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Dáil Éireann debate -
Wednesday, 28 Sep 2011

Vol. 741 No. 4

Other Questions

General Medical Services Contracts

Brian Stanley

Question:

6 Deputy Brian Stanley asked the Minister for Health his plans to reform the consultants’ contract and the general practitioner contract; and if he will make a statement on the matter. [26389/11]

The programme for Government provides for the introduction of a new GMS contract with general practitioners, with an increased emphasis on the management of chronic conditions, such as diabetes and cardiovascular conditions. I envisage that the new contract will also focus on prevention and will include a requirement for GPs to provide care as part of integrated multidisciplinary primary care teams. My colleague, Deputy Shortall, the Minister of State at my Department, is very much involved in this. She will answer a question on this subject later and will give the House greater detail.

The preparation of a revised contract will be advanced by my Department and Health Service Executive officials. There will be a full consultation process with relevant stakeholders.

New contractual arrangements for medical consultants were agreed with their representative organisations, the IHCA and the IMO, in 2008, following more than four years of protracted and detailed negotiations. Currently 2,087 consultants hold the 2008 contract, while approximately 396 consultants continue to work under the 1997 contract. The 2008 contract provides for consultants to work as part of a team over an extended working day of 8 a.m. to 8 p.m., an increase in the length of the working week and also structured weekend work. It also includes new private practice provisions ranging from a total prohibition on such practice to an upper limit of 20% for newly appointed consultants and up to 30% for consultants who previously held the 1997 contract.

The successful implementation of the consultant contract 2008 continues to be a priority for my Department and the HSE. The executive has been focusing, in particular, on provisions aimed at maximising consultant availability to public patients. In due course the contract will be subject to review in the context of reform of the health services as set out in the programme for Government and changes to the model for delivery of services.

The Minister will be aware from his position as Opposition spokesperson and in his previous professional capacity that Sinn Féin and I have long advocated addressing the privileged position of consultants in the health services. This is not a response to the current economic difficulties post the Celtic tiger era; it long predates all of that.

Does the Minister accept, as I expect he will, that the basis of any reform in so far as consultants are concerned must be best outcomes for patients and equal access for all patients to best care? Steps must be taken to address what can only be described as the obscene level of remuneration which some consultants enjoy under the current contract and the aberrations that have recently come to light, namely, that consultants are entitled to take off, with full pay, their final year of service prior to retirement or, more bizarre, to appoint themselves as their own locum and be paid double for a year's work. These are absolute obscenities. What steps is the Minister taking to address those particular unacceptable anomalies with the current arrangement?

The HSE has been clear in respect of its pursuit of consultants who are in breach of their contracts in terms of the 80%-20% split. A number of consultants will be prevented from engaging in private practice, which means, not that they will not be able to see private patients but that they will not be able to charge them. I am given to understand this may be challenged in the courts by the HCA. So be it. Those in the next tranche who are found to be transgressing will also be pursued. It is not acceptable to me or the Government that a small number of our 2,500 consultants are behaving in an utterly unacceptable manner and are not alone being unfair to patients but are casting a slur on the remainder of their colleagues.

The Deputy can be assured that my Department and the HSE will not yield on this matter. We are going to pursue it.

I am aware of the Minister's intent in that regard, having received a written response to a parliamentary question from him in which it was stated that two consultants are currently being targeted and that 40 others will be pursued. It was also stated in the reply that the Minister is serious in this regard, for which I commend him. However, I specifically asked the Minister about the anomalies in respect of the entitlement of consultants to take off, with pay, the final year of service prior to retirement or to employ themselves as locums and be paid twice for the same year's work.

The Minister's reply to me on 14 September contained a tabular statement outlining the various levels to which consultants' pay could drop and the impact of this on the overall health budget. It would appear that if consultants' pay was capped at €150,000, the coffers of the Department and HSE would be significantly improved by tens of millions of euro. Is the Minister actively working towards a new contract for consultants and general practitioners? Will he indicate to the House today if engagement with the representative bodies is already under way and that progress has been made on such a new contract?

The Deputy, like me, is aware of the law of the land, the ability of legislation to be retrospective and the rights of people under contracts. The law is not the only road open to us in this regard. There can be negotiation and are broader matters that can be brought to the table that might help people see things in a different light.

On the Deputy's specific point, a number of consultants have extraordinary arrangements in place, with which I do not agree and will seek to change. The Deputy and I are law makers, not law breakers, and we must abide by the law. Within that framework, we will do everything we can to reduce the impact on our coffers.

I am interested in achieving from consultants, the vast bulk of whom are hardworking and give great public service, the flexibility around working hours and days that will provide us with the productivity that will deliver the service to our patients, reduce waiting times on trolleys in hospitals and reduce the duration of stay within hospitals. That is what I want to achieve. If I can achieve that, well and good. If consultants do not wish to co-operate, there will be a heavy price to pay.

Hospital Waiting Lists

Billy Kelleher

Question:

7 Deputy Billy Kelleher asked the Minister for Health if his attention has been drawn to the emerging difficulties with the special delivery unit in Northern Ireland and rising waiting times there; in view of same, is he confident in the special delivery unit’s capacity to reduce waiting times here. [26254/11]

Reducing patient waiting times is a central part of the Government's commitment to increase equity in the Irish health system. One of my first priorities, therefore, was to establish the special delivery unit in June under the leadership of Dr. Martin Connor.

I know that the SDU in Northern Ireland — in respect of which Deputy Kelleher raised issues yesterday, to which I was unable to reply — was very successful when established in reducing waiting times. I do not propose to enter into an analysis of the Northern Ireland health system or to comment on the issues there other than to say that there were other issues at play which may not have been addressed. There is a series of reasons the initial, impressive effect of the special delivery unit was not sustained. The Government here is engaged in thorough reform of our health service. As such, what occurred in Northern Ireland will not pertain here. Underlying reforms that did not take place in other jurisdictions will happen here.

In my view, we need to embed performance management in the system to sustain shorter waiting times. That is critical. A once-off improvement will not work. The change has to be sustained and ongoing. Regardless of how well one improves, one must always strive to do better and must always have assistance to help one do better. As I stated earlier, to do that, one needs real time information.

As the Deputy knows, this Government has an ambitious programme of reform which includes institutional reforms and economic incentives which will make health care providers truly accountable for delivering patient centred care. I can assure the Deputy that I have the commitment and determination to deliver this agenda. I am very impressed with the work already begun by Dr. Connor. Our problems did not arise overnight and will take time to resolve but they are being tackled in a systematic and relentless fashion through the SDU. I do not minimise the scale of the task before us but I am very confident that the special delivery unit will provide a real performance management function for the Irish hospital system and will drive down waiting times.

I wish Dr. Connor, head of the special delivery unit, well in trying to address the difficulties in the system. However, while the special delivery unit, in the context of Northern Ireland, did initially create a positive momentum that has, in recent times, slowed dramatically for a number of reasons. In putting the emphasis on increasing capacity in the public health system, the use of private care was reduced. This appears to be the reason for the increase in the number of patients waiting more than three months to be seen. The figure in respect of people in Northern Ireland waiting more than three months to be seen increased from 17,000 in 2009 to 26,000 in 2010. This means, in the context of the Republic, that we have performed better than has Northern Ireland, even with the establishment of the so-called special delivery unit.

Some €29 million was taken from the National Treatment Purchase Fund budget to assist in the establishment of the special delivery unit in the Republic. How will this shortfall of funding be addressed in the context of private care in the delivery of outcomes?

There is no obligation on the Government to provide funding for private health care or private hospitals. The National Treatment Purchase Fund was established under Deputy Kelleher's Government to use the private sector as a stream for procedures. I never agreed with the ideology that only 10% of that work could be done in public hospitals. The Government is changing that. We will use the funding from the NTPF to get the best value for the taxpayer and the patient.

That does not mean just purchasing procedures. It means employing key personnel in different areas to increase productivity or purchasing from the public system on a money-follows-the-patient basis, as we have already done with orthopaedic procedures. In such a scenario, when a hospital puts in the bill for a patient, the Department will pay it. If it does not perform the procedure, the money will be docked and diverted elsewhere in the system where it can deliver.

This is about bringing accountability to the system. There is little point in having transparency if there is no accountability to go with it.

Will the Minister accept that in trying to increase capacity, 1,900 beds are actually closed in the public health system, as the previous question from Deputy Ó Caoláin showed? People who need treatment will need beds but the capacity is not available. With a reduction of €29 million in the NTPF, how will additional capacity be achieved to deal with the immediate issue of people waiting over three months for treatments?

Earlier this year, I sent a message to hospitals to inform them no patient should be left waiting longer than 12 months for treatment. A patient left for longer than 12 months for an inpatient procedure in a hospital will be treated elsewhere while the hospital in question will be deducted the quantum required to treat the patient. We must wait and see what this yields by 1 January 2012. That is what I mean by transparency and consequence. There will be consequences for hospitals that do not perform.

Regarding the €29 million alluded to by the Deputy, much of that may still end up in some private hospitals or not. It is being used in different ways to achieve the best outcome. Some of our public hospitals are extremely efficient at delivering care and more cost-effective than the private sector. The revers situation is also the case.

While one would wish the health service situation in the North to be better than it is, at least we are able to assess it from the data published by the health Department in the Six Counties. Is the Minister aware the Health Service Executive decided to suppress the publication of details on the length of time patients must wait for access to given services in this jurisdiction? This was reported in June by the website, www.ratemyhospital.ie, when the HSE admitted it suppressed the publication of vital information on how long average patients have to wait for outpatient appointments in public hospitals.

Thank you, Deputy. I must call the Minister.

We are not able to make comparisons here because the HSE does not want the information to be made available.

The Deputy has made a statement over which I cannot stand. I know there is not sufficient information around outpatients due to double-counting and other problems. These are, however, being addressed.

I do not want the Minister to stand over my statement. I want him to have these reversed.

I am sure there are many things that Deputy Ó Caoláin may want but not all of them are achievable or desirable even.

We have acknowledged we are still gathering outpatient figures while we have got more information on inpatients and real-time waiting in accident and emergency departments. I cannot wave a magic wand and get it all done in one go. Six months into our tenure, however, we have made major strides in information gathering which allows us to analyse and plan how to tackle problems.

The spikes that occur in numbers at Limerick regional hospital have nothing to do with the number of attendees and admissions but other factors at the hospital. We cannot address any of these issues because they are not funding issues. We need co-operation from all members of staff to address these which I hope we will get from the Irish Nurses and Midwives Organisation, INMO, and others.

The spike is also attributable to the closure of certain hospital services at Ennis and Nenagh hospitals and the displacement of countless numbers of patients.

Health Service Staff

Catherine Murphy

Question:

8 Deputy Catherine Murphy asked the Minister for Health in the context of the public service redundancy early retirement scheme, if there is a forward planning system in place to ensure that front-line services will not be adversely affected; if a risk assessment is being carried out in each public hospital; and if he will make a statement on the matter. [26204/11]

There is currently no voluntary redundancy or early retirement schemes available in the public service. However, the grace period during which the calculation of public service pensions is unaffected by the pay reductions applied under the Financial Emergency Measures in the Public Interest (No. 2) Act, 2009, will expire on 29 February 2012.

In this context, a three-month minimum notice period for retirement was introduced for the public service in July this year. The purpose of this minimum notice period is to allow management to have advance knowledge of the number of staff planning to retire in a particular service or area and to plan accordingly. I have asked the HSE, as a matter of urgency, to carry out an assessment of the likely impact of retirements in the coming months, based on the three months' notice period, queries to superannuation departments and the age profile of staff. I have also requested the executive to identify particular pressure points as a priority and to develop appropriate measures to deal with significant departures in a given service or area. My Department will work with the HSE to ensure, as the position becomes clearer over the coming weeks and in the event that significant numbers of staff intend to retire, plans are developed to protect front-line services as far as possible.

Many experienced health service staff are likely to take early retirement which will have an impact on service provision. Can the Minister refuse applications for early retirement? Can the retirement scheme be devised in such a way to ensure it does not affect front-line health staff? Several months ago, there was much debate about raising the qualification age for the State pension to 67 years. With this early retirement scheme, many people will end up retiring earlier than 65 years. We could also end up with agency staff being hired, a much more expensive way of providing staff. This scheme does not seem to be well thought out.

Last night, a news report showed how an ambulance service could not be provided at one hospital because of the public service recruitment embargo. This impacted on the hospital's ability to take in cases, meaning that not just front-line staff are affected by the embargo. I am not sure there is a plan to this retirement scheme.

I must call the Minister, Deputy.

I have similar concerns and have asked the HSE to put in place a plan to examine possible areas of greatest impact caused by many taking early retirement due to the pension reductions that will apply after February 2012. The executive will also need to examine age profiles in certain health services to identify greater areas of entitlement to retire and the number of inquiries about retiring.

The Deputy is correct that the employment of agency staff is horrendously expensive and one which we seek to avoid at all costs. With a proper plan after the ongoing analysis, we will be able to accommodate for the likelihood of deficits in services in particular areas. I accept many health service staff with great experience may consider taking up early retirement. Perhaps when they reflect on where the country is at, they may stay on to help out and continue to serve this nation and its ongoing recovery.

It is not exclusively front line staff who need to be taken into account. One does not save money if a hospital porter who leaves needs to be replaced. We need a broad understanding of the impact of each individual who leaves a front line service like the health service, particularly in acute hospitals. This was the point of my question.

I accept the Deputy's point that it is not always the obvious people leaving who have an impact in terms of real savings, but this is where flexibility comes into the equation. People may be leaving in an area where we can ill afford their loss, yet others from areas where they are not as necessary could replace them. We could still allow people to exercise their right to leave.

I will allow Deputy Ó Caoláin in briefly, as we are almost out of time.

Given early retirements and so on, does the Minister not accept that the crisis in our health service can never be properly addressed until the measures include a lifting of the recruitment embargo? This is essential, given that many front line positions are not being filled. Only a moment ago, the Minister referred to the Mid-Western Regional Hospital in Limerick. Is he aware that the Irish Nurses and Midwives Organisation, INMO, stated today that, due to the moratorium on recruitment and the considerable financial deficit in which the hospital finds itself, local HSE management was not in a position to address immediately, even on an interim basis of five to six weeks, the patient safety concerns of the INMO's members? The Minister needs to examine the INMO's full statement. What steps will he take to address the INMO's service delivery concerns?

We were always clear as regards the moratorium, in that it would remain in place, be examined more flexibly and undergo changes where a real need existed. Each time there is a crisis in our hospitals, the only suggestion the INMO makes to us is for more nurses and beds, but that sort of thinking is from yesterday and another country. Ireland is in a different place and does not have the money. We must pursue greater flexibility. Some 450,000 people are unemployed. We must seek to work in a different way to get us to where we want to be without relying on what used to be the obvious solutions when money was plentiful.

During the past decade, Ireland was awash with money, yet the health services were still a mess. It is not just a question of money or beds. It is a question of how we work and use our facilities. It is clear that the capacity of our system is not being fully utilised. We need a change in work practices. I do not expect the likes of the Irish Hospital Consultants Association, IHCA, the Irish Medical Organisation, IMO, and the INMO to roll over and have their tummies tickled, but they had better look around, see the hardships people are enduring, remember that they are in the public service and that we have a duty of care to our citizens and act accordingly.

Absolutely, but front line staff and beds form a critical part of any solution.

Health Insurance

Sandra McLellan

Question:

9 Deputy Sandra McLellan asked the Minister for Health if he will provide an update on the current state of preparation regarding his plans for universal health insurance. [26387/11]

The Government is embarking on a major programme of reform of the health system. The aim is to deliver a single-tier health service supported by universal health insurance to ensure equal access to care based on need, not income. There are a number of important stepping stones along the way, each of which will play a critical role in improving our health service in advance of the introduction of universal health insurance.

A key immediate priority was the establishment in June of the special delivery unit, SDU, under the leadership of Dr. Martin Connor to drive down waiting times for patients. A great deal of work has already been undertaken in this regard. The resources of the National Treatment Purchase Fund, NTPF, will be refocused to align with the work of the SDU, allowing for a progressive improvement in the performance of the nation's hospitals.

A further fundamental element in the reform process involves significant strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients. The phased implementation programme will be overseen by me as the Minister for Health and the Minister of State with responsibility for primary care, Deputy Shortall, assisted by a project team of officials from my Department and the HSE.

Reform of the funding system for hospital care will also be implemented. A money-follows-the-patient funding mechanism and a purchaser-provider split, whereby hospitals will be established as independent, not-for-profit trusts, will be implemented. To achieve this, a number of initiatives are already under way, including a patient level costing project and a pilot initiative in respect of prospective funding of certain elective orthopaedic procedures at selected sites. I intend to establish an implementation group on universal health insurance, details of which are being finalised and will be announced in due course.

The Government promised a White paper on universal health insurance "early in its term". That was the phrase used when this proposal was first mooted. When will the White Paper be published? To be specific, will that be before the end of this year or within the next three odd months? When can we expect legislation to be published? Will it be one item of legislation or will it be a number of items? Has the Minister any idea of how this matter will present in the time ahead? Will the White Paper include financial projections? This is an important question. Are these items in preparation and will this entire matter be taken into account in the spending review that I presume is under way in the Minister's Department in advance of early December's budget? Is it as immediate and presenting as that?

We made it clear during and since the election campaign that completing this development would take two terms of Government. The idea that we will have a White Paper before Christmas is a non-runner, as that will certainly not be the case. The Deputy's questions were not unreasonable, but these measures will not be delivered within the timeframe to which he alluded. They are a number of important stepping stones along the way. We must build a proper primary care structure. We do not have sufficient primary care centres or a new general practitioner, GP, contract. My colleague, the Minister of State, Deputy Shortall, will oversee work on the latter. We need to move the care of the chronically ill from the hospitals back into the community. The contract needs to reflect this. Equally, we need to introduce a money-follows-the-patient system of budgeting for our hospitals so that we can have greater transparency and accountability.

Into what does "two terms of Government" translate? Is it two general election terms, per se? The Minister should be clear with the House.

That is not a question on health.

It is a reasonable question and I am sure the Leas-Cheann Comhairle is also anxious to get the answer.

I would be delighted to answer.

We will not have a White Paper Christmas in 2011, but tell us——

We might have a white Christmas.

We may have one soon. What exactly is the Minister's expected timeframe for the publication of the White Paper on universal health insurance? How will the legislation present? Will it be one or more items of legislation? Into what does "two terms of Government" translate in the Minister's mind?

I am sure it might be three years in the Deputy's mind. In mine, it means ten years, but this does not mean that introducing these measures will take ten years.

Some of us might not be here.

I would love to be in a position to deliver full universal health insurance by the end of this term, but I am a realist and a pragmatist and I know it will not be possible. However, we will be well advanced along the road by the time of the next general election. For this reason, I stated that a second term would be required to bed things in fully. It is too early to say how many items of legislation will be required. This policy will be implemented incrementally to ensure this development is done properly instead of rushing matters and causing problems down the road.

We are committed to achieving this. For the first time ever, a political party has acknowledged that bedding in a policy will take two terms. Generally speaking, it is not seen as a successful political tactic, but we are determined to make it happen because people deserve it. As we have often done in the past, we are asking everyone to share the pain. We want to ensure that, at the other end, everyone shares the gain.

I will briefly allow in Deputy Kelleher, as I want to move on to Deputy Keating's question.

One could also say that the Government is trying to kick the can so far down the road because it knows that it will not be able to implement the political promises it made as quickly as it claimed.

The Dutch model was very much espoused before the general election. What is the position thereon in the context of the instructions to be given to the implementation body? Will there be clear guidelines given to the body about the type of universal health insurance the Minister requires? Will it come back with proposals as to the type of health insurance it recommends the Minister should consider and discuss in the context of a White Paper, as referred to by Deputy Ó Caoláin? This is a fundamental change to how we go about funding health services. Will there be a proper, open debate when the report is produced?

Absolutely. I welcome debate and full discussion. One should bear in mind it took the Dutch 20 years to achieve their model. We are learning from their mistakes and what they did right. Therefore, we do not need to reinvent the wheel. None the less, Ireland is a very different country, geographically, culturally and in terms of population. We know there are many variations on the Dutch system that will not work here but that the core of it can and will. We must ensure we have a properly regulated health insurance market before we proceed. There are many aspects to be considered. There will be many full debates as the various parts of the programme are put together so we can realise what I believe is a worthy aspiration, namely, that everybody in the country will have access to medical care based on need, not on what they can afford.

Hospital Staff

Robert Troy

Question:

10 Deputy Robert Troy asked the Minister for Health the number of junior doctors recruited from abroad; the total costs of accommodating them; and the time line for assessing them and ensuring that they commence working. [26271/11]

Derek Keating

Question:

11 Deputy Derek Keating asked the Minister for Health if he will outline the progress made for filling vacant non-consultant doctors’ posts; the number of unfilled posts in all of the public hospitals here in tabular form; and if he will make a statement on the matter. [26146/11]

I propose to take Questions Nos. 10 and 11 together.

I am pleased to advise the Deputies that excellent progress has been made in filling vacant non-consultant hospital doctor, NCHD, posts over the past three months. I appreciate the co-operation of the Deputies opposite in achieving this.

The decision to recruit from abroad was made due to an ongoing vacancy level of approximately 150 NCHDs and a significant number of additional vacancies anticipated in July 2011 arising from the cyclical rotation of posts. Most doctors start their careers in July after their exams, at which time the greatest rotations occur, although they also feature in December and January. In total, 259 NCHDs have been appointed from centralised recruitment and a further 226 doctors recruited in India and Pakistan for the July rotation.

Given the shortage of NCHDs over the past two years, the HSE developed a range of strategies and initiatives to maximise recruitment, including the development of a centralised recruitment process for service or non-training posts. All vacant service NCHD posts were advertised as "professional development posts" under two-year contracts to one of the four HSE areas, with a minimum of six months in a regional centre and participation in a professional development scheme under the relevant postgraduate training body. Notwithstanding these measures, about 150 posts remained vacant and it was decided to undertake a recruitment campaign in India and Pakistan.

I introduced legislation on 8 July to amend the Medical Practitioners Act 2007 to facilitate the registration of these doctors. The Act was amended to allow for the creation of a new supervised division on the medical register. Registration in the supervised division means a person is registered for a period not exceeding two years in an identified post approved by the Medical Council and subject to supervision by the employer in line with criteria set down by the council.

No exam is perfect. In the old system, there were problems with staff who were found not to be competent leaving a job in Donegal to take up a position in a different speciality in Cork. The supervised division means this cannot happen with the doctors in question. It is a step further in terms of protecting patients.

The Medical Council introduced new rules for the supervised division and with co-operation from the medical schools and postgraduate training bodies organised specialty-specific examinations for the candidates. Two hundred and thirty-six candidates were successful and as of 28 September, 226 NCHDs have been registered on the supervised division, and more will be registered in the coming days. As of 26 September, approximately ten NCHD posts of the 190 identified as vacant by the HSE before the recruitment of doctors from India and Pakistan remain vacant. Approximately 60 doctors are expected to sit further assessments for the supervised division and if successful will be offered employment.

To date, the HSE has spent €80,000 accommodating NCHDs recruited from India and Pakistan. The HSE is allowing these doctors a modest weekly allowance in respect of accommodation, €100, and the provision of meals. It cannot be argued that these allowances are in any way excessive.

The doctors are making significant contributions to vacancies which existed in areas such as anaesthetics, paediatrics, emergency medicine and general surgery, and are delivering a safe, effective service to patients. In addition, they are reducing the HSE reliance on agency staff, reducing overtime costs, improving the quality of the service and ensuring further compliance with the European working time directive.

I thank the Minister. I ask my question fully aware that the Minister is a mere six months in his new post and has inherited his difficulties. He is committed to his tasks. It is heartening that, even within six months, progress has been made in this area. Can the Minister assure the House that where there are unfilled doctors' posts, priority will be given to front-line services such as accident and emergency services and surgery?

I am concerned about doctors who trained in our educational system, commenced their medical internship and senior house officer post and who may be attracted to working in the private sector. We may have a brain drain in this area. Will the Minister comment on this? What can be done to assist in this area? I am grateful for the Minister's response.

In the context of concerns I raised about doctors on the supervised medical register when we discussed the medical practitioners legislation, we must ensure the doctors are not regarded as yellow-pack doctors or doctors with lesser qualifications. This is critical. If campaigns are required to prove they have the same competencies as others, so be it. If they are not regarded as the same, inherent difficulties could arise.

There is the old phrase, "belt-and-braces approach". In more rural areas, we say, "to be sure to be sure". It is absolutely the case that the doctors are extremely well screened and trained. They have been interviewed by the consultants in respect of language skills and ability and have gone through the documentation and examination processes. In their places of work they have been monitored. I thank the doctors who have come to this country and wish them well. I expect that when they leave to return to their own countries in two years, they will do so with enhanced skills and knowledge which they can use when treating their fellow countrymen.

Written Answers follow Adjournment.

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