Skip to main content
Normal View

Dáil Éireann debate -
Tuesday, 1 Apr 2014

Vol. 836 No. 3

Topical Issue Debate

Middle East Issues

I thank the Office of the Ceann Comhairle for allowing Deputy Nolan and me to bring this very important issue to the attention of the House. Having visited Hebron six months ago, I have seen first-hand the plight of the Palestinians within the city. I saw the al-Rajabi house itself - the site of the proposed settlement - when I was there. There was a doubt about the legality of the purchase of the house, but the Israeli Supreme Court has ruled that it was legally purchased. The final decision will be with the Minister of Defence in Israel.

The significance of the matter is the impact it will have on the Palestinians who are living there. I have seen myself that the whole centre of the city of Hebron has been sterilised. No Palestinian can engage in business, live within the centre or walk through the city. If I were a settler in the city of Hebron and wanted to reach the Minister of State, Deputy Paschal Donohoe, I could simply cross the floor. If I were a Palestinian, I would have to take a circuitous route around the building and come back to meet with him. That is the life of the Palestinians living there. The proposed settlement will split the communities within the city of Hebron and increase tensions which are already rising.

This is part of a wider issue. Negotiations are ongoing within a sham peace process between the Israelis and the Palestinians. It is split at the moment. Within the West Bank area, the Israelis have a policy of not forcibly but gradually removing farmers from land and householders from their properties. I hope that in his response, the Minister of State will offer strong support for the Palestinians, particularly those in the Hebron area. Within the location of the house which has been purchased, there will be sterilisation. Businesses will close and Palestinians in the locality will have to generate their activity elsewhere.

I had the privilege of visiting the West Bank, Gaza and Israel last year. Of all the situations of complete abnormality that were evident between Israel and Palestine and their two peoples, the most toxic was the one which obtained in Hebron. We are talking about a large Palestinian city which is solidly in the West Bank and nowhere near the state of Israel. Settlements have been cropping up all around over recent years. In the historic centre of Hebron, where the markets once flourished and shops once existed, settlements have grown up. They have expanded and caused a complete collapse. I often say to people in Galway when I recount my trip that it is like walking down Shop Street if all the shops were closed, the Galwegians were told to keep away and the only people permitted to be there were a few settlers. That is how appallingly the native Palestinian residents of Hebron are treated.

These little settlements are gradually extending into each other. The expansion into this new area called "the house of contention" has been signalled for some time since it was illegally purchased in March 2007 with forged documentation, a matter which has been going through the courts over recent years. It is another symbol of just how powerless, helpless and destructive matters are in Hebron. Hebron is the centre which demonstrates the hatred, viciousness and lack of trust on both sides. If the settlement goes ahead, we must lose hope that there is a genuine attempt to create a two-state solution. Ultimately, this will be a political decision in Israel. It must go through the Israeli Minister of Defence. Regardless of the European Union and international positions, I would like the Irish position to be articulated to the effect that we are against the expansion of the settlements and to have it communicated to the Israeli Government.

I thank the Deputies for raising the issue. The Tánaiste and Minister for Foreign Affairs and Trade, Deputy Eamon Gilmore, has consistently made clear the Government's strong criticism of and opposition to Israeli settlements and settlement expansion, which are illegal under international law and constitute a major obstacle to peace. Settlements and related policies in area C seem designed to drive Palestinians off the bulk of the land they occupy and to crowd them into the cities under Palestinian Authority control. Settlements establishment and the policies implemented to support them inherently involve continual injustices, hardships and humiliations for Palestinians. They are perhaps the main source of tension between the two communities on the ground. The Deputies, through the analogies they have used, have made very clear the injustices involved in these arrangements. Deputy Lawlor spoke about the difficulties in someone coming to approach me.

Deputy Nolan's use of the analogy of Galway made clear the injustices involved in these arrangements.

The Israeli Government and Israeli public opinion are in no doubt about the Irish Government's views on this issue. The city of Hebron presents a showcase or microcosm of these issues in action. Hebron is the largest city fully in the West Bank, with 170,000 Palestinian inhabitants and an additional 7,000 Israeli settlers in a large settlement on its outskirts. In the centre of this ancient city some 850 settlers have established a number of small scattered settlements around the old town. In many cases, settlers simply occupied buildings and the new settlement was subsequently recognised by the Israeli authorities.

To protect the settlers and their rights a large force of Israeli soldiers is also based in the centre of Hebron. Palestinian residents have been subject to extensive movement controls, as the Deputies noted, and are excluded entirely from the main street and other areas in the interests of the small minority of settlers in their midst. As a result, many Palestinian businesses in the old city have closed down.

In March, the Israeli Supreme Court issued a ruling, anticipated for several months, on the purchase by Israeli settlers of a house in Hebron known as al-Rajabi house or the house of contention. The ruling upheld a 2012 decision by the Jerusalem District Court that the purchase of the house was legal and settlers should be allowed to resume living there. This house, which is a large apartment building, would constitute the nucleus for a new settlement in Hebron and become the first settlement established in the city since the 1980s. It would inevitably be accompanied by new security checkpoints and closures and developing pressure on Palestinian residents. There is a strong possibility that its occupation would lead to further tension and violence in the area. When clashes occur the response is always to further restrict and exclude Palestinian residents.

As the Deputies noted, the next stage in the process is for the Israeli defence Minister to authorise and permit the transaction. Until then, the settlers continue to be prohibited from entering the building. The Deputies asked me to elaborate on the Irish position on this matter. Ireland calls on the Israeli defence Minister not to grant the purchase permit for the building given the very sensitive political nature of the settlement.

Israelis and Palestinians are engaged in direct negotiations, which are intended to decide within months all questions about the future of settlements. Ongoing settlement announcements such as this have clearly been damaging to confidence in the peace process. Israel has regularly announced new settlement units since the talks began, including significant plans for more than 2,300 new housing units in six West Bank settlements announced in March.

On the European Union position, in a statement on 21 March, High Representative Ashton strongly condemned the latest settlement announcement on behalf of the EU. She stated that such actions undermine the current negotiations and, as a consequence, the two-state solution and urged the Israeli authorities to reconsider their plans and reverse their decision. Ireland fully supports this position.

More broadly, the Tánaiste has also called for the international community to be more forceful in its response to continued settlement expansion. Ireland has supported all measures by the European Union to increase pressure on the Israeli Government on the issue of settlements and the Government will continue to be active on this issue.

I welcome the strong views expressed by the Minister of State, which strengthen the position held by many people here and throughout the European Union on developments on the ground in the West Bank. Unfortunately, words do not have much effect on Israeli policy on settlement expansion in the West Bank. Strong measures such as a boycott of goods produced in settlements and sold in the European Union are required. I hope the Government will take this matter further because strong condemnation by the Oireachtas and European Union do not have an effect on Israeli policy on settlement expansion. A boycott of goods produced on settlements would indicate we have a serious policy on the ongoing peace process, which I believe is a sham. Talks may be taking place but nothing is being done on the ground.

I thank the Minister of State for his clear, concise and powerful statement in response to the issue Deputy Lawlor and I raise. We are discussing a conflict that is complex, detailed, historical and ingrained. It involves many stakeholders, specifically the Arab states bordering Israel and Palestine and the Israelis and Palestinians. The respective positions of Palestine and Israel are characterised by a power imbalance. While we should give the latest round of negotiations a shot, that should not prevent us from pointing out that nothing is improving for Palestinians despite many years of peace negotiations. On the contrary, the position in the West Bank is deteriorating and Gaza is in crisis. We must prepare options and inform the Israelis and Palestinians that this is their final chance to arrive at a solution together and on their terms as we will otherwise enforce the principles of international law and stop the import of products from illegal settlements. We must indicate that this is the last chance and we will move to enforcement if the talks fail.

I thank Deputies Lawlor and Nolan again for their contributions. I agree with Deputy Nolan's analysis regarding the inherent complexity of the situation, the weight of history and the dilemmas and challenges facing the countries and communities in the region. Amid this complexity, the view of the Government, one which is clearly shared by the Deputies, is that we strongly support a two-state solution and the creation of a peaceful and secure future for the communities in the region. We strongly believe the current negotiations are vital in this regard.

It is within this framework that the continued expansion of settlements is destabilising and difficult. The negotiations are challenging, subtle and fraught and will have a major impact on the region and beyond. The expansion of settlements presents a major challenge to the success and continuation of the negotiations. For this reason, I emphasise our overall view on settlement expansion, with reference to the specific building in Hebron and the decision to be made by the Israeli Minister for defence. There are people of good sense and courage involved on both sides of the current negotiations. The Tánaiste and I sincerely hope that courage and common sense will prevail when the Minister takes his decision and an atmosphere will be created that is conducive to a successful conclusion of the negotiations.

Patient Safety Agency Establishment

I would like to discuss with the Minister for Health the establishment of a patient safety authority in the Irish health service. I call on him to bring forward legislation to establish a robust patient safety authority that will inspire confidence in patients that their concerns will be properly addressed; to ensure that the structures and governance of such an organisation are properly resourced so that complaints are dealt with in a timely manner; and that the patient safety authority can enforce the changes needed in our health service to protect patients.

I call on the Minister to ensure the establishment of a comprehensive patient safety authority in this country, one that has real power and teeth in representing patients. I would like to see established a patient safety authority powerful enough to oversee the Irish Medical Council, the Health and Social Professionals Council, the nursing organisations, the Health Information and Quality Authority, HIQA, and the Irish Mental Health Commission. Currently, outside of the Department of Health there is no patient-focused organisation to represent patients in terms of their needs and complaints. This is not good governance. There is a need for a strong, robust organisation, outside of the Department of Health. The Health Service Executive is to be abolished. We need an organisation which patients can have confidence will protect them and for whom their interests are the primary focus.

The Irish Mental Health Commission has been in place for more than ten years and there is a policy document driving change in the mental health services, namely, A Vision for Change, yet in the health supplement of today's The Irish Times it is stated that patients still do not have individual care plans. Those working in the health service will know that the Irish Mental Health Commission has given increased autonomy and power to patients suffering mental health problems. While their rights within the health service have improved dramatically, there are weaknesses in the system.

In terms of the many weaknesses that have arisen time and again within our health services, which fell to the Minister to deal with, there is a need for a one-stop-shop, such as an ombudsman to whom patients can go to have their issues dealt with. I call on the Minister to ensure a robust and well resourced patient safety authority is put in place to protect patients. I do not think it is right that the Department of Health should be investigating itself when issues arise. The response to the Portlaoise crisis was rapid and good but to instil confidence in patients we need a separate, strong and powerful organisation.

When it comes to enforcing standards in our nursing homes and hospitals, HIQA does its job well. However, its remit is not the same as would be the remit of a robust patient safety authority. There has been a patient safety authority in the UK for more than a decade now. When this issue was raised years ago with former Minister, Mary Harney, the best she could come up with was the establishment of a commission to look into the matter. We have gone past that point. What we need now is a strong organisation in this area.

The Minister plans to introduce universal health insurance in this country and to reform how our health services operate. For this to work and to ensure that standards do not slip again, we need a robust patient safety authority. I ask that the Minister respond to my proposal.

I thank Deputy Twomey for raising this critical issue. Patient safety must be at the heart of everything we do in health. It is a priority issue for me and the Government. It was for this reason patient safety was the primary focus of the 2014 national service plan for the HSE. It is also the reason we decided to expedite the patient safety agency through the HSE on an administrative basis, although ultimately, it will be supported by legislation and be independent.

I have listened carefully to what Deputy Twomey had to say, much of which I agree with. The recent report by the Chief Medical Officer into the perinatal deaths at Portlaoise hospital indicates there is a huge need to improve the quality and safety of services across the health system. As the Deputy will be aware, HIQA has been asked to undertake a report into the services at Portlaoise hospital, which will follow on from other investigations undertaken by HIQA in recent years. The HIQA report into Tallaght hospital has prompted significant changes to the governance arrangements not alone at Tallaght hospital, but right across our hospital system. Similarly, a HIQA investigation into Galway maternal deaths will have implications for the safety and quality of maternity services nationally.

In formulating proposals for the establishment of a patient safety agency, the Department of Health considered the international evidence and advice that suggests that health care regulation and the broader quality improvement and patient safety agenda are not appropriately situated together within one agency and that the regulatory function should maintain its independence and remain separate. This suggests that the health and social service regulatory and monitoring function should be maintained separately and enhanced within HIQA. The HSE has statutory responsibility for dealing with complaints from patients who are dissatisfied with the service they receive. National and international best practice would suggest that the best way of resolving complaints is to have them dealt with at a local level. Therefore, the vast majority of complaints to the HSE are managed and should be resolved locally. However, we know that this does not always happen. We know that sometimes people do not get satisfaction and that despite taking up matters with hospital complaints officers, they feel no better off.

I would like at this stage to make a few points rather than read the remainder of my script. I do not believe that we could provide that the Medical Council would be answerable to the patient safety agency or HIQA or that HIQA would be answerable to the Medical Council. All of these organisations are regulatory bodies and stand alone. What I would like to see in a patient safety authority is a champion for the patient, an organisation that can support the patient in getting satisfaction in relation to his or her complaint. It is my view and has been my experience as a doctor that the three As apply here. What people want when something goes wrong is an acknowledgement that something went wrong, an apology for it going wrong and an assurance that it will not happen again because things will change. I envisage that the patient safety agency will be such a body. It will be the patient's friend and the go-to-place for patients when issues arise, be that an issue such as the serious issues that arose in Portlaoise hospital or a staff member being rude.

I genuinely believe that the agency will be supportive of patients, improve the quality of care we provide and hugely reduce the amount of money we spend in medical legal litigation. It is a matter of grave concern to me that of the tens of millions of euro we pay out annually in relation to medical legal consequences, one third of it goes to the legal profession. It should be going to the people who have suffered as a consequence of misadventure and negligence and not the legal profession, whom I have nothing against.

The patient safety agency is a critical part of any new health service. Patients need to be empowered. The informed and empowered patient is the safest patient.

I thank the Minister for his reply and for coming to the House to take this issue, which shows he takes this matter seriously. What is important is not how the patient safety authority is set up, but that it can deal with complaints from individuals or groups before they become part of the system. We cannot expect the HSE or the Department of Health, no more than we can expect the Garda Síochána or any other organisation, to investigate themselves. We need strong legislation in this area. The establishment of a patient safety authority must be prioritised. As stated, it will instil confidence in patients and improve outcomes within the system for them. It is vitally important the legislation in this regard is prioritised.

In regard to the Minister's reference to an administrative structure, I do not believe that is what we need or that it would instil confidence in patients. I ask that the Minister prioritise the legislation for the patient safety authority and to ensure that what is established is the right type of organisation. It is important we wait until we get it right rather than establish an organisation that will not satisfy what patients want from the health care system.

I agree with the Deputy that the new agency must be underpinned by legislation. In the interests of getting it up and running quickly and teasing out any problems in that regard, I believe it is sensible to introduce it on an administrative basis first.

When I spoke to the parents of the children who died in Portlaoise hospital, they indicated their concern that such an agency should be established. They were very unhappy that, as the Deputy pointed out, this agency might in any way be dependent on the HSE. I was careful to explain that this is only a temporary administrative arrangement and that supporting legislation will be introduced to make the agency absolutely independent of the Department and, in particular, the HSE and the entity - namely, the proposed health commissioning agency - which is due to replace it.

As the Deputy indicated, the days when the Garda, the HSE and the Department of Health could investigate their own activities are gone. There is value to these entities carrying out initial investigations for their own quality assurance requirements. For any institution or body to have the confidence of the public, however, outside individuals must be involved. The need for this was made obvious in the past in the context of the issues relating to Dr. Neary and all of the women who attended Our Lady of Lourdes Hospital in Drogheda, who were so poorly treated by him and who have suffered dire consequences in their everyday lives since then. There is a need for independence, transparency and clarity in respect of all investigations carried out in this country in order that citizens will have absolute confidence that matters will be brought into the open rather than hidden. There must be no sense among people that a lack of objectivity might apply.

Hospital Staff

The Minister is very familiar with this issue, having attended a meeting with the parents involved and with management from Letterkenny General Hospital. The difficulty which arises is that despite the protestations of the management at the hospital and those of the management of the west northwest hospitals group, the parents to whom I refer are of the view that they have lost access to a critically important service provided by the paediatric clinical nurse specialist. Approximately 145 children in Donegal under the age of 18 have type 1 diabetes. The Minister is well aware of what this means for families and of the challenges faced by their children. At a recent public meeting in Donegal, the families involved told their stories and outlined the type of pressure and anxiety with which they are obliged to live. They also indicated how desperately important this resource - which is provided at the hospital - is to them. Under the national diabetes plan, there was to have been one paediatric clinical nurse specialist for every 100 children. One could argue that the number should be 1.5 specialists in place for the children to whom I refer in Donegal.

It is clear that there is confusion in respect of this matter. The management of the hospital has written to public representatives in Donegal since the meeting to which I refer took place. Management has not agreed to a further meeting with parents and public representatives in order that matters might be clarified. Is the Minister in a position to intervene in respect of this matter? I am aware that he has agreed to attend a meeting organised by the parents on Tuesday next. I welcome this development but I ask him to resolve the matters to which I refer before that meeting takes place. I request that he make clear to management at the hospital that what is not needed is someone who deals with children on a part-time basis and that what is actually required is a dedicated paediatric clinical nurse specialist who will deal solely with the children in question and their families.

I echo what Deputy Mac Lochlainn stated with regard to the Minister's acceptance of an invitation to meet the families next week. Oireachtas Members from the county will be also at that meeting and I hope it will be possible to bring about some finality in respect of this matter. It is unique that the four Opposition Deputies from Donegal have raised this matter. I accept, however, that the Government Members from the county support us in respect of it.

When he met the families in April 2013, the Minister informed them that they were reasonable people with a reasonable request. The request they were making at that time related to the diabetic clinical nurse specialist. As Deputy Mac Lochlainn indicated, we have received reports from the hospital to the effect that this is an enhanced service and we have been asked why we are complaining because what is on offer is actually better than the service which previously obtained. On paper and otherwise, it does appear to be enhanced. This is because there is an integrated clinical nurse specialist on site. As a result, there is not a shadow of a doubt that there is an enhanced service available for those with diabetes. However, we are focusing on the area of paediatrics and the nurse who previously provided the service in this regard has been replaced. The upshot is that there will now be a clinical nurse in place to deal with both adult and paediatric patients. The nurse who previously worked in this area was a specialist and she provided expert care to children. What is required here is a dedicated clinical nurse specialist.

The parents are concerned with regard to the amount of time the new nurse will be in a position to allocate in respect of paediatrics. The relevant expert group recommended that there should be one clinical nurse specialist for every 100 children. As Deputy Mac Lochlainn indicated, in Donegal at present there are 145 children under the age of 18 who have type 1 diabetes. Six of those children were diagnosed with the disease in the first 12 weeks of this year. This indicates that one case is being diagnosed very second week and that the rate is increasing quite significantly. I understand that the Minister has called on the management at the hospital to resolve this matter and stated that a clinical nurse specialist should be appointed to the area of paediatrics. I hope he will confirm that the latter is, in fact, the case and that we will be united on this issue.

I acknowledge the Minister's support in respect of Letterkenny General Hospital since it was flooded and thank him for it. I also thank him for providing - in conjunction with west northwest hospitals group - the funding necessary for repairing the hospital and for coming to Donegal to reopen it. When he came to Letterkenny, the Minister met representatives from the parents support group who were protesting outside the hospital. As welcome as the new facilities are, the level of staffing and the qualify of service provision are crucially important in the context of how hospitals operate. There is an inadequacy at the hospital at present in the context of the service which is supposed to be provided by a paediatric clinical nurse specialist. The relevant unit is under-resourced, particularly in the context of the number of children who visit the hospital. Some 145 children in Donegal have been diagnosed with type 1 diabetes. The most recent policy advice available from the Department indicates that there should be one paediatric diabetic clinical nurse specialist for every 100 children. On that basis, one and a half specialists would be required to cover all of the children in Donegal with type 1 diabetes. I accept that an additional person has been appointed to deal with the adults in Donegal - approximately 5,000 - who have diabetes. The service is stretched but I welcome the appointment to which I refer. There is a need for a commitment from the Minister that a full-time paediatric clinical nurse specialist will be appointed to Letterkenny General Hospital.

The other point I wish to raise - in respect of which I ask the Minister to communicate further with us - is that which relates to centres of excellence for paediatric diabetes. There are currently five such centres throughout the country, all of which are located south of the Dublin-Galway line. There are three centres in Dublin, one in Limerick and one in Cork. The nearest centre for those in the north west is located in Dublin. When one looks at a map, the position is this regard is made obvious in very stark terms. There is a significant imbalance in this regard. That is not appropriate. I ask the Minister to provide a commitment to the effect that a centre of excellence will be developed in the north west in order that children there who suffer with diabetes might have easier access to services. When those children travel to the existing centres of excellence, they have access to dieticians, consultants, clinical nurse specialists and psychologists. It is important that the services of such individuals be made available in the north-west region.

I thank the Ceann Comhairle for selecting this very important issue for discussion. Its importance is emphasised by the fact that it has been raised by the four Opposition Deputies who represent the county. As Deputy Pearse Doherty stated, the Government Deputies from the county support the request we are making. I take this opportunity to acknowledge the Donegal Diabetes Parents Support Group and the Donegal branch of Diabetes Ireland for the work they have done to highlight this issue on a continuous basis. I hope the Minister will be in a position to indicate that a clinical nurse specialist for paediatrics will be appointed to Letterkenny General Hospital because this is the only acceptable solution.

The claim made by the management at the hospital has indicated that an enhanced service is available is not really acceptable, particularly as parents do not know what way the nurse specialist on site will divide his or her time in the context of dealing with adult and paediatric cases. Children from Donegal will be still obliged to travel to Dublin to avail of services.

Mr. Paul Gillespie of the Donegal branch of Diabetes Ireland put it well when he referred to the effects that travel has on children with diabetes. He remarked that one of the problems of travelling with a child with diabetes related to if their blood sugars became a little high since they would be more prone to getting car sick and that they would be four hours from their destination. Also, once they got to Dublin they found the Dublin clinics were jammed out the door and he adverted to the associated difficulties.

The HSE standards indicate that there should be a nurse specialist for every 100 children. We argue that there should be 1.5 posts in Donegal but the Donegal branch is looking for one post to provide a service close to home for the children that need and deserve it.

The diabetes expert advisory group has outlined nine standards for diabetes care. Standard No. 4 states that the provision of diabetes services for children and adolescents should be equitable and fair throughout the country. Equitable and fair treatment is all we are looking for in Donegal and this is something the Minister should be able to deliver.

I thank the Deputies for raising this issue, which is clearly of considerable importance and concern to parents in Donegal. I also thank Deputies Mac Lochlainn, Doherty, Pringle and McConalogue for affording me the opportunity to reassure parents of children with diabetes and adults with diabetes that the restructuring of nursing resources for diabetes in Letterkenny will not result in a reduction of current service levels and will enhance patient care by strengthening the links between diabetes care in primary, community and acute settings. I realise this issue, as others have pointed out, is of great concern to Deputy Joe McHugh, who asked me to meet the families concerned, and to the Minister of State, Deputy Dinny McGinley.

As the Deputies are aware, I had the honour of presiding over the official reopening of the emergency department at Letterkenny General Hospital last month and seeing at first hand what can be and has been achieved through the commitment and hard work of management and the entire community around Letterkenny. Despite the pressures and challenges facing our health system there is a determination to move forward to improve what we are doing and to deliver the best outcomes for patients. I had the chance to meet representatives of the parents of children attending diabetes services and I understand the concerns.

As parents we want dedicated resources for our children and, as a parent, I accept this. When dealing with a complex chronic illness such as diabetes we want consistent support. As a doctor, I appreciate the reassurance that such supports can bring. I believe these supports are in place as a result of the restructuring of the diabetes nursing resource in Letterkenny.

I am working from memory but, as I understood it, there was the equivalent of 0.8 time given by the nurse. She is now becoming whole-time but across adult and paediatric care. She is involved with paediatrics at the level of approximately 0.6. However, she will have the additional resource of another clinical nurse on half-time, which means the service is going from 0.8 to 1.1. I realise on paper, as the Deputy has said, this is an improvement and I believe this will be the case, but I recognise that the parents want a full-time dedicated nurse. One of the parents put it to me that they need to be reassured such that at night when something happens, such as a hypo, they can pick up the telephone to talk to someone who knows what they are talking about. It would be wonderful if that person knows the child but that is not always possible because people cannot be on-call 24 hours, seven days per week. That is not reasonable and it is no life.

I have been thinking about what is happening in Sligo and the nursing expertise there and I cannot understand why we have been unable to put together a 24 hour, seven day on-call service whereby people can lift the telephone to talk to an experienced paediatric nurse who can advise them what to do when a child's blood sugar is going off, whether high or low. We will certainly examine that. I have heard clearly what people have said about a centre of excellence north of the Dublin to Galway line and it is something I will certainly look into.

When I was in Letterkenny to officially open the emergency department in early March I spoke of my gratification at seeing the way Letterkenny General Hospital works in partnership with local general practitioners and primary care services to address local population health needs in order that those who need acute hospital care are directed to that care. This approach supports the aims of the national clinical programme for diabetes, including the development of an integrated care programme to improve diabetes control, the development of a chronic disease management programme for diabetes and the reduction in overall bed days for acute hospital diabetic care by 40,000.

I wish to make a particular comment about Donegal. It has always been the case that primary care there has been well supported because of the huge geographic area that it covers. There was a realisation many years ago that a hospital-centred delivery system simply could not deliver for such a wide geographic space. That is why primary care in Donegal is probably more developed than in many places in our country.

I am keen to ensure that our health service provides safe, quality and timely care and this is a priority concern of the Government. I acknowledge sincerely the commitment of the staff of the Letterkenny General Hospital diabetes service to the patients and I believe that commitment is reflected by the interaction I have had with the families, who have nothing but the height of regard and respect for the paediatric nurses. I assure the many families for whom the service is so vital that the addition of an integrated clinical nurse specialist will enhance the quality and timeliness of their children's care.

I will not leave it at that. I have taken on board what the Deputies and families have said and I look forward to meeting them next week. I will be seeking to address the issue as outlined by them as well as meeting the needs and improving the service from their point of view. Yesterday, I launched a new awareness site for Adam Harris, who has set up a site for people with autism. During the event I remarked that the service needs to listen to what people want from it and not only take the view that it knows best about what to deliver for them.

I concur with the last remarks the Minister made to the effect that the system should not consider that it knows best. This is the concern we have. We received another response yesterday from the management of Letterkenny General Hospital in co-operation with the management of the west northwest hospitals group. It reads to a lay person as if it is addressing the concerns of the parents but I am somewhat unsure. I am trying to be practical and constructive about this. Could the Department obtain a copy of that letter from the manager of Letterkenny General Hospital, Sean Murphy? The Minister knows what the parents are looking for and he has met them. Could the Minister and his Department, in their expert opinion, establish whether the changes are now addressing the concerns of the parents ahead of the meeting next Tuesday? That would be helpful. There seems to be some breakdown or misunderstanding of what is happening. It was clear to us, as public representatives, at a packed public meeting in recent weeks in Donegal that parents who desperately need help expressed the view that they were not getting it and that they were not satisfied with what is on the table. We are asking the Minister to referee and sort it out. I thank the Minister for the work he has done thus far on the issue.

I am going to read positivity into the Minister's comments because he did not deliver the standard HSE response, which is largely a defence of the existing position. I read into the Minister's comments that there is a need to address this and I hope it can be addressed. As we have said, the call is for a diabetes clinical nurse specialist. The half staff nursing position that will accommodate the clinical nurse, which is a 0.67 position, is a trained adult position not a paediatric post. Again, it looks fine on paper but in reality it does not. I hope we can bridge this gap.

I agree completely and concur with the Minister's last statement about listening to service users. My nephew and godson is among this number. I have listened to what he goes through, what his mother goes through and the fears, anxieties and concerns about someone going hypo or hyper. After the public meeting I had the opportunity to talk to teenagers who use the service. They had nothing but the height of respect and regard for the person they are losing. Much of this comes down to that emotional attachment but this is an opportunity for them and for all of us to live up to best practice as per the 2008 expert group recommendation, that is to say, there should be a clinical nurse specialist for paediatrics. I hope we can finalise this next Tuesday.

I thank the Minister for his response. The parents have been indicating for a long time that they believe the resources for diabetes paediatric care in Letterkenny General Hospital are inadequate for the number of children that are attending there.

Although the appointment of an additional clinical nurse specialist in the community who will focus on adults is welcome and will improve the overall level of service provided to diabetes patients in Donegal, it does not enhance the level of staffing that parents believe is necessary to meet demand at the hospital. Some 145 or 150 children are involved. According to the Department's own policy, this number is sufficient for 1.5 dedicated diabetes nurses.

We are seeking a commitment from the Minister to allocate a dedicated paediatric nursing post to the hospital at a minimum, as there is none currently. This is what the parents want. I welcome the Minister's statement that he will re-examine the current setup of the centres of excellence, given the fact that there are five south of the Galway-Dublin line and none above. Will the Minister indicate a timeline for a response on what can be delivered in that respect?

Like other Deputies, I thank the Minister for his response. He stated that the HSE needed to listen to parents and those who use the service and deliver a service that responds to their needs instead of just telling them what they will get. This is important. I hope that the Minister will be able to reassure parents at next Tuesday's meeting that he will go down this road. What will make a difference for families across Donegal is a commitment that whole-time paediatric diabetes nurse specialists will be recruited for Letterkenny. As the Minister stated, this would have a major effect by preventing future complications for people and costs for the health service. He should grasp this matter, reassure parents at next Tuesday's meeting and ensure it gets done.

I thank the Deputies for their contributions and the tone in which this debate has been held. We are all trying to improve services for our people. There is no more emotive issue than services for our children. I will endeavour to get a copy of the letter that Mr. Murphy wrote, review it and have my Department review it before next Tuesday's meeting.

I also listened to Deputy Pearse Doherty. I wish his nephew well and a bright future. Perhaps he will follow his uncle into the Chamber some day, although not necessarily under the same banner. I jest.

I want to determine how we can address the issue raised by Deputies McConalogue and Pringle. It is not just a question of economics, as it makes perfect economic sense, but also a question of children's quality of life. No one wants to hear of children having to travel four hours by car when the alternative could be just one hour regardless of in which part of Donegal they are. I will examine the matter and try to get the best outcome that I can for parents and their children.