Priority Questions

General Practitioner Contracts

Billy Kelleher


1. Deputy Billy Kelleher asked the Minister for Health to outline the measures that will be taken to put general practice on a sustainable basis, especially in rural areas; the progress that is being made on a new contract for general practitioners; and if he will make a statement on the matter. [43125/15]

What measures will be taken to put medical general practice on a sustainable basis, especially in rural areas? What progress has been made on the new contract for general practitioners? Will the Minister of State make a statement on the matter?

The Government is committed to ensuring that patients throughout the country continue to have access to GP services, especially in remote rural areas, and that general practice is sustainable in such areas in future. It is imperative that services meet patient needs, that existing GP services are maintained and that general practice remains an attractive career option for newly-qualified GPs.

Under the current General Medical Services contract, GPs who practise in remote rural areas of low population qualify for special rural practice concessions, including an annual rural practice allowance of a little over €16,200, subsidies towards the employment of certain practice staff at the maximum applicable rate, regardless of the size of the patient panel, and the maximum applicable contribution towards locum costs for periods of leave.

Where a GP holds the allowance but the circumstances underpinning it change, the GP retains the allowance while he or she continues to practise in that location. When a new GP commences in the area, the application for the allowance is considered afresh by the HSE.

The HSE has recently reviewed its guidelines for dealing with applications for a rural practice allowance.

The purpose of the new guidance is to ensure consistency, transparency and fairness in decision making in respect of the relevant discretionary provisions of the GMS contract pertaining to the granting or otherwise of the allowance to new applicants. The new guidance does not affect existing holders of the allowance.

The HSE, Department of Health and Irish Medical Organisation are engaged in a comprehensive review of the GMS and other publicly funded health sector contracts involving GPs. Among the many topics being considered under this review process is the issue of supports for general practice, especially in remote rural areas. I welcome the engagement which is taking place with a view to achieving revised and modernised contractual arrangements which support the sustainable delivery of enhanced general practitioner services in local communities.

I am raising the issue because there is a crisis in rural GP services. Given the age profile of rural GPs and the regional imbalances in it, there is genuine concern that rural GP practices are not feasible or viable and that, as doctors retire, there will be no applications. Given the age profile, there will be a steady increase in the number of rural GPs retiring. If we do not have incentives or encouragement to sustain rural GP practices, we will have difficulty maintaining services in those areas.

Last week, there was a meeting in Bansha in south Tipperary. Dr. Marguerite Madden is retiring, and a large crowd turned out to highlight their concerns about attracting a GP to take over the practice. This is not the first time it has happened. We have had problems in Laois, Blarney in Cork a few years ago, and in Ballybunion more recently. If there were sustainability, viability and financial incentive, people would not refuse to take up these practices.

It is one of the central issues under negotiation with the IMO. The figures are important. As of 1 November 2015, 20 GMS lists do not have a permanent GP in place, eight of which are in rural areas with populations of fewer than 1,500. However, each of the lists has either a locum GP or a neighbouring GP who has taken over the list and provides the full range of GP services to patients. Patients continue to have access to GP and primary care services. Permanent GPs are supplying over 99.9% of the GMS general practice services. This compares favourably with other countries, such as the UK, where the latest figures for 2013-14 showed a GP vacancy rate of 8% in the NHS. Of the GMS vacancies in Ireland, 50% of the 20 permanent vacancies are recent and have occurred during the past six months. It is a recent phenomenon and has more effect on urban areas of deprivation than in rural areas. Sometimes, we miss this point.

While I highlighted the age profile of the GPs, the age profile and demographics of the remote and isolated areas where there is rural decline also show that there is a higher proportion of older people there. Given the principle of primary care, treating a person suffering from chronic illness or minor procedures in the least complex environment, the need is obviously to retain GPs in rural areas to provide primary care. This would be complementary to other primary care and community-based services. The fact that these areas have low populations does not mean there is not a high dependency on rural GP practices and primary care, particularly when one considers the demographics of these rural areas and the regional disparities between urban and rural areas but, more importantly, in the isolated areas.

Again, the GP vacancy rate in England is 8% compared to 1% here. The population across the country is aging. There are exceptional circumstances in rural areas and this is why we have additional allowances and give additional leave allowances regarding employment of staff and locums. Although a substantial grant is available, it is not just about money, as we know. Maybe, people do not want to develop their careers in that type of isolation. Maybe they want to be in urban areas. This is why we need to make it more attractive. This is central to what we are doing regarding the IMO.

Vaccination Programme

Caoimhghín Ó Caoláin


2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health while acknowledging the findings of the European Medical Agency in regard to the Gardasil vaccine, if he will acknowledge that there are many young women who are extremely ill and suffering from symptoms such as complex regional pain syndrome and postural orthostatic tachycardia syndrome but who are not eligible for any State support; if he is aware that some symptoms are so severe that some of these young women have had to drop out of school and their parents are faced with no other option but to quit work and become carers for their children; if he will ensure that these parents and young women alike are supported and made eligible for benefits such as disability allowance, carer's allowance, medical cards and so on; if he will ensure that the appropriate support services are set up for these girls and their families; and if he will make a statement on the matter. [43044/15]

I seek advice regarding the Minister's intention to address the dreadful circumstances that a not insignificant cohort of young women, and their families, face, consequent, they believe, on the Gardasil vaccination at school.

I thank the Deputy for raising the matter. I am aware of claims of an association between HPV vaccination and a number of conditions experienced by a group of young women. Anyone who is suffering ill health is eligible to seek medical attention and access appropriate health and social care services, irrespective of the cause of their symptoms. People are assessed for eligibility for medical cards, disability or carers allowance individually. The assessment takes into account their family income and individual needs rather than a specific diagnosis.

In particular, people who are suffering from the conditions raised by Deputy Ó Caoláin, complex regional pain syndrome and postural orthostatic tachycardia syndrome, do not have to prove a particular cause of their symptoms to be eligible to receive treatment or access other appropriate services. Young women and their families should seek medical advice from their family doctor in the normal manner and be guided by this advice in accessing appropriate services including specialist opinion where necessary.

The HPV vaccine, which was introduced in 2010, protects girls from developing cervical cancer when they are adults. It is available free of charge from the HSE for all girls in the first year of secondary school. Gardasil is the vaccine used by the HSE in the school immunisation programme and more than 100,000 girls have received this vaccine since its introduction. While no medicine, including vaccines, is entirely without risk, the safety profile of Gardasil has been continuously monitored since it was first authorised, both nationally and at EU level. Each year in Ireland approximately 300 women are diagnosed with cervical cancer. The HPV vaccine protects against two high-risk types of HPV that cause 73% of all cervical cancers.

It appears that some girls first suffered symptoms around the same time that they received the HPV vaccine, and, understandably, some parents have connected the vaccine to their daughters' conditions. However, the European Medicines Agency has recently completed a review of the vaccine. The review, in which the Health Products Regulatory Authority participated, specifically focused on two conditions, to which I have already referred, and found no evidence of a link between the vaccine and the conditions. I want to emphasise clearly the expert findings that the HPV vaccine is a safe vaccine, and encourage all parents to have their daughters vaccinated. This will reduce the numbers of deaths from cervical cancer, head and neck cancers and other cancers in years to come.

The Minister's reply will offer no comfort to the 130 families associated with the campaign group, REGRET. The Health Products Regulatory Authority has received 919 reports of adverse reactions and events associated with the use of Gardasil in Ireland. This could affect many more than the 130 families we know about, given that the condition can present by degrees. The 130 girls are displaying debilitating, long-term and chronic symptoms that include severe fatigue, short-term memory and concentration deterioration, food intolerances, visual disturbances, noise sensitivity, severe headaches, burning muscles and joint pain.

Will the Minister ensure that these young women and their families have access to such benefits as disability allowance, carer's allowance, medical cards and what other appropriate supports are deemed necessary? Will the Minister and his Department look favourably on their particular circumstances and needs?

Carer's allowance, carer's benefit, disability allowance and disability benefit are matters for the Department of Social Protection, but no one gets carer's allowance or disability benefit based on a diagnosis or a particular set of symptoms. Even if someone has a serious illness, for example, a severe cancer, he or she does not automatically get disability allowance. Everyone is assessed individually based on income and needs regardless of the cause of the illness or what he or she believes the cause to be.

Similarly, medical card applications are assessed initially based on the income of the individual or family. The cost of people's medical treatments and their other potential needs are then taken into account, in particular for discretionary medical cards. I am sure that the Deputy knows this from his own work. It is not that anyone has an automatic entitlement to any of these benefits based on what symptoms they have or what they believe the cause of the symptoms to be. People are assessed individually initially and also on their needs. This is the way it is for every citizen, which is as it should be.

What I would like to see of course is a situation where everyone would be entitled. Unfortunately, that is not the case. The Minister has made the exception in respect of some specific areas of need, in particular children with cancer symptoms, only in the very relatively recent past. We are not only looking at the 130 young women of whom we know - there are possibly many more - but also their families, some of which have had their lives suspended. Work and other opportunities in the fulfilment of life's hopes have been set aside in order to provide the supports and care for their daughters. It is imperative that some measure of recognition and some realistic reach-out be organised. It is not good enough just to reject their strong beliefs regarding the underlying causes of their daughters' conditions.

I am sorry, Deputy, but we are over time.

We have to take on board the facts they outline. I am appealing to the Minister. The representatives of Reactions and Effects of Gardasil Resulting in Extreme Trauma, REGRET, will be before the health committee later today. What would the Minister say to them if he were, as I am, a member of the health committee?

I ask Deputies to stick to the time limit. All that they are doing is preventing other Deputies from asking questions.

I agree with Deputy Ó Caoláin that it would be ideal if everyone had a medical card, but that is not the case. We have a means-tested system and people are assessed according to their means, not their diagnoses. In the case of discretionary medical cards, the assessment can take into account the burden of the illness and the cost of medical needs, but that is an individual assessment. After an expert group reported on this matter not too long ago, most people accepted that this was the best way forward.

Regarding the adverse reactions to which the Deputy referred, the Health Products Regulatory Authority, HPRA, had received 936 reports of adverse reactions and events by 27 November. It should be borne in mind that this was out of 100,000 people who had received the vaccine. The majority of the reports received by the HPRA have been consistent with the expected pattern of short-term adverse side effects for the use of any vaccine as described in the product information. The most frequently reported side effects are local redness and swelling at the point of injection and fever. These are usually mild and temporary reactions to any kind of vaccine. Fainting has occurred after vaccination with Gardasil, especially in adolescents, and less commonly reported side effects from Gardasil include pain in the injected arm site, bruising, itchiness, red hives and, on occasion, wheezing. Like most vaccines, severe allergic reactions are rare.

The fact that a suspected adverse reaction has been reported does not necessarily mean that the medicine or vaccine has caused the observed effect, as it may also be caused by the disease being treated, a new disease that the patient has developed around the same time or by another medicine that the patient is taking. Further data are usually needed to complete the picture.

Accident and Emergency Department Waiting Times

Finian McGrath


3. Deputy Finian McGrath asked the Minister for Health to resolve the crisis at the accident and emergency department in Beaumont Hospital in Dublin 9 and to deal with the lack of beds; and if he will make a statement on the matter. [43046/15]

I thank the Ceann Comhairle for the opportunity to ask the Minister this question. I raise this matter because I was invited a few months ago by staff, in particular those working in the accident and emergency department, to walk the corridors and meet the people who were on trolleys and chairs. I was astounded by what I saw. For the doctors, nurses and all other staff, the bottom line of the issue was bed capacity.

Last December, I convened the emergency department task force to assist in dealing with the challenges presented by emergency department overcrowding. Significant progress has been made to date. The special delivery unit, SDU, figures showed an 8% decrease in the number of patients on trolleys in November 2015 compared with November 2014. While the Irish Nurses and Midwives Organisation, INMO, figures for the month of November showed a 4% rise, it is significant that the nursing union's own figures also showed an 8% decrease in the second half of that month. This indicates that we are headed in the right direction. The numbers for November, whichever are used, are a considerable change from August when overcrowding was 20% to 40% worse than in August 2014. It is clear that the situation is not as bad as it was in the early new year when there were 500 to 600 people on trolleys every day. This morning, the number of people recorded as being on trolleys in the TrolleyGAR report was 244, with 110 people having waited for longer than nine hours. This represents a 23% reduction on this day last year.

The improved results that we are starting to see are the result of the implementation of the emergency task force plan, the investment of further funding of €117 million, the employment of more nurses and the opening of approximately 200 additional and previously closed beds, with a further 250 due to open in the next few weeks. In April, €74 million was provided to reduce delayed discharges, lower the waiting time for fair deal funding and provide additional transitional care beds and home care packages. In July, €18 million was allocated to support the acute hospital system over the winter period by providing additional bed capacity and other initiatives to support access to care. This included additional funding for Beaumont Hospital to enable St. Joseph's day hospital in Raheny to provide a five-day service, thus reducing presentations at the emergency department and the need for elderly people to be admitted.

Six of the beds at Beaumont that had been closed for refurbishment or infection control purposes during 2015 have re-opened and a further 21 beds are to re-open in December. Beaumont Hospital is one of the sites that has been the subject of particular focus, with the SDU supporting it to implement solutions. For example, the number of delayed discharges at Beaumont has decreased from 95 in November 2014 to 70 last month, thus freeing up 25 beds every day for acutely ill patients.

All hospitals, including Beaumont, have escalation plans to manage not only patient flow, but also patient safety in a responsive, controlled and planned way that supports and ensures the delivery of optimum patient care. Last week, I co-signed the emergency department congestion escalation directive to ensure that the progress made to date on overcrowding was improved upon. The directive requires hospitals to implement their escalation plans whenever their emergency departments experience overcrowding. It is expected that this will add to the progress made to date.

I welcome the fact that beds will be opened in Beaumont but we must focus on resolving the real issue. We all receive regular complaints from families, in particular those of senior citizens who find themselves on trolleys. This is especially the case at Beaumont Hospital. This situation is not acceptable. The Minister mentioned that 21 beds would be re-opened in Beaumont and six had been re-opened, amounting to 27 beds, but the staff on the ground have told me that they need approximately 80 long-term beds to resolve this regular crisis. I hope that the Minister pays attention. The professionals were objective and clinical about this issue. They told me that they needed approximately 80 beds, but the Minister has stated that they will only get 27. We must focus on this because we cannot have patients on trolleys this Christmas.

Beaumont is an overcrowded hospital. There is no denying that. All efforts are being made to improve the situation. That the number of delayed discharges has been reduced from 95 to 70 has freed up 25 beds. This decrease needs to be sustained and we need to reduce delayed discharges further. That will involve more nursing home places and more home care, but not necessarily more acute hospital beds.

The ward that was closed for refurbishment has now partially reopened. Six beds are open and a further 21 beds are yet to open.

While I do not have the statistics for the special delivery units before me, I have the numbers from the Irish Nurses and Midwives Organisation. According to those numbers, some 586 people spent time on a trolley at Beaumont Hospital at some point in November. That can range from one or two hours to a very long period of time. The figure for November 2014 was 729. This means that based on the numbers from the nurses' union, there was a 20% reduction from November 2014 to November 2015. Clearly, we need to do even better than that. I remind Deputy McGrath that there are plenty of examples of hospitals where we have put in lots of extra beds but it has not worked. Additional bed capacity is not the only factor that gives rise to hospital overcrowding - if only it were that easy - because there are many other factors at play.

If what the Minister is saying is the case, I want to know why the doctors and nurses in Beaumont Hospital are telling me that the reality is otherwise. I would like to mention two appalling cases in my constituency that recently highlighted the need to deal with this issue. A 90 year old woman ended up on a trolley after arriving at the accident and emergency department. Her family was treated appallingly. I am sending the details of that case to the Minister. I would appreciate it if he could look at them. The family in question does not want to go public. The second case relates to a 20 year old man with cerebral palsy who is PEG-fed, non-verbal and 5 stone in weight. There was nobody in the radiology department to deal with his needs at 6 o'clock on Saturday, 31 October last. His family members were so distressed that they had to take him home. When they came back on Sunday, 1 November, there was nobody in the radiology department again. They had to take him home again on the second day. When they came in on the Monday, they eventually got to see a doctor in the radiology department. It is not acceptable for a young man with cerebral palsy to be treated in such a way in any hospital in 2015. I ask the Minister to focus on the provision of proper services to people at Beaumont Hospital.

The Deputy will appreciate that I cannot comment on individual cases. I do not have all the information on them. I might never have all the details, for reasons of patient confidentiality and for other reasons. If the Deputy wants to make those details available to the chief executive officer of the hospital, I will make sure the matter is looked into appropriately. He is not the only person who knows doctors and nurses in Beaumont Hospital. I do too. I have visited the hospital on two occasions and the emergency department on one occasion. The doctors and nurses there acknowledge that many factors give rise to overcrowding. It is not just about bed capacity; it is also about delayed discharges, length of stay and other issues. In theory, a hospital in which the average patient spends eight days needs twice as many beds as a hospital in which the average patient spends four days. In practice, it needs to reduce its average length of stay per patient. A reduction of half a day in the average length of stay in a hospital can free up a huge number of beds. Many factors other than bed capacity contribute to overcrowding. On a bad day, there can be 30 or 40 people on trolleys at Beaumont Hospital. If it were as simple as providing extra beds, this problem should be solved by a reduction of 25 in the number of delayed discharges and the opening of 25 beds. That will not happen, however. There are many other factors at play. All of them need to be worked on as well.

Hospital Waiting Lists

Colm Keaveney


4. Deputy Colm Keaveney asked the Minister for Health the action being taken to address the unacceptable waiting times for surgical intervention to treat scoliosis; and if he will make a statement on the matter. [43126/15]

I am fully cognisant of section 6 of the Health Service Executive (Governance) Act 2013. For that reason, I will not refer to a specific individual in putting this question. The objective of the question is to get the Minister to profile his plans to deal with the unacceptable waiting times for scoliosis interventions. Will the Minister tell me why children have been waiting up to three years for such interventions from the HSE?

The Government is working to ensure long waiting times for scoliosis surgery are reduced. It is focussing on additional resources and capacity to carry out this surgery. Our Lady's Children's Hospital in Crumlin is the largest provider of scoliosis surgery for children and young people. Additional funding was allocated in 2015 for additional consultant posts, including two consultant orthopaedic surgeons, as well as an anaesthetist and support staff, at Crumlin. Capital funding has been provided for a new theatre on that site to expand theatre capacity further. This theatre will be open in the spring. In the interim, patients from Crumlin are being transferred to other hospitals in which capacity is available, where that is clinically appropriate. Temple Street Hospital has taken some cases. Cappagh Hospital is being used for older kids. Patients are also being transferred to Tallaght Hospital and the Blackrock Clinic, where it is being paid for privately. Recently, external capacity has been identified at the UK Royal National Orthopaedic Hospital in Stanmore near London. These measures have more than doubled capacity for this surgery for patients on the Crumlin waiting list in 2015. Two consultant orthopaedic surgeons have recently been appointed at Galway University Hospital to support the spinal service there. In the short term, the authorities in Galway are actively working to assign dedicated beds to support this service and exploring the potential to refer some patients out for surgery. The HSE is continuing to work with the children’s hospital group, the Saolta hospital group and the individual hospitals to identify all options to increase capacity further to improve access times for surgery.

The Minister will be aware that there is no national screening service for the onset of scoliosis. The curvature of the spine is probably first observed by a general practitioner or family member. Waiting lists and waiting times are increasing significantly. I have been advised by an orthopaedic surgeon that immediate intervention is required beyond the age of 16. It is next to pointless for an acute intervention to address the progressive nature of scoliosis. Children have been languishing on waiting lists for over three years. The interventions they are waiting for would not be considered lightly by families. It is a serious operation. What are the Minister's plans to accelerate the waiting times? It appears that the waiting times in the HSE west area are out of kilter with those elsewhere. There is a three-year wait for an intervention to address the chronic and acute nature of this condition.

Thank you, Deputy.

This is not an elective procedure. There are children who are begging the Minister for operations.

I will let you back in again.

I ask the Minister to be more specific. What plans does he have to ensure people are taken off the waiting list in Galway?

Sorry, would you recognise the Chair, please? There are other Deputies with other questions.

I notice that, a Cheann Comhairle.

The number of operations done every year needs to be increased substantially.

That is the only solution. There are barriers to that. Appropriately qualified consultant orthopaedic surgeons and theatre nurses need to be recruited. There needs to be sufficient theatre time and theatre space. I met the consultants in Crumlin who are the specialists in this area quite some time ago. They agreed that a whole new theatre was needed in Crumlin to provide additional capacity there. That is now under construction. Work is being done to staff the new theatre, which should be open in the new year. It will allow us to double capacity for children's orthopaedic surgery in Crumlin. This development is taking place even though an entire new hospital will be built in a few years time. The situation is so serious that we cannot wait for the new hospital to be completed. That is why the new theatre is being built. Efforts are under way to staff it. In the meantime, other hospitals that can help out are helping out. Temple Street Hospital, for example, is taking three patients. Stanmore Hospital near London is taking patients. That is important too. Some cases are being sent out privately to be done in Blackrock. In regard to Galway, I have asked my Department-----

Sorry, Minister, I will let you back in again.

I would like to speak about the human cost of not intervening. This is an intervention. I am aware of the case of a young woman who used to be a grade A student, but has had to miss 70 days of school in this academic year. At the age of 16, she is a user of the mental health services in Galway as a consequence of having spent three years languishing on a waiting list. I ask the Minister to ensure a national screening programme is introduced to enable us to intervene at an earlier juncture of somebody's life. If young people who are dealing with the scourge of scoliosis get the interventions they require, they will have an opportunity to live the most successful lives they can under these circumstances. Greater investment in taking people off waiting lists and getting them to Crumlin will be required to facilitate such interventions. The Minister referred to Crumlin, Cappagh and Blackrock, but I am talking about the case of a young woman in the west of Ireland. The Minister and I are both familiar with the case. This young woman, who used to be a grade A student, has collapsed while waiting for an intervention. It is completely unacceptable that HSE west has not made progress with this case to ensure she has an opportunity to live a successful and equal life like any other child of her age. She is not being given such an opportunity as a consequence of the mismanagement by HSE west.

Again, it is not appropriate for me to comment on individual cases. We do not know the details of all the individual cases that exist out there. There may be cases of people with greater levels of need.

Have they been waiting since March 2014?

I am sure Deputy Keaveney would not want to be personally responsible for deciding which cases should be prioritised and which cases should not. I am not going to make such decisions either.

On the west and Galway specifically, one thing that might make sense is a national list. It does not make sense that children in the Galway region should be waiting longer than those in the Leinster region. I have asked my officials to discuss the issue with the HSE and the children's hospital group. Any time a low volume of surgery is being done, there are concerns about that and about whether any surgeon should be doing only a few types of operations every year. It is something I have asked my officials to investigate. As I said, everything is being done to double capacity for this type of surgery this year. London, Blackrock and other hospitals are being used. Everything that can be done, within reason, is being done to address this very serious problem.

Industrial Disputes

Caoimhghín Ó Caoláin


5. Deputy Caoimhghín Ó Caoláin asked the Minister for Health given the decision by members of the Irish Nurses and Midwives Organisation to initiate industrial action on 15 December 2015, the steps he is taking to address the real crisis across our hospital network, specifically through the recruitment of additional staff, including consultants, nurses and midwives, and the provision of additional bed capacity through the re-opening of closed beds and the introduction of new bed numbers, both within existing build, and through planned expansion; and if he will make a statement on the matter. [43045/15]

I am mindful of the decision of the Irish Nurses and Midwives Organisation, INMO, membership to initiate industrial action later this month. I want to establish what steps the Minister is taking to address the real crisis in our hospital network. It presents in particular in the context of accident and emergency departments but is not confined to those units in terms of staff recruitment, bed capacity and other matters.

The HSE will seek to minimise the impact of any industrial action on patients in the seven emergency departments where strike action is proposed. Hospital management will agree contingency arrangements with staff to ensure that adequate resources are provided during the two-hour period of industrial action at each site on 15 December. The strike is avoidable and management and nursing union representatives can reach agreement before then with the assistance of the State's industrial relations machinery. I understand the pressure and frustration that has given rise to the strike ballot.

Recruitment of additional nurses and consultants is a subject of considerable ongoing activity by the HSE and voluntary hospitals. Recruitment campaigns are under way in Ireland and abroad. The HSE staff census returns for the end of October 2015 show that 754 more nurses are employed in the public health services than this time last year. The number of consultants has increased by 393 since March 2011, when this Government came into office, and the number of non-consultant hospital doctors has increased by 1,007, the highest number ever.

We have a plan to address emergency department overcrowding, which was developed by the emergency department task force. The plan benefitted from considerable input by staff representatives, including the nurses' unions. The measures in the plan are currently being implemented and are beginning to show results. Additional funding of €18 million has been provided to support the acute hospital system over the winter period by providing additional bed capacity and other initiatives to improve access to care. This is supporting hospitals to reopen closed beds and to add more beds. Some 197 hospital beds have opened nationally since October, another 38 due to open in the next two weeks and another 200 will open in subsequent weeks.

As I mentioned, HSE figures show an 8% reduction in overcrowding this November compared to last. The INMO figures also show significant improvement in the second half of November. This contrasts with the position during the summer, when overcrowding was 20% to 40% worse compared to last year. Recent progress is definitely going in the right direction and is a big improvement on the start of this year, when there were 500 to 600 people on trolleys on some mornings. For example, at 8 a.m. today, the number of people waiting on trolleys was 244 and 110 patients were waiting for more than nine hours. This is 23% lower than this time last year.

I recognise the continued difficulties being experienced in emergency department and the enormous contribution staff make in meeting the needs of patients. Progress is being made but this needs to be sustained in each hospital and nationally through the full implementation of the emergency department task force recommendations. Additional nurses, doctors and consultants are being appointed. The waiting time for the fair deal scheme, for example, has been reduced from 11 weeks to three to four weeks and the number of patients whose discharges are delayed has been reduced by over 270, which alone frees up 270 beds every day. New acute hospital beds have been introduced for the first time in years. Given the progress that is emerging and the further development under way, I hope that the proposed action can be avoided.

Whatever about the proposed action of the INMO, the crisis continues and is likely to continue until such time as we properly resource our acute hospital network. I refer to the Supplementary Estimate the Minister is bringing forward and which, I understand, will be brought before the Joint Committee on Health and Children in the coming week. Has the Minister built into that Supplementary Estimate a sum of money that will address the current potential for the delivery of additional staff and bed capacity up to the end of 2015? The Supplementary Estimate is particular to this year, in terms of the budgetary provision. Can the Minister tell us whether he has built into it provision for particular steps to address this crisis?

I refer to 15 December, which is imminent. What engagement, if any, has the Minister had since the ballot taken by the INMO? Has he sought such a meeting?

As the Deputy knows, the Supplementary Estimate of €665 million refers to this year. Built into that is the provision for the winter initiative to open additional beds, if we can find and pay the required staff, and to keep fair deal waiting times at between two and four weeks. Its purpose is also to ensure we can keep providing the additional 180,000 additional home care packages and home help hours provided this year. The short answer to the Deputy's question is that all of those measures are built in to the Supplementary Estimate.

I met the general secretary of the INMO on Monday. We have spoken on the phone since then. I met the INMO emergency department nurses committee, at its request, a couple of weeks ago. The current position is that talks have begun at the Workplace Relations Commission, which has now intervened in the matter, and that is the best place for these matters to be resolved, as they almost always are.

In terms of the Supplementary Estimate, could the Minister indicate the breakdown in terms of how the overspend will be addressed, as he would regard it, up to this point in 2015, and the additional moneys he has secured? I presume that is the case in order to address the deficiencies, in terms of resourcing, in the numbers of consultants doctors, nurses, midwives and other professional inputs and bed capacity. Can the Minister tell us what the overspend is, as against the add-on moneys, to bring us up to the end of this month?

On engagement with the INMO, does the Minister have any expectation of revisiting the decision already taken or in terms of any of the measures he is currently working on? Are they being viewed in any way as sufficient to allow for a re-evaluation of the position by the INMO in advance of 15 December?

The questions the Deputy asked on the Supplementary Estimate are entirely reasonable but the question he put down did not ask about it at all. I did not bring the big binder of figures that I will have with me when we discuss it at a committee meeting next week.

It is important to bear in mind that the Supplementary Estimate includes a number of different things. It includes some one-off measures that will not be repeated next year, such as the cost of the symphysiotomy payment scheme, the €50 million waiting lists initiative, the extra payday that occurred this year compared to last year and a number of policy decisions made during the year. These were not overruns. Rather, they were decisions made by the Minister of State, Deputy Lynch, and I, in conjunction with Government colleagues, to put more resources into the fair deal, to spend a little bit more on GP care for those aged under six, to bring in the diabetes cycle of care and open additional beds in hospitals.

There are different aspects to the Supplementary Estimate and it does not involve just overruns. There were overruns in the cost of medicines because more medicines were used and prescribed than we thought. The reduction in the number of medical cards as a result of the improving economy was not as great as we thought it would be.

What about engagement with the INMO?

We are over time and have to move on.

I do not follow the Deputy's question.

I asked the Minister whether he had any expectation the INMO decision regarding 15 December would be revisited.

We are over time.

I cannot speak for it.