Priority Questions

Hospital Services

Billy Kelleher


1. Deputy Billy Kelleher asked the Minister for Health when he will bring forward proposals on the formation of new hospital groups; and if he will make a statement on the matter. [13933/13]

We have a large number and range of acute hospitals in Ireland, all of which are held in high esteem and used mainly by local people for the majority of their hospital care. However, the provision of modern, high quality, safe care requires increasing levels of co-operation and overarching systems of governance and communication. We know that the traditional practice of providing as many services as possible in every hospital is neither sustainable nor safe. Experience in Ireland and abroad teaches us that a co-ordinated system of care rather than a sporadic approach from hospital to hospital is clearly better for patients. The formation of Irish acute hospitals into a small number of groups, each with its own governance and management, will provide an optimum opportunity for hospital services to be configured to deliver high-quality, safe patient care in a cost-effective manner.

It was with this in mind that I appointed Professor John Higgins in June of last year to chair a strategic board on the establishment of hospital groups. I have received Professor Higgins’ report, which is based on a comprehensive consultation process and contains almost 60 recommendations on the formation, management and governance of hospital groups, all of which are strongly endorsed by the strategic board. I will shortly submit this report to Government for consideration and decision on the final formation of each hospital group.

I appreciate that this report and the related Government decision are anxiously awaited. However, this is the most radical and fundamental modernisation of our health system infrastructure since the State's foundation and I take very seriously my obligation to consider the report closely, to assure myself and my Cabinet colleagues that it provides a robust basis to enable timely access to a high quality and sustainable hospital service for those who need it.

The Government will decide on the initial make up of hospital groups which will be established on an administrative basis pending the legislation required to set up hospital trusts by 2015. Before these trusts are established, the composition and functioning of the groups will be reviewed and if changes prove necessary, then they will be made with Government approval when the hospital trusts are being formed.

The public is awaiting the publication of Professor Higgins's report and its consideration by Cabinet. It should be published as soon as possible. The Government has an obligation to consider it, but why not publish the 60 recommendations highlighted by the Minister so we can have a broad discussion on them?

I listened with great interest when the Minister stated he takes seriously his position with regard to reconfiguration of hospitals. This is a first for him, because when he was in opposition he took it anything but seriously. He was reckless in his commentary on many occasions, and completely irresponsible when it came to the issue of ensuring patient safety was a priority and that reconfiguration in certain areas was necessary. We have seen this with regard to the commitments made in Roscommon and Navan which clearly have been betrayed. The reconfiguration report should be published, rather than having a political brickbat on a continual basis, and indeterminable leaks to agitate the public and gauge public opinion to see where there is resistance and least resistance, pitting hospitals, public representatives and parties against each other.

A question please, Deputy.

I want the Minister to publish the report as quickly as possible so we can have a fully informed debate. Does the Minister agree if the Government is making the decision, we can have a look at it and the Government can adjudicate on it and then make a decision based on its recommendations? The Minister should not object to the public and the Opposition having the report. Does the Minister agree with regard to previous commitments made on reconfiguration, with regard to Navan accident and emergency services and the retention of all key supports there, that the pledge being requested should be signed by all public representatives and all parties?

Deputy Kelleher seems to be in fine fettle today-----

-----making all sorts of allegations about the past.

Why do we not look at some of his past endeavours and those of his leader-----

I am on about statements-----

I did not interrupt the Deputy.

The Minister has accused me of allegations. That is a very serious offence.

It is not unusual though.

Exactly, it is not unusual. Deputy Kelleher accused me of being reckless with regard to patient safety; I have been anything but. The issue with regard to Roscommon was a safety issue as demonstrated very clearly by HIQA. No matter what I sought to do with regard to resources, this could not be addressed so I had to take the action I did. However, I am very pleased to say this hospital's future is secure and more services are available there than when the decision was made. We now have the addition of rheumatology, plastic surgery and a sleep apnoea clinic to mention but a few of the services which were not available previously. Deputy Naughten has tabled a question and I am sure we will have more time to go into the Roscommon issue.

Since the outset my focus has been on outcomes for patients and not inputs and how many doctors, nurses or billions. My focus has been on how many patients are treated and how quickly, and how many have had to be readmitted because they were not treated correctly in the first instance. This is what I am about and we have shown we have been able to do this, even with a reduction in resources in terms of finance and personnel.

The report is the greatest shake-up of the hospital system since the foundation of the State and I will consider it closely. I do not wish to delay any longer than I must to do it properly.

The big difference between this Minister for Health and a former one, who is now Deputy Kelleher's party leader, is that when I publish a report I will act on it. I will not leave it sitting on a shelf as the Deputy's leader did with I do not know how many reports.

When he was in opposition the Minister's priority was votes, and cynically so. Whether or not he has changed is still questionable.

In the context of the Higgins report, it was said that there were discussions between Waterford Regional Hospital and South Tipperary Hospital, and that they would be linked with Cork. In addition, it was reported that Wexford Hospital and St. Luke's Hospital would be linked with Dublin hospitals. There are clearly concerns about that because there have been claims of political interference in the decision-making process. The Minister should alleviate any such concerns because there has been political interference in other health areas concerning primary care centres and the funding of hospitals.

If the report is published, we will all know exactly what it recommends and can then have a political debate on it. Until it is published, however, there will obviously be concerns because there are continual leaks. In addition, there have been huge protests in the south east concerning Waterford Regional Hospital, and there are also concerns about Navan Hospital where the accident and emergency unit has been downgraded. In the latter case, commitments were made that a new hospital would be built prior to any service reduction in Navan. In the interests of transparency this report should be published quickly so that we can have a fully informed debate on it.

I wish to correct the record of the House. My focus, and my reason for entering politics, is patient welfare. As a practising GP, I watched in frustration the ongoing shambles of a chaotic health service that had billions of taxpayers' money poured into it with no net effect. The consequence of that was that in January 2011, a mere two years ago, we had 569 people lying on trolleys despite the previous Government and the then Minister for Health stating clearly that this would be treated as a national emergency. If that was how a national emergency was to be dealt with, God help us if we had a major national emergency. Of course, we did ultimately have such an emergency because we had to give away our financial sovereignty due to the mismanagement of the previous government.

The focus here is on outcomes for patients. It is about making this a service for patients and not a self-serving system which is what we inherited from the previous Government.

Disability Grant Schemes

Caoimhghín Ó Caoláin


2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will reverse the decision to cease the mobility allowance and motorised transport grant schemes until such time as an alternative scheme or schemes are put in place that is both compliant with equality legislation and provides at least equivalent support to all individuals qualifying under the said two schemes; and if he will make a statement on the matter. [14001/13]

The Government is very conscious of the needs of people with a disability who require transport supports from the State and also conscious of the position of the Ombudsman that the mobility allowance and the motorised transport grant schemes are illegal in the context of the Equal Status Acts.

The Minister, Deputy Reilly, and I considered carefully the recommendations of the Ombudsman in regard to both schemes and, in particular, we looked at the potential cost of implementing the recommended changes. Any additional cost incurred by expansion of the schemes would have to be met from current expenditure and result in a reduction of front-line specialist disability, older people and mental health services for people who need them. It is clear that an extension of either scheme would create serious financial pressure on the health budget in the current climate and would be unsustainable.

Following detailed consideration of issues involved with Cabinet colleagues, the Government decided on 26 February that it is no longer possible to allow the two schemes to continue as they presently operate and to devise an alternative solution for meeting people's needs. A special review group, which is independently chaired, has been established to seek an alternative method to provide for the needs of people in a manner that does not run counter to the Equal Status Acts.

The initial phase of the group's work, which is led by the Department of Health, will concentrate on issues around mobility allowance and the motorised transport grant. Thereafter, the group will continue, under the leadership of a different Department, to look at opportunities for the enhancement of the transport options provided to the relevant persons in need.

As part of the initial phase of the review, the Health Service Executive will examine the circumstances of all those currently benefiting from the schemes to ensure the identified solutions will encompass their priority mobility needs. In addition, the Minister for Health has instructed the HSE to contact each individual in receipt of the payments to notify them of this decision.

It is important to note that, although the Government's decision ends both schemes to new applicants with immediate effect, the payment of mobility allowance to those currently in receipt of it will continue for a period of four months following the decision.

It is also important to note the decision is in no way intended to save costs and the funding involved in the two schemes of €10.6 million remains committed to meeting the priority transport needs of people with a disability.

Additional information not given on the floor of the House

In advance of the establishment of the project group, Department of Health officials met representatives of the National Federation of Voluntary Bodies, the Disability Federation of Ireland and the Irish Wheelchair Association at my request. In addition, membership of the project group, which is independently chaired, is drawn from both the statutory and non-statutory sectors. The work of the project group is being supported by the National Disability Authority and includes representatives from the Irish Wheelchair Association, the Disability Federation of Ireland, an independent service user and advocate for people with disabilities, and a retired county council manager with relevant experience. Both the Minister, Deputy Reilly, and I have instructed the project group to seek solutions across the whole of Government in order that alongside representatives from the Department of Health and the HSE, membership also includes representatives from Pobal and from the Departments of Transport, Tourism and Sport, the Environment, Community and Local Government, Social Protection and Finance.

The project group has met twice and its next meeting is scheduled for 25 March. The Government decision includes a requirement that the results of the review will be presented to the Government before any final decisions are made on future arrangements.

This issue has not been addressed in the two years since the coalition came to power. The entire focus on the mobility allowance and the motorised transport grant scheme has only come to pass again because it is out of sync with the equality legislation. No action has taken place over that two year period and there is no point in hiding behind the failures of the previous Administration. The current Government has failed to do it over two years and now, in one fell swoop, it is leaving a significantly targeted sector of people further targeted with the loss of such schemes. It is no comfort to those who would be applicants or to those who have the mobility allowance and for whom it will cease in four months time.

Put a question please, Deputy.

What should have happened for this sector of people with disabilities is that an alternative should have been devised and the scheme should have been extended to accommodate this if, at whatever point, the commencement of this consideration got under way. As the Minister of State can be no less aware of the extent of the hurt and pain this has caused throughout the State, I again ask and appeal to her to withdraw this cut-off date, to give certainty to those who currently have these supports and to create a deadline for the introduction of a scheme that will serve, within a specified timeframe, all the need that exists. As this is what people need, will the Minister of State do so?

Members should recognise the Government is more than conscious of the effect the abolition of these two schemes will have on those who are reliant on them. This is the reason it took the Government so long, not that it was unaware of it. The Government has been considering these two schemes since coming into office. The difficulty is they are in contravention of the Equal Status Acts and even were one to comply with this legislation, the Government also believes there are certain areas in which it will contravene the Disability Act. Consequently, it was not one but two legislative items that were involved. To a great extent, the report by the Ombudsman forced the Government's hand. This is not to suggest the Ombudsman's report was wrong. It was perfectly clear and legitimate for the Ombudsman, Ms Emily O'Reilly, to make such a report and it became clear that both schemes were operating illegally. Were the Government to extend both these schemes in the manner suggested, the Government simply could not afford it. At present, it is examining how to meet the transport needs of this group of people, but it is highly conscious of the difficulties that arise in respect of both these schemes.

It is known that the Department of Health - I will leave it as being that Department, as distinct from the two successive Governments - was aware since 2008 that these particular schemes were not in line with the Equal Status Acts. The aforementioned schemes have been akimbo since the millennium year of 2000. What has the Minister of State discovered the Department of Health to have been doing to address this issue over the years spanning the end of the previous Administration to the time the present Government took office? Was it doing anything at all to address this particular issue? It is unacceptable, and in a point I have made to the Minister of State previously, I have it to say that for people in large parts of the country in which there is extremely limited public transport, not least in my own constituency, there is no great return from the travel pass for many in circumstances such as those that obtain in rural Cavan, Monaghan and many other places throughout this State. I refer to the scenario in which she is not prepared to reverse the decision announced.

Can the Minister at least tell us what might replace these schemes? Importantly, given that she has put a time frame of four months for the death of entitlement, can she give us a sense of when whatever is to replace them will come on stream?

In fact, the Ombudsman tells us that these schemes have been illegal for the last 13 years. That is not to put blame on anybody.

Since the millennium year.

We looked at alternatives but each alternative we proposed was found to be illegal on the advice of the Attorney General. The group we have put together is wide-ranging and will examine transport needs. It will meet again on 25 March. With regard to the time frame, we hope to have a proposed scheme in place to replace the schemes we have abolished. It will not be an individualised scheme. The Deputy is correct in what he said. We all know what the circumstances are. It might be okay if one lives in the middle of a city and there is a transport solution at the end of one's street, even though that is not always the case in urban areas. However, what if one lives in a very rural area? We must seriously examine how to put in place a transport scheme for people with disabilities, not a separate transport scheme just for them but a scheme that is capable of allowing people with disabilities to travel. That is the type of mainstreaming we should have been examining for the last 20 years anyway.

Medical Card Review

Thomas Pringle


3. Deputy Thomas Pringle asked the Minister for Health the reason many elderly persons have had their medical cards cancelled by the primary care reimbursement scheme without any notice; the steps being taken to ensure that the system prevents this happening again avoiding undue distress and cost on elderly patients; and if he will make a statement on the matter. [14090/13]

Under the provisions of the Health Act 1970, as amended, determination of eligibility for a medical card is the responsibility of the HSE. The HSE has produced national assessment guidelines to provide a clear framework to assist the making of reasonable, consistent and equitable decisions when assessing an applicant. These guidelines are publicly available and can be downloaded from the HSE’s medical card website.

A new medical card scheme for persons aged 70 years or over was introduced with effect from 1 January 2009. Under this scheme, a person who is ordinarily resident in the State qualifies for a medical card as long as their gross income does not exceed the means test income limit. The income limit for a single person is currently €700 per week. The relevant income limit for a couple is €1,400 per week.

The standard procedure for the review of medical cards for persons aged 66 years or older is that their medical card will be reviewed every four years. In the interest of fairness between medical cardholders, it is important that all people aged 70 years or over are treated in a like manner by the HSE. The primary care reimbursement office, PCRS, has confirmed that medical cards are not cancelled without notice. The PCRS notifies all medical card holders by letter three months in advance of the renewal date of their eligibility for a medical card, or when a review is due. A further reminder letter is sent to card holders who have failed to return their renewal form a month prior to the card expiry date. If no contact is made by a client with the central office within this period, their medical card will expire. The central office makes every effort to contact clients. In a small number of cases a client may not receive the renewal notice due to having changed address. When notified of such cases the central office extends the person's eligibility for a sufficient period to allow them to complete and submit a renewal.

Additional information not given on the floor of the House

Any medical cardholder undergoing a review for a renewed medical card, who genuinely engages with the HSE in that review, will not have their entitlement withdrawn before the review is complete, regardless of the expiry date shown on their medical card. In cases where a decision is made not to grant a medical card, the applicant will be informed of the decision and notified of their right to appeal this decision. Contact details for the appeals office are provided to them with that decision. Where a person submits an appeal to a decision not to renew a medical card within 21 days of that decision, they will retain their medical card until the appeal is decided. In conclusion, all efforts are being made to deal with the individuals properly, fairly and impartially.

I put down this question because I have been contacted over recent months by a large number of elderly people who had their cards cancelled by the PCRS without prior notice. Indeed, when contacted, the PCRS acknowledged that the system did not send out the letters to the people concerned, and it reinstated the cards. However, this has caused huge distress for elderly people who, when seeking to renew their prescription, were told by either their GP or pharmacist they did not have a valid card. There was some type of system failure within the PCRS. It must be identified and steps must be taken to ensure the system does not allow such incidents to happen again. Elderly people should not have to go through that type of distress. They should always be notified.

I can only agree with the Deputy that this should not occur.

I ask him to relay to me details of cases where people were not notified in the manner that I have been advised is practice. I am satisfied there have been significant improvements recently in the administration of the medical cards system and primary care reimbursement system, PCRS. While it may well be the case that the system does not work at full throttle in all circumstances, I am convinced it is working very well. If the Deputy provides me with details of the specific cases he raised, I will address them.

Where someone is undergoing a review or is uncertain about the nature of the contact, it is vital that he or she engage with the service. In most, if not all, circumstances a proper resolution will be found.

I thank the Minister of State for his response. I will arrange to have details of the relevant cases sent to him. When my office contacted the primary care reimbursement system, the medical cards of the individuals in question were reinstated as soon as it was realised that a system failure had occurred. The problem, however, is the distress caused by such failures. The system should be sufficiently robust to prevent such cases or at least minimise the number of them.

Health Services Provision

Billy Kelleher


4. Deputy Billy Kelleher asked the Minister for Health his assessment of the new Health Service Executive regional service plans; and if he will make a statement on the matter. [13934/13]

Under the Health Act 2004, the Health Service Executive must prepare a service plan and submit it to me for my approval following publication of the Estimates. The national service plan which was submitted to me in December sets out the quantum and type of health services to be provided in 2013 within the overall level of funding provided. In accordance with the Act, I approved the national service plan and laid a copy of the plan before both Houses of the Oireachtas on 9 January this year. At the end of February, the executive prepared and published its operational plan and the regional service plans which underpin the national service plan. The HSE has responsibility for the delivery of services set out in these regional plans and ensuring services are delivered within budget. The director general designate of the HSE, Mr. Tony O'Brien, has provided a full briefing on the regional service plans to the regional fora.

When one breaks down the regional service plan, specifically in respect of the number of whole-time equivalent staff in services for older people and mental health and disability services, one finds that a significant reduction in staff numbers is envisaged. For example, in HSE west, HSE south, HSE Dublin-midlands and HSE Dublin north east, the number of whole-time equivalent staff is expected to fall by 267, 382, 446 and 277, respectively, giving a total reduction in whole-time equivalent staff of 1,372. Given that staff are under serious pressure as matters stand, does the Minister agree that further reductions in staff will result in a reduction in services? The Minister's view that fewer staff can continue to provide more care is not sustainable because one reaches a breaking or tipping point at some stage. It is evident that it will not be possible to sustain the level of service required in services for older people and mental health and disability services with the reduced number of staff envisaged in the regional service plans.

A reduction in staff does not necessarily mean less service. We are seeking to reduce the cost rather than level of service provided. This policy forms part of the Government's general approach to public services. We must reduce our cost base because we became uncompetitive. We are, however, becoming more competitive and we must secure further reductions across the board. Everybody understands that we cannot continue to spend more than we raise in taxes.

There is room for major improvement in certain areas of the health service. I refer specifically to community nursing home units where we are struggling in many cases to achieve a nurse to health care assistant ratio of 1:1. The Royal College of Nursing in England has indicated the ratio should be 2.5 health care assistants per nurse. Moreover, consultants are seeing patients who could be treated by general practitioners and GPs are seeing patients who could be cared for by nurses.

Nurses are looking after patients whom health care assistants could be looking after. A prime example is provided by a study conducted at St. Mary's Orthopaedic Hospital in the Deputy's county of Cork.

The study showed that, if physiotherapists were able to screen referrals to orthopaedic outpatient services, 50% of cases would not need to be seen by orthopaedic surgeons and could be dealt with by physiotherapists.

The Minister has just reminded me of another broken promise as regards St. Mary's Orthopaedic Hospital, namely, that it would retain orthopaedic services. However, they have been moved to the South Infirmary Victoria University Hospital. However, let that be the case.

Did the area not get the urgent care centre, which is doing great work? Is the Deputy against it?

Deputy, please. This is Question Time.

I supported that move, but the current Government opposed it. In fact, I was the only one who supported it. I welcome the fact that the Minister came to Cork to open the urgent care centre, which is working well.

When discussing the reduction in services, it is evident that a tipping point must be reached. It has been reached with the attempt to provide the same level of service this year as last despite a reduction of 1,732 in staff numbers. Something will give at some stage. When it does, older people, people with disabilities and people with mental health issues will suffer.

I will make two points. First, the building and funding process in the case of St. Mary's Orthopaedic Hospital had more or less been completed by that point. It would not have made sense to start reversing the decision. We were left with something that was as good as a fait accompli.

I tried to tell the Minister that, but he would not listen.

Second, and if I may answer the Deputy's question on the reduction in staff numbers, an additional 884 new staff have been provided for mental health services.

We are reviewing the nursing home support scheme with a view to determining how the money might be better spent supporting people at home. I have no wish to engage in political point scoring, but we were left with a situation in which different criteria were used in various parts of the country to assess people's needs for long-term care. As a result, in one third of cases people need to be in nursing homes, that need is questionable in another third and, in the last third, they should definitely not be in homes.

We have invested heavily. I wish to put on record a note of gratitude for Atlantic Philanthropies, which supported us with a couple of million euro in the development of a new single assessment tool for older people to determine whether they need long-term care or what sort of home care packages might keep them at home for longer.

Health Service Recruitment

Catherine Murphy


5. Deputy Catherine Murphy asked the Minister for Health when he intends to move forward with employing extra occupational therapists, speech and language therapists and psychological services to address the shortfall which exists in all three services; the numbers of new recruits expected to be employed; the locations that will be targeted for the deployment of new therapists; if the budget that was withdrawn in 2012 has been reinstated for 2013 in respect of same; and if he will make a statement on the matter. [14362/13]

The Government is committed to reforming our model of delivering health care so that we can reduce the cost of achieving the best health outcomes for our citizens. The implementation of the primary care strategy continues to be a priority for the Government. The objective is to develop services in the community that will give people direct access to integrated multidisciplinary teams of general practitioners, GPs, nurses, physiotherapists, occupational therapists and others.

An allocation of €20 million was set aside in the HSE's 2012 national service plan for approximately 250 primary care posts. Due to financial constraints, however, it was not possible to fill these posts last year. This allocation of €20 million is ring-fenced in the 2013 national service plan to enable recruitment of posts to strengthen primary care services. The posts will be filled using the resource allocation model, based on deprivation and need, which was developed by the HSE's National Primary Care Office and health intelligence unit. Using this model, the HSE completed a detailed analysis of the numbers and distribution of public health nurses, registered general nurses, occupational therapists, physiotherapists and speech and language therapists. The analysis revealed considerable variation across the 17 integrated service areas, ISAs, in ratios of health care professionals to population and to population numbers in areas of high deprivation.

Based on this analysis, it proposed that, in addition to public health nurse and registered general nurse posts, the following therapy posts will be recruited to primary care teams across the four HSE regions as follows: Dublin mid-Leinster is to get 12 occupational therapists, 24 physiotherapists and 22 speech and language therapists; Dublin north east is to get nine occupational therapists, 14 physiotherapists and 13 speech and language therapists; the south is to get 17 occupational therapists, six physiotherapists and four speech and language therapists; and the west is to get 13 occupational therapists, two physiotherapists and seven speech and language therapists. It is my firm intention, along with that of the Minister for Health, to have these posts and the public health and registered general nursing posts filled as soon as possible in 2013.

In relation to mental health, a special allocation of €35 million was provided in budget 2012 to be used primarily to further strengthen community mental health teams in both adult and children’s mental health services.
A total of 414 posts, to include clinical psychologists, social workers, occupational therapists and speech and language therapists, were approved to implement the €35 million package of special measures. As at end of February, 307 posts have been filled, by which I mean an employment contract has issued and is signed with a start date agreed, and the remainder are at various stages of selection.
Additional information not given on the floor of the House
Budgetary pressures within the HSE delayed the full utilisation of this funding, but this sum is now available to mental health services along with an additional €35 million allocated in budget 2013 for the continued development of mental health services. The HSE National Service Plan 2013 commits to a number of objectives including the further development of forensics and community mental health teams for adults, children, older persons and mental health intellectual disability and to the recruitment of 477 additional staff to implement these measures.
In order to ensure that the additional resources will be used to best effect, discussions are ongoing within the HSE, and in consultation with the Department of Health, to finalise the allocation of these resources. Each HSE region is being asked to submit a business case against each of the identified objectives detailing how the funding is to be spent and the type and number of whole-time equivalents, WTEs, to be recruited. It is expected that this process will be concluded in the very near future.
My colleague, the Minister for Health, has been assured by the HSE that the recruitment process for the new mental health posts being funded in 2013 and any outstanding posts from the 414 approved in 2012 is being given priority within the HSE.

I tabled this question because not a day goes by that someone does not come into my office or contact me by e-mail or otherwise about the deficiency of services in my area. Most of the people to whom I speak have heart-breaking stories about lobbying for services that do not exist. I welcome the fact that the money is ring-fenced for this year but the fact that it was in the budget for last year and was not spent leaves me very nervous about what will happen this year. I would have thought if the 2013 allocation is ring-fenced that we would already have begun to see people filling those posts. I could give a litany of people who indicate-----

Could the Deputy ask a question please?

I will ask a question. I could give a litany of cases that indicate the kind of problems that exist and where there is not even a waiting list. Given the ring-fencing of the money for 2013, why have those posts not been filled at this stage? What assurances can I get from the Minister that the money will go where it is intended because that is not what happened last year?

I understand the point raised by the Deputy, but we are proceeding with the recruitment of the posts. I have indicated that already in terms of the mental health posts for which my colleague, the Minister of State, Deputy Kathleen Lynch, has principal responsibility. The primary care posts will be filled. There is not a basis for any nervousness about the posts. I say that in good faith, straight to the Deputy through you, a Leas-Cheann Comhairle. There is no basis for nervousness and the primary care posts will be filled this year. As a sign of our intention and goodwill in that regard, one can see on the basis of the information I have just given the progress that has been made on the mental health posts. Similarly, the Deputy will see the primary care posts filled. I have been in touch with the director-designate of the HSE about the posts as recently as today. The posts are going ahead and they will be filled.

My nervousness is based on an unwillingness to welcome the posts until I see the people physically in place. When that happens I will be the first one to welcome them because they are critically important for children given that the windows of learning opportunity must be filled at an appropriate time. I see the upshot of the posts not being filled last year by virtue of the fact that I have a stream of people coming to me about deficiencies in service. Will the posts be filled in the first half of this year? If the situation drifts into the latter half of the year I would be concerned about the way budgets can get depleted and the ring-fencing becomes unhinged.

There will be no unhinging of any fence with regard to these posts. The Deputy is correct to raise the issue and I have no difficulty with her doing so and pressing me on it. My job is to deliver and I will deliver.