Priority Questions

General Practitioner Contracts

Stephen Donnelly


1. Deputy Stephen S. Donnelly asked the Minister for Health the status of the negotiation of a new general practitioner contract, the engagement he has had with an organisation (details supplied) in the negotiations and if he will make a statement on the matter. [28600/18]

As the Minister for Health will be aware, the GP sector is in crisis. GPs have faced repeated cuts, there is an almost complete breakdown in relationships between GPs and the HSE and there are massive recruitment and retention problems. According to some estimates, seven out of ten GP surgeries are no longer taking in new patients.

One of the keys to rebuilding the sector is a new GP contract. Sadly, one of the organisations that is key to this, the National Association of General Practitioners, NAGP, which represents approximately 2,000 GPs around the country, has been left out in the cold. Despite repeated letters to the Minister, the Taoiseach and the assistant secretary in the Department of Health, the association has not been had any meaningful interaction and it has not been allowed to come to the table to join the negotiations the Irish Medical Organisation, IMO, is engaged in. Why has the NAGP been left out in the cold in these critical negotiations? What is the Government's plan to bring the association inside in order that it can be part of negotiating a GP contract fit for the future?

I thank the Deputy for his question. He is correct to highlight the fact that there are number of challenges facing general practice we need to work on, including the resourcing and, most importantly, ensuring it is well positioned to serve the community now and into the future in line with the Sláintecare report. It is important to acknowledge the factual situation. The number of GPs on the specialist register continues to increase. There were 2,270 GPs on the specialist register in 2010 compared with 3,668 GPs as of 18 May 2018. The number of GPs contracted by the HSE under the general medical services, GMS, scheme has increased from 2,098 in 2008 to 2,497 as of 1 June 2018. The number of GPs providing services under the GMS contract has increased, therefore, along with the number of GPs registered on the specialist register. There are challenges, as we have an ageing and growing population and more chronic diseases that need to be managed in our community. I do not dispute that in any manner.

General practice is one of the cornerstones of the health service. The Government is committed to engaging with the representatives of GPs on the development of a package of measures and reforms to modernise the 1989 GMS contract. Our goal is to develop a contractual framework that has a population health focus providing, in particular, for chronic disease, structured care for chronic disease in the community and up-to-date provisions on service quality and standards, performance and accountability. Officials from my Department and the HSE met the IMO at the beginning of May to set out the State's position. The Department subsequently wrote to the IMO setting out these proposals formally. In line with the long established industrial relations approach to such processes, and with the agreement of the parties concerned, I am not in a position to give further details while this engagement is under way. That is normal during negotiations.

I acknowledge that the NAGP is also anxious to be involved in discussions about reform of the GMS contract. I have indicated my willingness to consult the association formally on the many issues facing general practice and I anticipate that arrangements in this regard will be made in the coming weeks. My Department has written to the NAGP in this regard pointing out that we would commence discussions and negotiations with the IMO, which is a member of ICTU. That is how the State does its business on many contractual issues. However, the Department also stated that we would also provide the NAGP with an opportunity to contribute meaningfully to that. That will happen in the coming weeks and I have put that in writing to the NAGP. I look forward to positive and productive engagement with all parties concerned. The delivery of these new measures for general practice is a priority for Government.

While I accept that the Minister is speaking in good faith, I have read all the correspondence from his Department to the NAGP and none of it gives any dates whatsoever. I will refer to the timeline. On 13 March 2018, the NAGP wrote to the Minister seeking a meeting on the referendum on the eighth amendment. It was concerned about talks about a GP-led service when GPs were not being consulted on that. There was no response from Government to that letter. On 23 April 2018, the association wrote to an assistant secretary in the Department seeking a meeting to discuss the various issues raised. There was no response from Government to that letter. On 21 May 2018, the association wrote again to the assistant secretary, copying the Taoiseach and the Minister. In the letter, the NAGP expressed disappointment at the lack of a response from Government to the issues raised. The association again requested a timeline for engagement on FEMPI and the new contract citing the fact that the IMO had started negotiations and quoting the Minister's own commitment. It received no response from Government. On 31 May 2018, the NAGP wrote again to the assistant secretary, included the previous letters and cited the lack of response. The association raised four issues: FEMPI, the new GP contract, CervicalCheck - it was concerned that it was not getting the information it needed - and the implementation of the referendum outcome. As of 24 June 2018, it received no response to that.

It has received one letter from the Government stating that at some point in the future, the Government will engage with the association. Does the Minister believe that is an adequate response from the Government to date given that the Minister has given a commitment to engage with the association, which represents over 2,000 GPs?

I believe we are following the correct sequence to bring about a new GP contract. It is the position of the Deputy's party and of all parties in the House that the Irish Congress of Trade Unions, ICTU, has a crucial role in how we do our business in respect of industrial relations. The Irish Medical Organisation is a member of ICTU and it is the body with which successive Governments, including those led by the Deputy's party, have engaged on delivering issues for general practice and for the health service generally. The NAGP has a constructive role to play and it has some good ideas for how to reform and improve our health service. I want to engage with it in that regard. In doing so, I will be the first Minister for Health to engage with the association and bring it into a process. However, I must respect the structures in which we operate and the agreements we have for how these processes are carried out with the Irish Medical Organisation. As the financial emergency measures in the public interest, FEMPI, and these issues were negotiated when both the Deputy's party and my party were in government through the ICTU structures and engagement with ICTU, it is appropriate that I begin the conversation with the IMO. The NAGP will have a role to play.

With regard to the eighth amendment, I fundamentally disagree with the approach being adopted by members of the NAGP in this regard in terms of the sequence. We will agree the clinical guidelines first with the medical colleges, which includes the Irish College of General Practitioners, and then we will engage on how we will resource it. We will get the clinical guidelines right. I do not wish to see the issues around implementing the mandate of the Irish people in the referendum being conflated, and the Deputy is not doing this, with issues regarding FEMPI and the future of general practice.

I thank the NAGP for the constructive role it played with regard to CervicalCheck. Its president did an excellent job in putting forth important information about the screening programme. The association has a role to play and we will engage with it in the coming weeks.

The Minister is right that the eighth amendment is a separate issue, but I was concerned that the NAGP was hearing Ministers talk about a GP-led service when it, as the representative of many of the GPs, has not been consulted. Similarly, the association wrote to the Minister about CervicalCheck pointing out that although the Minister was saying that GPs would play a big role in supporting the women concerned, the association could not get any information from him. When it cannot get responses from the Government to those letters, one must be worried.

However, this question is about the negotiation on the GP contract. In August 2016 the Minister said the following: "I think it is absolutely essential that we have the new contract negotiated and I want to see the NAGP as part of that ... what I am doing is saying very clearly that when we get down to negotiating the GP contact, which I expect to happen by the end of the year [which was by the end of 2016], that the NAGP need to be in the room". It is now two years later and the negotiations on the GP contract started months ago. The NAGP, on foot of this promise, has written to the Minister repeatedly but it cannot even get a letter in response to say when he expects its representatives to be in the room. Does the Minister think that is sufficient or have the Minister and the Department fallen short of the standards and level of engagement required in this case? Will he now give the NAGP a clear timeline for when it can negotiate as well?

While it has taken longer to negotiate a new GP contract than I would have liked, I should point out that we are discussing a contract that has been in place since 1989 and we are going to deliver significant reforms to general practice. Deputy Harty has been a strong advocate for this for a number of years as well. I believe the sequence we are following is correct. If a different sequence were put in place it would be a significant cause of concern for organisations such as the Irish Medical Organisation and possibly, by extension, the broader industrial relations mechanism in this country. We negotiate with the Irish Medical Organisation but I did say, and I stand by what I said, that we must have an inclusive process that enables other organisations to put forward their ideas. Incidentally, the NAGP has some very good ideas. The NAGP will be formally consulted and it received correspondence to that effect. I had a number of conversations with leadership figures in the NAGP, as I do with all stakeholders across the health service. They will hear about their opportunity to contribute to the process in the coming weeks.

My priorities have been, first, deciding the State's position for the contract negotiations and, second, getting that position endorsed by the Government. There is no point in it just being the Minister for Health's position as it is necessary to have the buy-in of the Department of Public Expenditure and Reform, which I have now. Then there is an initial discussion in which we present the State's position to the IMO, which we have done, and then we provide an opportunity for other stakeholders, including the NAGP, to contribute.

Paediatric Services

Louise O'Reilly


2. Deputy Louise O'Reilly asked the Minister for Health the number of children on scoliosis waiting lists; the length of time they have been on the waiting lists; when the 2018 action plan for scoliosis will be published; and if he will make a statement on the matter. [27992/18]

The question is self-explanatory. It is not long since we all watched, with a combination of sadness and horror, children who were in extreme pain and their parents who had been battling with the system. Unfortunately, I believe they are still battling with the system and there are still long waiters. Those children are still in pain and their parents are still worried about them.

I thank Deputy O'Reilly for the question and for the opportunity to update the House on the progress we are making on the scoliosis waiting list and, more importantly, what we will do next. The long-term strategy to develop sustainable scoliosis services has been prioritised by my Department and the HSE in the 2018 HSE national service plan. The Deputy is correct that the country was appalled by what it saw on RTÉ, and it should not have been necessary to see it on RTÉ to respond to it. It is clearly an issue that had been ongoing for many years. The country made progress on it from time to time but never fully got on top of it. That is why we have taken it very seriously. An additional €9 million has been provided to the HSE this year specifically to develop paediatric orthopaedic services, including further increasing access to scoliosis services. 

The Children's hospital group committed to a two-year service development plan to implement an orthopaedic service that provides timely access for outpatient and inpatient services. The HSE has confirmed that as part of this plan, the four-month target for all patients who are clinically deemed - the phrase "clinically deemed" is important - to require surgery will be maintained.

The Children's hospital group has advised that at the end of May, there were 166 active patients on the group's spinal waiting list, of whom 88 were waiting in excess of four months.  However, the hospital group advises that it is confident the four-month target will be met as activity levels are predicted to increase with the expected appointment this year of two new paediatric orthopaedic consultants. While it is not good that anybody is waiting a long time there are 88 now and there were 182 last September. We have made significant progress in reducing the number of people waiting and the length of time they are waiting.

The increased investment in the service in 2018 will stabilise and expand the current capacity. Consultants in the group clinically prioritise patients for surgery. Up to the end of May, 177 surgeries have taken place across the Children's hospital group.  The scheduling of spinal surgery for patients in this age group is frequently dependent on the timetabling of examinations and other school commitments, which is logical. As a result, activity is set to increase significantly during the summer months and I met the CEO of the Children's hospital group about this last week.

In addition, from April this year, additional theatre capacity for Temple Street Hospital is being facilitated in Cappagh National Orthopaedic Hospital. I received correspondence from the Scoliosis Awareness and Support Ireland advocacy group. It is holding an event at the hospital on Saturday to highlight the fact that Cappagh is open for business and that there is capacity to do more there.

Funding for two additional consultant posts for paediatric orthopaedics has been provided and it is expected the consultants will be appointed in the fourth quarter of this year. As an interim step, Our Lady's Children's Hospital, Crumlin commenced an outpatient department spinal review clinic in May. The aim of this clinic is to reduce the wait for the first outpatient appointment to six months by September. Importantly, we will be launching the scoliosis co-design plan in July. This plan is not written by me but by the clinicians, the hospital group and, crucially, the advocacy groups. All three advocacy groups have been part of that. I have recently written to the Scoliosis Advocacy Network to inform it of this publication date.

That is a lovely list of the things the Minister might be doing in the future, but he failed to mention the 88 children whose targets have been missed. He gave a commitment on the four-month target but it has been missed in 88 cases. Some of those children have been waiting in pain for more than three years. They are not able to live a full life. They are in agony. What is the status of the scoliosis plan? It was due to be published but there is no sign of it. I appreciate that things may happen in the future but commitments were given in the immediate aftermath of the "Prime Time Investigates" programme and they have been broken. The families have been let down time and again. Some of the 88 children have been waiting for more than three years. That is unacceptable. Those children received an apology from the Minister and others in the immediate aftermath of the programme. It is not good enough just to say "sorry". They need to know when they will get their surgery. They also need an acknowledgement that the targets are being missed in a substantial number of cases. The parents in the Scoliosis Advocacy Network and in the other groups want honesty from the Minister and the HSE about when they can realistically expect to get treatment.

The Deputy is right. If I was just saying I was sorry or listing a number of things we will do in the future that would not be enough but that is not a fair representation of what I have said or done. There will be 447 spinal procedures carried out in 2018, compared with 371 in 2017 and 224 in 2016. The figures do not lie and we are dramatically increasing the number of scoliosis operations being carried out in this country. We are not done and we are not there yet but we are significantly increasing it by any measure or metric.

In addition we have funded two new consultant posts. They are with the consultant appointments committee and they will be appointed this year. I acknowledge the Deputy has been advocating for extra capacity for some time and this will provide it through additional theatre sessions in Crumlin. The Deputy rightly asked where the plan is and that is a fair point. The plan is co-designed. It is written by the advocacy groups with the clinicians. These are surgeons who the Deputy and I and any parent with a child with scoliosis would know who are carrying out the operations. It is an excellent plan, chaired by Brian O'Mahony who has done great work. It will be published in July and I am happy to brief the Deputy in this regard as well. The advocacy groups have received correspondence telling them the date of the publication, which I believe might be 12 July.

Cappagh is now doing more and we have had the extra outpatient appointments in Crumlin on Saturdays. We have more to do but we genuinely are making a lot of progress.

We welcome the plan if and when it is published. Some parents have contacted us - we have raised this with the Minister previously - to the effect that the waiting lists are being managed in an aggressive way and parents are receiving letters asking them if their child still requires surgery. Can the Minister please request that this practice ceases? These children will not get better on their own. There is no prospect of them not needing surgery. They are getting these letters, they are given an impossibly short timeframe in which to respond and then they are being taken off the waiting list. I sincerely hope that is not contributing to the reduction in the waiting list numbers because if it is, that is a shame on the Department and the HSE. That is happening. Can the Minister issue an instruction to his officials to tell them to desist from that practice or if they must write to the parents, to give them sufficient time to respond. Parents are panicking about getting the post or responding in time. They are busy people with sick children and they do not need this extra hassle. Their kids will not get better on their own and the doctors know that.

When the Deputy highlighted this issue with me in the Dáil last week, or perhaps it was her party leader, I asked the National Treatment Purchase Fund, NTPF, to ensure that all the proper protocols and procedures are being followed. I have no evidence to suggest they are not but in light of the Deputy raising it I have asked to make sure that is the case and I will correspond with her on that. The reason the waiting lists are reducing is logical enough - we are carrying out a lot more procedures. I have spoken directly to the clinicians. They are eminent medical professionals who work extremely hard on this and I know the Deputy accepts this too. They are satisfied that progress is being made. We have more to do. The scoliosis co-design plan is an exciting and important step forward. It has had the direct input of children, including young children, in how they want their services to be designed. It will be published next month and I look forward to the arrival of the two extra consultant posts which we promised, which we will deliver and which we have funded. They will start working in the Irish health service later this year. That will mark another step forward in building sustainable services in order that we never return to the place we were in last year and in years gone by. I do not want to see us ever go back there as a country and we will do everything that we can to make sure that never happens.

Disability Support Services Provision

Margaret Murphy O'Mahony


3. Deputy Margaret Murphy O'Mahony asked the Minister for Health when the full complement of children’s disability network teams will be in place; and if he will make a statement on the matter. [28601/18]

I ask the Minister of State when the full complement of children's disability network teams will be in place and if he will make a statement on the matter.

I thank the Deputy for the question. First, the HSE is rolling out the progressing disability services for children and young people programme. This programme entails the reconfiguration of all current HSE and HSE-funded children’s disability services into geographically based children’s disability network teams. The programme aims to achieve a nationally equitable approach to service provision for all children based on their individual need and regardless of where they live or where they go to school. That is an important part of the plan. Some HSE areas have already reconfigured into interdisciplinary children’s disability network teams. Thus far, a total of 56 networks are in place. The remaining 82 teams are developing their reconfiguration and implementation plan and will be reconfigured in 2018. HSE areas currently planning reconfiguration continue to have significant early intervention and school age services in place, provided either directly by the HSE or by the voluntary service providers funded by the HSE. A key enabler to the establishment of the remaining children’s disability network teams is the recruitment of children’s disability network managers. The grade and role for this post has been agreed. However, following the outcome of a protracted industrial relations process with Fórsa, a process of mediation is currently ongoing with the relevant lead agencies, including key voluntary providers, to agree a path forward for recruitment for these posts. This process is due to conclude shortly, following which it is hoped the recruitment process will commence. In parallel with the recruitment of network managers, work is proceeding between HSE national disabilities and the HSE estates on enhancing accommodation options for children's disability network teams.

There is a long standing commitment to provide children's disability network teams across the country. It has been ongoing for some time now. The 2016 HSE service plan said that work is under way in reconfiguring children's disability services into geographically-based children's disability network teams with 56 of the 129 teams reconfigured. It went on to say that "2016 will see the completion of the full reconfiguration of 0–18s disability services into 129 Children’s Disability Network Teams". A total of 56 teams had been reconfigured at the start of 2016 with 129 to be in place at the end of 2016. At the end of 2016, 56 of the promised 129 teams had been reconfigured, so in essence no progress was made. In 2017, the service plan told us that the number of children’s disability network teams to be established by the end of 2017 was 129. At the end of 2017, 56 of the promised 129 teams had been reconfigured, so no progress was made yet again. What is the delay here? Why is it taking so long? Not a single extra team was reconfigured during 2016 or 2017. Have any been reconfigured so far in 2018?

As I said in my response, the important thing is that we all recognise that early intervention services and services for school age children with disabilities need to be improved and I accept that criticism. We need to ensure that they are organised more effectively and this process is well under way. The important thing to remember is that a total of 56 are in place. The remaining 82 are developing their reconfiguration. I have given a commitment today that it will be concluded in 2018. There are issues in the background in industrial relations, negotiations with the trade union group Fórsa and there are delays on the process of mediation but these issues are being dealt with. I am optimistic that this process will conclude shortly and we will have these teams out there to provide services and networks for children with disabilities, because we have to ensure that when we are planning these services, children get the maximum early intervention service as quickly as possible. That is my objective and hopefully it will be completed by the end of this year.

I again ask the Minister of State to say, insofar as he can, that all of these will be reconfigured by the end of this year. The HSE told me in a recent reply that a second key enabler is accommodation for these multi-agency and multidisciplinary teams. From the child and family's perspective, a co-located children's disability team is essential to achieve optimal outcomes for the child, particularly where in the majority of new teams, staff are coming together from different organisations and cultures to form one new team providing for all children with a complex disability within the defined geographical area.

In recent years, however, funding for accommodation has not been allocated for progressing disability services. As a result, there is a significant shortfall in accommodation in some areas for newly forming teams that are suitable for children with disabilities. Has the Minister of State sought any direct State funding? The HSE is engaging with the European Investment Bank but should he not be delivering direct State intervention in this area?

To go back to the Deputy's original question, the plan is to have the full complement of children's disability network teams in place by the end of 2018. As I said, we have to deal with the industrial relations issues but I am confident they will be hammered out.

On the funding issue, the Deputy can take it that we are pushing very strongly for support for that. With the support of the Minister - I also mentioned this matter at Government level recently - we will be prioritising early intervention services for children in the Estimates discussions that will take place with the HSE in the coming weeks. We have already started that process. I am also prioritising the urgent need for emergency residential places for people with intellectual disabilities with older parents. Some Deputies have spoken to me privately about that issue. I am prioritising those issues because the current delays are unacceptable.

The HSE is providing the funding to enhance accommodation for the teams in question. Accommodation is urgently needed. This is a matter in respect of which we need to respond.

Public Sector Pay

Michael Harty


4. Deputy Michael Harty asked the Minister for Health the provisions he is making to unwind the provisions of the financial emergency measures in the public interest, FEMPI, legislation for contract holders, including general practitioners, GPs; and if he will make a statement on the matter. [28530/18]

The FEMPI Act, as it applies to contract holders, including GPs, remains one of the most destructive legislative measures introduced in the history of this State. The disproportionality of its application to GP resources has undermined the financial viability and sustainability of general practice into the future. When will the Minister make provisions to unwind FEMPI as it applies to contract holders, particularly GPs?

I thank Deputy Harty for his question. I acknowledge the contribution made by health contractors through reductions in their fees to addressing the unprecedented economic crisis faced by the State when successive Governments, prior to and after 2011, found it necessary, in the interests of the financial crisis facing the State, to make reductions to public sector pay and to fees. I want to acknowledge that those reductions have been painful and extremely difficult. I have talked to many GPs who have articulated, just as Deputy Harty has done, the huge difficulty that has posed in terms of the viability of their practices. I acknowledge that it is a challenge through which we need to work our way.

The Public Service Pay and Pensions Act 2017, which was passed by this House at the end of last year, now allows the setting and varying of contractor payments on a non-emergency statutory basis. There is a new power now available to Government in respect of this, as passed by the Oireachtas.

It is my intention to put in place a new multi-annual approach to fees as part of the contract discussions currently under way in the first instance with the Irish Medical Organisation based upon health policy considerations and engagement with representative bodies.

As I said earlier, my Department and the HSE met the Irish Medical Organisation at the beginning of last month to set out the State's position on the general medical services, GMS, contract and on the issue of FEMPI.  The Department subsequently wrote to the Irish Medical Organisation to formally set out the proposals made at that meeting. This is a real opportunity for general practice to secure significant additional funding and to move to that post-FEMPI era if agreement can be reached.

In line with the long established approach to such processes, and by agreement of all the parties, including the GP organisation, I am not in a position to give further details while the discussions are under way but subject to the conclusion of arrangements in respect of GPs, my officials will examine the setting of fees for other contracted health professionals with any revision of fees also linked to contract discussions. We have started with general practice, after which we will examine the position regarding other contracted health professionals.

I thank the Minister. I do not believe he appreciates the destruction the application of FEMPI is causing to general practice. It started in rural areas but now it is creeping into urban areas where it is impossible to attract GPs into the service. One of the principal reasons for that is the application of FEMPI. There has been a 38% reduction in the gross income of practices as a result of FEMPI. That is because the latter was applied to gross fees, not to the incomes of GPs. It is the gross fee which goes to support the structure of a general practice and not just the income of the GP. It has eroded the business model that has been sustained since the previous contract was agreed in 1972, some 46 years ago.

FEMPI has been unwound for all other public servants. There will be two pay increases this year and two next year but the Government has decided it will not unwind FEMPI for contract holders unless extra services are provided. It is tying that into the negotiations relating to the new contract. FEMPI was applied without negotiation but the Minister is using it as a stick with which to beat general practice in order to get the maximum out of the new contract. That is unprofessional.

The Minister must recognise the destruction FEMPI is causing to general practice. If he proposes to reform our health service, how can he expect it to be delivered if he does not have the GPs on which to build the foundation of a reorientation of health services from the hospital-centric scenario to a primary care model? The Minister must recognise - I do not believe he does - the destruction FEMPI is causing to general practice. He indicated that he has been speaking to GPs. He needs to engage with them. He needs to take charge of the negotiations because, in reality-----

The Deputy will have another opportunity.

-----there are no negotiations taking place at present. It is an exchange of letters. People are not sitting down and speaking to each other.

I thank the Deputy. I recognise the challenges and, more importantly, so does the Government. That is why we have taken a number of steps to try to address the issue of manpower and woman-power in terms of the number of general practitioners in the country. That is why we have significantly increased the number of training places. In 2009, there were 120 GP training places available. This year, it is expected that 194 training places will be filled. That is an increase of approximately 60% over a nine-year period. There were over 400 applications for the 2018 training programme, which is a significant increase of approximately 50% on the number applying to be GPs last year. That is an encouraging sign that more people wish to become GPs. More people are applying for the places and we are responding in kind by increasing the number available.

Keeping those GPs in this country is the challenge. That is why we need a new contract. I know from our exchanges publicly and our conversations also that the Deputy believes, as I do, that a new way of working as a GP, providing more supports and flexible working options is crucial in terms of a new generation of GPs. That is part of what we want to discuss as part of the contracts. We have already increased the rural support allowance from €16,216 to €20,000 per annum but we must remember that these are self-employed contractors. I have to look at it from the perspective of the GP. I have to look at it also from the perspective of the patient and the taxpayer.

The clock, please. We will have one more supplementary question.

I have to wear all three hats in that regard. We have to pay a fair fee for a fair service. We need to negotiate the fee and the service-----

This is getting out of hand.

-----and that engagement is getting under way.

The Deputy has one minute to respond. I ask him to confine himself to that.

The Minister has referred to training places again. If he is going to use training places as a means of sorting out this problem, he is way behind the eight ball because of every 100 GPs trained, 50% will not be working in general practice in five years. They will have left the service to work in other parts of the health service. They will have emigrated or they will be working on a part-time basis.

In his initial reply, the Minister seemed to indicate that there is not a problem with the recruitment of GPs. He has figures which state that there are more GPs holding contracts now than was the case at any other time. Many of those GPs are not working full-time in general practice. Many of them do not have patients on their list. They have taken out GP contracts but they are not actually working full-time. If the Minister believes there is not a manpower crisis in general practice, he is deluded. There is a huge manpower crisis in general practice. If he proposes to develop a Sláintecare response and a reorientation of our health service from a hospital centric model to a primary care centric model and he does not have the GPs but continues to say we have many GPs and that we do not have a problem, he is out of touch. He is not talking to the right people. He has to take charge of the negotiations of a new GP contract because if he is leaving it to the current negotiators, there is nothing happening. The Minister has been in office for 800 days. Sláintecare was published 390 days ago.

The Minister has done nothing to reform the health service and it is frustrating to have him say there is not a problem. There is a huge problem and the Minister has to recognise it.

That might be a fine speech but it does not tally with the reality. The Government and I have taken a number of actions to reform the health service, and to try to turn around what is a major tanker and get it to a place where we can reform it. We supported the establishment of an all-party committee and people on the Government benches worked extremely hard to come up with a cross-party plan as well. That plan is not just owned by Deputies on the other side of the House. We are determined to deliver it. I will bring a Sláintecare implementation plan to Government before the summer recess, but I will bring one can be implemented and that addresses the challenges and does not duck the hard questions about how we fund these measures and how we make sure we get the sequencing correct. If we implemented Sláintecare in the order it is in today, I guarantee the Deputy's GP colleagues would not be happy about the immediate rush to universal free-for-all without addressing the capacity issues. I have had to work hard to put a structure and a sequence on the Sláintecare report in order that that it can be implemented, which is recognised by the Deputy's colleagues in the NAGP and the IMO.

I have a direct responsibility to make sure we train enough healthcare professionals. We are training more nurses than ever before and we are dramatically increasing the number of training places. However, I take the point. The Deputy must not misrepresent me, accidentally or otherwise. I accept there is a challenge in respect of general practice. We will resolve it in a negotiation in which both sides have ask. That is under way.

We are losing a lot of time. I ask Members to respect the clock.

Mental Health Services Provision

Seamus Healy


5. Deputy Seamus Healy asked the Minister for Health his plans to open adult inpatient psychiatric beds in County Tipperary; and if he will make a statement on the matter. [28609/18]

This raises again the need for the provision of a properly resourced, properly funded and integrated mental health service for County Tipperary with particular reference to the need to reopen adult inpatient psychiatric beds wrongly closed at St. Michael's unit in Clonmel in 2012.

The provision of acute inpatient care to the adult population of north Tipperary, which is in CHO 3, is provided between the acute unit in University Hospital Limerick, which has 50 beds, and the acute psychiatric unit in Ennis, which has 39 beds.

The 44 bed department of psychiatry based at St Luke's General Hospital, Kilkenny, is the designated approved centre for acute inpatient services for south Tipperary, which is in CHO 5. This enables all acute inpatient admissions for this CHO area to be managed at a single site. Referrals to St. Luke's are through a consultant psychiatrist who makes the clinical decision to admit based on the level of acute presentation or need. In addition to the department of psychiatry, a dedicated psychiatric liaison team operates out of the emergency department in St. Luke's. All service users presenting to the emergency department who require psychiatric assessment will receive that assessment within agreed timeframes in line with relevant guidelines. Onward referral pathways are agreed with all service users upon completion of psychiatric assessment in the emergency department. Pathways can include admission to an acute unit, referral to a relevant community mental health service team or referral back to a GP.

There are a range of other mental health services for adults in Tipperary. These include, for example, psychiatry of old age teams, non-acute beds, day hospitals and day centres. In addition, there are community mental health teams and high, medium and low-support community residences. In respect of those under 18, there are three CAMHS teams operating in Tipperary, one in north Tipperary and two in south Tipperary. The CAMHS acute units at Eist Linn in Cork and Merlin Park in Galway, which have a total of 42 beds, serve the Tipperary catchment area.

The HSE indicates that the south east community healthcare area has the second lowest rate of acute psychiatric bed provision. If this area were to be provided with the national average rate of bed provision, an additional 18 acute psychiatric care beds would be required. Evolving demographic pressures have recently led to over-occupancy at the departments of psychiatry at both St. Luke's General Hospital Kilkenny and University Hospital Waterford.

The Deputy will be aware that I met local delegations on several occasions over recent months to discuss current and future provision of mental health services in Tipperary, including reviewing bed capacity. I also visited mental health facilities in south Tipperary in February last. Further to my correspondence of 11 May with the chief officer of CHO 5, the south east mental health service management team met a delegation of local representatives and discussed in detail all issues concerning the delivery of mental health services in Tipperary, including the potential for additional acute psychiatric beds across the south east community healthcare area. South east community healthcare mental health services has also engaged with HSE estates on the potential to develop psychiatric inpatient beds at the four acute hospital sites in the region.

I will continue to monitor the development of all mental health services in Tipperary, particularly in the context of progressing new service developments agreed under the HSE service plan and through additional investment for mental health provided by Government.

I acknowledge the interest and involvement of the Minister of State in this issue since his appointment. As he said, he met representatives of the Save Our Acute Hospital Services Committee and Oireachtas Members on two occasions in Leinster House. He has visited the services in Clonmel and met all the stakeholders involved, including mental health service management in the south east. There is a serious and growing concern about the state of mental health services in the county, specifically that they are substandard and that there are no inpatient beds. A new umbrella organisation, Tipperary's Fight for Mental Health Services, has been involved recently in public meetings and a public march on this issue. That organisation is supported by all the local Oireachtas Members and a large number of councillors as well. The Save Our Acute Hospital Services Committee has been engaging with mental health service management in the south east. At our most recent meeting, the management accepted that there was a shortage of beds in the south east and that Tipperary had a strong case for additional beds. They also indicated it would be helpful if the Minister of State was in a position to meet the negotiating team. Will he do that?

The Deputy was present at the meeting with local Oireachtas representatives on 2 May and he has consistently been proactive on this issue. On 11 May, I wrote to the chief officer of CHO 5 outlining that there is a need to restore some acute bed provision for adults in Tipperary following the closure of St. Michael's unit some years ago and given the consequent transport and access difficulties to St. Luke's mental health unit in Kilkenny and to Ennis, which were highlighted to me. I emphasised the need for progress to construction as quickly as possible of the new respite crisis house in Clonmel to replace the existing facility there, including the provision of a construction date for that facility. I also highlighted the inadequate enhancement of community-based services since 2012 to compensate for the closure of St. Michael's, particularly comparing the level of services envisaged by the HSE against what has been delivered, and referred to the inadequate staffing levels for both adult and CAMHS teams in Tipperary. I referred to the further issue of poor access to Eist Linn CAMHS unit in Cork, resulting in long stays for under-18s in adult health facilities in Tipperary, which has always been a concern of mine. The Deputy will be aware that I have spoken to a number of parents of children who have been left waiting in South Tipperary General Hospital, which is not appropriate or acceptable.

The representatives of the Save Our Acute Hospital Services Committee have met mental health service management on three occasions. On the most recent occasion, they accepted that there is a need for additional beds in the area and that south Tipperary has a strong case. They also indicated that the Minister of State's involvement at a future meeting would be helpful and I ask again if he would be prepared to do that. At this stage, we need action and political input at the highest level to move this issue forward.

I would be more than happy to continue the engagement I have had with the Deputy. I am concerned about the issues in south Tipperary and have a good understanding of them. I am awaiting a response from the chief officer of CHO 5. I asked my officials this week to follow up to ensure that I get a written response, which I expect to have in the next week or ten days. As soon as I have it, I will certainly be happy to engage further with the Deputy. There is potential in the development of the new 50-bed unit. I have asked HSE estates section to consider the provision of a number of those beds for mental health services without distorting the plans that are in progress. It should not create a delay. That is the route I am following and I will certainly meet with the Deputy, Oireachtas colleagues and whomever they want me to meet in Tipperary. My focus on working with the HSE and as soon as I receive a response from the chief officer, I will progress the issue.