Topical Issue Debate

Company Closures

I thank the Ceann Comhairle for selecting this matter. Last Thursday evening, the village of Clarecastle and County Clare were rocked by the news that Roche Ireland is to withdraw from manufacturing in its plant in Clarecastle. The site was opened by a company called Syntex in 1974 and was subsequently taken over by Roche in 1994. As a native of Clarecastle and having been raised in the shadow of the plant, I am acutely aware of the enormous contribution this manufacturing facility has made to the community of Clarecastle, to County Clare and to the mid-west region for the past four decades. The importance of the plant to the economy of Ennis, Clarecastle and County Clare cannot be overstated. It is worth in the region of €20 million in salaries alone. It is the biggest single employer in Ennis, with 240 direct employees and another 200 contractors working on site.

This shock decision was made in the headquarters of Roche in Basel and results from a review of Roche's worldwide manufacturing network. Roche intends to move away from the traditional method of manufacturing its product to a system focused on producing less volume with higher potency, which is not compatible with the way its four manufacturing plants in Clarecastle, South Carolina, Spain and Italy work, therefore, the Roche Corporation has moved to divest from its interests in these plants. It must be noted that Roche has invested heavily in its site in Clarecastle over the past four years. Some €100 million has been pumped into the plant, making it a most attractive prospect for a potential investor. As well as the state of the art infrastructure, there is a very talented and dedicated workforce at Roche who are highly skilled and committed.

Since this news broke in recent days I have engaged directly with the managing director of the plant. I have met with him and the members of the management team. I have spoken with many workers and their families. I have met with the Minister for Jobs, Enterprise and Innovation, Deputy Bruton. I have also met with the Taoiseach and on a daily basis I have spoken to the IDA.

It is critical that every effort is made to identify an investor for the plant. It is critical also that the Department of Jobs, Enterprise and Innovation dedicates every resource available to finding a solution to securing the future of this immensely important site. It is my understanding that the IDA is to meet with Roche Corporation in its headquarters in Basel this week, and I also understand that the IDA is to visit the plant in Clarecastle tomorrow. It is encouraging that a potential investor has already visited the site, and I look forward to that investor engaging further in the weeks ahead.

While there is a three year lead-in period, the next six to nine months are critically important for the future of the plant and to the workforce in Clarecastle. Our economy has moved to a different space over the past four and a half years. We now have the fastest growing economy in Europe. There is a sense of optimism in our country and a growing environment of investment. For this reason, and because of the talented, well thought of workforce, coupled with the significant investment made in the plant over the past four years, the ease of access through Shannon Airport and a top class road network, I am confident that an investor will move to acquire the site in Clarecastle.

Last Thursday evening when this story broke I immediately met with the Minister, Deputy Bruton. I welcome his interest and determination to find a solution for this plant. The Minister has a track record in delivering solutions to manufacturing plants in similar predicaments. I ask him to outline to the House his plans to encourage an investor to the site in Clarecastle. I ask him also to outline his work to date and his future plans, and those of the Government agencies, to bring about a solution for the plant in Clarecastle.

I thank Deputy Joe Carey for raising this issue. His portrayal of the situation is accurate and balanced. Our first thoughts are with the workers in Roche in terms of the uncertainty they face. However, we have a good track record in working on difficult issues like this one and I am confident for the future.

Last week's announcement of the company's intention to exit the plant was very disappointing. This factory has been in operation since 1974, providing substantial employment since then, with the workforce now standing at 240 employees. The company is proposing to seek a buyer for the site.

The announcement by Roche that it is planning to exit the site and market it to alternative investors arises from a global review undertaken by the company, which has resulted in its focus for the future being on a pipeline of new products that are smaller scale rather than the large, blockbusting products that have been the pattern. That has given rise to substantial restructuring within the group, which as the Deputy indicated has resulted in the proposed exit from a number of Roche facilities in the USA, Spain and Italy.

The State agencies have a strong record in finding alternative employment in facilities earmarked for closure, in particular where there is a long lead-in time which allows the site to be marketed effectively. It is of note in this case that the company has not planned any redundancies and plans to continue operation for a considerable period. I have directed the agencies that no effort be spared in the search for an alternative investor for this facility.

I have also spoken to senior executives at the company on these issues. IDA Ireland has been engaging with the company for some time and will continue to engage with the company as it seeks to find a buyer for the plant. It is encouraging that in a number of similar situations where closures have been announced, the State enterprises have been able to find alternative investors, including the GSK-Stiefel case in Sligo, Pfizer-Amgen in Dún Laoghaire and J & J-Amneal in Tipperary. It is important also to remember the situation in Waterford where we had both the closure of TalkTalk, which resulted in the emergence of Eishtec, and the restructuring that was successfully negotiated in Bausch and Lomb.

I have directed the IDA to actively pursue a new buyer for the plant and it will work actively with the company, which is also committed to seeking a buyer. The IDA will draw up a detailed prospectus with the company. It will highlight the attractions of this facility for both its existing client companies and potential new investors who may be interested in such a facility. It will use its wide international network to highlight this opportunity. The gradual wind-down period will give a welcome window in which to pursue this objective.

Despite some challenges in the pharma sector in recent years in Ireland, it is worth pointing out that the sector has adapted very well to a fast-changing landscape. Between 2011 and 2014, employment numbers in the pharmaceutical and chemical sector have actually increased by 7%. In addition, the profile of the Irish industry has changed significantly with huge levels of investment having taken place by companies, and we now have a very impressive footprint in the growing biopharmaceutical sector in particular.

Since the launch of the National Action Plan for Jobs, we are seeing encouraging recovery in the mid-west region. There are 7,000 additional people at work in the region, which contrasts with the previous period of 20,000 job losses. We have also seen the start of a strong recovery in Clare. In 2014, an additional 700 people were at work in enterprises supported by the agencies of my Department: the IDA, Enterprise lreland and the local enterprise office. The live register in Clare also fell by 10% in the past 12 months. However, we recognise that there are opportunities to build on that and that is the reason we have developed the mid-west regional action plan, which includes counties Clare and Limerick. That was launched last month and has a comprehensive set of proposals both to increase the attraction of foreign direct investment but also to build on the strong employment base within the region already.

As the Deputy said, we have had a very strong flow of foreign investment and this plant represents an opportunity to attract new investors. I can assure the Deputy that no effort will be spared in my Department or through the agencies of my Department in pursuing new opportunities for the workforce and supporting the company in its plan to sell the plant as a going concern.

I thank the Minister for his reply. The next six to nine months are critically important for the future of the plant and its workforce. It is encouraging to hear the Minister say that no effort will be spared to find a solution but I want to hear that every resource will be used in his office and by the agencies under the Minister's control. This is too big an issue and we have to get a solution. People's livelihoods are on the line.

The economy of County Clare and Ennis are on the line. It is so important that we find a solution. It is encouraging to hear the Minister's words today. I look forward to working closely with him and Government agencies, as well as the workforce, management and unions at Roche to find a solution. The next six to nine months will be critical, but I am confident we can find a solution with the Minister's help. It is encouraging to hear his words today.

I thank the Deputy. The period of the crash has sharpened the agencies. IDA Ireland is to be complimented on its enhanced regional focus and the stronger connections it has built between its regional presence and its offices on the front line in various countries. It has also built a particularly strong network around the pharmaceutical and life sciences sector, where it has unrivalled international access to companies that are significant players and would have the capacity to look at this opportunity. IDA Ireland has put itself in a good position. I assure the Deputy that no effort will be spared and the resources of the Department and agencies will be used.

The Deputy is right in saying that the next six to nine months will be a very important period because volumes will be high in the Roche plant, which gives an incoming investor a bedrock of supply to which it could subsequently add. We are conscious of the time sensitivity of the work that needs to be done on the project. I assure the Deputy of continuing contact with him and other Deputies in the region to ensure we respond in every way possible.

Mental Health Services Staff

I thank the Ceann Comhairle for selecting the Topical Issue on Maryville health centre, a five-day hospital service for 60 to 70 patients in New Ross and surrounding areas.

Recently a psychiatric nurse was transferred from Maryville to another centre without a replacement, causing much concern to the patients attending the centre. A Vision for Change which was implemented in Wexford, as it was across the country, outlined the provision of a better service for people with mental health issues, including depression. A nurse who had been in Maryville for a number of years and was a key contact for the 60 to 70 patients attending the centre is no longer there. She was their first and, in many cases, only contact owing to the lack of adequate services in the New Ross area. The patients are devastated by the decision, as they had built up trust in the nurse during the years. They had formed a bond and a relationship with her.

People with mental health difficulties, including depression, find it very difficult to relate to people and trust them. Now someone they trusted has been taken away from them and they are very concerned. A number of patients told me this nurse was a friend more than a nurse. She went above and beyond the call of duty to help patients at Maryville and to be there for them. The patients are devastated and many of them told me the centre was no longer relevant to them owing to the removal of the nurse. They want her to be returned to the New Ross area and Maryville as a matter of urgency.

I received a reply from the HSE recently which contained the usual gobbledygook about the importance of A Vision for Change. It referred to the services provided at Maryville, contrary to what the patients who attend there had said. It outlined details about staffing levels. A nurse is on maternity leave and a number of staff members have retired. In Wexford mental health services a number of other nurses are on maternity leave. The decision to move the nurse from New Ross to another centre in the county was robbing Peter to pay Paul and has left a bad taste for the patients in New Ross. Naturally they would prefer to see the return of the nurse who was there and had built up a bond of friendship. She had helped them to find jobs and be part of the community. She should be returned to New Ross as a matter of urgency. A Vision for Change never envisaged a person essential to one centre being transferred to another, leaving the centre from which he or she has come lacking the people needed to provide a service.

It is important that the nurse who left Maryville return. Some of the patients attending Maryville have sent me letters indicating that it is no longer of relevance to them because of the removal of the nurse. They are trying to develop their own group, New Me ~ New Ross, totally on a voluntary basis, without any financial support. They also claim that professionals come to Maryville and hold endless meetings, with nothing coming from them. They now want the services restored to them as a matter of urgency.

I thank the Deputy for raising this important matter. I am replying on behalf of the Minister for Health who is unavoidably absent and sends his apologies.

In line with national policy, Waterford and Wexford mental health services implemented the recommendations of A Vision for Change on the organisation and provision of mental health services, transforming them from a largely bed-based in-patient service towards a more community-based service. In Wexford mental health services are arranged by geographic location. There are general adult mental health teams based in Summerhill in Wexford, Carn House in Enniscorthy and Tara House in Gorey, all of which operate a seven-day service from 9 a.m. to 5 p.m., while Maryville in New Ross operates a five-day service, also from 9 a.m. to 5 p.m. If someone is feeling suicidal in County Wexford and wishes to have a consultation, he or she can be referred through his or her GP to any of these four day hospitals and be seen by a consultant psychiatrist. All general practitioners in County Wexford are aware of these day hospitals and familiar with the process for making direct referrals to these units.

A multidisciplinary mental health team based at Maryville includes a consultant psychiatrist for adults, a non-consultant hospital doctor, nursing staff, an occupational therapist, a psychologist, a social worker, a secretary, a community mental health nurse and a part-time addiction counsellor. In line with the proposed skill mix in A Vision for Change, the multidisciplinary team based at Maryville has expanded with the appointment of the aforementioned social worker and occupational therapist posts.

With regard to nurse staffing levels in Maryville, a nurse currently on maternity leave will be reassigned to the service on her return. In addition, a number of nursing staff have retired from Wexford mental health services in recent years. Aside from the nurse in Maryville, a number of other nurses are on maternity leave in Wexford mental health services generally. It is challenging to recruit candidates to fill temporary short-term positions such as maternity leave cover.

Management from the HSE's Waterford and Wexford mental health services continues to monitor staffing levels on a regular basis and explore all possible options within resources available to try to improve service provision. Given the number of nursing retirements and staff on maternity leave, at times the service needs to reallocate staff between mental health services and units to optimise services so as to meet patients' needs, as appropriate.

The overall recruitment of nursing staff is proving very challenging in Ireland generally, let alone in County Wexford. For example, all 11 recent nursing graduates from Waterford and Wexford mental health services have been offered full-time employment within the local mental health services. In addition, posts are advertised nationally and overseas. Other recruitment measures include bespoke recruitment campaigns.

Local HSE management and mental health service personnel are working closely with the national mental health division on nurse staffing issues. In addition, a national mental health workforce planning review group has been established to better plan and deliver staffing and service needs overall, including in the mental health area. I trust that clarifies the issues for the Deputy.

I thank the Minister of State, Deputy Coffey, for his reply, which I am sure has come from the Department of Health. I am aware of Summerhill, Carn House and Tara House in Gorey. They provide an excellent service throughout the county, as do the outreach nurses with whom we deal on a regular basis. The point made by the patients and others who seek a restoration of the service in New Ross is that patients had built up a bond, trust and friendship with the nurse in question who understood them and their needs and how difficult it was for them at times to attend the services or to leave their home and be part and parcel of the community. In the reply, the Minister of State outlined that there is a nurse on maternity leave and that she will return eventually. It is the right of any person on maternity leave to be out of the workforce for a year or a year and a half. Is the HSE saying Maryville will have to survive and continue without a nurse for a period of time? Could the Minister of State, Deputy Coffey, request the Minister for Health to re-examine the situation and return the nurse who was located in Maryville and find a replacement nurse for the other service to which she has been deployed? That would be very important.

I deal regularly with Ciarán Cullen and Martin Fitzhenry and others who are outreach nurses for mental health services. They say it is very important for there to be continuity in the care provided, given the bond and trusting relationship that is built up over the years. It is important that such a level of care would continue to be provided, not in the interests of the nurses but of the patients. I urge the Minister of State to request that the Minister for Health, through the HSE, restores the services that were available in the New Ross area as quickly as possible. Wexford, Gorey and Enniscorthy have a seven day service while Maryville in New Ross only provides a five day service and it is important that the service would be adequate to serve the needs of the people. It is also important that the particular nurse who has the ear of the people suffering from mental health and depression disorders in New Ross would be returned as quickly as possible.

It is acknowledged in the initial reply that HSE management has a responsibility to ensure adequate provisions in terms of staffing at each of the four units based in County Wexford, namely, the one in Wexford town, and the centres in Gorey, Enniscorthy and New Ross, which is the subject of the current debate. The recruitment of nurses in this country is proving challenging in general. I note that all of the 11 nursing graduates this year have been offered full-time employment in the mental health services in the Waterford and Wexford areas, which is to be welcomed. In addition, advertisements continue to be placed both nationally and internationally to attract some of the nurses who qualified and possibly worked in this country back here so that we can enhance services in this country. I recognise that the matter raised is of genuine concern and I will undertake to relay the concerns outlined to the Minister.

Health Care Policy

I thank the Ceann Comhairle for allowing me to raise this very important issue. It was intended to be raised yesterday, which was World Prematurity Day, but due to the change in business and the statements in the House I am raising it today.

In recognition of yesterday being World Prematurity Day, I wish to raise the need for the Government to make prematurity and neonatal health a health care and welfare policy priority. Approximately 4,500 babies are born prematurely every year in Ireland and yet despite that, there is no national neonatal health policy or programme in place. The number of premature births is rising but, sadly, the issue is not on our radar. It was not on my radar until my first granddaughter was born ten weeks premature almost two years ago. Amy-Berry, who spent 81 days in hospital before being brought home, is thankfully thriving today and that is due to the excellent care she received in both Cork University Maternity Hospital and in the maternity services unit in South Tipperary General Hospital. The health care professionals were excellent and the care she received both in hospital and in the follow-up process was second to none. It is important to state that fact.

I compliment and thank the staff in both hospitals as well as the early intervention team in south Tipperary all of whom have been fantastic. That said, there are significant issues surrounding preterm birth in this country which need to be addressed. It is not acceptable that the care any vulnerable preterm baby should receive would be dependent on his or her geographic location. Our neonatal health policy is fragmented and unco-ordinated and the absence of a targeted national policy is preventing access to high quality health care and social support for preterm infants and their families.

Two years ago, the national neonatal transport programme was thankfully extended to a 24 hour service. This year the focus is on the need to put in place and fund a retro transfer service. We have experience of this system working very well whereby my granddaughter, Amy, who was born in Cork, was transferred back to South Tipperary General Hospital after seven weeks when she became well enough to continue care there, thereby freeing up an intensive care unit bed in Cork. Beds in intensive care units are vital. The transfer of patients frees up pressure on the hospital system and can reduce the pressure on families as their child can be moved to a regional hospital closer to home for continuing care. That is important for families and extended families. This system works well but in order to ensure that every baby in the country has access to equal care, we need a fully operational retro service to compliment the neonatal transport programme. It is important to free up pressure in regional hospitals and it brings babies closer to home in local hospitals.

The second major issue is the lack of consistent follow-up care for preterm infants across the country. Geography plays a vital role in determining what aftercare services one can avail of. That is not right or fair by any yardstick. Some units carry out developmental check-ups but, sadly, many do not because they do not have the expertise and resources to do so. That discriminates against certain regions and affects families and their children in those areas. If we invested in adequate follow-up care for neonates, we would pick up on far more developmental problems and initiate early intervention at the earliest possible opportunity. It is vital that we would pick up on a range of issues that might affect infants and provide timely intervention. As I am out of time, I will wait for the Minister of State to reply before I add anything further.

I apologise to the Deputy for the unavoidable absence of the Minister for Health today. I wish to respond to this Topical Issue debate on his behalf. Premature birth is the largest cause of neonatal death worldwide. In Ireland, 6% of babies are born prematurely, a rate that is increasing for a variety of reasons, including assisted reproduction, higher rates of multiple births and increasing maternal age.

It is a sad fact that many families have been touched directly or indirectly by the consequences of premature birth.

Thankfully, however, there has been a dramatic fall in mortality and morbidity rates for newborn infants and 90% of infants born prematurely at 28 weeks now survive, whereas in the early 1980s, 90% of those babies unfortunately died. Clearly, neonatology is one of medicine's greatest success stories over the past 30 years. This success is not only because of scientific advances and the availability and application of new technology but also is due to the centralisation of complex cases in tertiary hospitals and the training of a highly skilled and specialised workforce.

The national clinical programme for paediatrics and neonatology was established in 2011 as a joint clinical initiative between the Health Service Executive, HSE, and the faculty of paediatrics in the Royal College of Physicians of Ireland, RCPI. The programme aims to provide high-quality care to more than 67,000 babies born in Ireland annually through effective screening, the provision of equal, rapid access to neonatal intensive care where and when required and the eradication of fragmentation and duplication of newborn specialist and intensive care services. High-quality care is vital for fragile infants and, together with good policies and well-planned programmes, the outcome for preterm infants is very positive.

It is recognised that the key to good neonatal services is to concentrate the care of preterm infants in a small number of centres where highly trained staff become experienced in managing the complex problems these high-risk infants develop. In this regard, there are 19 neonatal units and 300 special care baby unit cots across the State to care for preterm and sick newborn infants. The neonatal units provide differing levels of care depending on their size and medical and nursing numbers. Four tertiary units provide the most complex level of care and four secondary units provide an intermediate level of care, while the 11 remaining primary units provide routine newborn care and immediate resuscitation facilities. The process that integrates these neonatal units is the national neonatal transport service. This facilitates the rapid transfer of babies who need a higher level of clinical support. A specially equipped ambulance staffed by trained neonatal doctors and nurses travels from Dublin to the smaller hospitals to help with the transfer of the baby to the tertiary centre. These babies can be transported at short notice, day or night, seven days a week.

The Minister for Health also is delighted to mention today that last Monday, the HSE, working in close partnership with the RCPI, launched a new model of care for neonatal services in Ireland. This was developed following wide consultation with professional groups and parents. Importantly, the recommendations have been benchmarked against international standards. The model of care is intended to ensure sustainability in the neonatal services and has three core objectives, namely, improving safety and quality in the delivery of baby-centred care, improving access to the appropriate services and improving cost-effectiveness of services delivered. In conclusion, I assure the Deputy and Members that there is little need to discuss making prematurity and neonatal health a national health care and welfare policy priority, because it already is a priority.

I do not accept the last statement made by the Minister of State. While I acknowledge he is doing his best here today, I am disappointed by the absence of the Minister of State in the Department of Health, as I met her in the House only half an hour ago. This issue is not a national priority and must be dealt with sensitively. Were the health service to invest in adequate follow-up care for neonates, it would pick up far more issues, would be able to mount early intervention and could address many other issues. The availability of proper early intervention services is not simply a preterm issue, however, and the system is failing many children with special needs due to a lack of access to appropriate services. This is clear and the Minister of State cannot claim Ireland has state-of-art services. The Government has been claiming for the past four and a half years that a free medical service would be implemented but it has capitulated on that for the present. There is no point in putting one's head in the sand.

The lack of social and financial support also is a major issue because the cost to families with preterm infants places undue stress and economic hardship on those families. As I stated, the financial costs in respect of pre-terms is considerable and the State must understand this and must provide the services. The Minister of State mentioned the transfer ambulance but in cases in which South Tipperary General Hospital must transfer an infant to Cork, that is, in the opposite direction to the journey made by my granddaughter Amy, who came back from Cork, a specially-trained nurse must travel in the ambulance with the infant, thereby leaving behind a shortage of such scarce and vital nurses who do such good work. Consequently, there is much tweaking and much work that can be done. The front-line staff in most parts are excellent and do tremendous work but through no fault of theirs, the lack of a national neonatal health policy means some premature infants or their families simply will not get the care they need because of where they live and this is most regrettable. This is why I disagree with the Minister of State's concluding remarks.

I also compliment the Irish Neonatal Health Alliance and the Irish Premature Babies group, both of which offer wonderful supports to the families of premature children. However, they cannot do it alone. This is a growing issue and the Government must address it to ensure that all premature children born in Ireland can reach their full potential. My family is delighted with our situation now and are thankful to the HSE and its staff but the issue must be examined and considered. Each year, 4,500 babies are born in that situation, which is a high number. I recognise the Minister of State's observation that the position and the numbers have improved but much more tweaking and a lot more assistance and support is needed on this highly sensitive issue.

I acknowledge to the Deputy this is indeed a sensitive issue and this is why the Government treats it with the highest priority. I will take this opportunity to congratulate the Deputy on the arrival of his granddaughter, Amy, and I am happy there was a positive outcome. The Deputy is right to put on record the assistance and support of the health services that assisted his granddaughter to come into the world in a preterm situation that now has proven to be successful. I congratulate the Deputy and his family in this regard.

I reiterate that neonatal services and preterm care are a national priority for the Government and this is reflected in the positive mortality reports that have been published. I have already referred to some statistics and the facts are that in the 1980s, 90% of infants who were born at 28 weeks unfortunately did not survive whereas at present, with the current level of services, technology and sciences, as well as the support and care available to preterm births and babies, 90% of those infants born at 28 weeks survive, which is a wonderful achievement. However, this is a highly sensitive matter and I am conscious of the 10% and more of infants who unfortunately do not survive and it is extremely tough for any family or mother and father to find themselves in that situation.

I will pass on the Deputy's comments to the Minister and reassure him that this service and this matter are being treated as a priority.

General Practitioner Services Provision

This issue concerns Shannondoc, which is a general practitioner, GP, co-operative based in County Clare that provides out-of-hours services to cover what GPs normally do during office hours in the evening and at weekends. It is an important service but there have been repeated rumours throughout County Clare of various reductions in Shannondoc services in west Clare, Shannon and elsewhere. Thankfully, this has not come to pass and it is important to state there has been no reduction in the Shannondoc services thus far but nevertheless, it also is important to acknowledge there is a great deal of pressure on the services Shannondoc provides because of GP shortages. When the present Government was elected, there were 20 GPs operating out of north and west County Clare but that number has now fallen to 15 and therefore, the number of GPs Shannondoc can pool and put on a roster in the evening is reduced. While this might not appear to be so important, the ambulance service is already at breaking point or at least is at the very edge of what it can achieve, and likewise the accident and emergency facilities in Limerick. While I thank the Minister of State, Deputy Coffey, for coming into the Chamber, I appreciate he is not a Minister in the Department of Health and consequently may not be aware of the overcrowding situation in the accident and emergency unit, but it is at an unacceptable level.

If people are unable to get a doctor to call out to them at night time, they have no alternative but to call an ambulance or make their way to an accident and emergency department and join the lengthy queues there. It is a serious issue which arises not as a result of a lack of HSE funding of the service but owing to a lack of doctors practising as GPs in the area. Many of the GPs currently working in the area are elderly and are, understandably, less inclined to work long hours. Very few of the GPs coming on stream these days are going into rural practices across County Clare.

Doctors and graduates of medicine in Ireland generally earn a lot of money. They earn what would appear to me to be a great deal of money and it would certainly be a huge amount in comparison with the earnings of most of the people I represent but it is still a lot less than they can earn in Canada and in other countries across the world. For young doctors who are not tied to any particular place and do not have a family of their own, the option of going to work in the health service in another country is very attractive and that service is probably better funded. There is little this Government can do to stop that happening. It would be wrong to try to stop anybody emigrating. We had a referendum a long time ago, the aim of which was to stop certain people leaving the country, which would be a preposterous proposal to most.

Older doctors also earn a lot of money. Many older GPs were encouraged by the HSE to set up GP practices in which they invested very heavily in terms of equipment and so on and in respect of which they received funding from the HSE. However, that funding has been reduced. Every backbencher has a constituency office. I assume Deputy Coffey, although a Minister of State, still maintains a constituency office. Constituency offices are funded by the Exchequer such that Members are not required to pay for them. While GPs were encouraged by the HSE to invest in their facilities and in that regard took out mortgages and so on, they now find that the funding they receive is a lot less than they anticipated when they took out loans and so on. There is a real problem in relation to general practitioners in this country. If there are not sufficient GPs, people go elsewhere with their health problems. They clog up accident and emergency departments and inevitably rely on the ambulance service, which is already over-stretched.

I apologise to Deputy McNamara on behalf of the Minister for Health, Deputy Varadkar, who is unavoidably absent today. However, I am happy to take this important matter on the Minister's behalf.

Shannondoc is a GP co-operative funded by the HSE. It provides a valuable urgent out-of-hours service to the population in the mid-west region. Operating out of 11 treatment centres, spread across the region and a fleet of mobile doctors, Shannondoc had 110,000 patient contacts last year, with 90,000 receiving treatment. At the heart of the operation is the call centre. Based in St. Camillus' Hospital, the centre processes all patient calls, with nurses assessing and managing concerns or directing patients, where necessary, to a treatment centre or assigning a home GP visit. It is acknowledged that Shannondoc is facing a resource challenge in relation to the availability of doctors, especially in west and north Clare, as indicated at the start of the summer period.

A review of the out-of-hours service has commenced to ensure that a safe and appropriate GP out-of-hours service continues to be available to all people living in the mid-west region, which can be accessed as and when needed. In the meantime, the HSE has advised that Shannondoc is providing the same service and is continuing its consultation with GPs in County Clare to meet the current service needs. The HSE remains focused on ensuring out-of-hours service will continue to be delivered for all throughout the country.

In relation to the Shannon treatment centre, Shannondoc has confirmed that this will not be closing. In addition, there has been no diminution in the level of service being provided at the Shannon centre. When required, patients will be seen at the centre. Last week, 112 patients attended the Shannon centre for treatment. Patients who require treatment at the centre are assigned appointments during the time when the doctor is on-site. There are occasions when the Shannon centre augments the busy Ennis centre. Normally at weekends, the Shannon treatment centre experiences a low level of patient appointments between the hours of 9 p.m. and midnight - averaging two per night, compared with the higher throughput at the Ennis centre. When there are no further scheduled appointments at Shannon, one of its GPs relocates to Ennis during those hours. However, should an appointment be required at the Shannon centre, and if the patient is unable to travel to Ennis, a GP will travel back to Shannon to ensure the patient receives an appropriate service. This system has been in place since 22 September 2015 and has run seamlessly. House calls continue to be provided in the Shannon area as normal. This level of co-operation between treatment centres allows Shannondoc to provide a more effective service to the patients in the mid-west region while making the most effective use of its resources.

The HSE has stated that Shannondoc wishes to reassure the Clare community and the people in the mid-west that they will continue to be able to access and receive a GP out-of-hours service in the area.

I thank the Minister of State for his response and I welcome the fact there is no diminution in services. I also welcome his acknowledgement that the problem is one of resources and is related not to funding provided by the HSE but the availability of general practitioners. This problem is exacerbated by the lack of locums, for which there are two reasons. Many locums come from outside of Ireland. Many are what might be termed third country nationals and do not come from within the European Union. The visa regime with regard to locums has changed such that they are now required to leave Ireland for a portion of every year.

I previously worked in the area of immigration law. I have always thought there was a particular discernible attitude within the Department of Justice and Equality towards third country nationals, non-EU citizens in particular. It is almost as if we are saying that these people are good enough to come here and save our lives but we would not want them to get too comfortable lest they might decide to stay. That is appalling. If locums come here and provide essential services, the least we can do is ensure we have in place a visa regime which enables them to remain here if they so wish. A similar problem arose in the context of the shortage of junior and senior house doctors at the time when this Government came to power. While those brought into the country at that time were deemed good enough to be junior and senior house doctors, they were unable to access training programmes. Many of those involved were from India, Pakistan and other countries. They were well qualified and good doctors but they were unable to access training programmes, which was akin to saying that they were good enough to provide some services but we would not want them to get too comfortable, lest they might decide to stay, which is an appalling attitude but not one that surprises me because that is how our immigration system works. It is a problem that not only creates a further problem for these excellent doctors and their families but for ordinary people across this country in terms of not being able to access as good a medical service as they might otherwise get if this visa regime did not exist. This issue needs to be addressed.

Another problem is the high wages paid to locums in the UK. I understand there are Irish doctors going to the UK to work as locums because they know locums there are paid more. As I said at the outset, doctors earn a great deal more money than many of the people I represent. Many of our doctors are going to other countries where the wages are higher because they are under financial pressure here.

It is important to put on the record that GP services and primary care in general in this country receive substantial State support, although an argument can always be made for more. I accept the Deputy's genuine concerns in that regard. This is a priority area for Government, one in which we will continue to invest.

As stated, the HSE and Shannondoc have asked that the Deputy be assured that the people in Clare and the mid-west region will continue to be able to access and receive a GP out-of-hours service, which I am sure the Deputy will welcome. In terms of the topical issues raised today, recruitment and attraction of professionals into our health service remains an ongoing challenge. The Government and HSE is committed to ensuring that we have a successful recruitment programme. The Minister and Department of Health will continue to monitor and evaluate that programme and respond accordingly.