed. At all clinics every Friday in Nenagh, I have people crying out for nursing home care. The Minister of State will be aware that patients in public nursing homes are often such high-dependency cases that private nursing homes will not bloody well take them. These are the people who are being let down. There are in hospital tonight in the mid-west and they need to get into this unit. We were told at the health forum that the unit would be opened this month. These people cannot get into private nursing homes because they are too high dependency. This is not acceptable.

We got screwed in 2009 when our coronary care unit, intensive care unit and accident and emergency department in Nenagh were taken away. Reconfiguration was going to happen, but it never happened. We are not going to get screwed a second time. We are not going to allow the people of Nenagh and surrounding areas in north Tipperary to get screwed again. We are not going to allow our elderly people to be treated like this. The people of Nenagh will not tolerate this. The people of north Tipperary will not tolerate it. Two wrongs do not make a right. It is shameful that the staff, local management, the management at HSE level and HR management in the area knew nothing about this. They knew zilch. This decision was made by a very small number of people, or maybe only one person. It is wrong, and it cannot be allowed to happen.

The unions and staff were not consulted. The Employees (Provision of Information and Consultation) Act was not adhered to. That is completely wrong because the Act has to be adhered to. Those involved met with the unions yesterday. They came back and said they were doing the same thing. The unions will now ballot for industrial action. Do we really want industrial action at St. Conlon's home? Such action would have a knock-on effect on Nenagh Hospital, on the ambulance service and on a range of other things because SIPTU, the INMO, Fórsa and, possibly, other unions would be involved. Is this the way to start regionality? Is this the way to treat elderly people by putting fear out there? There are 20 residents in the unit and 30 more to go in. If the latter happens, there would be 50 people in this state-of-the-art unit. We were thinking about what we were going to use St. Conlon's for in the future, either for the provision of mental health services or other services. We never dreamt that anyone would come up with this preposterous and disgraceful decision. What is proposed cannot happen. The unions will not allow it to happen, including the staff in Nenagh Hospital, who, along with the ambulance drivers and those who perform diagnostics, will show solidarity with those in St. Conlon's.

The HSE will all be dependent on the people to whom I refer in order to make this sub-acute unit to work. What is a sub-acute unit anyway? This unit was built as a nursing home. It is either an acute unit or a nursing home. It cannot be both. A great deal of money would have to be spent if it were to be converted into a sub-acute unit.

We do not need to end up in this situation. The reason the unions will automatically oppose this wholeheartedly is because the people of Nenagh do not deserve to be treated like this. The workers deserve to be in this unit and so do the residents and future residents. Not only is it being taken off the elderly in Nenagh but it is also going to be privatised. Public jobs are being taken and privatised and everybody is expected to dance to the tune and accept that it will only be for a year. It is now the end of March 2024. It is said that it will be brought back to being a nursing unit in 2025, but by the time all of the works are done, even if people did co-operate, it would be a number of months away. This will not happen. Once this is gone it is gone. The crisis in UHL will not be solved overnight with the best will in the world. It will be gone.

What will happen to the residents in St. Conlon's? Will they ever see this new unit? Some of them will never see it. Will the man I am thinking about in UHL or the woman I am thinking about in Nenagh Hospital ever see it? No, they will not. Where are they going to go? The Minister of State has responsibility for the elderly. Where are they going to go? Among all the nursing homes in north Tipperary and further afield up as far as Offaly and into Limerick, Clare and Galway, I beg, borrow and steal to try to find places for people who are loved ones. I know what this is like. I have gone through it with my wider family.

I also know what it is to look after elderly people. My parents are 84 and 85. My mother was 84 the other day. I love her more than anything in the world. We have to look after these people. The people of the area deserve this unit. It was built for them. It was built to future-proof because HIQA said the old unit could not continue. It worries me that people in the HSE and in government would think it is okay to do this to the elderly. We have just had a referendum on care but it is okay to do this to the elderly. It is damn well not okay. I will oppose it with all my might and for passionate reasons, not for political reasons. I know it is damn wrong. Everyone in the HSE up to a certain level does not want this and they, too, know it is damn wrong. The people of Tipperary will not put up with this.

I ask the Minister of State to please intervene with the HSE. Another meeting will take place tomorrow between the new regional manager and her team and the senior union officials. I know the senior union officials because I am from the Labour Party and I talk to them. We all know they will not accept privatisation. We all know they will not accept a situation where this is not an elderly care unit. Will the Minister of State please intervene with the HSE and say, for God's sake, this is not the way to start, this is not the way regionalisation should work, this is not the way to communicate and, most of all, this is not the way to treat workers who go way above and beyond what is necessary to look after these people. It is certainly not the way to treat the residents of St. Conlon's home, who have been looking forward to going into this new community nursing home. It is certainly not the way to treat future residents who need it and will need it in the coming years. I am at the stage of begging the Minister of State to intervene. I know she has it in her to help us. Please do so. Otherwise, this will end up in a scenario where people will be on the streets. There will be a situation with industrial action and we do not want to start this. It should not be the way we treat the elderly.

8:05 pm

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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I commend Sinn Féin on tabling this very important motion on public health. There is no doubt there are deficits in public health throughout the country. Some areas are worse than others. There are circumstances as to why there are deficits. which can come down to a lack of recruitment and the retention of staff. A big issue with keeping people in the health service is the price of housing. Pay and conditions in the workplace are also big factors in filling posts in our health service. Throughout the country there is a shortage of GPs. There are enormous waiting lists just to see a GP. This never really happened until six or seven years ago. There are circumstances as to why this is happening.

I bring to the attention of the Minister of State a particular issue in Dublin Mid-West, and I am guessing it is not an isolated issue. It is with regard to public health nurses. There is quite an astonishing situation in parts of Dublin Mid-West, particularly in Lucan, Rathcoole and Newcastle, where there are no public health nurses. There are none. A public health nurse is very important not only for infants' health but also for the elderly. I got a response from the HSE on why there are no public health nurses in Dublin Mid-West which states it is down to recruitment. What is more worrying is that it has tried to recruit student public health nurses but to date it has succeeded in recruiting zero. It is extremely worrying that student nurses who go into public health nursing do not see a role in the public health system.

This is having a knock-on effect. Mothers are contacting public representatives in Dublin Mid-West to say they cannot get access to public health nurses for their children. Public health nurses are very important for developmental checks, and not having them is very worrying. It is incredible we do not have this service, especially in Dublin Mid-West. My guess is that the same situation arises in various parts of Ireland. Public health nursing is a basic service. I remember my mother bringing me to the public health nurse when I was young. Children had at least four or five checks before the age of five. Now for some parents there are none. This is very worrying and it is having a knock-on effect. If we cannot recruit student nurses because of all sorts of circumstances, it is deeply worrying. I hope the gap can be plugged very quickly.

Photo of Seán CanneySeán Canney (Galway East, Independent)
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I thank Sinn Féin for tabling the motion, which is very important. In a rural constituency such as Galway East, which I represent, we can see the lack of services. The first issue is with GPs. Even in the towns they are under awful pressure. I was in a GP practice on Tuesday morning. One of the doctors was not there and there was great pressure on the rest of the staff because he was out sick. There is no fallback position. What is wrong is that we do not have enough GPs. We all know what the problem is but how are we going to resolve it? We have to make sure the working environment for our GPs is such that it is an attractive proposition.

The sooner we get to a stage where we are building our own capacity in our education system and attracting some of our emigrants back home without creating barriers for them, the better. If they are coming back, they should not have to work here for two years before they can get a mortgage and silly things like this. A bit of joined-up thinking must be done in all Departments to make sure that when somebody comes back to this country, they are not just told to come on back and it is great. They should be able to get a mortgage and get car insurance without being ripped off. They should be able to do all of the things they enjoy now in another country. These are only small things but they are the things that would make a difference.

The work done by public health nurses is incredible. It is important that we support it. It can be a lonely existence for a public health nurse going out visiting people. They should know and be reassured there is backup. We have plenty of colleges that are now training nurses. There is St. Angela's College in Sligo. It is also being done in Castlebar, Galway, Athlone and Letterkenny.

We have all of that, but we do not seem able to attract the requisite number of students and, importantly, retain them once they are qualified. We have to consider this matter as part of the question of the ill.

Issues to do with older people are the Minister of State’s delegated responsibility. In October, she opened the community nursing unit in Tuam. Not one patient has gone into it yet. HIQA has not provided it full certification and I understand that the certification for the old building runs out at the end of this month. There was fanfare, everyone was present and we had a great day, but there are still no patients in the unit today. This kind of situation should not be happening. I will give another example. At our newly built primary care centre in Tuam, the X-ray facility that was omitted from its design but for which funding was granted by the then Minister for Health, Deputy Harris, in 2017 has still not been installed. It is being worked on but will probably not be in place until next year, which will be seven years later. It was just a case of converting a room into an X-ray facility by installing lead-lined walls. The work will probably take two months. Had the facility been included when the centre was being built and when I requested it, it would have been finished within the timeframe of the contract and for a great deal less money. I do not know why it has taken seven years. These are the issues I am seeing on the ground.

Thankfully, we found a solution for the Seven Springs day centre in Loughrea, but we spent the past two years doing so. I made the Minister of State aware of how there were older people who were not getting a service. That the service had been transferred from a purpose-built unit to a local hotel was a crying shame. It is important to point out that it was local people – the concerned citizens of Loughrea – who got the service back. No one else should take credit for it.

Silly things like this are affecting older people. Services are being distributed because people are making decisions without thinking about the person who will be using them. As politicians, we need to step above that and ensure that our older people get the respect and services they deserve.

The day the Minister of State was in Tuam, we opened the office that the children’s disability network team would be moving into. A great deal of money was invested in the building, but we do not have the staff to run the services. The situation is so bad that, just before Christmas last December, the parents took to the streets and protested outside the building because there were so many people who could not access services. It was when they were called to a family forum meeting that they realised it was not just them talking about the issue, but everyone else as well. Children were not getting services, although not because of the staff who were in place. It was because there were not enough staff, including therapists. The HSE publishes different reports. One report says there are so many whole-time equivalents funded, another says something different. You wonder whether people know what they are doing.

We need a root-and-branch review of what is happening in these services. The last thing people want to hear, especially where children’s disability services are concerned, is talk of reconfiguration of services. All that is is another excuse to postpone doing anything for 24 months. The suggestion is that something has to be reconfigured and, until we get that right, we will not be able to do anything. That kind of excuse is worn out.

Something that galls me about the Joe and Helen O’Toole community nursing unit situation is that a local trust invested €7 million in it. That beautiful building is still not occupied. This issue needs to be thrashed out as soon as possible.

8:15 pm

Photo of Mary ButlerMary Butler (Waterford, Fianna Fail)
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I will get on that straight away.

Photo of Seán CanneySeán Canney (Galway East, Independent)
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I thank the Minister of State. Her heart is in the right place where getting things done is concerned, but there are so many issues within the systems that have been set up that it is difficult to find out what is happening. I get many calls from parents who are trying to get their children assessed, into special needs care or into ASD units. Last week, I encountered the case of a school that wanted to put an ASD unit in place. Everyone was happy with that plan and there was a demand for it, but the Department of Education stated that it would only fund ASD units where there was an existing empty room in the school and that it would not fund the capital works necessary to create a new room. In this day and age, it is damning that the Department of Education would decide to do things this way. In rural Ireland, particularly in constituencies like Galway East, there are schools like Castlehackett that want to provide services for people with autism, yet barriers are being placed in front of them. Parents are being told that they can send their children to a school eight, ten or 12 miles away. The child is being taken away from his or her siblings, who are attending the local school, and from the local area if he or she has to travel to another school that has a unit. It is a fancy word, but there is a disconnect between the decision makers in the Department of Education and people on the ground in terms of what is the best way to provide services for young people.

I am a member of the Joint Committee on Disability Matters, where we encounter many people who are frustrated because the services they are told exist are not there when they seek them out or because they do not know where to find them. The same applies to older people. Home care is of paramount importance to older people if we are to keep them in their homes for longer and save the State a great deal of money. We need to ensure that enough people are attracted to a career in home help.

We will table a Private Members’ motion on the matter of people caring for others. We are looking for a non-means-tested payment for carers. It is high time that was done. We hope that the Government will support our motion and that we will see some action to ensure that people with disabilities and others who need help are kept in their homes for as long as possible, as is their right.

Photo of Carol NolanCarol Nolan (Laois-Offaly, Independent)
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I support this motion, which in many ways replicates some of the points that my colleagues and I have raised recently about local access to healthcare. In particular, I support the motion’s call to establish a multidisciplinary working group on the development of primary care and for the Government to launch a pilot programme in areas where there is a shortage of GPs for out-of-hours services and leave cover.

In my constituency, we are finally seeing the development of the Birr primary care centre after a long wait and a rather complicated process. I fought hard to keep that primary care centre for Birr on the political agenda in the Dáil and engaged continuously with the HSE over the past number of years. I commend the HSE on giving its final sign-off.

In terms of local health services, I wish to mention the ongoing crisis in our dental services. Offaly and Laois are particularly badly impacted. The number of children being failed by the current contract arrangements is mind-boggling. We have major deficits right across the board in health and a chronic lack of services, including elective surgery capacity at the regional hospital in Tullamore, which is of serious concern. We need an elective surgery hub for Tullamore hospital. I hope that will happen.

For now at least, I commend the motion and offer my support to it.

Photo of Michael Healy-RaeMichael Healy-Rae (Kerry, Independent)
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I thank Deputy Cullinane and his party for bringing this issue to the fore. In discussing the delivery of services, I wish to speak about GP services in places such as the Iveragh Peninsula in south Kerry, which is losing GPs. If we do not have access to care in our rural locations in particular and if we do not have the requisite resources in those locations, it will be detrimental.

I very much welcome that a deputation from the Iveragh Peninsula, comprising people from Cahersiveen, Waterville, Portmagee, Valentia Island and places from that direction, met the Minister for Health recently. Fair dues to Deputy Cullinane because although he forgot to invite me to the meeting, he came to Kerry where he was most welcome. He understands perfectly well when he stands in the Chamber the issues in rural areas such as those. We need to have services that are based locally to take pressure off our accident and emergency departments. I am sorry if I am repeating myself but I will keep saying the following to see if it will get through to somebody. I want the people of Ireland to be treated with the same care and consideration that our animals are given. Any time an animal in Ireland gets sick, a veterinarian can be in the yard within two hours. The farmer does not have to carry the animal to the veterinarian but he or she comes to the animal in the yard or on the farm. At the same time, a human being who wants to see a GP might be waiting for 14 hours or for days on a trolley. That is detrimental. It is awful to think that we are in a situation like that when we are spending €22 billion or €23 billion per year on health. We are not delivering healthcare where it needs to be, which is closest to the home.

8:25 pm

Photo of Danny Healy-RaeDanny Healy-Rae (Kerry, Independent)
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I too thank Sinn Féin for bringing forward this motion. We proposed a similar motion four weeks ago. It is important because so many areas, including Killarney and areas in south Kerry, are under pressure for GPs. Those areas are losing doctors. Even more people are being brought into the area but there is no other doctor to cater for those extra people. We are talking about different ways to help GPs. Going back in time, I remember when there was a doctor's residence and dispensary in every parish. Deputy Micheál Martin has boasted that he got rid of the health boards but that was a backwards step because the health boards were accountable to elected members, which is not the case anymore. We had residences and dispensaries in every parish. In 2012, the HSE centralised the ambulance service, which meant a reduction in services. Ordinary people need care. They get sick at weekends and at night and need to be treated urgently. I know of a case where a young baby stopped breathing on a Friday evening and the family had to wait for two hours before the ambulance came. That is not good enough. The baby was six weeks old. Elderly people need and deserve care. Enough money is being pumped into the HSE but we are not getting the results for it.

Photo of Mattie McGrathMattie McGrath (Tipperary, Independent)
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I too thank Sinn Féin for bringing forward this motion. It is a simple matter of fact that all services across the regions have been diminished and the lack of accountability is shocking. What happened recently in Nenagh with St. Conleth's nursing home was nothing short of blackguarding. Deputies Lowry and Cahill are both claiming that they got this centre to be a step-down facility from Limerick University Hospital but HIQA has condemned the building. That was why it built a new building at the cost of €23 million or €24 million. We are now told that building will not be available. HIQA can stand over that. How can it stand over that and stand idly by? A private company is going to be put in to run the facility. This is madness. I cannot believe my two colleagues, one of whom has welcomed it and the other said he went to the Minister to look for it.

There are considerable numbers of people in my constituency waiting because of the lack of autism spectrum disorder, ASD, places. Parents express enormous concern on a daily basis about the lack of school places for the children in September. Those parents are applying to up to ten schools and many of them are now saying they will try to hold back their five-year-old children in preschool in order to get a place in a school the following year. What is going on is shocking.

Photo of Michael CollinsMichael Collins (Cork South West, Independent)
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The Rural Independent Group's Private Members' motion last month called on the Government to act immediately to address the severe shortage of general practitioners across rural Ireland. We are happy to support this motion. This crisis has been escalating for over four years, with recent data revealing that over two thirds, 66%, of rural GPs are currently unable to accept new patients. I will fast-track my contribution because my time is short. I remember not so long ago the position of Dr. Fiona Kelly in Castletownbere. She had to return from holidays because of the lack of a GP and another GP was a day over on his licence, or whatever nonsense was going on at the time. It was a scandalous position that a doctor who gives so much of her time and energy to her community had to cut short her family holiday.

There are many issues we could talk about. We in the Opposition get quite a lot of criticism when we raise issues. I recently raised issues about Clonakilty Community Hospital because two wards were closing and a new ward was being opened. I praised the staff who are in the hospital but I wanted to know how many people were going to be re-homed in the new unit. No response, only criticism, was afforded to me. I got criticism from a TD in Clonakilty who let Belgooly nursing home close down only a few months earlier. I am standing up for the people and I want answers. I will continue to do that while I am here.

Photo of Richard O'DonoghueRichard O'Donoghue (Limerick County, Independent)
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Primary care centres around the country can allow for step-down care. Why has the Government not used primary care centres more often? Who is stopping the primary care centres from being built and why have we not extended the primary care centres that are there at the moment to ensure we can take the pressure off accident and emergency departments? If somebody wants oxygen or wants to have a drip for a day, why can we not use the primary care centres to do it? That would encourage the GPs to put a structure in place. Let us consider Kilmallock. It has five GPs and a primary care centre. There is planing permission in place for another 6,000 sq. ft to be added, which could allow for step-back care that would take the pressure off for people who want to get stitches. It would also allow more young GPs to go into primary care centres with structures that would allow them to have time off and allow them to have quality of life and a family. We are killing GPs at the moment by overloading them with people who are looking for care. What do they do? They have to send those patients into the accident and emergency departments that are oversubscribed at the moment. Why can the Government not look at the primary care centres? Who is responsible for stopping primary care centres being built in Munster and other areas where the infrastructure and planning can be put in place straight away? We could take care into our own hands.

Photo of Catherine ConnollyCatherine Connolly (Galway West, Independent)
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Gabhaim buíochas leis an gCathaoirleach Gníomhach. Mo bhuíochas le Sinn Féin arís as an deis cainte seo a bheith agam chun cur síos a dhéanamh ar sheirbhísí leighis taobh amuigh de na hospidéil agus chomh lochtach is atá sé in ainneoin pholasaí an Rialtais le fada an lá. I thank Sinn Féin for the opportunity to speak on this motion. I did not think I was going to make it but I have. This is a practical motion that calls for action, for a task force to be set up and for a public contract for GPs to be developed. Of course, that was done in our neighbouring country a long time ago. The motion includes other practical suggestions and I could not disagree with it. Last Monday week, I attended a public meeting organised by Fine Gael Senator, Seán Kyne in Clifden. There were over 200 people in a small hall because the district hospital has closed once again. There were somewhere between 200 and 250 people expressing their utter frustration. That meeting took place approximately one year after a previous public meeting at which they were given assurances that the hospital would be kept open. I say this with Galway city in mind. There are 33 people on trolleys in Galway today. I am going to zone in on that figure. Has the Minister of State or his officials spent time on a trolley?

Photo of Peter BurkePeter Burke (Longford-Westmeath, Fine Gael)
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Photo of Catherine ConnollyCatherine Connolly (Galway West, Independent)
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The Minister of State has; it is not pleasant. Somebody related to a person who works with me spent time on a trolley in a hospital in Dublin today and it was utterly chaotic. I have been a Member of the House since 2016 and nothing has changed. Representatives of HIQA attended the regional hospital last year. The hospital serves almost 1 million people. HIQA stated in March last year that the emergency department was grossly overcrowded. There were something like 27 people on trolleys at that time; today there are 33.

On 6 March, we had 52 so it is an ongoing problem and there is ongoing pressure. All of the Members on the Government side nodded when I asked whether they had ever been on trolleys but I would like to know how long they spent on trolleys because it would not be unusual in Galway to spend between 24 hours and six days on a trolley depending on the season and phone calls to TDs. It is a desperate situation for the patient and the TDs to contact the hospital asking how many people are on trolleys.

This clearly tells us that hospitals are under-resourced, under-staffed and on occasions, badly managed. This is why we need primary care centres. In 2001, we rolled out a strategy but, unfortunately, that strategy has never been properly fulfilled or reviewed, so we see company after company setting up. Indeed the former CEO is now in one of those companies working with another big company owning the private care centres upon which this Government and the HSE are dependent. Health centres are either being built in public private partnerships or are completely private and then leased to the State at enormous rents. Those rents do not even satisfy the owners. We see from recent reports in the Irish Independentthat primary care centres have been stalled because they do not believe they are getting enough in rent. We have learned nothing from the financial crisis or the privatisation of medicine over and over again.

Could the Minister of State depart from his script in his reply and deal with the issues we are raising? We are not doing it to embarrass him. We are doing it because the system is a complete mess and the Government is relying on private for-profit companies to build the infrastructure for primary care. There is a primary care centre outside Merlin Park Hospital in Galway. I understand that the rent is €250,000 per year every single year with nothing to be gained by the State except helping companies to make profits. It is completely in the arms of private companies, which can determine the conditions. Surely at some stage, we should review the risk assessment and cost-effectiveness of such a model but we are not doing anything like that. In the heart of Connemara, i gcroílár na Gaeltachta níl plean ar bith le haghaidh ionad cúraim phríomhúil don cheantar. Ar an gCeathrú Rua, níl plean ar bith chun ionad príomhúil sláinte a chur ar fáil ansin. Tá siad ag caint faoi ionad sa Spidéal. Cad atá tarlaithe? Táimid ag fanacht ar an forbróir príobháideach chun é sin a sholáthar dúinn. Mura n-éiríonn leis nó léi, ní bheidh aon ionad cúraim phríomhúil againn. In the heart of Connemara, there is not a single plan for a primary care centre. The nearest plan is for Spiddal, which is in Chois Fharraige and will not serve the vast area of Connemara. Again, this is in the hands of a private developer. I have no problems with private developers but when we are utterly reliant on them, there is a problem. If they decide they are not building them for a range of reasons, for example, if they are in trouble or if there are planning problems, there is no primary care centre. That is the situation as I speak. We finally got one in Moycullen after many years - again, on a private basis.

The day centre in Áras Mhic Dara in Carraroe functions one day per week. The management tells us there is no demand for a day centre i gcroílár Connemara. Clifden hospital is closed. This was a wonderful hospital in theory with wonderful staff. We were told by the wise management a year ago that there was no demand for a district hospital. Then we were told there was a problem with staff and then we were told there was a union problem. Finally we were told that the new 40-bed nursing home - it was to have had 50 beds but the number was reduced to 40 - will solve all the problems. There is a misunderstanding here that a district hospital is the same as a nursing home and that a nursing home will fulfil the role the district hospital had. A GP stood up at a public meeting to appeal for the second time for the district hospital to be kept open.

The focus of the motion is primary care and improving conditions for GPs. We can do none of that unless we roll out the vision. The vision was set over 23 years ago but it was never rolled out. Indeed it was one of the reasons Deputy Shortall left the Labour Party. She left because of the manner in which that party in government dealt with the primary care strategy. Here we are in 2024. I would love it if the Minister of State would tell me in his reply how many primary care centres are owned by the State. How many centres are in planning but are held up for various reasons - financial or planning? When will there be a review of the primary care strategy? When will we have a review of the day centres, which constitute an essential piece of infrastructure to take pressure off hospitals?

When HIQA visited the regional hospital last year, it said it was grossly overcrowded. I told the Minister of State that the number was 25 or 27. This number has trebled on occasions since then so the term "grossly overcrowded" loses its meaning. If it was grossly overcrowded when the number was in the mid-twenties, what language will we use when the number is in the sixties as has been the case repeatedly? How do we keep going from crisis to crisis rather than building up the basic infrastructure that every town needs?

We go back to Carraroe. Where is the day centre? Since I entered the Dáil in 2016, I have amassed a library of replies about the transfer of land to enable a primary care centre to be built on Inishbofin but there is still no primary care centre there. It is the same with Inis Aran off the coast of Galway. It was promised a brand new primary care centre. I am here eight years and have never seen a review. I have never seen a Minister stand up and say this is unacceptable and we need to review this, take the pressure off the hospitals and give basic services to rural areas and towns. I will work with the Government. I would be delighted to hear some senior or junior Minister actually stand up and say that. Instead we go from crisis to crisis and we rely on the Irish Independent to tell us about the problems in the provision of primary care centres. We see people who are heading the HSE walk into other jobs in the private sector and benefit from their knowledge of what is needed rather than having learned our lesson from Covid and the financial crisis that certain services are essential to a civilised society. Primary care centres are one of those services. It makes sense on so many levels and yet here I am eight years later highlighting the absences on the ground reliant on a Sinn Féin motion to put pressure on a Government with the rest of us in opposition while the Government utterly fails to be honest and direct, tell us what the problem is and learn from its mistakes.

8:35 pm

Photo of Peter BurkePeter Burke (Longford-Westmeath, Fine Gael)
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I would like to thank Sinn Féin for raising this discussion on primary care health services. The Government acknowledges there are issues in delivering healthcare in some communities, including issues regarding access to care for GP services in certain areas. However, the actions of this

Government to improve service provision over the longer term will lead to significant improvements in the delivery of patient care within communities. Indeed, we have addressed most of the points raised in this motion.

The Government has substantially increased investment in general practice in recent years with a view to increasing GP capacity. In 2019, fees and other supports paid to GPs amounted to just over €560 million. This increased to €807 million in 2023, an increase of €247 million, or 44%, when compared to 2019. This increase was largely provided for under the 2019 GP agreement. The agreement increased GP capitation fees; increased supports, including the rural practice support; and introduced a support for practices in urban areas of deprivation.

The 2019 GP agreement also introduced the very well-regarded GP chronic disease management, CDM, programme, which has since been fully rolled out and expanded upon under the 2023 GP agreement. As of 1 January 2024, in total, almost 400,000 patients have been registered to the CDM treatment programme and GPs and practice nurses have conducted over two million chronic disease patient reviews under the programme from end January 2020 to end December 2023. Building on the GP element of the CDM programme, patients can now also access services for their conditions from the 53 specialist older persons and chronic disease teams that have been established under the enhanced community care, ECC, programme.

I will say more about that in a moment. The Government's investment in general practice will increase further following last year's GP agreement.

The 2023 agreement provides for payments for the provision of GMS contraception services, €30 million in additional capacity supports for practice staff, as well as €2 million to further support GP out-of-hours services. Both interest in GP training and the actual number of GP trainees has increased in recent years. The number of GPs entering training has more than doubled from 120 in 2009 to 286 in 2023, with a further increase to 350 places provided for in 2024. The latest ICGP GP graduate survey highlighted the high retention of GPs after graduating, with 96% of those surveyed who graduated between 2017 and 2022 found to be working in general practice in Ireland. Based on the increases made to GP training places and expected GMS GP retirements, work undertaken in the Department of Health indicates that between three and six GPs will be onboarded for every two GMS retirements over the next few years.

The Government is committed to delivering the enhanced community care, ECC, programme, to enable the reorientation of service delivery towards general practice and community-based services. Under the ECC programme, all 96 community healthcare networks are operational, as are 53 specialist teams for older people and for chronic disease. Some 2,800 staff have been onboarded, with, ultimately, 3,500 staff to be recruited into the ECC programme. Since 2021, the GP access to community diagnostics, GPACD, programme has facilitated GPs to directly refer patients for radiology diagnostic scans in the community. The programme provided over 339,000 directly referred scans in 2023 and the Government has provided funding to continue the programme with full adult population access in 2024. In addition, we have provided funding of €22.7 million in the waiting list action plan 2023 for identified HSE community initiatives.

The Government is also conscious of the need to increase the number of healthcare professionals working across the health services, and, in particular, the need for Ireland as a country to ensure we are providing training places sufficient to meet this demand. In collaboration with the third-level sector, the Government has provided for over 660 additional student places in medicine, nursing and midwifery, pharmacy and other key healthcare courses in the academic year 2023-24. The number of doctors in training has increased by 25% over the past five years, a 23% increase across basic specialist training intakes and a 26% increase across higher specialist training intakes. Undergraduate nurse and midwife education places have also been increased.

With the financial support of the Sláintecare integration innovation fund, the UCD pilot graduate diploma in primary care nursing practice was established to provide an education programme that specifically supports general practice, primary care and community nurses and midwives in the reorientation of care towards the community. Commenced in September 2023, 27 community registered general nurses, CRGNs, and 33 general practice nurses enrolled in the pilot course. Increases in healthcare-related high-level education places and in doctor and nurse training places will help provide for our healthcare workforce into the future, including for the provision of primary care and community care services.

The Government also recognises that Irish pharmacies play an important role in the provision of care in the community, and to that end, the Government is committed to enabling the optimisation of pharmacy services and pharmacist practice. The pharmacy task force was established last year to make recommendations on expanding the scope of the practice of pharmacists. The first recommendation of the pharmacy task force, to empower prescribers to write 12-month prescriptions for patients, where appropriate, was implemented on 1 March. A report with further recommendations regarding pharmacist prescribing will be published by the Department of Health by the end of the second quarter.

The Department of Health and the HSE commenced the strategic review of general practice last year. The review, with input from relevant stakeholders, is examining the broad range of issues impacting general practice. The review will examine some of the issues raised in the motion in relation to the modernisation of the GMS GP contract, capacity issues and the use of HSE-salaried GPs. When completed this year, a report will be presented to the Minister for Health setting out the findings of the review and recommendations to address the issues examined.

We have heard in the course of this debate a number of very genuine concerns that exist across this House about the provision of GP healthcare services. The Government is fully cognisant of these and has been active in addressing them. We share the view that developing health service provision at the local level, within communities and as close to the home as possible, has many advantages for patients and for the health services. On this basis, the motion before us is not opposed.

8:45 pm

Photo of Thomas GouldThomas Gould (Cork North Central, Sinn Fein)
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I commend my party colleague, Deputy Cullinane, on bringing forward this motion. Unlike this Government, he has his finger on the pulse. If the Minister of State were to ask him about out-of-hours services in Cork city, he could tell him they are not functioning as they should. The Minister for Health told me on 29 February that he was not aware of any reduction of out-of-hours GP services in Cork city. This is extremely worrying because it has now been proven beyond a doubt that SouthDoc in Blackpool has again shut down. SouthDoc tried to close the Blackpool service under the umbrella of the Covid pandemic, and then tried to keep it closed. The community and I, however, fought a hard campaign to get it reopened.

A family member of mine was sick last week and I rang SouthDoc at 8 p.m., only to be told that my local SouthDoc out-of-hours GP service in Blackpool was closed and that there was no doctor available. That is what I was told last weekend. Now, SouthDoc is getting paid millions of euro to provide a service it is not providing. Some of my constituents are being sent to the Kinsale Road, while others are being sent as far away as Mallow. I refer to how difficult it is for people living on the north side of Cork city to get to the Kinsale Road or to Mallow if they do not have a car. One family told me it cost them €60 to get out and back from the GP. Another family said it had cost them almost €100 to get in and out from the GP.

This is happening on the watch of this Government. We are now seeing the craziness of all this because SouthDoc is not doing the job it is getting paid to do and patients are going into accident and emergency departments in Mercy Hospital and Cork University Hospital, where people are lined up along the corridors on trolleys. If the Minister of State were to go onto my Facebook page, he could look at a post I put up last weekend. People told their stories concerning how they cannot get an appointment, how the SouthDoc GP service in Blackpool is closed and how that organisation is pulling the wool over this Government and this Minister for Health and not doing its job.

Photo of Rose Conway-WalshRose Conway-Walsh (Mayo, Sinn Fein)
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An example of how the health services in County Mayo are getting worse and worse is a call I got from a mother today who has been waiting three years for her child to get a diagnosis. Finally, she said she could not stick another night of this and had to take the child to the hospital. I would say she is probably in the accident and emergency department in Castlebar hospital right now. This is because the health services in County Mayo are under severe pressure and this has continued to grow for the last decade. The Minister of State's party has ignored what is happening in local communities. The Government has failed to take every action available to it.

The lack of GPs is a slow-moving crisis and no action has been taken to address it. We do not train the number of doctors we need. This is not rocket science. We know how many doctors we need, but we do not train them. The Government continues to fail to join the dots between the number of training places and the workforce needed. Dental care for people with medical cards has collapsed in County Mayo as well, and this has happened over months and months.

The Government has also failed to invest in the community and district hospitals like those in Belmullet, Ballina and Swinford. This has resulted in heaping avoidable pressure on acute hospitals and accident and emergency departments. Primary care centres are now delivered almost exclusively by the private sector. I do not know how many times a primary care centre has been announced for Bangor Erris, but there is still no sight of it. This has led to delays and setbacks with projects, such as in Ballyhaunis, which is another area that has waited for years and years for a primary care centre.

Budget 2024 was a disaster for health services and the people of County Mayo deserve better. This is just one reason the people of County Mayo have run out of patience with this Government. People in County Mayo are crying out for change. Leo Varadkar reviewed his record and decided it was time to go. I am now calling on the Government parties to do the right thing and to call a general election. The leader of the country should not be chosen by Fine Gael alone. I ask the Government to do the right thing, call a general election and let people decide the type of health care service they need.

Photo of Ruairi Ó MurchúRuairi Ó Murchú (Louth, Sinn Fein)
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Go raibh maith agat. I thank Deputy Cullinane for bringing this motion forward. We could deal with the multiple proposals he has put forward, but I just wish to deal with one. I refer to developing a public contract for GPs and launching a pilot programme in areas where there are shortages of GPs for out-of-hours services and leave cover. We all know the issues that exist, including in my town of Dundalk.

There are many people in surgeries who cannot see a GP without waiting for two weeks unless it is an emergency. We know of people who cannot get a GP at all. We know in some of these cases that people are so frustrated, they end up going to the accident and emergency department. Many people believe that, because of the overcrowding and other issues, the best thing they can do is call an ambulance, putting further strain on the ambulance service. I recently tabled a parliamentary question and, in an over-and-back interaction, I was pleased that the Minister said he was open to having directly employed GPs. However, we need to accept that the business model for GPs has changed. At this stage, GPs do not want to be running businesses so we need to consider State employment. We cannot leave people in the circumstances they are in.

The other issue I want to bring up is orthodontic care. I recently got answers from the HSE regarding the absolute disaster in CHO 8. At this point it is only looking at an initiative to deal with people who are grade 5, the worst-case scenario. It has not looked at this in 2021, 2022 or 2023, while dealing with grade 4s at huge cost. I am glad people are getting some necessary works, but we really need to deal with the worst-case scenario because, in the long term, they will be under severe pressure and serious harm will be done.

8:55 pm

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I thank all the speakers who supported the motion. I also acknowledge that the Government is not opposing the motion but I ask the Minister of State present and the Cabinet to go much further and deliver on the recommendations. As my colleague an Teachta Conway-Walsh said, in reality, given the news today, we need a general election and we need to give the people the opportunity to vote for the Government they want and a Government that will actually deal with the many challenges we have in our health service.

I have no problem in welcoming and acknowledging the putting in place of the enhanced community care model, which was a very positive development in recent years. For a long time, I and my party have been calling for multidisciplinary teams working in the community at primary care and community care level, providing supports to older people and people with chronic diseases, for example, to keep them away from acute hospitals, which is really important. We have to build on that. It is one of the important foundations to building up primary community care but also to take pressure away from our acute hospitals.

Again, I welcome and acknowledge that the number of training places for GPs has increased in recent years. However, we also have real pressures in many parts of the country and in many communities. Very often when we hear about a shortage of GPs, people will rightly point to rural areas where we have a dire shortage of GPs. I gave an example of it in south Kerry in the Cahersiveen and Waterville area. I attended a public meeting without the permission of some of the Kerry TDs, as they pointed out earlier. It was very important for me to go down and listen at first hand to people who were telling me their stories of having to wait days on end to access a GP. An area that had six GPs at its height is now operating with one full-time GP and one locum. It is also an issue in urban areas.

While we have more GPs in training at the moment, we also have a growing population and an ageing population. We need to acknowledge that many people cannot even register with a GP. People are waiting longer to access a GP. We are also asking GPs to do more when in fact we could be looking at other elements of the health service, like pharmacists, as our motion points out, to take pressure away from GPs. There have been some small moves in all of these areas. I call them small moves because that is what they are. They are not revolutionary and are not as decisive as they could have been and should have been. We can do much more with primary care, with pharmacists and with GPs if we have the vision and the plan but, more importantly, if we put the resources into it.

I cannot let this motion pass and conclude without acknowledging that, in the budget just gone, the Government did not even provide the health service with enough money to stand still. It provided for about €100 million of new measures, which is a drop in the ocean relative to the overall funding for the health service. That means it does not matter what the Minister thinks. He does not have the resources for this entire year to build up capacity across primary and community care. Worse still, we now have a recruitment freeze and recruitment embargo in place at the time when we have so many trainees who are going through a range of training courses in many areas. They will be coming out of those training places and will not be given a job in the public system because of a crazy recruitment embargo which, again, came from a bad decision the Government made with the budget.

I passionately believe we can actually deal with the problems in our hospitals and in our emergency departments by doing the simple things. Very often I listen to politicians who think the answers are complicated and we have to come up with all sorts of novel ideas. It is very simple. Healthcare needs capacity. Healthcare is about people treating people. If we do not have the people, including the GPs, if we are not making best use of pharmacists, and if hospitals do not have beds or do not have access to recovery beds, step-down beds and convalescence beds in the community, it results in pressures in the system and people waiting on trolleys. That is just one example of everything going wrong at the same time in our health service.

I again acknowledge that the Government is not opposing the motion. However, it should go further by looking at its recommendations and implementing them.

Question put and agreed to.