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Dáil Éireann debate -
Thursday, 9 Jul 2015

Vol. 886 No. 4

Other Questions

Hospital Waiting Lists

Brendan Smith

Question:

6. Deputy Brendan Smith asked the Minister for Health how it is proposed to reduce waiting times for orthopaedic surgery, with particular reference to the north east; and if he will make a statement on the matter. [27578/15]

As the Minister is aware, there is a problem with waiting lists for orthopaedic surgery in the north east, and the problem is particularly acute for patients in the Cavan-Monaghan area. Of the total on outpatient waiting lists in the north east, 43% are referred through Cavan General Hospital and they are awaiting appointments and assessments by orthopaedic surgeons. There is an urgent need to increase the orthopaedic capacity in the north east.

Improving waiting times for scheduled care is a key priority for Government. In January, I put in place maximum permissible waiting times for inpatient and day case treatments and outpatient appointments of 18 months by mid-year and 15 months by the end of the year. As of 30 June, the HSE is reporting a 99.6% achievement against the maximum permissible waiting time for inpatient and day-case treatment and a 96% achievement against the maximum permissible waiting time for outpatient appointments.

In respect of orthopaedic services in the north east, a national initiative was introduced in 2013 which provides physiotherapy triage of patients on orthopaedic OPD waiting lists. As a result, approximately 40% of patients are getting earlier intervention. The national trauma programme is also looking at orthopaedic services nationally to determine recommendations for managing both trauma and elective workloads.

Our Lady’s Hospital Navan and Cappagh National Orthopaedic Hospital provide the majority of inpatient and day-case elective care for the north east. Navan Hospital is close to maintaining a six-month inpatient and day-case access time, which is relatively good. Cappagh National Orthopaedic Hospital has received an additional allocation of €3.8 million this year. Consequently, activity in 2015 has exceeded 2014 levels and will continue to improve month-on-month to the end of the year. This has resulted in a gradual reduction in access times. Both hospitals have met the current maximum permissible waiting time of 18 months at the end of June 2015 and anticipate that they will be compliant with the 15-month maximum permissible waiting time by the end of this year.

Constituents have been making an increasing number of representations in the past two years concerning people, particularly those in the older age cohort, who need care and attention or surgery in respect of hips, knees and shoulders. In many instances, when people are suffering a particular ailment and are awaiting orthopaedic treatment, this drags down their general health, as the Minister will appreciate better than most in this Chamber. GPs in the Cavan-Monaghan area tell me that when they refer a patient to, say, Navan, they typically wait up to two years for their first assessment, although that is through no fault of the surgeons in Navan. In the meantime, their health can deteriorate.

The patients referred through Cavan General Hospital catchment area make up 90% of the patient waiting list in the north east, and 90% of those are waiting longer than 12 months. It is a very acute problem in Cavan-Monaghan and I would like some particular initiative to try to deal with this backlog.

The particular initiative that has occurred in the last few months is additional capacity, where possible, within the public system and the outsourcing of some patients to the private sector, where they were waiting more than 18 months. On the outpatient waiting list figures, there are about 50,000 people waiting for orthopaedic treatment, but the largest single category within that are waiting less than three months, some 16,000 people. Approximately 9,800 are waiting three to six months and 14,000 are waiting between six and 12 months. The number waiting over two years is much lower, but any of those should have been picked up in the last few weeks and should have appointments by now, if they do not already. If the Deputy knows of cases of people waiting over 18 months, I would be interested to see them. If the Deputy wants to pass them on to my office, we will certainly check them out, because that should not be the case at this stage.

I thank the Minister and I will refer some particular queries I have. Cappagh Hospital is an important hospital for the north east, as well as the hospitals in Navan and Drogheda. My understanding is that two years ago or less there was a reduction in bed capacity at Cappagh. Did the Minister say the capacity had been increased in Cappagh?

A comment was made to me by one GP that if GPs were in a position to carry out injections into joints, in many instances that could ease people's pain and suffering. As the cost of this injection is quite high, the typical GP in a small practice with a patient on a medical card would not be in a position to provide that service without some additional remuneration. The point made to me was that it could ease the immediate suffering for the patient concerned and perhaps also ease pressure in terms of referrals to hospitals. It might be considered.

As the Deputy knows, GPs can inject joints, provided they are sufficiently trained to do so. They often do not do it for medical card patients because it is not economical to do so. One of the items that will be under discussion in the new contract talks with the IMO, which are due to start shortly, is that of changes to what are called special-type consultations - the additional fees that GPs get for suturing a wound, injecting a joint and the like. That is certainly one of the things that can be negotiated as part of the new contract.

Because of the budget cuts, Cappagh was very restricted last year and, at one point, only two of the seven theatres were open. Now, because of the additional finance we got this year, of which Cappagh got an extra €3.8 million, four or five of the seven theatres are functioning.

That has allowed it to increase capacity. I would like to get them all open but the issue we are now running into in Cappagh is a shortage of theatre nurses. That is a further barrier but there is an increase in activity.

Mental Health Services Funding

Mick Wallace

Question:

7. Deputy Mick Wallace asked the Minister for Health the rationale behind the differences in mental health spending per capita in the various regions; and if he will make a statement on the matter. [27699/15]

As the Minister is aware, I have raised this issue previously but as nothing has changed on the ground, I have to continue raising it. Why is it that in 2015 mental health spending per capita in the Wexford-Waterford region is €148 compared to €223 in Carlow-Kilkenny-south Tipperary, €198 in Mayo and €206 in Galway-Roscommon? Will the Minister explain the regional variation? Given that Wexford has one of the highest suicide rates in the country, I find it difficult to understand why there is such a discrepancy.

Historically, there has been significant variation in mental health funding across the country. This was influenced by the location of major mental health institutions and different priorities on the part of health boards over the years.

The establishment of the HSE mental health division in mid-2013 created a national management structure for all mental health services. In 2014, the division commenced a process of developing financial information specific to mental health services. This exercise included the validation and costing of approximately 9,000 staff working in HSE mental health services nationwide, representing about 80% of total spending on mental health services. This work is continuing. As there is no single financial ICT system available to the HSE, such validation is labour intensive and difficult to achieve with full accuracy.

This financial analysis has been combined with population figures adjusted for deprivation to inform decisions regarding the allocation of new funding in 2014 and 2015. In this way, the HSE mental health division is moving towards population-based funding through reassigning discretionary funding in favour of comparatively under-funded services. The information and methodology will continue to be refined in order to support funding allocations and arrive at a situation where mental health spending per capita is more consistent. It is recognised that such allocation processes have to be phased in to allow time for costs to be adjusted in line with national norms.

The Deputy may wish to note that, in response to Parliamentary Question No. 22548/15, the HSE in its reply of 30 June 2015 gave detailed financial information for mental health, broken down by geographic area for the years 2013-15, inclusive. I will arrange to have a copy of this information sent to the Deputy.

The Deputy will appreciate that the Government has made significant efforts to prioritise and modernise mental health care nationally. While the concept of geographic equity is to the fore in allocation decisions, other practical realities have to be taken into consideration such as the need to address delays in accessing services and the need to introduce alternative community-based models of care.

I thank the Minister. I am aware there is more positive thinking about how this issue should be dealt with. In 2006, A Vision for Change was launched on the basis of 8% of the health budget being spent on mental health when in fact it only reached 7.2%. It has since been cut back to 5.2%. According to the World Health Organization, mental health illness accounts for more than 15% of the disease burden in developed countries. It is reckoned that 11% of Irish people have personally experienced mental health problems. I agree that putting resources into the community is the way forward. In Wexford, there are four units that work well and are open from 9 a.m. to 5 p.m. After 5 p.m., people have to go to an accident and emergency unit in Wexford and if they are referred to Waterford, they have to go through the accident and emergency unit there before eventually being admitted to an acute unit. Until we sort out the services in the community, will the Minister agree that in the meantime there is a need for acute units in Wexford?

I am not sure it is ever a good idea to set a crude percentage figure as to what percentage of the health budget, or any budget, should be spent on anything. The reality is that some health care is more expensive than others. One of the areas that is enormously expensive is cancer because of the cost of the new medicines that become available every year. Even though fewer people may have cancer than have mental health problems, the cost of treating each cancer patient is always going to be very much higher than the cost of treating somebody with common mental illnesses, such as depression. That is an issue that needs to be borne in mind in setting financial targets.

In terms of actual cash, the mental health budget for 2012 was €711 million; in 2013, it increased to €737 million; in 2014, it was 766 million; and in 2015, it is €792 million. It is clear there has been a substantial increase in non-capital funding for mental health in recent years. I am sure it is not enough but it is a significant increase during a period when so many other things have been cut back.

In 2010, before Wexford was merged with Waterford, there were 31 acute beds in St. Senan's hospital and 44 in Waterford, giving a total of 75 beds. Today, there are just 44 because St. Senan's has closed and the population has increased by 20,000 in the region. I am aware there are five beds in Newcastle in north Wicklow. It appears that the service in Wexford has decreased. Most of the indicators show that Wexford is a more deprived region than most and with almost 24% unemployment, one can understand why that is the case. On the ground, there is significant concern that the resources available are not matching demand. Perhaps the Government would look at the issue again and see whether something can be done even in the short term.

I was not prepared for questions from the Deputy on Wexford specifically. I do not have a briefing on it with me but certainly I will convey his comments on the matter to the Minister of State, Deputy Kathleen Lynch, and perhaps she can speak to the Deputy.

Nursing Homes Support Scheme

Thomas P. Broughan

Question:

8. Deputy Thomas P. Broughan asked the Minister for Health the current status of the fair deal scheme; how advanced planning is for dealing with the seasonal upsurge during the winter; and if he will make a statement on the matter. [27370/15]

I am aware that total funding for the fair deal scheme is almost €1 billion and that there was an increase earlier this year. How many of the promised 1,600 places have been delivered? Also, how many of the 300 places promised earlier have been delivered? In general, how prepared are we for the forthcoming winter? Last November, 2,000 people were waiting for a nursing home place. What preparations are being made to avoid that happening this winter?

The nursing homes support scheme, the fair deal scheme, is a system of financial support for those in need of long-term nursing home care. Participants contribute according to their means while the State pays the balance of the cost.

In 2015, the scheme has an allocation of €993 million. In budget 2015, additional funding of €25 million was provided to support services that provide alternatives to, and relieve pressures on, acute hospitals. Of this €25 million, some €10 million was used to provide an additional 300 places under the fair deal scheme. This reduced the waiting time for approved applicants from 17 weeks to four weeks. Some €8 million was used to provide access to an additional 115 short-stay beds across the Dublin area, €5 million was used to provide 400 additional home care packages which will benefit 600 people in the course of the year, and €2 million was used to expand the community intervention team services in primary care across Dublin and the surrounding region.

In April 2015, the Government provided a further €74 million to address issues that impact on delayed discharges. This amount was in addition to €25 million provided earlier and was allocated as follows. Some €44 million was allocated to the nursing homes support scheme to provide an additional 1,600 places and to further reduce waiting times for approved applicants from 11 to four weeks. This funding will allow the HSE to increase the rate of approvals during periods of increased demand, including any surge during the winter months so as to maintain the waiting time for approved applicants at no more than four weeks. In the coming months, the number of people supported under the scheme will increase on an ongoing basis. The scheme will be supporting in excess of 23,900 people by the end of 2015. The remaining €30 million was principally applied to provide additional transitional beds, some of which were on a temporary basis to address the particular pressures then being experienced by acute hospitals.

When the nursing homes support scheme commenced, a commitment was made that it would be reviewed after three years. This review is considering the scheme's long-term viability as well as looking at how well the current model of provision is balancing residential care with care in the community, and whether this needs to be adjusted to better reflect what older people want and need. The review of the scheme is almost completed and is expected to be published shortly.

On the review, is the Minister aware that recommendations have been reported in the media? Are those accurate? When does he expect to be able to publish the recommendations and what might he expect to be in them? There are indications that additional finance will be required from clients of the scheme.

More generally, the Minister spoke a few weeks ago about unmet needs in the health service and indicated that up to €1 billion in additional funding might be required this year. I asked the Taoiseach about this the other day and he seemed to indicate that there might be a supplementary budget before the end of the year for 2015. Will that include the fair deal scheme? The Minister is aware of the work of ALONE and the Home First campaign, which indicates very clearly that many more seniors would do well at home if the Minister were able to put more money into home supports and home care packages. There is a long waiting list for that.

There are a number of questions there. The fair deal review is done and I expect it to be published in the next few weeks. It does not so much make recommendations as suggest different things that could be done to make the scheme more sustainable in the years to come. It then makes recommendations about alternative ways of funding home care in a better way. There are lots of other things like that and it is quite an interesting report. The report also addresses some of the unfairness that may exist, particularly for self-employed people and farmers, in the way people are assessed for the fair deal scheme, and makes recommendations in that regard.

On the ALONE campaign, it is absolutely our preference that people stay at home for as long as possible. By and large, it is also less expensive to provide a home care package than to provide a fair deal place. The proportion of people aged over 65 going in to nursing homes is actually falling, notwithstanding that the raw numbers are increasing. That is illustrative of the fact that better home care is now available.

There is still a significant waiting list for home care packages. The waiting time for the fair deal scheme has decreased significantly, to four or five weeks, but what does the Minister intend to do about the waiting time for home care packages themselves? Does that form part of the amount the Minister was thinking of in terms of unmet needs?

An additional €5 million was provided this year to provide an additional 400 home care packages to the benefit of 600 people. The waiting time for a package varies from region to region quite significantly, which is a real difficulty. The HSE has been given flexibility to spend more on home care packages where it is running into trouble in staffing units. Where the HSE cannot get nursing staff to open a community unit, it can divert funding to additional home care packages. That is actually being done.

Mental Health Services Provision

Terence Flanagan

Question:

9. Deputy Terence Flanagan asked the Minister for Health if he will ensure that an out-of-hours assessment service is provided at the Ashlin Centre in Beaumont Hospital in Dublin 9; and if he will make a statement on the matter. [27373/15]

My question is on the provision of a 24-7 service for psychiatric patients at the Ashlin Centre at Beaumont Hospital. Unfortunately, there have been reports of in the media in recent weeks of clashes and potential problems. Can the Minister advise the House as to when 24-7 care will be provided in the Ashlin Centre?

It has been the experience of north Dublin mental health service clinicians that most of the cases presenting to the emergency department at Beaumont Hospital out of hours and referred to the on-call psychiatry team are complex and multifaceted and often require the input of other hospital services. Persons presenting, for example, with intoxication, overdose, confusion or self-harm require assistance with these issues and, while there may be an allied psychiatric condition, other aspects of their care will fall to the emergency department to deal with first. Acute mental-health units, such as the Ashlin unit, are not designed or staffed to deal with these issues. Direct admission to a psychiatric bed without a thorough medical assessment would constitute a significant risk for patients. As there are no plans to include an out-of-hours assessment centre at the unit, persons presenting with complex issues are first assessed in the emergency department.

North Dublin mental health services work in partnership with Beaumont Hospital liaison psychiatry and the emergency department so that the needs of individuals requiring mental health services are co-ordinated to ensure optimised patient care. Two nurses assigned to the self-harm programme of the mental health service work in the emergency department. An additional self-harm nurse at clinical nurse specialist level is also being recruited. It is acknowledged that north Dublin mental health services have recently experienced some difficulties in terms of bed capacity. However, the HSE is working proactively to address these issues, with the number of available acute beds being kept under review and the recent approval of funding to facilitate onward discharges to community placement. The Ashlin Centre currently has 38 psychiatric adult beds, of which 37 are occupied. Approval is being sought for a further ten beds for 2016 as part of the ongoing development of north Dublin mental health services.

While I thank the Minister for his response, the situation in Beaumont is terrifying. The accident and emergency department is already overstretched, but when one has psychiatric patients as well as ordinary patients attending, there can be problems. Unfortunately, there have been some negative incidents. Staff are trying to work and do their jobs, but unfortunately one staff member was stabbed. It is horrific. It does not feel like a safe environment if something like that could happen. There is an absence of 24-7 assessment for mental health patients. They should be getting the help and care they need. Can the Minister address that?

It is important to say that all major emergency departments have security on site. It is not just mental health patients who can attack staff or other patients. It is a very sad feature of our health service that sometimes patients attack staff. It can be true for ambulance crew and even reception staff. It is an unfortunate reality that we have to face all the time. When psychiatric patients present in emergency departments, they generally do so with other problems also. A patient may have had an overdose, which is a medical toxicological issue that must be dealt with first. A patient may have injured himself, cut his wrists, tried to hang himself, even tried to shoot himself or done some other form of harm to himself. A patient can also present with very severe medical problems because he has not been looking after himself due to his psychiatric illness. For example, he may have a very bad infection. All of those things must be dealt with first. It is not the case that someone with a mental illness can be shipped straight to the psych ward. It should never have been done that way. When a patient has medical, surgical or other problems, it is important that those are dealt with first and the patient is medically cleared before he goes to the psych ward.

Have there been incidents in other hospitals in which violence has been directed towards HSE staff that have not been reported in the media? A Vision for Change stated that 24-7 assessment would be provided for mental health patients. When will that happen? There is a commitment there. When will the necessary resources be put in place, particularly at the Ashlin unit?

I support my colleague, Deputy Flanagan. We are receiving incredible complaints about the situation. Other mental health hospital facilities have accident and emergency functions. Can there not be a separate function even within the existing accident and emergency department in Beaumont Hospital?

I do not have the figures, but it is certainly the case that assaults on staff occur at other hospitals. It is a particular feature of psychiatric hospitals and care homes and it can also be a feature in emergency departments. It is not particular to the health service; it happens to gardaí, prison officers and teachers also. It is never acceptable for public servants to be assaulted by their clients, but it is a reality of the environment in which dedicated public servants have to work.

In terms of the 24-7 service, I am advised that the service currently has two nurses assigned to the self-harm programme working in the emergency department. One is a qualified clinical nurse specialist, CNS, and the other is working in an acting capacity. One of the nurses works a seven-day fortnight roster, which is a 12-hour shift, and the other staff member works a 5-7 roster, which is 9 a.m. to 5 p.m. A further appointment of a self-harm nurse at clinical nurse specialist level is being progressed via the national recruitment service, NRS, panel and it will be filled in the near future.

I do not know if it is the case for Beaumont but it would be the norm for a large hospital like that to have a psychiatry doctor on-call at all times but that doctor may not be called until the patient's medical issues are dealt with first.

The Minister is happy with the situation in Beaumont.

No, I am not, but that is beside the point.

The Deputy who tabled Question No. 10 is not present. I call Deputy Fleming on Question No. 11.

Question No. 10 replied to with Written Answers.

Accident and Emergency Departments

Seán Fleming

Question:

11. Deputy Sean Fleming asked the Minister for Health if he will ensure that the emergency department at the Midland Regional Hospital in Portlaoise, County Laois continues to provide a 24-hour service; and if he will make a statement on the matter. [27571/15]

Will the Minister ensure that the emergency department in the Midland Regional Hospital in Portlaoise continues to provide a 24-hour service?

I am committed to securing and further developing the role of Portlaoise hospital as a constituent hospital within the Dublin Midlands Hospital Group, which also includes St. James's, Tallaght, Tullamore, Naas and the Coombe hospitals.

The hospital group and the HSE acute hospitals division are examining the scope of services in Portlaoise, and other hospitals in the group, subsequent to the recent Health Information and Quality Authority, HIQA, report on the hospital. The important point here is that work is being undertaken to strengthen services in Portlaoise hospital from a patient safety and quality perspective and also to ensure that services that are viable are safety assured and appropriately resourced and that services that are not viable or cannot be made safe are discontinued.

Detailed planning is under way for staff to develop the best clinical services for all patients. Consultation is ongoing this month with the national clinical leads for medicine, surgery, critical care, patient transport, emergency medicine, obstetrics and paediatrics, as well as the national ambulance service. Further consultation with local general practitioners, GPs, is expected to begin this month and other stakeholders will also be engaged.

Decisions will be made on the basis of ensuring patient safety and getting best outcomes for patients, not financial or political considerations. Any change to services at Portlaoise, including emergency department services, will be undertaken in a planned and orderly manner and will take account of existing patient flows, demands in other hospitals and the need to develop particular services at Portlaoise in the context of overall service reorganisation within the hospital group.

I thank the Minister for that general reply. A number of public representatives met him in his office a few weeks ago and I thank him for meeting a bigger group that he may have thought would arrive on that occasion. He indicated then that he expected to have a report from the HSE within three or four weeks. Can he advise when he expects to receive it? He referred to planning, negotiations and consultations in his reply and that sounds as if it is a long way off yet and will not happen in the immediate future. He might indicate the timescale he envisages for this.

As the Minister said, consultation is taking place with the GPs. He will know that they issued a letter publicly on this issue in recent days and it is important that it be taken into account. We all agree that patient safety is the first and foremost issue and that quality of service and outcome for patients is the most important issue. The Minister spoke about the demands in other hospitals in the context of his consideration of the accident and emergency department in Portlaoise hospital. He must know that the accident and emergency departments in Naas and Tallaght hospitals are totally overcrowded, all the more reason to maintain the 24-hour service in Portlaoise hospital. We need adequate cover for that.

I am told now that a report will probably not be ready until sometime in September. That is down to the fact that so much consultation has to take place with everyone who is affected, not only the staff in the hospital but GPs in the area and, as the Deputy rightly pointed out, the impacts that this may have on other hospitals such as those in Naas, Tallaght and Tullamore. I am told it could be September before a plan of action will be ready. I have seen the letter from the Laois GPs. I was pleased to note they called for the HIQA report to be implemented but of course reports have to be implemented in full, not only the parts of them that one likes while leaving out the parts that one does not like.

Part of the under-six contract was that we made it a stipulation that anyone getting such a contract would have to be a member of a specialist register for general practitioners because we do not think it is acceptable that somebody who is not on the specialist register should work as a GP and treat children for their ailments. Yet we do see it as acceptable in Ireland that we can staff emergency departments with people who are not on the specialist register for emergency medicine. It is an issue up and down the country that we allow so many of our centres not to be staffed with specialists. The reality is that there may not be sufficient specialists available to staff them all with specialists. Therefore, are we willing to accept an inferior level of care?

I understand and appreciate the issues and we all acknowledge the HIQA report. I believe the Minister accepts that people locally welcome the improvements in the maternity services that have flown from the HIQA report. Essentially, we want the same level of determination to be shown to make the accident and emergency service safe. If the HSE and HIQA cannot stand over it being safe, the issue is to make it safe; the issue is not to close it, or close it for half of the day or half of the 24 hour period. The Minister will be aware that between 25% and one third of admissions to the accident and emergency department are paediatric cases as a result of the large paediatric unit, and the maternity services, in the hospital. To ensure that the hospital works fully, it is essential that it has permanent consultant cover. I do not believe there is a permanent consultant covering the accident and emergency department in Portlaoise and that is a central issue that must be addressed.

I had tabled a similar question. The key issue is consultant cover. Having met the Minister and discussed that issue with him, and I thank him for the meeting with the public representatives from the County Laois area, he will be aware of that. Portlaoise hospital has only 24 hours per week temporary, part-time consultant cover. That is not satisfactory, and the GPs have gone to great lengths to explain that. In terms of throughput over the years, Portlaoise hospital had 38,000 attendances through its emergency department while Tullamore hospital had, on average, about two thirds of that figure. The general practitioners have outlined clearly the interdependency of the other important parts of the hospital, including the maternity and paediatric services, on the emergency department. Its paediatric unit is very busy and is one of the top eight in the country. I ask the Minister to take that into consideration in his deliberations.

Thank you, Deputy. We are over time.

I hope that the GPs' letter and the report will be given favourable consideration.

We all need to consider this one carefully because we have to ask ourselves what consultant cover actually means. We have very large emergency departments in this country with four and five emergency department consultants who are not in the departments after 6 o'clock or 8 o'clock at night. They are on-call from home or, in some cases, they will not cover weekends. Even with four or five consultants, either because of unwillingness or too onerous a rota, we do not have 24-7 consultant cover. I am not sure we have that in any emergency department in Ireland; they are probably on-call from home.

We have only a limited number of specialists, and we have to consider the level of patient safety risks we are willing to accept. If it is not possible to recruit people to cover a special service 24-7, or if there are not enough patients for them to keep up their skills in which case they cease to become specialists, we have to decide if we are unwilling to accept an inferior and non-specialist service just because it is local, and that is not particular to Portlaoise as it also applies elsewhere. One of the big struggles that will happen in Portlaoise is hiring the additional consultants for obstetrics and paediatrics. We need those additional consultants in obstetrics and paediatrics to ensure there is senior cover in that unit, but what if we cannot recruit them? We have serious difficulties recruiting people. The Rotunda hospital advertised two jobs not that long ago and did not get any applicants. We need to have a very serious conversation with the public as to what we do if it is not possible to staff units with specialists. Are we willing to accept an inferior service on that basis?

Written Answers follow Adjournment.
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