Topical Issue Debate

General Practitioner Training

I thank the Minister of State for taking this important Topical Issue, namely, the need for a dedicated general practitioner, GP, training programme for County Kildare. We have a great GP service, but I am concerned about the amount of pressure on the county's current GPs. It will only worsen as the county's population grows and older GPs move towards retirement.

Someone who wants to become a GP studies medicine for six years, does a one-year internship and spends four years in the training programme for dedicated GPs, which entails two years in a hospital and two in practice.

There is no clearly defined area for Kildare at present. This creates a problem for retention levels. The latest Medical Council workforce intelligence report shows that County Kildare has only 41 GPs per 100,000 population. This is the fifth lowest ratio in the country and is well below the national and international averages, the national average being 51 per 100,000. Up to 25% of Kildare GPs are predicted to retire in the coming decade. This is concerning and, if they are not replaced and even more recruited, it has implications for patients, practices and an already overstretched out-of-hours service.

As the Minister of State will be aware, Kildare has one of the fastest-growing population centres in the country, with an increase of 5.6% according to the 2016 census, the third-largest growth nationally after Fingal and Meath. That percentage represents an extra 11,800 people living in Kildare since 2011. It is estimated that every 2,500 in population growth in the county creates the need for a new GP, which means that almost five new GPs are now needed in addition to our 2011 numbers.

The programme for a partnership Government emphasised the need to focus on enhancing primary health care services, including by building up GP capacity and increasing the number of therapists and other health professionals in primary care. In order to do this while also investing in primary care centres, we must ensure that we can attract and retain more young doctors to work as GPs. Specifically, I want to ensure that Kildare has a sufficient supply. We are lucky to have 20 GP trainers operating in the county. They are spread across a variety of schemes - midlands, midlands-Naas, Royal College of Surgeons in Ireland, RCSI, TCD and UCD. It is this spread that is the crux of the issue. While these programmes get all of the benefits of the Kildare GP community and the KDOC out-of-hours service, Kildare itself does not retain enough graduates to meet future demand.

Internationally, it has been shown that the presence of a local and identifiable GP training programme is an effective way of doing this. County Donegal is a good example. One would imagine that, due to geographics, it would be harder for that area to retain GPs after training than it would be for somewhere like County Kildare, yet Donegal exceeds the national average of GPs per population because it has its own identifiable training scheme.

During recent presentations on the future of health care, Professor Susan Smith stated that one of the solutions to the issue of GP retention was providing targeted GP training in areas where GPs were needed. I would like to see a GP training programme in County Kildare to help retain GPs. The necessary skills and infrastructure are already in place, so this measure should not have a significant additional cost. I understand that a reorganisation of GP training has been proposed for 2018 when the Irish College of General Practitioners, ICGP, will take over from the HSE. This is an opportunity for Kildare to have our own training programme. We would welcome the Minister of State's support in this regard. The programme would have the support of the majority of Kildare GPs and GP trainers and would be of significant benefit to Naas General Hospital, as trainees would spend two years on hospital placement.

I will outline the pressure that our GP services are under. KDOC deals with 60,000 clients per year. This phenomenal figure shows the level of work involved, but we will need to be able to increase our numbers in light of our growing population. The age profile of GPs is heading in the wrong direction.

I thank Deputy Heydon for raising this important issue. I commend him on his work and interest in GP training in particular and on his views on and support for developing our GP services and, more generally, the national health service. I assure the House that the Government is committed to ensuring that patients across Ireland continue to have access to GP services, especially in remote rural areas and disadvantaged or socially deprived ones.

Several efforts have been undertaken in recent years to ensure that general practice remains an attractive and rewarding career option and to attract more GPs into the workforce. These include: changes to the entry provisions to the general medical services, GMS, scheme to accommodate flexible-shared GMS-GP contracts and the extension of the retirement age for GPs under the GMS scheme to 72 years; an increase in the annual number of GP training places; and the introduction of an enhanced supports package for rural GP practices. In addition, proposals are being developed to introduce supports for GPs working in areas of social deprivation as part of the GP contracts review process. A mapping exercise is under way and will inform the setting of eligibility criteria and the actual content of the support framework. The GP contracts review process will, inter alia, seek to introduce further measures aimed at making general practice an attractive, fulfilling and rewarding career option into the future.

GPs are essential to the provision of accessible services to patients in the most appropriate setting. Increasing demands on the health system will have a major impact on the future need for GPs. The HSE's national doctors training and planning unit is working on developing detailed workforce plans for different medical specialties. Its report, Future Demand for General Practitioners 2015-2025, found that there was an under-supply of GPs. I accept Deputy Heydon's point in that regard. Medical workforce planning for general practice has, therefore, been prioritised in this context.

The HSE and the ICGP announced this year that they had reached general agreement on the future delivery of the national programme of specialist GP training by the latter. This is an important change in the way that GP training is delivered and funded and will ensure that we build more training capacity while maintaining the high quality of training required of our GPs.

The annual GP trainee intake was increased from 157 to 172 this year. This is an increase of 53 places on the number for 2010, when GP training places stood at only 119. This further step is crucial to ensure the capacity is there for GPs and primary care to take on additional responsibilities, including greater GP care coverage and the management of chronic diseases within the community rather than in hospitals. The programme for a partnership Government also recognises the need to build GP capacity and commits to increasing the number of GP training places over the next five years to 259 places annually.

GP training programmes are delivered by 14 separate GP training programmes throughout the country and are not designed along county boundaries. County Kildare does not have its own dedicated GP training programme but there are several GP trainees based in GP trainer practices in County Kildare. These trainees are principally aligned to the midlands and Trinity training programmes, with 14 in the midlands programme and four in the Trinity programme, a total of 18. The Department will continue to work with the HSE and the Irish College of General Practitioners to ensure the general public can continue to have ready access to GP services and that doctors have access to GP training opportunities.

I thank the Minister of State for his response and, in particular, I welcome the increase in the number of training places that he mentioned, as well as the agreement between the HSE and the Irish College of General Practitioners announced earlier this year on the future delivery of the national programme of specialist GP training by the college. That is a positive. What I want to take from this debate is an acknowledgement that the demographics of Kildare, with such a young population that is due to age and which is consistently growing, will lead to greater demand on GP services into the future. There is an ageing aspect in our current GP services and a problem in Kildare with retention of the trainees we are putting through the system.

We have 20 trainer GPs throughout the county doing great work but we are not retaining enough of those they are training. Any GP in Kildare wants to know that when he or she retires, somebody else will take his or her place and care for patients at the consistent level shown heretofore. A rural area such as Castledermot reaches from the Wicklow border over to Athy. In places such as Athy town, Newbridge, Kilcullen and everywhere in between, patients are concerned about this matter. With many families, the GP is the first port of call when anybody needs a service. KDOC is doing a fantastic job out of hours and, as I said, there were 60,000 clients last year. It is phenomenal and one of the most successful out-of-hours services in the country. With GP services, now is the time for us to plan adequately for the future. I hope that consideration will be taken as part of the realignment with the Irish College of General Practitioners. I ask the Minister of State to make the point through his good offices.

I thank Deputy Heydon and accept his point regarding the pressure on our GP services, which we must deal with. We had some difficult times during the past seven or eight years when there has not been enough investment in the health services. I take that point. Under the programme for Government, we intend to rebuild and invest in our health services. As part of that development, increasing the number of GPs will be a major part of our strategy. GPs play a major role in providing community medical services and they assist in relieving the pressure on emergency departments in hospitals as well.

I stated earlier that the development of the GP services was not designed along county boundaries. The Deputy has real concerns about this issue and spoke about Castledermot, Newbridge and Kilcullen. I will bring his views back to the Minister, Deputy Harris. If there are gaps in GP services in individual counties such as Kildare, they should be dealt with. I give a commitment that I will deliver that strong message to the Minister. I am strongly supportive of developing GP services, whether they are in Kildare or other counties. I stated earlier that we have prioritised disadvantaged areas but that is another day's work. I will commit to do my best to expand and develop those GP services.

Services for People with Disabilities

On Saturday, I visited St. Mary of the Angels along with Councillor Damian Quigg. We met the residents and staff there. Currently, there are 76 residents in St. Mary of the Angels and 16 residents are affected as they are housed in two places, the St. Brendan and St. Fidelis units, which hold nine and seven residents, respectively. This is a response to a HIQA report and St. John of God services being non-compliant with two living conditions elements. Apparently, the St. John of God service position is that there should be consultation and agreement with the HSE to set up a national task force to progress decongregation, with St. Mary of the Angels as a national pilot site. St. Fidelis is top priority and the plan was drawn up in agreement with the HSE.

This has caused consternation with some of the residents and their families. Some of the parents have already been contacted by St. Mary of the Angels about a proposed move for their children to various sites in communities around Kerry. Some have been told that the names of their sons and daughters are on the list for council houses. None of the parents would disagree with allowing residents not totally dependent on others leaving if they could move into the community. That is a given. Many of the residents have been there a long time and some have been there for as many as 29 years. It is their home away from home and they are used to the service. It is an excellent service and I would like the Minister of State to visit and see it for himself if he had the opportunity.

The service includes a general practitioner who visits the centre each week and an out-of-hours GP service. There are regular medical assessments, on-site services, allied health specialist services and speech and language and occupational therapy. There is also massage, music therapy and physiotherapy, along with a hydrotherapy pool, special sensory rooms and heated water beds. It is a fantastic service for Kerry and beyond. I hope what we are hearing is not true. With a bit of investment from the Government for the St. Fidelis and St. Brendan centres, we could resolve the issue.

I thank the Minister of State for taking this very important matter. I ask him to reverse the decision being made by the HSE and St. John of God services. Not only are they talking about moving 17 people out of these wards, they are also talking about closing down the entire facility. We are told this is a HSE national policy that was ordained in 2011. One size does not fit all and I am sorry but many of these people are not fit to live on their own. I saw that for myself on Friday last. We would all be delighted if some of those at the facilities could make it in the outside world but it is my firm belief - and that of many of those involved - that this is only an attempt by the HSE to throw responsibility back on the families. These are old people and it is difficult enough for them to mind themselves. They are brothers and sisters with their own families and are involved in a tough struggle to survive as matters stand. Their relatives come home for weekends and at other times.

That is very much appreciated.

The cost of keeping one person in a house in a community is €600 per week. Neither the HSE nor the country has that kind of money. I know of an 89 year old woman who had two hours of home help per week which has now been cut back to one hour. Hospital beds are not available for patients who need operations and those operations are being held up. I ask the Minister of State to determine how much time HSE officials have spent on this project. Is this how valuable money is being spent?

I thank the staff who work in the centre for the loving care and attention they give to the residents and to their families. They are part of the extended family really. They work together and provide a great service. I ask the Minister of State not to break this up.

I thank Deputies Martin Ferris and Danny Healy-Rae for raising this issue. I have also been speaking to a number of their colleagues about this matter, including Danny's brother Deputy Michael Healy-Rae, in the last 24 hours. It is important when dealing with this issue to look at the facts and at what is happening on the ground. Of course, I will always listen to public representatives and to the concerns of parents.

In June 2011 the report, Time to Move on from Congregated Settings - A Strategy for Community Inclusion, was published by the HSE. The report identified that approximately 4,000 individuals with disabilities were living in congregated settings, defined as where ten or more people reside in a single living unit or are campus based. It found, notwithstanding the commitment and initiative of dedicated staff and management, that there was a significant number of individuals still experiencing institutional living conditions where they lacked basic privacy and dignity and lived their lives apart from any community and family.

St. John of God service in Kerry has been identified as one of the priority sites for de-congregation. The HSE is committed to working with St. John of God services and the families to transition 17 residents in ward-style accommodation from the current unsuitable accommodation on campus to more appropriate settings in the local community. The HSE has put in place comprehensive transition plans which include extensive engagement with the individuals themselves, their families, carers and advocates, as well as the service provider, to ensure successful and sustainable transitions into the community.

In May 2014 all families received correspondence from St. John of God services advising them that a development committee was being set up to explore with service users and their families the community options available within the county and to plan a strategy for future housing requirements. Reassurance was given to families that individual plans would be made in conjunction with each person and their family. In April 2015 at the regular family forum meeting an overview of the HIQA regulations and an update on de-congregation was provided. Throughout 2015 and 2016, the primary focus of St. John of God Kerry services has been on addressing the high risk areas of the HIQA action plan and in particular the issues relating to fire safety. There was significant consultation with residents and their families while this work was undertaken as some residents were temporarily relocated while the work was completed.

On 18 September 2016, a family forum meeting took place at which the HIQA inspections and de-congregation were discussed again. Concerns were raised and many family members were worried that their relative would not be suitable for community living. It was agreed that a family representative group would be set up and a meeting with the senior management of St. John of God Kerry services would be scheduled. In total, 78 people currently residing on the Beaufort campus will ultimately be supported over a number of years to move to more suitable accommodation in the community, depending on available funding and on sourcing suitable houses in the community.

Earlier this year, I announced that we are providing €100 million in capital funding from now until 2021 to ensure that people are able to move out of congregated settings and into their own homes in the community. I want to emphasise that the appropriate supports and resources are being put in place to ensure that people are supported as they move out of residential centres. I want to assure any concerned residents or family members that the process of moving a person with disabilities out of a congregated setting is not something that happens overnight. This process of moving people to more suitable accommodation in the community will take place over a number of years and will be done in full consultation with all residents and their families.

I thank the Minister of State for his response and do not doubt his sincerity concerning the residents of St. Mary of the Angels.

Effectively concern centres on two units, namely St. Fidela's and St. Brendan's. The other 60 residents are housed in chalets and state-of-the-art facilities. It would appear, however, from the Minister of State's response that the whole of St. Mary's will be closed down over a period of time.

The people I have spoken to have told me there has not been any consultation to date. I hope that will change. They are hugely concerned and worried because their loved ones have been at St. Mary's for many years. As I said earlier, one individual has been there for 29 years and has known no other home. The parents and relatives of the residents are very satisfied with the services provided and speak glowingly of the staff and facilities.

A lot of the money used in St. Mary of the Angels was raised by local people when the State failed them.

St. Mary of the Angels should have been the last place to be de-congregated, given its tranquility, the beauty of its location between Carrauntoohil and Beaufort and the fact that it is in the heart of the county, making it accessible to everyone equally. If there is a problem with the two wards then the Department should, as locals have suggested, build more bungalows on the land. The State got the land for nothing, from a retired farmer and his daughter. Is this what he wanted done with it? Did he want the centre to be closed down and the land to be sold off to pay for more HSE officials? I ask the Minister of State to visit the centre himself. What is going on there is wrong and what has been proposed is wrong. The Minister of State will only understand what we are talking about when he sees the centre for himself. If he does not do that, he will hear plenty more about this. It will not be closed very easily.

Again, I thank my colleagues for raising this matter. I also thank them for the invitation which I will seriously consider. I spent the summer visiting centres all over the country but have not reached Kerry yet -----

We will look after him if he comes down.

I assure Deputies Ferris and Healy-Rae that I will visit the centre. I would be delighted to see it.

To be honest, I disagree with some of the points made by the Deputies. I want bring an end to the situation where persons with disabilities are housed in large institutions. That is my policy, vision and plan. I have €100 million over five years at my disposal to do something about this. Of course, I listened to what the Deputies said regarding the fears and concerns of parents. I also take the point that in the past people were moved into the community but were not provided with support services. That will not happen on my watch.

I agree that we must be very vigilant about how money is spent. Further, I accept the point that there was no consultation and that is not acceptable. I had a meeting in my office about 20 minutes ago with representatives from St. Michael's House. St. Michael's House provides fantastic services and is very focused on consultation with parents through a parents forum. It recognises the importance of letting the service users and their families make important decisions. I accept the argument that one size does not fit all. I accept it totally.

We need to have an equal partnership between the service providers and the people with disabilities. Two days ago, I came across a centre in Dublin city that has started the process of moving out from a congregated setting into smaller units in the community. Members of staff have been transferring as well. The CEO of that company told me that the transfer was very difficult for some of the staff and some of the individuals for the first few weeks. Some of the staff had been working in the institution for so long that they had become institutionalised. Having said that, they are now in the community. Services are being provided to four people in a beautiful house in south Dublin. That is the way I want to go forward. As far as I am concerned, the days of institutions are over. I will listen to the parents and engage in full consultation with them.

Nitrates Usage

I thank the Ceann Comhairle for accepting my proposal to have a debate on this important matter for the farming community. I am sure the Minister of State is aware of the calls for the October deadline for slurry spreading to be extended. The severe weather we have experienced in recent months has severely curtailed spreading activity. Next week's 15 October deadline needs to be extended. Farmland across the country has had little time to recover from the severe downpours during the summer. Many farms are still waterlogged and large areas of land have simply become unworkable. The current slurry spreading deadline is too tight. Farmers are severely limited in their ability to do the required spreading. Each year, we face a similar scenario and the deadline must be extended. Extending it is the only sensible thing to do.

While I appreciate that the nitrates directive is in effect, I call on the Minister to talk with his European counterparts to secure some flexibility for farmers whose lands have been severely damaged as a result of recent weather conditions. Farmers need to be reassured that the Government is doing everything in its power to extend this deadline. The weather defines all options for spreading slurry for tillage farmers in various parts of the country with crop losses and for farmers who have been unable to conserve sufficient fodder for the winter period. In some parts of the country, livestock had to be housed for the better part of the summer and opportunities to spread slurry were limited by poor ground conditions. This has left many farmers with full tanks as they face next week's deadline.

The abnormal levels of rainfall that have been experienced in most parts of Ireland in recent months have made farming exceptionally difficult. Under the nitrates directive, the spreading of chemical fertilisers, livestock manure, soiled water or organic fertilisers is prohibited when the land is waterlogged, when the land is flooded or is likely to flood, and when heavy rain is forecast within 48 hours. Farmers must check the forecasts from Met Éireann. In light of these regulations, allowances need to be made in cases where farmers have not had adequate time to spread slurry given the poor conditions. Farmers have faced increased difficulties with getting machinery onto land. The weather has also affected silage and arable crop harvesting and the emptying of slurry tanks. There have been exceptional challenges in some counties as a result of high rainfall.

I understand that farmers in Northern Ireland have been given an exemption to spread slurry past next week's deadline, as long as they can provide a reasonable explanation for such an extension.  I urge the Minister to argue for a similar exemption for farmers here. The Northern Ireland Minister of Agriculture, Environment and Rural Affairs, Michelle McIlveen, MLA, understands all of these difficulties, including the increased costs associated with worsening land conditions and the need to house animals earlier than usual. The recent bad weather had devastated tillage farmers' crops in some counties. Fianna Fáil has called for an emergency fund to be created to cater for farmers who have seen their farmland destroyed. A fodder scheme is needed to support farmers who have lost hay, silage and straw. I urge the Minister to take a reasoned approach to this issue and to accommodate farmers who are trying to cope with dire conditions.

I am glad to have an opportunity to outline the position in respect of the spreading periods for organic fertilisers. I thank Deputy Scanlon for raising the matter and for giving me the opportunity to bring some clarity to it.

The nitrates directive and Ireland's nitrates action programme are given legal effect by the consolidated European Communities (Good Agricultural Practice for Protection of Waters) Regulations 2014, as amended. The objective of the regulations is to protect ground and surface waters, including drinking water sources, primarily through the management of livestock manures and other fertilisers. Good agricultural practice involves the land spreading of organic fertilisers as early as practicable in the growing season to maximise the uptake of nutrients by crops and to minimise pollution risks to water courses and ground waters.

In accordance with the requirements of the nitrates directive, the regulations mandate closed periods when the application of certain types of fertilisers is prohibited. In addition, the regulations prohibit such application at any time of the year when the ground is frozen or waterlogged or when heavy rain is forecast. Specified closed periods are a key feature of the directive in all member states. The closed periods in Ireland were decided following extensive public consultation and discussions with farming bodies and the European Commission. Recent data from the agricultural catchments programme, which is operated by Teagasc, support the current closed periods in Ireland. A key message from the research is that there are disproportionately high nutrient losses to waters during the winter. The current closed period coincides with the time during which risks of incidental nutrient losses to water are at their highest.

The expert review group that was established to manage the review of the nitrates action programme in 2013 considered whether the current closed periods were sufficient. The group was of the opinion that any change in or relaxation of the closed periods would need to be supported by science. This view was also strongly expressed by the European Commission. Having considered all the information available to it, the group concluded that no scientific evidence had been provided to it to support increased flexibility in light of the risks from spreading at this time of the year. The expert review group also agreed that the shoulder periods on either side of the opening and closing dates should be considered risky times for nutrient losses to water. As a precautionary measure, the group recommended that the stipulated setback distance from surface waters should be doubled from 5 m to 10 m for two weeks before the commencement of the closed period and two weeks after the conclusion of the closed period.

On foot of negotiations with the Commission, the current third nitrates action programme clarified that soiled farmyard water, depending on the level of dry matter content, does not need to be treated as slurry. This is of benefit to dairy farmers in addressing slurry storage capacity issues. In order to prevent an elevated risk of pollution to water bodies and the danger of the contamination of drinking water supplies, the Minister has no plans at this time to consider an extension to the period for spreading slurry in 2016. However, he will keep the matter under review. I hope my reply has been of some assistance to the Deputy.

The Minister of State has given me a very disappointing answer. Last year, which was not quite as bad as this year, the time was extended by two weeks. It is very disappointing to hear that the same thing will not be done this year. This decision will cause severe hardship. The tanks are full. Cattle are back in sheds again. There is nowhere to put the slurry. That will cause greater pollution over the next month, two months or three months. I am extremely disappointed. I ask the Minister of State to talk to the senior Minister to see whether he might take another look at this decision, which will cause severe hardship.

I would like to know whether the Minister, Deputy Creed, will attend next week's meeting of the Council of Ministers. He needs to do so to support tillage farmers. I understand the meeting in question will take place in Brussels next Wednesday.

I would like to mention another issue in this context. The moneys which are due to farmers should be paid straightaway. People who apply for various schemes, such as the area aid scheme, the targeted agricultural modernisation scheme, the area of natural constraint scheme and the green low-carbon agri-environment scheme, sometimes do not discover there are problems with their applications until the time comes for payment. The Minister of State and I, as rural Deputies, have often been contacted by farmers who want to know why they have not been paid. It is only then that they discover there are problems. In fairness to farmers, they should be told about such issues when they make their applications and not three, four or five months later when payments are due to be made. There can be further delays of five, six or seven months in such circumstances. This is the only income that many farmers have. I appeal to the Minister of State to try to ensure the officials in the Department notify farmers when issues or problems arise. Farmers need to be informed of difficulties so that they have a chance to deal with these issues.

As a rural Deputy who deals with farmers in the circumstances mentioned by Deputy Scanlon, I agree with what he said about the last two issues. I will certainly bring the message back to the Minister, Deputy Creed, on that matter and the other issues as well. I presume he is attending next week's European meeting, but I do not know for sure. Both of those issues fall under the remit of the Department of Agriculture, Food and the Marine, whereas the Minister for Housing, Planning, Community and Local Government, Deputy Coveney, and his Department are responsible for the decision on the nitrates directive. I will bring the two other issues to the attention of the Minister, Deputy Creed, when I meet him later this evening. I agree with Deputy Scanlon that the earlier we can identify problems with applications, the better our chances of getting them solved. It is a bit too late when we go looking at these difficulties as Deputies. I will mention that. I know the Minister, Deputy Creed, like his predecessor, Deputy Coveney, is trying to improve the service in this area. There is always room to add value in that regard.

I want to make it clear that the Ministers for Housing, Planning, Community and Local Government and Agriculture, Food and the Marine, Deputies Coveney and Creed, are in communication on the nitrates directive issue which is before the House. They are keeping an open view on the matter. At present, the advice and the science behind it does not lead to the granting of an extension.

It is something that will be kept under review at all times.

Nursing Staff Remuneration

I thank the Minister for Public Expenditure and Reform, Deputy Donohoe, for coming in to the House to respond to this topical issue.

In December 2015, the Irish Nurses and Midwives Organisation, the Psychiatric Nurses Association of Ireland and the SIPTU nursing unions concluded an agreement with the HSE and the Department of Health. The agreement was to restore recognition of the incremental credit for the 36-week clinical placement to all graduates since 2011, when it was stopped. However, as the Minister is aware, the Department of Public Expenditure and Reform chose to amend this agreement to sanction recognition only for those currently on placement and future graduates. As a result, nurses who graduated between 2011 and 2015 will now be earning less than their colleagues who graduated before 2011 and the new 2016 graduates.

In reply to parliamentary questions on the matter tabled by me last week, the Minister stated that the question of extending the recognition to these nurses may be reviewed on foot of consideration of whether the sanction granted would result in an increase in recruitment and retention rates of trainee nurses in 2016 and 2017. How on earth does the Minister intend to measure this? The fact is that for the majority of recent graduates, full-time positions are simply not on offer. Consequently, the Minister's strategy cannot accurately gauge the effectiveness of this measure to retain nurses in Ireland. Why is such a study necessary given that in the business case set out by the HSE and the Department of Health in favour of the 2015 agreement, it was acknowledged that restoration of the increment would aid in the retention of graduate nurses, a problem the HSE was trying to grapple with at the time. This finding was further supported by a recent survey conducted by the Union of Students in Ireland. The survey suggested that the withdrawal of the incremental credit was a factor not only for those who had remained in Ireland and are now deciding to leave, but also for those who have left when it comes to deciding whether to stay abroad or come back home.

In recent briefings to Deputies, representatives from the Irish Nurses and Midwives Organisation, the Psychiatric Nurses Association of Ireland and SIPTU nursing unions raised the real prospect of a scenario whereby unless we take action now, we may not be able to ensure that the winter initiative beds will actually be opened and, moreover, that we will face spiralling overtime and agency costs. Given that we are currently spending in excess of €22 million on agency staff, should every effort not have been made to retain the staff we currently have, and, thereby, demonstrate the value of their contribution to the health service? On the most basic level, this is where these measures falter. Nurses serve on the front line of our health service. Without their dedication and commitment to patients, our health system would simply cease to function. How can we expect them to believe they are valued when faced with such evident inequality in their treatment? The HSE has no issue with this. The Department of Health has no issue with this. Why is the Minister blocking this agreement?

I thank Deputy Shortall for raising this matter, which I know to be of interest to many within the House.

The issue, as the Deputy described, relates to the campaign by the INMO and other nursing unions, including the Psychiatric Nurses Association of Ireland and SIPTU nursing unions, aimed at restoring incremental credit for the 36-week clinical placement undertaken in the fourth and final year of their degree programme in respect of former nursing trainees serving in the period 2011-15. The background to this matter is that incremental credit for the 36-week clinical placement undertaken by fourth year student nurses was abolished by the then Government in December 2010 as part of a range of measures aimed at reducing the public service wage bill.

Following consideration of a submission made on behalf of the nursing representative bodies, including INMO, PNAI and SIPTU nursing, as well as the Department of Health and the HSE, my predecessor sanctioned recognition of the 36-week placement as qualifying for incremental credit for students on a placement in 2016 and in future on 19 February this year. The sanction stated that the question of awarding incremental credit for the placement to nurses who graduated between 2011 and 2015 may be reviewed on foot of consideration of whether the sanction granted in respect of 2016 and future graduates resulted in an increase in the retention rates for these graduate nurses. Nurses who undertook the placement in 2016 have recently completed their placements and are only now in the process of becoming registered. Therefore, the extent to which the restoration of the credit will result in an increase in the retention rate of graduate nurses will not become evident in the immediate term.

Notwithstanding this matter, it is the case that officials from my Department and the Department of Health met recently to discuss whether there was scope to accelerate this review process for the restoration of incremental credit to 2011-15 nurses. Furthermore, the Minister for Health has now written to me on this matter.

Many initiatives are currently under way to improve nursing staff levels throughout the country. The HSE is offering permanent posts to the 2016 degree programme graduates and is offering full-time permanent contracts to those in temporary posts. The HSE launched an international staff nurse recruitment campaign focused on attracting nurses back from the UK to jobs in Ireland last year. There was a particular emphasis on targeting Irish nurses who had left Ireland in recent years and who are keen to return home. The campaign offered them a relocation package of €1,500, nursing registration costs with NMBI and funded postgraduate education. There has now been an increase of 1,163 nurses employed in the public health service, from over 34,000 to a little over 35,500 in the two years to August 2016, numbers having fallen by 4,000 in the previous seven years.

The question of whether there is scope to accelerate the review process for the restoration of incremental credit to 2011-15 graduates is currently being reviewed by my Department in consultation with the Department of Health with a view to bringing the matter to a conclusion at the earliest time.

I thank the Minister for that reply but there are several points that the Minister seems to be ignoring. Can the Minister stand over a situation whereby people doing the same job are not being paid the same amount? That is what it amounts to for graduates who came out between 2011 and 2015. People who graduated before that get the incremental credit, but people who graduated this year do not. How can the Minister justify an arbitrary decision to single out particular graduates by virtue of the year they graduated and suggest that they are worth less than their colleagues who graduated in other years?

Does the Minister accept that the campaign run last year by the HSE to try to attract back graduates was not very successful? Graduate nurses who have found work elsewhere, who are being paid decent wages and who are living in countries where the cost of living is not as high as here will continue in their current roles if they continue to be discriminated against, as in the case of recent graduates here.

The Minister has said he will review the situation on the basis of recruitment in 2016 and 2017. Again, that is completely unfair to these people. Why should they have to wait to see the result of the outcome of the review post 2017? The Minister for Health could tell the Minister for Public Expenditure and Reform very clearly that the biggest issue facing the health service at the moment is the difficulty in staff recruitment and retention.

There are many reasons for that. Pay is one, cost of living is another and lack of respect and a sense that people are not being adequately valued is certainly another. People can only feel that sense is reinforced by the Minister's failure to honour the agreement the nursing unions have reached with the Minister for Health, the Department of Health and the HSE. The Minister is welching on an agreement already reached between the nursing unions and his Cabinet colleague, and that is unacceptable. Will he apply himself to this as a matter of urgency, restore parity for these nurses and take some steps to try to assist in the recruitment and retention of vital nurses in the health service? We cannot afford to delay this any longer.

I am not welching on any agreement. A process was put in place between the Department of Health and my Department and that process is being carried out. On the different points the Deputy put to me and the effect of recruitment, my colleague, the Minister for Health, is best placed to comment on the effect of that campaign. I note, to emphasise the figures, that the number of nurses working within the HSE has grown this summer compared with last summer when there were 34,953 nurses working within the health service. That figure now stands at 35,538.

How many vacancies are there?

In respect of recruitment in the United Kingdom I understand 420 applications have been received for posts. That work is under way.

In response to the Deputy’s first question about standing over this, I did not do this. This decision was taken in December 2010 when our country was facing gigantic economic difficulty. Now, because of the change in our circumstances, it has been possible to undo and change some of the decisions made then. On foot of my discussion with the Department of Health and with the Minister for Health, who has raised this with me on several occasions, I am committed to completing the process we have and honouring the agreement we had in respect of the people who have already received this credit and putting in place a process to review where we stand for people who fall between the two periods the Deputy has referred to. I will do that with the Minister for Health.