Denis O'Donovan (Fianna Fail)
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The Minister of State can take her seat. Usually Members have four minutes and the Minister has four minutes to reply. It is at my discretion to allow a supplementary question. I normally do but sometimes the times have been totally breached, which puts pressure on later speakers. Senator Paul Gavan has four minutes to outline his case.

Paul Gavan (Sinn Fein)
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The Minister of State is very welcome. I wish to raise the issue of health services in County Clare, with specific reference to the drastic curtailment of the Shannondoc service. As no doubt she is aware, Shannondoc is an urgent out-of-hours GP co-operative that was established in 2002. Its main purpose was to provide an urgent out-of-hours GP service to the people of the County Clare area. On November 14 of last year, despite protests from the local community, the service was massively scaled back in the county. Both Shannondoc centres at Kilrush and Ennistymon have relocated to Milltown Malbay on weekdays from 6 p.m. to 8 a.m. and on weekends the service is operational until 7 p.m. As Kilrush has such a large catchment, Shannondoc decided that it would introduce a nurse service on weekday evenings for an additional two hours to enable remote video consultations to soften the blow of taking the doctor away fully.

According to the HSE, which funds Shannondoc to the tune of nearly €5 million each year, the reason for the scaling back of the service is not related to funding. According to Shannondoc, the reduction in service is as a result of the inability to attract doctors to work in rural areas combined with a lack of available locums. Changes in immigration law in 2015 have also been cited as making it unattractive for locums. The long-standing failure to complete negotiations for a new GP contract has also been cited.

With the withdrawal of the Killaloe service, patients in east Clare now face the prospect of travelling to Nenagh, Limerick or Ennis to be seen by a GP after 6 p.m. We are informed that neither the Minister nor the HSE can determine or make changes to the decision of individual practitioners. The HSE promised to keep the situation under review every three months for the next 12 months. I ask the Minister of State to give me the details of that review in her reply. I would be interested to hear how the review got on and what were the results. A HSE spokesperson has been quoted as saying that the HSE might consider a rethink of the situation if there were "significant or adverse consequences to these changes". I wish to repeat that: If there are significant or adverse consequences to these changes, the HSE may consider a rethink of the situation.

What does that mean? Does it mean that it might reconsider the situation if a few people die? If so, how many deaths are required? This is a publicly funded service and families rely on it. What will the Minister do? Are the Minister and the Minister of State telling the people of County Clare that they do not deserve the same level of out-of-hours GP services as the rest of the country? Are people in rural parts of Ireland now expected to be treated as second-class citizens? I remind the House that, in the context of County Clare, the hospital in Ennis has been downgraded. Fianna Fáil took care of that. It only runs a 12-hour accident and emergency unit. There are no maternity services in County Clare. People living in remote parts of the county cannot get sick after 6 p.m. because the nearest doctor is stationed an hour's drive away. That is the same length of time it would take them to drive to the hospitals in Limerick or Galway, which happen to be the two hospitals worst hit by over-crowding.

I want answers with regard to the review, the action her Department is taking to address the situation, the GP contract negotiations and the visas issues that have been raised previously with the Minister.

Catherine Byrne (Dublin South Central, Fine Gael)
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On behalf of the Minister, Deputy Harris, I thank the Senator for raising this issue.

At the outset, I would like to assure the House that the Government is committed to enhancing primary health care services, including GP services, throughout the country. The development of primary care is central to the Government's objective to deliver a high quality, integrated and cost-effective health service.

GPs contracted under the General Medical Services scheme must make suitable arrangements to enable contact to be made with them, a locum or a deputy for emergencies outside normal practice hours. While there is no obligation on GPs to participate in GP out-of-hours co-operatives as a means of meeting the contractual requirement, such services have been developed and expanded over time and are now an essential part of the primary care services. This helps to ensure that, to the greatest extent possible, urgent care needs are met in the primary care setting.

As the Senator will be aware, in the mid-west region out-of-hours arrangements are discharged through Shannondoc, a not-for-profit GP co-operative owned and managed by a group of individual GPs across Limerick, Clare and north Tipperary, which is funded by the HSE. The HSE has signed a service arrangement with Shannondoc for 2017. Last year, Shannondoc announced that, due to a difficulty in attracting GPs, in particular, locum cover, it was no longer able to maintain its existing service across all its centres. Following discussions with Shannondoc, in order to ensure the sustainability of the service, the HSE accepted a proposal from the co-operative to changes in the provision of the service. The HSE's funding model to Shannondoc has not been altered and the changes to service provision decided on were not influenced by the availability of funding from the HSE. The most significant changes relate to part of east and west Clare, essentially affecting Ennistymon, Kilrush, and Killaloe, with minor changes in terms of operating hours in two locations in north Tipperary.

The changes made to the Shannondoc out-of-hours services are subject to a three-monthly review and their impact is being closely monitored and evaluated by the HSE. There have been no further changes in the provision of Shannondoc services to date. The Government is committed to ensuring that patients throughout the country continue to have access to GP services, especially in remote rural areas and also in disadvantaged urban areas, and that general practice is sustainable in all areas into the future. It is imperative that existing GP services in these areas are retained and that general practice remains an attractive career option.

As part of ongoing attempts to provide additional supports to GP services, and to ensure the future provision of these services in all areas, the programme for partnership Government commits to increasing the number of GP training places to 259 places annually. In July 2016, the GP training intake increased from 157 to 172 places and the HSE's 2017 National Service Plan envisages a further increase, to 187 places this year.

The Minister, Deputy Harris, is anxious to achieve further increases in future years in order to ensure that the future manpower needs of general practice can be met. Further efforts undertaken in recent years to increase the number of practising GPs include changes to the entry provisions to the GMS scheme to accommodate more flexible-shared GMS-GP contracts, and to the retirement provisions for GPs under the GMS scheme. An enhanced supports package for rural GPs was also introduced last year.

The Minister has also emphasised the need for a new GP services contract which will help modernise our health service and develop a strengthened primary care sector, and health service management have already progressed a number of significant measures through engagement with GP representatives. The GP contracts review process will, among other things, seek to introduce further measures aimed at making general practice a fulfilling and rewarding career option in the future.

Paul Gavan (Sinn Fein)
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I do not mean to be disrespectful but I must be frank with the Minister of State. I asked for detail of the three-month review that should have taken place by now and the Minister of State has given me no detail. I asked her to comment on any steps in relation to the visa restrictions issue for locums and she has not given me an answer in regard to that. I asked what steps the Department is taking to attract GPs to rural Ireland and the Minister of State has given me no answer on that. I asked what did the HSE mean by "significant or adverse consequences to these changes" and the Minister of State has ignored that as well.

I will put this in context for the people of County Clare. We hear a lot of guff from the Government in regard to protecting and enhancing rural areas. In reality, the Government is shutting down bus services. It is shutting down health care services. It is shutting down post offices. The Government is killing rural areas. The people of County Clare want to know why are they being treated as second-class citizens when it comes to their health service.

Catherine Byrne (Dublin South Central, Fine Gael)
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I again thank the Senator. Unfortunately, I do not have some of the information he is looking for but I will come back to him.

Paul Gavan (Sinn Fein)
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The Minister of State has given no answers.

Catherine Byrne (Dublin South Central, Fine Gael)
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I will come back to the Senator. There is a clear answer. The Minister has outlined and explained about the GP services. The Senator made it clear in his opening statement that there is a need for GPs in rural areas. Unfortunately, for whatever reason, GPs are not attracted to rural areas in some cases. The Government cannot force GPs to go into rural areas to become part of a practice.

Paul Gavan (Sinn Fein)
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The Government could take enhanced measures to attract them. They have done nothing.

Catherine Byrne (Dublin South Central, Fine Gael)
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There is a clear indication from the Minister's reply that the HSE and the Department are doing everything to enhance training for GPs and to bring more GPs into the service. That is something we all welcome. I will get the Minister's office to come back to the Senator on the review for the past three months and what the accomplishments have been.

It is not fair to say that the people do not deserve a proper health care system. Every citizen in this country does.

Paul Gavan (Sinn Fein)
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I never said that. I said the Government is treated them as second-class citizens, and it is.

Catherine Byrne (Dublin South Central, Fine Gael)
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I do not agree with Senator Gavan on that one-----

Paul Gavan (Sinn Fein)
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The people of County Clare would agree.

Catherine Byrne (Dublin South Central, Fine Gael)
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-----and neither does the Minister. I will come back to the Senator on the various points which I have made note of and I will relay them back to the Minister's office.