Development of Primary Care: Statements

I am pleased to be here this evening to update the House on a range of important developments in the area of primary care. As many Deputies will be aware, the reality is that our primary and community care system, as currently configured, is ill-equipped to play the role we all know it should play, and must play, if we are to respond to the healthcare challenges of the 21st century.

Our population is not only growing but is becoming older, and we face a growing prevalence of chronic disease. Our current hospital-centric model of care, which has its roots in responding to accidents and episodic diseases, simply cannot respond efficiently and effectively to meet the health needs of our population.

It is for this reason the expansion of community and primary care is at the heart of the Sláintecare vision, and it is important to recognise the progress that has been made in delivering on that vision. The provision of modern, well equipped and accessible infrastructure is essential if we are change our model of care which is why we have prioritised investment in primary care centres. There are now 127 operational primary care centres across the country, up from just 70 at the end of 2012, which represents an increase of some 80% over a six year period. A further three centres are currently being equipped and will open shortly, while another 16 are under construction. Just as importantly, there is a pipeline of more than 60 projects at the advanced or early planning stages. Furthermore, at the beginning of May, the HSE placed an advertisement in the national press seeking expressions of interest from developers with a view to progressing a further 47 centres.

As well as enabling the delivery of services in high quality modern facilities, primary care centres support the delivery of integrated care by facilitating closer co-ordination and co-operation between health professionals from across different disciplines. They also provide a single point of access to services for the individual and can serve as a resource more broadly for the community, creating a focal point for local health initiatives or providing community groups with a place to meet. The delivery of additional primary care centres in the years ahead will support other initiatives as part of the Sláintecare plan to ensure more healthcare services will be available in our communities.

In tandem with the delivery of primary care infrastructure, there has been a continuing programme of investment in the sector to build capacity. The HSE’s national service plan for this year allocates €897.2 million to primary care. This headline figure reflects several important funding initiatives that have been introduced since 2016, including the following: ring-fenced funding of €4 million to facilitate the recruitment of 83 posts in speech and language services; dedicated funding of €5 million to recruit 114 assistant psychologists and 20 staff grade psychologists to provide early intervention mental health services for those aged under 18; and provision of a €25 million primary care development fund to enable a range of initiatives to be progressed.

Primary care was prioritised in this year's budget, with an additional €50 million provided to boost capacity in the sector, which is an increase of 6.1% on 2018. This will allow the recruitment of additional therapy staff and nurses, alongside further service development. As well as supporting therapy services, the investment has allowed us to develop such services as paediatric home care packages to allow children with complex needs to be cared for at home while enabling the expansion of community intervention teams, CITs, which prevent unnecessary hospital admission or attendance. CITs are a prime example of how an expanded primary care setting can help ease the pressure on acute hospitals, with an estimated 11,307 bed days saved in the first four months of this year alone. We are also working to develop our diagnostic services in the community. This will be an important achievement if we get it right. In 2019, 67,000 ultrasound tests and 79,500 X-rays will be delivered via direct GP access to radiology services.

This investment in primary care infrastructure and services in recent years provides a solid foundation for developing a much more comprehensive community and primary care system. We intend to build on this foundation with the development of community healthcare networks. Under the network model, one identifiable and accountable network manager will be responsible for the delivery of primary care services to a local population of approximately 50,000 people. Primary care will be positioned at the heart of service delivery and emphasis will be placed on ensuring effective integration of other specialised services such as social care, mental health and access to hospital. The network model will be central to the development of improved primary and community services. Implementation will begin this year with the establishment of nine learning sites.

April was a significant month in clearly signalling that we are serious about radically changing how the health system works. The month saw three important achievements, namely, securing agreement on GP contractual reform, publishing the national oral health policy and introducing a series of measures to enable more people to access affordable healthcare. The development of a new, modernised contract for the provision of general practitioner services was always going to be a significant element in facilitating a move to primary-care-centred health services. The agreement reached with the Irish Medical Organisation, IMO, has the potential to be a landmark moment for health reform and I was delighted to see it win the support of 95% of members of the IMO in a recent ballot. For the first time, we will see the delivery in a primary care setting of structured care on a large scale for patients with chronic conditions. More than 400,000 medical card and GP visit card patients with chronic illnesses such as diabetes, asthma, chronic obstructive pulmonary disease and heart disease will benefit from new and improved chronic disease management. In addition, the agreement paves the way for a wide-ranging set of modernisation measures in the areas of e-health, medicines management and multidisciplinary working.

For its part, the Government has committed to increasing investment in general practice by €210 million, or approximately 40%, over the next four years. This will mean significant increases in capitation fees for GPs who participate in the reform programme, as well as the introduction of new fees and subsidies for additional services. There will also be increased support for rural practices and for those in disadvantaged urban areas. For the first time, there will be a ring-fenced fund for general practice in urban areas, an important development that arises directly from the work of the Sláintecare committee. In short, the agreement will allow GPs to care for their patients both in the way they want to and in the way we need them to. It will help to stabilise general practice after some difficult years.

Smile agus Sláinte, the new national oral health policy, was also published in April. It provides a framework for the dental service to evolve from a diagnose-and-treat model to a locally available, person-centred, proactive and preventative approach. Under the policy, all children up to 16 years of age will receive eight oral healthcare packages, including examinations, assessments, advice, prevention interventions, emergency care and referrals as appropriate. Oral healthcare packages will also be provided for medical card holders over 16 years of age. The packages will be provided in a primary care setting by oral healthcare practitioners contracted by the HSE. Smile agus Sláinte provides the groundwork to transform oral health services. It embraces the same ideals as Sláintecare, with the needs of people at the core and the provision of services in the local community paramount.

The third development delivered in April was the introduction of a series of measures to enable more people to access affordable healthcare, which is also generally in line with the recommendations of Sláintecare. First announced as part of budget 2019, the measures included a 10% increase in all GP visit card weekly income thresholds, the benefit of which we have seen through the several thousand additional people accessing free GP care as a result. There were also reductions in the monthly drugs payment scheme threshold and a reduction in prescription charges for all medical card holders over the age of 70, making it cheaper for people to make a trip to their pharmacy, whether they are on the drugs payment scheme or paying prescription charges. With a focus on ensuring and supporting care in the community, the measures extend free healthcare to more people and reduce the cost for others. The Government is committed to widening access to primary health services, which is reflected by our intention to engage with the IMO on the proposal to extend GP care without fees to children aged between six and 12 on a phased basis, something for which I look forward to legislating this year. I also look forward to sitting down with pharmacists' representative organisation, the Irish Pharmaceutical Union, IPU, this year to negotiate a new pharmacist contract. I addressed the IPU conference in Galway in recent weeks. Deputy Brassil raises this issue with me often. We will sit down with pharmacists to examine how they can play a greater role in the provision of healthcare, as is their wish, and how the Government can invest in the pharmacy network.

It is clear that we are investing in and developing primary and community care. There has been momentum in that regard this year, as I have outlined. The momentum needs to gather pace, however, as it will do in the months and years ahead. We all know there are many grand plans now sitting on shelves and gathering dust but this time will be different, not least because of the unified focus of the House on realising Sláintecare and the structures we are putting in place to deliver it, such as the appointment of Laura Magahy as the executive director of the Sláintecare office and the publication of a Sláintecare action plan in March. The action plan sets out milestones against which we will report progress every quarter using the same model as we did in the case of the Action Plan for Jobs, showing exactly where delivery is achieved.

The developments I have highlighted are only the beginning and much more needs to be done. Crucially, we must expand the workforce and infrastructure capacity in the primary and community sector, develop structures that allow for the planning and operation of services on the basis of population need and size and create an enabling environment through e-health and other initiatives. Nonetheless, I am confident that we are, at last perhaps, moving in the right direction and that we have begun the process of delivering a universal health service that offers people the right care, in the right place, at the right time.

As my party's spokesperson on primary care, I am delighted to have the opportunity to lead the debate. The message from Fianna Fáil is clear: robust and active primary and community care plays an essential role in enhancing health outcomes and limiting costs. A strong primary and community care system will be invaluable for preventing the development of conditions that could ultimately require acute hospital care. It will also provide a suitable environment to enable earlier discharges from hospital. From the patient's perspective, it helps to enhance quality of life and reduce the undue stress of admission to hospital.

Unfortunately, the Government's record on primary care leaves much to be desired. While more primary care centres have opened, there have often been significant delays between their announcement and delivery. In the HSE service plan for 2019, there seem to be no new measures for primary care, while on a like-for-like basis, as a share of the HSE budget, primary care has fallen from 6.9% to 6.6%. The Minister correctly pointed out that the essential pillar of Sláintecare is the improvement of primary care services. It is a simple concept. If as many people as possible in the community can be treated, they will naturally be prevented from entering an already clogged hospital system. To do that, there must be investment in capital costs to provide primary care centres. While I accept that progress has been made in this regard, much more is needed and many more structures on the ground need to be delivered. Without centres, the service cannot be delivered. Primary care centres also require staff, in the form of GPs, practice nurses, community nurses, dietitians, physiotherapists, community dentists, podiatrists and so on. The full medical team needs to be present in the community to provide the required services.

The Minister rightly referred to e-health and e-prescribing. As he knows, I am a practising pharmacist and have an interest in the area but, as I informed him at the meeting of the Joint Committee on Health last week, pharmacists are underused. In countries such as Canada, pharmacists provide a much greater role and are an invaluable addition to primary care services. As well as the unwinding of measures under the Financial Emergency Measures in the Public Interest, FEMPI, Acts relating to GPs, which I welcome, I look forward to the same happening for pharmacists and to the Minister engaging with the pharmacy sector to allow it to deliver its full potential on issues such as the minor ailment scheme and the provision of contraception.

I look forward to a new contract and pharmacists playing a much more progressive role.

The staffing of GPs is one issue we must meet head on. At present, there is a shortfall of 500 general practitioners and under current projections, we will have a shortfall of 1,500 by 2025. At present, we train 174 GPs per annum. This figure needs to double and I recommend training up to 300 GPs per annum to meet future requirements. If we can do this, we will be able to attract and retain new staff and perhaps get back many of those who have emigrated to Australia, Canada and the like.

Another issue I ask the Minister to consider is salaried GPs and salaried employees for the health system. There are rural and urban areas where practices cannot exist viably. In such circumstances, we must look at the salaried employee model. It is should be rolled out because it can work.

The Minister mentioned e-health and this is critical, as is e-prescribing. As a pharmacist, I do not know how many times over the years I received phone calls from hospitals looking for patients' medical records and drug records. Pharmacists in the country receive such calls on a daily basis. This is a total waste of thousands of man hours every week. We need integrated patient records to be available at GP practices, pharmacies and hospitals.

Universal access to diagnostics in the community is very important. If we roll out centres and have availability of diagnostics, all our chronic disease management can be done in the community, including the management of arthritis, asthma, COPD, Crohn's disease and Alzheimer's disease. We are more than capable of dealing with these conditions in the community. To do this, we must put the services in place. I will refer specifically to the care of the elderly because the increased prevalence of dementia and Alzheimer's disease is something we have to come to grips with. Many people would be more than happy to keep their loved ones in their homes if they were provided with a backup service. As I have said to the Minister and to Mr. Paul Reid and Ms Laura Magahy at committee meetings, putting the fair deal budget and the home care budget into one package would make huge financial sense. At present, the incentive is to refer anybody going to the community nurse looking for home care hours for a fair deal package instead because the money is not available in the home care budget.

In the course of canvassing two weeks ago, I came across a couple aged in their mid-90s. The woman of the house has Alzheimer's disease and she is being cared for by her 93 year old husband who has multiple medical conditions. They are getting the sum total of one and a half hours of home care per day, five days a week and nothing at the weekend. This is just not acceptable. Despite pleading as much as I could with the community nurse, she told me she does not have the money or the hours to give but that if I got an increased allocation, she would help the couple more. This issue has to be addressed as otherwise the ageing population will cause demand on our hospital system to go through the roof.

Another area of equal importance is mental health care in the community. GPs tell us they will be able to cater for 90% of mental health issues if they were given the resources in the community. This area of growing need has clogged up our hospital facilities. We need to expand primary care to deal with mental health issues. If we do so, we will go a long way towards resolving what is now an ongoing crisis.

I will work with the Minister or anybody else to try to resolve the current healthcare crisis. The key to doing so is in the Sláintecare report. The Minister has full buy-in from all of the political parties. Deputy O'Reilly was a member of the relevant committee, as were Deputy Harty and I. We have an opportunity, perhaps a once in a lifetime opportunity, to improve the healthcare of our country and give our citizens the health system they deserve. I look forward to working with the Minister to bring it about but I will hold him to account if it does not.

The health service is our most important public service. It is there for us when we are born, throughout our lives and at the end. The health of our nation is Sinn Féin’s number one priority. Sinn Féin has a very simple vision and commitment that healthcare should be free at the point of delivery and available to those who need it based on their clinical and medical needs and not on their ability to pay. Unfortunately, time and again we see that those who have a few extra bob in their back pocket can skip the queue. Children in my constituency will wait 30 months to access a diagnosis. We often say that diagnosis is the key to getting into the system but if people have to wait on that diagnosis and wait three years for what is called early intervention, they find it very hard to see neighbours who might be in a better financial position skipping the queue. For this reason, Sinn Féin believes healthcare should be available based on need and never on ability to pay.

Key to this delivery is the development of primary care services and the delivery of GP and community-led care. General practitioners and those who work with them are the cornerstone of our primary care services. We must ensure that we have a supply of GPs for the whole of the State. Primary care is very much the absolute front of the front line. It should be the coalface for dealing with the bulk of the health needs of the population. We know it is cheaper than acute care and can deliver better quality preventative care faster and closer to home. People end up in hospital when primary care has failed, they have been unable to access primary care or the State has failed to provide accessible primary care for them. This means not only that we must train more GPs but also that we must make the profession more accessible and attractive through lifting the burden of uncertainty created by self-employment and creating directly employed GPs. I have been calling for this since long before I came into the House. We need a mix of self-employed and directly employed GPs. This would allow doctors to be doctors and not have to worry about renting a building, paying the electricity bill, employing a practice nurse and a secretary and all that goes with running a small business. It would mean directly employed GPs with a yearly HSE salary and all of the rights that accompany direct employment, such as maternity, paternity and annual leave and a pension. I believe this would make the profession significantly more attractive.

We also need to ensure that primary care centres are properly staffed and have a full complement of staff. The Minister has heard me say this before, but in case he was not listening on the million other occasions although I know he does listen, I will raise the issue of Balbriggan primary care centre, a lovely primary care centre in my constituency, just up the road from my house.

No additional staff were provided for this centre. I have raised this issue many times and on each occasion the response was that services will be provided from within existing resources, which is code for there will be no additional staff. Despite the rapidly growing population in Balbriggan, there is no diagnostic equipment in Balbriggan primary care centre. When I raised this issue recently via a parliamentary question the response was that there are no plans to provide additional diagnostic equipment. We have not yet had sight of the capital plan as we approach the end of May. I sincerely hope that not much more time will pass before we see it and that when we do, there will be something in it for people in Balbriggan. As recently as last week, as per the response to my parliamentary question, there were no plans to install diagnostic equipment or provide additional staff. I understand that this is a local issue but this situation is replicated in many primary care centres, making it a national issue.

Another response to a parliamentary question indicated that one in five primary care centres around the country has failed to attract a general practitioner. The Minister has pledged to deliver primary care. The Minister is not a doctor and nor am I but there is a doctor in the Chamber. Primary care is not possible without general practitioners. It is startling that approximately 26 of the 126 operational primary care centres, which are supposed to be a one-stop-shop for people's basic health needs outside of hospital, do not have a general practitioner. Without general practitioners these centres cannot deliver care. The lack of staff to deliver primary care calls into question the Government's commitment to primary care.

The newly built primary care centres have each cost millions of euro but they are not being properly utilised. For example, Boyle primary care centre in Roscommon cost approximately €6 million to build. It opened last August and it still has no general practitioner. These centres are supposed to be staffed by a general practitioner and other health professionals such as physiotherapists, occupational therapists and counsellors. According to the figures provided to me, 15 primary care centres were without psychologists and 19 did not have a single social worker. This seriously undermines the Government's claim that it is committed to Sláintecare. We all know that we need to shift to primary and community care. That argument has been won. There were many battles in that regard years ago but, as I said, that argument has been won. Sláintecare has gone a long way towards ensuring that argument was won. The move to primary care is essential. It will take the pressure off acute services but we will never deliver free GP care without general practitioners and the facilities from which they can operate.

The Minister told us he would introduce a new contract for GPs. I understand there is a commitment to unwind FEMPI, which, I know, is extremely important, but where stands the delivery of a new contract? A revision of the existing contract will not suffice. We need a detailed contract which is fit for the 21st century. As I said previously, the issue of salaried GPs needs to be examined. Directly employed GPs means doctors can be doctors. We need to examine how the dual model might work. The self-employed model has worked well in some but not all circumstances so we need to examine how the dual model might work. There is definitely a space for it.

Any party that is serious about delivering healthcare to communities and the people who need it must be serious about primary care. As I have said, that argument has been won. We no longer hear people arguing about the need to increase staff numbers in acute care, which is already overstretched as the Minister will know. The argument has been won in regard to primary care. What is lacking is the vital investment to ensure our primary care centres are one-stop-shops. I refer again to the primary care centre in Balbriggan. While it is not the most beautiful building, the inside is lovely and practically laid out but it lacks staff. The population of Balbriggan is growing and there are no plans for additional staff or diagnostic equipment at this centre. People who live in Balbriggan still have to travel to the Mater Hospital in the city centre for a diagnostic test. This makes no sense. This service could and should be accessible in Balbriggan or north County Dublin. The test in terms of the Government's commitment to the delivery of primary care will be its capacity to deliver fully staffed, equipped and functioning primary care centres.

I welcome the opportunity to participate in this debate, although I wish that rather than statements on primary care, we were getting an update from the Minister for Health, Deputy Harris, on the 2001 report, Primary Care - A New Direction, and what parts of it have and have not been rolled out. Primary Care - A New Direction was produced 18 years ago. We were told at that point that primary care is the appropriate setting to meet between 90% and 95% of all health and personal social services need; that primary care needs to become the central focus of the health system; that primary care has to be rolled out; and that we need an interdisciplinary and multidisciplinary team based approach and so on. As Governments of various persuasions are inclined to produce a report and not follow it up, we were told a national primary care task force would be established. Does the Minister recall A Vision for Change and the implementation body? It did such a good job over two to three years the Government dismantled it.

In regard to primary care, a task force was to be established. There were to be 20 actions, including a community based diagnostic centre pilot and an implementation plan. An implementation plan for primary care is outlined in the 2001 document. The Minister might consider reading it. On physical infrastructure, it states that modern, well equipped, accessible premises will be central to the effective functioning of the primary care team, a national primary care task force will be established and evaluation is absolutely essential to implementation. That is plan number one. There are many other plans, including one from the Adelaide Health Foundation. There are many recommendations in it tangential to the 2001 report. It refers to the need to future-proof the health system, to borrow ideas from abroad and, interestingly, to promote parity between physical and mental health in practice, not just in rhetoric, to recognise and plan for the co-existence of physical and mental health morbidity in patients and to provide services that are in a position to respond to this type of complexity.

Then came the Sláintecare document, which was brought about by the range of voices in the new Dáil calling on the Government to do something about our health services. Ireland distinguishes itself among its European colleagues by not providing universal equitable access to either primary or acute hospital care. The Minister opened this debate with a statement, which I will try to balance that with what is happening in Galway city and county. There is a health centre in Connemara. I will spare the doctors' blushes but I will refer to a sign therein which states that private patients must pay €20 for blood tests and medical cardholders must pay €10 for blood tests. This sign features in various doctors' surgeries throughout Connemara. The health service response is that it is provided in the contract that blood tests should be provided free of charge.

There was obviously a disagreement but that is the result for people on the ground.

I recently asked a question about social workers in Connemara, the waiting list and the number of vacancies. In the response I eventually got, I was told that there was no waiting list for social workers in Connemara because there were no social workers in Connemara. I appreciate the sense of irony and honesty of the man who responded to me, in that there is no waiting list because there are no social workers in Connemara. There are no physiotherapy services in south Connemara so potentially vulnerable people of all ages are brought from Connemara to Galway. Tá siad ag iarraidh seirbhís a fháil trí Ghaeilge, ach níl sé le fáil san áit ina bhfuil siad ag dul. Tá orthu teacht tríd an tranglam tráchta i lár na cathrach chun seirbhís trí Bhéarla a fháil i gCaisleán Nua, agus ansin tá orthu filleadh ar Chonamara. They have to come in from Connemara to get physiotherapy in places where services are provided in English, not in Irish, adding to the traffic congestion and all sorts of problems. I sometimes cannot put words to what I feel when I hear speeches in the House about primary care, mental health and new ways of doing things when all of these problems were foreseen and solutions were given. We went forward to build primary care centres. In Galway, in Doughiska, we are paying over €250,000 in taxpayers' money on rent for a private building every year. On the west side of the city of Galway, we have no primary care building.

In the bad 1980s, I had the privilege of working in what was then called community care, in a multidisciplinary team, where somebody could walk in and see a psychologist, speech therapist or social worker. We thought things were improving. We now have all these beautiful reports and all this lovely language but things have actually gone backwards. In addition, we are paying high rent for buildings that should be publicly owned. If we were seriously interested in primary care and taking the pressure off acute hospitals, we would roll out public buildings throughout the country where we would locate essential services and take account of the regional balance. We would certainly take account of the needs of those living in the Gaeltacht agus seirbhísí trí Ghaeilge ag teastáil go géar uathu.

The Department of Health's report, Future Health: A Strategic Framework for Reform of the Health Service 2012-2015, stated that primary care teams must form part of the dedicated facilities and no one must pay GP fees. GPs must work with other primary care professionals. Staffing and resourcing of primary care must be allocated rationally, and there is a great absence of rationality, to meet regularly assessed needs. Structurally, primary care in Ireland remains highly fragmented. It involves a mixture of public and private patients, which is not an efficient or equitable way of arranging healthcare. Despite this, we are subjected to this speech all over again. I have said a number of times that whoever writes these speeches should perhaps read the reports first and look at the recommendations. One can look at any period one likes, which is 18 years in this case, and work from the original report.

I will finish with a review of primary care island services. I know it is difficult and that the Minister is busy. We are all busy. I find it increasingly difficult to keep up with all the reports but we have a duty to read them. There is certainly a duty on whomever writes the speeches to read them. A review was carried out on all our islands in April 2017, including the Irish-speaking islands. It was a very good report but it was not published until earlier this year with no explanation given for the delay. It tells us, among many things, of the essential need for primary care services on the islands where we do not have hospitals. It then looks at Galway, Inishbofin and Árann, where we have health centres that are not fit for purpose. These are simple practical matters. There are health centres which are not fit for purpose on the islands of Inishbofin and Árann. Níl siad cuí. There are many other recommendations in the report relating to the Irish language and so on which I will not go into. I accept the Minister's bona fides on many subjects he has spoken on in the Dáil but at the end of the day, the proof of that lies in what was on the ground in these reports and was not on the ground. He should tell us what has happened and why we cannot roll out public buildings for primary care if we are seriously interested.

I am happy to speak on this important matter this evening. Some 12 months ago, we in the Rural Independent Group tabled a motion on healthcare, in which we said that there was a failure of Government to fully implement A Vision for Change. Indeed, A Vision for Change has been very unkind to us in Tipperary with regard to mental health services. I remember when it was introduced by the then Minister of State, former Teachta Moloney. We know that A Vision for Change is well out of date. It has lived up to very few of the expectations and promises made in it. A Vision for Change included building capacity in child and mental health services, CAMHS, provision of counselling and psychological services in primary care, and fully populating community psychiatric teams. We asked Government to ensure a coherent implementation plan which would be immediately acted on to address the increasing lack of capacity and unmet need in our health services, especially at primary care and local level. We cannot deal with that on the ground. We have the result in Tipperary. The hospitals that serve us, South Tipperary General Hospital and Limerick University Hospital, are jammed daily. The numbers attending are shocking and increasing by the month.

There needs to be consistent work towards expanding the availability of diagnostic services to seven-day access, to speed up patient diagnosis and indeed treatment in a timely manner at primary care level. I thank the Minister for joining me two years ago to visit two wonderful healthcare facilities in Clonmel, Mary Street Medical Centre and Western House Medical Centre. The first one is a wonderful service. I have to declare an interest in this, since it is my family's medical centre. It had fabulous diagnostic equipment which the Minister saw. It dealt with all the ups and downs and ins and outs of the HSE to try to offer a diagnostic service. Several months after the Minister's visit and intervention, which I acknowledge, it got a contract one Friday evening and it was delighted to get a two-week service. There were substantial waiting lists in South Tipperary General Hospital and the centre was offering this service. It got the contract that Friday to start on Monday morning. There was no time to roll it out to all the GPs in south Tipperary. It did it and there was good take-up, which relieved the pressure on the hospital. After eight days, as I discussed both in the Chamber and privately with the Minister, the service was withdrawn. After two and a half years and high level meetings, including with the Minister, it was removed after eight days because there was no money to fund it.

It was a no-brainer because it was relieving the queues for ultrasound in South Tipperary General Hospital and people were being seen almost immediately. There was connectivity with University Hospital Limerick to read X-rays and such. Much work went into this but the service fell before it got to the second fence. That is a shame. It has the equipment and there are several doctors there whom the Minister met. Between the complement of doctors, they have hundreds of years of experience.

A person has to wait several months to get into South Tipperary General Hospital, meet a locum or junior doctor who is falling asleep with fatigue and they have others to call on to deal with it. The entire situation is akin to putting the cart before the horse. It is frightening. Progress with the development of primary care has been appalling. That is not a new problem. In 2017 the Irish Medical Organisation, IMO, described primary care budget provision as deeply disappointing and regressive from a health perspective. They are not my words, I am quoting the IMO in 2017.

We have a agreed a new GP contract.

The IMO went on to say the reality is that spending on public health services has not kept pace with either rising demands or the increase in the number of patients over 65 years. That is a staggering statement by the IMO.

The same is true two years later in 2019. Everyone knows the primary care budget will not keep pace with the health demands and the various crises affecting the health services. The new CEO seems to have been brought in because he is a whizz kid at keeping within budget. That seems to be his main credentials for the job, and his career to date, although I accept he has other qualities also. This will not be good. It will not be fair. It is not decent. I accept that it is primarily a management issue but it is something we need to tackle once and for all. We must work to change this or else GP services will continue to be even more overwhelmed and will only be able to deliver the most acute of services due to the lack of resources and unsustainable costs.

An additional problem has also emerged due to the lack of focus on primary care delivery, namely, that doctors have continued to emigrate in droves rather than work in a service which is increasingly not fit for purpose. I know a doctor, Paddy Davern, from Tipperary town. He is an exceptional doctor who is known far and wide and he went to Dubai two years ago. He told a public meeting in Horse and Jockey that he had to leave and he reduced people to tears. He is sorely missed in Tipperary town and surrounding areas. That is happening in every county. When will the Minister deal with it? There is a serious lack of ambition.

Two years ago the Minister spoke about the much heralded transformation of the delivery of the health service and the move to GP-led primary care. Dhá bhliain ó shin. Has that happened? No, it has not. Does the Minister ever replay the clips of speeches? I do not blame him personally for everything but he is the man in charge. Does he ever look back and say he spoke those words with good intent, honesty and passion but it has not happened? The failures are heaped on failures that are heaped on failures, not only by the Minister but by successive Ministers and Governments. That is so disappointing given that primary care is one of the measures that has been shown to be successful in addressing the problems of chronic overcrowding and long delays in accident and emergency departments. That is shown to be the case in particular where ultrasound diagnostics have been introduced in local primary care centres. I am aware that it was implemented in CHO 5, where GPs could directly refer adult medical card and GP visit card holders for X-ray and ultrasound to a number of identified providers. That was supposedly a short-term emergency measure designed to relieve pressure on hospitals in the immediate post-Christmas period. We need such measures to be rolled out on a more consistent and long-term basis. The Mary Street Medical Centre in Clonmel is an excellent example of a primary care centre that has been attempting to implement the use of ultrasound in diagnostics in order to help patients receive quicker treatment. The Minister visited the centre.

In February 2017 it was awarded a contract by the HSE to carry out such diagnostics. Astonishingly, the contract was only for the duration of 14 days and was subsequently withdrawn after just seven days. That was after all the effort, work and high level meetings, in addition to the associated cost and the passionate and desperate efforts of the Mary Street Medical Centre to provide the service. It had the equipment and expertise but the contract was ended. That is incomprehensible. That is despite the fact that it carried out 35 scans in seven days, making earlier diagnosis possible, thereby benefitting patients and preventing referrals to a chronically overcrowded accident and emergency department in South Tipperary General Hospital. Patients and doctors alike praised the service yet the HSE refused to extend the contract. What is wrong? How can there be such a blockage and chronic administration issue that a tried and tested service was halted seven days after its introduction?

One patient who was helped by the ultrasound service was a lady who was diagnosed with a tumour in her womb. Thankfully, she has since had surgery to treat it. She might no longer be with us if the tumour was not diagnosed. That is simply bizarre and unbelievable. If she had experienced a 12-month delay waiting for an ultrasound in the public system her outcome would undoubtedly be far worse. She is a GMS patient and would otherwise have had to pay for her scan. The case clearly demonstrates the benefits primary care can deliver, not just for patients and their families but also for the entire health service where the bottleneck situation in accident and emergency departments can be reduced.

I appeal to the Minister, who is probably in the dying months if not weeks of the Government, to please make his mark and provide services in the Mary Street Medical Centre in Clonmel in Tipperary, which has the capacity, willingness and foresight to deliver a service which benefits everyone, gets rid of the queues and saves people's lives. Could he please cut out the dead wood in the HSE and allow this badly-needed service to continue and to deliver for sick patients who are waiting with anxiety.

I welcome the opportunity to make a contribution to the debate on the development of primary care. I acknowledge the Government's policy, which seeks to provide robust and active primary and community care. We all agree that it could and should enhance outcomes and limit costs. Sláintecare reaffirms the commitment, which is representative of all parties and none. In the absence of that being delivered in a timely manner, the responsibility for the provision of primary care and the advancement and its delivery rests with the Government.

It is opportune to speak on the topic at this time considering the level of engagement and conversation we have had with constituents, let alone the information that comes into our offices on a daily basis on the difficulties with the Government's implementation of the policy. At a time when there is grave difficultly in seeking to meet the demands of the policy and match the rhetoric with action on its implementation, parallel to that the Government is engaged in turmoil in terms of the overspend of €400 million on the national children's hospital. Likewise, in spite of the great delays that existed heretofore, regarding the provision of a national broadband plan and the vast and mammoth cost associated with that and the lack of clarity on a contract, there is no lack of clarity on the cost associated with such a mammoth project, amounting to an additional €1.9 billion, which is new money that must be found. That is despite the commitments made by the Government on current expenditure and the national development plan. The Minister for Finance and Public Expenditure and Reform said the moneys will come from future revenues, despite the fact that he made commitments on future expenditure based on Estimates. He now says there will be no impact on taxation. There will be no new taxes. There will be no new borrowings and there will be no cuts or projects forgone within the national development plan. It is magic money. It is Freddie Mercury stuff – A Kind of Magic, but it is not real. Then there are the difficulties we all witness with housing, health and Army pay, among others. There is no magic money to resolve those issues. It is my duty and that of anybody in this House to highlight the lack of delivery and action to match the rhetoric on the delivery of primary care.

Home help packages and hours are not available, or are being turned down in my constituency. Some progress was made at the beginning of the year but it would appear that this was because of the extra funding made available to the HSE to manage the winter crisis in hospitals.

There is a crisis in the area of housing aid for the elderly and disabled. Local authorities, which administer some of the funding in this area, have waiting lists of two to three years. We all want our elderly to remain in their communities and remain with their families, but they are being forced to look at the fair deal scheme in the absence of adequate funding being available to them to make their homes compatible with their needs in relation to community help and assistance and home help from the primary care sector. The costs associated with the fair deal scheme and nursing home care are far greater than what would be expended on these areas.

There are also astronomical waiting lists for psychological assessments for children. My constituency of Laois-Offaly now has the longest waiting list, having taken over from Cork. Other speakers have raised the lack of available and meaningful services in the mental health sectors. Communities are unable to meet the demands of their inhabitants. The time has come to take on board the suggestion made by Deputy Brassil and others to the effect that the funds within the fair deal scheme should be permitted to be directed towards home help packages and be used to adapt homes for the elderly, meeting the demand. The fair deal funding should also cater for specialist care for dementia and Alzheimer's patients, which has been neglected by the Government, despite its rhetoric.

I acknowledge the progress that has been made, albeit slowly, in terms of primary care centres and the professionalism that will bring. However, the provision of a primary care centre in the absence of GPs is a square that must be, but has not been, circled. I have had first-hand experience of the loss of the Midoc services and the loss of out-of-hours services from GPs. We were told by the HSE and members of the profession that such losses were caused by an inadequate GP contract and an inadequate rural allowance. We now hear that the new GP contract, which has been lauded and heralded by members of the Government, is a panacea for these issues. However, it has not resulted in the reinstatement of those services in places like Birr. Someone must ask whether the GP contract is adequate to meet the demands of a rural town like that. If it is not, that should be acknowledged and admitted and such a contract should be put in place to adequately provide for such demands.

We had statements on rural development earlier. A Minister for Rural and Community Development was appointed to the Cabinet in this Government. We were assured that all Departments would be rural-proofed and that no policy would emanate from any Department without adequate provision being made for rural areas. The provision of primary care, home help, adequate facilities and GPs and out-of-hours services is lacking in many parts of rural Ireland, including in my constituency. This speaks of a failing not just of the Department of Health but also the Department of Rural and Community Development. The Government should insist on facilities to meet the demands of such communities. I have outlined some hard facts about the issues we face on a continuous basis which are not being addressed despite utterings to the contrary. The GP contract is a case in point but I could give many other examples if I had more time. We will have ample opportunity to examine this further in the coming weeks and months as we prepare for a budget, notwithstanding the difficulties with that in its own right, considering the promises on the delivery of services during negotiations for the last budget that have not materialised. That, however, is a discussion for another day and for future negotiations. We will see where they will take us.

Primary care has really been a pipe dream since its conception. It is true that a new primary care centre has been approved in Donegal town and in Buncrana. However, the primary care project has been largely private sector-led, delivered by private developers offering up sites for primary care centres, which says a lot about healthcare in Ireland. The Government justified this by arguing that it is better for the delivery of healthcare and costs less as it pays a lease over 20 years instead of all at once upfront. However, the direct consequence of this Fine Gael way of thinking is there will be large gaps in the provision of primary healthcare. This is the case in my home town of Killybegs. We are unfortunate because we do not have a private developer. We have GPs but no private developer is willing to develop a primary care centre, meaning that one will not be provided. This Government, supported by the Independent Alliance, makes sure that this is the case.

The consequences are that the existing GPs are working out of a small health centre and cannot adequately meet the demands of the community. The closest primary care centre is Ballybofey or Ballyshannon, approximately 50 km or 60 km away. GP surgeries are available intermittently, but the idea is that health services are only based on a private sector model. Once again, we are at the mercy of the will of private developers and of course, by default, Donegal will lose out by virtue of the fact there are fewer private developers there. My colleague, Deputy Connolly, mentioned the islands off Galway which are crying out for primary care centres. If they had private developers there they would be tripping over themselves to build brand spanking new primary care centres.

We need State-run community healthcare with State-owned facilities. This will meet the needs of local communities upfront and into the future, as the asset remains State-owned. Tailoring health services according to what the private sector is offering, instead of deciding what we need, means that the facilities provided are entirely at the discretion of the private sector. There should be integrated settings that provide a range of ongoing services for common illnesses and conditions to which much of our population is or will be exposed as people age. For example, the Donegal branch of Diabetes Ireland has done much to raise awareness of the chronic lack of diabetes services across the county, despite ever-increasing demand for health services for people with this condition. It is a condition that does not discriminate against age or gender and is even increasing in school-age children, yet services still have not caught up. Diabetes can cause other health conditions affecting the kidneys, eyes and heart, and can cause blood pressure problems. Constant care is needed to ensure that persons with diabetes do not see their health worsen. This could be dealt with in primary care settings.

There is a significant lack of staff in clinics across Donegal, threatening the expansion of the primary care project. While cancer care is largely hospital-based, we still face the same problems. I have worked closely with Donegal Action for Cancer Care on this issue and have constantly pursued both the HSE and Letterkenny University Hospital on increasing access to services in Donegal. We still do not have adequate access to certain healthcare through our own hospital, let alone services being provided in a primary care setting. For example, men from Donegal must travel to the prostate rapid access clinic at Galway University Hospital. Some travel six or seven hours for treatment and must have their follow-up treatment there, if required. Better access would mean providing a prostrate rapid access clinic through Letterkenny University Hospital. Donegal women should not have to travel to the centre in Galway after having their BreastCheck mammogram if there is a query or concern. Donegal women should be able to be seen at Letterkenny University Hospital and, if required, have their surgery there.

With radiotherapy services at the north-west cancer centre at Altnagelvin hospital, in which the Government has invested, has a memorandum of understanding for 25 years, both the rapid access clinic and BreastCheck follow-up should be at Letterkenny University Hospital. All Donegal patients who need radiotherapy which can be treated at the north-west cancer centre at Altnagelvin hospital should have their treatment there and not be forced to travel to Galway and Dublin.

Importantly, we need investment in mental health services more than ever and placed within a primary care setting particularly in the area of child and adolescent mental health services, CAMHS. Findings from a national survey revealed that over 40% of service users indicated they had a poor experience of HSE mental health services. Almost 40% indicated they were not involved as much as they would like in decisions about the medication they take, while two thirds reported they did not have a written recovery or care plan developed with their community mental health team. Over 70% of family, friends, carers and supporters were dissatisfied with the extent to which HSE mental health services had considered their support needs. Almost half indicated none of their views had been incorporated into the recovery or care plan of the person they support. If a survey was done of the private developers who provided the primary care centres, I am sure it would find they would be happy with the service. That is probably where the service will be heading.

In a reply to my query recently, the HSE acknowledged one vacant consultant psychiatrist position within CAMHS, with numerous vacancies in nursing, health and social care professional categories, including one senior occupational therapist, one clinical nurse specialist as well as one principal social worker. The constant vacancies and issues retaining staff are at crisis levels and will severely hamper any effort to roll out effective primary care. It is time we move away from a private sector model and towards State-owned, State-run local community health care. It is a human right not a commodity. The Minister of State will claim that the private model is cheaper in the long run when it is not. It just provides fewer outcomes at the start. I would rather have fewer proper ones than more defective ones.

I thank the Minister of State, Deputy Finian McGrath, for taking the debate.

I am sure he is familiar with the difficulties which primary care has suffered for several years. I am also sure he is familiar with the Sláintecare report. The Sláintecare strategy and implementation plan, published in March, is an extremely important document which provides a beacon of hope for developing primary care services. It is a once-in-a-generation reform programme which must be pursued by the Government and its successors because it is a ten-year vision for change in the health service. Sláintecare is predicated on building our health services around primary care and re-orientating our services away from a hospital-centric model. Primary care will deliver not only general practice but primary care delivery of nursing services, physiotherapy, occupational therapy and mental health services.

The main issue regarding primary care and general practice is the recruitment and retention of GPs. We have a new primary care deal – it is not a contract - which returns investment to primary care and general practice which was removed during the financial emergency measures in the public interest, FEMPI, cuts from 2009 to 2013. It was absolutely essential that those cuts were reversed. The deal involves stabilising general practice by returning funding which was taken from general practice. This was funding for running general practice, not income for it. An important aspect of the new deal is stabilisation.

A second aspect of the deal is to provide chronic care delivery through general practice. A basic tenet of Sláintecare is that chronic care management is delivered through general practice in primary care. A third pillar of the new deal is to expand eligibility to patients, initially to those under 12 but also to those who have chronic illnesses.

Unfortunately, we will have to wait another four years before we have a GP contract and this new deal goes through the system between now and 2022. It is essential we have a new chief GP contract because if we are to address the medical manpower requirements of expanding services and eligibility, we need sufficient numbers of GPs to deliver that service. We are short 500 GPs. If we are to expand eligibility and chronic care, we will need more GPs. If one offers citizens services and eligibility without putting in place the capacity in general practice, then we will have similar waiting lists to those in the UK’s NHS where patients can wait up to a week or ten days before they see a GP for a routine appointment. That is unheard of in Irish general practice. However, one can have great difficulty seeing one’s GP on the day one wants because 70% of GPs have closed their lists to new patients as it is the only way they can control their workloads. One has to address the medical manpower issue in general practice. The only way to do that is through a new GP contract. Talks on a new GP contract need to start in parallel with rolling out this deal and it has to involve the Irish College of General Practitioners in developing the framework.

We have an ageing GP workforce. Up to 700 GPs are due to retire in the next five to ten years but only 100 GPs under the age of 40 years hold a GP contract. We need to increase our training places but also to attract GPs back to the country who have emigrated over the past several years. We must give them a career structure which they can value and will give them the sustainability they require within the profession.

Community intervention teams are an extremely important part of primary care. They are not rolled out nationwide. In Clare we are lucky to have an excellent community intervention team manned by dedicated nurses who receive people back out of hospital on early discharge, provide them with transitional care, intravenous antibiotics, look after the various equipment patients may have to use and provide an intensive level of care to allow them to return to their communities as soon as possible. We need to recruit more public health nurses. The public health nurse system is struggling to meet the demands placed on it by the early transfer of patients from hospitals back into the community. These nurses are stretched by the number of patients they have to deal with and services they have to provide. It is extremely important that public health nurses are supported and more are recruited to deliver the primary care services for which we all wish.

We need to reorient the health service away from the hospital-centric model to primary care. That requires integration of primary care and secondary care. I had the pleasure of spending the afternoon with Ms Laura Magahy from the Sláintecare implementation office during which we presented to her an analysis of reforms which have taken place in other jurisdictions, particularly in the Veterans Health Administration in the United States and NHS Scotland which has similar problems to ours trying to provide health services for a geographically dispersed population. We also discussed reforms in the Canterbury area of New Zealand which has also experienced similar problems. The most important aspect of those reform programmes was the integration of primary and secondary care. There was a free and seamless movement of patients from primary care to a timely service within secondary care service. It involved the delivery of investigations and treatments in an ambulatory setting which do not require admission to hospital.

However, that requires access to diagnostics and expert consultant opinion in a timely manner through medical assessment units, acute medical assessment units and ambulatory services to prevent patients from entering hospital to deliver hospital avoidance measures. That is extremely important. When the Minister develops primary care, it cannot be done in isolation. He must do so in conjunction with integrating care in our secondary services.

We had representatives from Mental Health Reform and from the Mental Health Commission before the health committee this morning. Their problem was the delivery of mental health services in primary care and the lack of staff and team members within community psychiatric services. There is a shortage of community psychiatric consultants, community psychiatric nurses, psychologists and occupational therapists and of the provision of cognitive behaviour therapy to provide mental health services within the community. An important aspect of primary care is that we deliver mental health services within the community.

Because of the gaps that have developed within primary care and the shortage of GPs, private enterprise is entering general practice, buying up general practices and putting GPs into work on a salaried basis within a primary care service, which is not in the best interests of patients. We also have pop-up primary care surgeries, which provide one-off consultations but no continuity of care. What people need in general practice is to meet the right doctor in the right place who can make the right decision and continuity of care is critical to primary care. We need to have a dedicated GP service, a dedicated primary care service, where people have continuity of care which is critical for making the right decisions because many decisions are made by inexperienced doctors which lead to unnecessary referrals and investigations. It is critical we have a coherent integrated primary care service.

I am delighted to have this opportunity to make a few points to the Minister of State on the development of primary care. This is an important aspect of Irish life and it is important that we get it right. It is said, and I can only conclude it is correct, that we should seek to meet 90% to 95% of all health and personal social service needs within a primary care setting. That is something towards which we should aim.

Robust and active primary and community care is essential in terms of enhancing health outcomes and limiting costs to the State. A strong primary and community care system will be invaluable in preventing the development of conditions that could ultimately require acute hospital care and it would also provide the right environment for early discharges from hospital. It helps to enhance quality of life and reduce the undue stress of admission to hospital from a patient’s perspective. The Government's record on primary care leaves a lot to be desired. There have often been significant delays between announcement and delivery of primary care centres. We have been waiting quite some time for a primary care centre in Athy. There were a number of photo opportunities on the site. When it is developed it will be good and will have many specialised services, but there has been a long gap between announcement and delivery.

There are no new measures for primary care in the HSE service plan for 2019. On a like-for-like basis, as a share of the HSE budget, the allocation will fall from 6.9% to 6.6%. That shows us where primary care is ranked. When we compare the figures, 6.6% of the total HSE budget is to be spent on primary care when it should be looking after 90% of people's needs. There is something wrong.

I want to mention a few areas I highlighted recently by tabling parliamentary questions and raising matters for Topical Issue debate. I spoke about the lack of GPs in Kildare, particularly in Kildare town where, following the retirement of a GP, people were told that they had to go to Monasterevin, which is a number of miles away. We are talking about many elderly people in their 70s who might find it difficult to access public transport or to drive themselves there. That has been difficult for them. There is a significant capacity issue, certainly within Kildare and across the country.

I doubt this is the case only in Kildare but there is a large number of issues in terms of the parents of children under the age of age who are having difficulty enrolling their children into a GP practice. Kildare is in the lowest 20% nationally for the number of GPs per head of population. A total of 15% of GPs in Kildare are set to retire in the next ten years and succession planning cannot take place due to the fact that there is no established feeder scheme into the county. That is a major problem.

Another issue I raised is the lack of resources to provide a replacement for the primary care psychologist for the Kildare area while she is on maternity leave. A replacement was not sought to cover maternity leave for the Kildare and Wicklow area. Many children are waiting for assessments and to think that they have to wait for at least another six months is shocking. I was contacted by one family who is paying more than €1,000 for a private assessment having waited many months for any type of assessment. In a reply to a parliamentary question I tabled, I was advised that the reason a temporary replacement has not been found is due to a lack of resources. They did not advertise due to a lack of resources, which is shocking. How can resources be so low that they cannot look for a replacement to continue a service across the Kildare area? It is scandalous that parents are being left in limbo while awaiting an assessment for their children.

My colleague, Deputy O’Dea, with the support of the Fianna Fáil Party, introduced a Private Members’ Bill on providing a fair deal on home care. It is a valuable Bill. I keep in touch on an ongoing basis with the Alzheimer’s Society in Kildare. I attended a meeting not too long ago at which I met many wonderful men and women who, with the right supports, have remained in their own homes and the familiar environment which is best for them and with their children and spouses caring for them. However, they face many challenges, as all families do, in dealing with dementia care. Thousands of them across the country are selflessly caring for older relatives with very little help from the Government. Staying at home with appropriate assistance from the State and appropriate primary centre healthcare is, without doubt, the preferred option for most of the people I have met and spoken to in my constituency week after week. They deserve dignity, respect and the choice as to where they want to live the final years of their lives. Not only is that the most humane solution but it is the best value for money for the State coffers. It is important that we examine that. We as a party believe that funding allocated to enable older people to remain at home with the support of primary health centres provides the best value for money and the fairest and most dignified result for older people. Progress needs to be made in that regard.

A strong primary care system would be invaluable for preventing the development of conditions that ultimately require acute hospital care. We need occupational therapists, physiotherapists, psychiatric nurses, speech therapists and many more to help plug the gaps in primary care. Continuity of care is crucial for everybody.

The 2018 service capacity review states that if reforms are to be implemented, there would be a requirement for a 50% increase in the primary care workforce, including approximately 1,000 extra GPs, 1,200 extra practice nurses, and 1,100 extra public health nurses. The Government's 2019 primary care plans do not match its supposed commitment to the sector. Certainly, the programme for Government commitment of a so-called decisive shift in health service practice to primary care is not supported in the HSE service plan. This is not good enough. An increase of 0.5% in the allocation for new developments in primary care was held back by the Department of Health last year. We had a similar situation in 2017 and 2018. In late 2017, the then director general of the HSE stated that the health service required an additional €500 million a year of transitional funding over ten years to move to a properly functioning primary care GP-based system. This should be a priority for the Minister of State, Deputy Finian McGrath, the Minister, Deputy Harris, and the Department of Health.

In a contribution to A Future Together: Building a Better GP and Primary Care Service, the former HSE director general stated, "We need a ... substantial transitional investment ... to move from the overly hospital-centric system we have now". Part of the problem is that doctors are incredibly cautious. That is my experience. They are afraid to make judgments and are sending many of their patients into accident and emergency. That is wrong. It is no wonder that we have a choked-up system. In Naas, we have people on trolleys every night. In Naas, one of the medical assessments is closed because they cannot get a doctor. That is adding to the problems there.

On behalf of the people I represent in south Kildare, I appeal for increased investment in primary care for the people whom we serve in this House.

The development of primary care is vital in reforming the health services. We need to look at ways of achieving a more balanced health service by ensuring the majority of patients who require urgent or planned care are managed within primary and community-based settings. This will achieve a more accessible and cost-effective health service for the benefit of everyone who uses it.

The document, Primary Care: A Framework for the Future, which issued in April 2016 when the Government took office, sought to outline the challenges that healthcare in urban and rural Ireland presented, and outlined possible solutions to these problems. Primary care teams in both urban and rural Ireland are undoubtedly dealing with a raft of challenges, and my main concern in our discussion is how primary care can function better in my large rural constituency of west Cork. I have spent recent months out on the road canvassing for my brother and from meeting my constituents during that time, I am aware of the following problems we face in west Cork when it comes to primary care such as the ageing population, the lack of available GPs, and diminishing services in rural primary care centres, to name but a few.

The ageing population needs to be cared for, either in their homes or in nursing homes. Parts of rural Ireland, however, are facing a bed shortage in nursing homes. Current projections suggest a shortfall of up to 7,500 beds by 2026. The HSE home support service, formerly called the home help service or home care package scheme, aims to support older people to remain in their homes for as long as possible and to support formal carers. From listening to my constituents, however, this vision of the home care service as portrayed by the HSE is a far cry from the reality faced by elderly people longing to stay in their homes. Many are lucky if they can get an hour a day of home care service. Most get only a half hour. Only the other day a lady in Bantry told me that when the family were looking for a home care service for her father, they were told there is an embargo on it. They will stop it altogether soon. Of course, we are told time and again that there are no hours available because they cannot find staff. Those carrying out the home care services are fiercely interested in getting extra hours but they will not be given them. It is a game. There appears to be a disconnect between each patient's needs and the services and facilities that are provided. There is no statutory right to home care in Ireland. The quality and availability of information about services is poor. This is difficult for families in trying to navigate the system and access services. We need to address the shortage of home care staff. This is a serious concern.

I commend the public health nurses who do a wonderful job, but there are not enough of them within the HSE to provide the service that is needed. This staffing issue results in too much responsibility resting on the shoulders of the understaffed public health nurses. They have too many decisions to make and too much to cope with and they do not have enough time allotted to carry out their jobs. There needs to be an increase in the number of public health nurses.

GPs are facing a manpower crisis. Approximately 55% of GPs are over 55, and many newly trained GPs are leaving Ireland to work abroad where pay and conditions are better. This shortage is particularly evident in rural areas, especially with many of the GPs close to retirement age with no great prospect of being replaced. Practising GPs report that they are in a situation of burnout and stress. This is another serious issue that we need to address.

Rural GPs are finding it increasingly difficult to run a viable practice in a small town or village, as the number of public patients in rural areas is increasing. The GP is still expected to maintain a properly equipped, technologically enhanced premises, employ expert staff in sufficient numbers and manage a range of expenses. It is now becoming impossible for a GP to run a viable practice in a small rural community.

I am also concerned about the diminishing services in rural primary care centres. In my constituency, there was a chiropody service in Schull which facilitated a large number of older members of the Mizen Peninsula. I am saddened to say this service was stopped in December 2018, and patients now must travel to Skibbereen Community Hospital to avail of this service. The additional patients have put increased pressure on the staff in Skibbereen. Many of the patients from Schull do not have their own mode of transport and there is no public transport from Schull passing the hospital, which is a few kilometres outside of the town.

It is welcome that new primary care centres are being built in Bantry and Bandon in west Cork. Bantry's new primary care centre will be a large building, set beside Bantry General Hospital. Among other services which will be provided there, this large building would provide an ideal location for a cataract unit. With considerable waiting lists for cataract surgery in west Cork, a cataract unit is essential to cope with the increasing numbers of patients coming on stream every year. At present, we have people on waiting lists up to five years for a cataract procedure that takes 15 minutes. It is a disgrace that they have to travel across the Border to save their sight. The Government appears to have no problem with allowing people to go slowly blind while waiting for their cataract procedure. So far, Deputy Danny Healy-Rae and I have carried 33 busloads - the 34th this weekend - to Belfast for cataract procedures. The Government should be ashamed of how it has let down the people of the country.

Earlier this week I raised a question in the Dáil about the charity-led air ambulance, which is based in Cork and has the capability of reaching out to most parts of Ireland, including remote areas in west Cork such as the Beara, Sheep's Head and Mizen peninsulas, within ten to 15 minutes. The development of the charity-led air ambulance has been delayed for months which has led to considerable frustration as this has the capability to save so many lives. It must be remembered that people have raised tens of thousands of euros and have put this in place. The effort some of these people put into this is incredible. It is sad to think that it is lying idle waiting for the HSE to tick the box, which I cannot see happening. This charity has complied with the required procedures and protocol, but we are faced with the situation that this lifesaving resource is still grounded. I want to know when the National Ambulance Service will confirm the deployment of this national lifesaving service. I have asked previously. Yesterday, I was told by the Minister, Deputy Humphreys, it was not on the programme for Government. It actually was. The Minister must correct the record and I will be notifying her. The national air ambulance service was on the programme for Government. We need to make sure that this service gets off the ground and is used. It is also not only for west Cork. It will be used all the way up to Galway, Mayo, etc. It will provide an excellent opportunity to save lives.

I cannot stand in front of the Government and talk about primary care services without mentioning how the ambulance staff have been reduced to strike action again.

The ambulance personnel belonging to the Psychiatric Nurses Association are to escalate their campaign of industrial action by engaging in strike action in six days' time because of the refusal of the HSE to afford its members the right to be members of a union of their choice. The first of these strikes will take place this Friday and Saturday. Once again, the HSE is forcing an escalation of this dispute which is entirely of the HSE's making. I support the ambulance staff 100% and will be standing beside them this weekend during their strike to show them my committed support.

The big guns are in now.

I welcome the opportunity to have a discussion on this very important issue.

I will first focus on the recruitment of GPs. It is becoming increasingly difficult to recruit GPs, who are vitally important when it comes to the delivery of primary care and keeping people out of hospitals. Rural GPs find it difficult financially, something in the past we never would have thought would happen. It is simply not as attractive as it might have been in the past for people to operate a rural GP practice because of all the different expenses involved. We must put more investment into primary care and reverse the cuts to general practice that took place a number of years ago and which have left it difficult for people to run general practices. The new deal which will enable stabilisation of the service probably will not be fully rolled out until 2021 or 2022. That is quite simply unacceptable because the primary care promised to the under-12s and patients with chronic illness is needed to keep them out of hospitals services as much as possible. We need that new GP contract to be rolled out and for it to be financially viable, feasible and sensible for people to operate primary care units in their own areas.

In Ireland we are running 500 or 600 GPs short of what we actually should have. That certainly is not welcome, as we all know how important the local GP is, in the same way we know how important the community welfare nurses are. Those nurses are a lifeline through their calling to people's homes. I commend these nurses, and I obviously can only speak of the community nurses I know personally in County Kerry who give 100% commitment, as well as a 100% correct and great service for their patients in communities. They are the reason people are able to live and stay at home. The GP who might call to a person's home on a regular basis, if that patient was unable to travel to meet the GP, is probably the lifeline keeping that person living in his or her own home, community and family structure.

Everything that can be done should be done to reduce the waiting list at accident and emergency hospital units. We should redirect patients by giving them the adequate services they need in community hospitals, by their GP service or by availing of the services of community nurses. Some people, obviously, must go to an emergency department but care can be provided in the community, rather than choking up emergency departments with people waiting for treatment. It is totally inhumane for people to have to wait for so many hours in an emergency department.

I regularly visit the emergency departments in Kerry, Cork and Limerick and usually do so in the middle of the night. The reason I do that is to see exactly what is happening in the middle of the night, which is what I call the hours from 12 midnight until 6 a.m. I suggest any Deputy or public representative who has not been in a major emergency department during those hours cannot talk about the service or what is happening.

I agree with the Deputy and have done it many times myself.

I know that the Minister of State, Deputy Finian McGrath, has done it because I have been told about it and it is very important. It is not that one is going in to stick one's nose into people's business, as all one needs to do is to observe what is happening. One is there in a helpful way, not to be obstructive or critical or anything like that. If a person knows what the problems are there on the ground, when he or she is up here, whether it is lobbying with people like the Minister of State or the other Ministers with responsibility for health, the public representative will know what he or she is talking about, which is very important.

Many GP practices have closed because their waiting lists will not allow them to take on any new patients and have been shut down. This is not because they do not want to but they quite simply cannot. The aging GP service is also an issue, as even the baby in the cradle is getting older by the day, and many GPs who are heading towards retirement are not being replaced new young GPs.

The community intervention teams are required all over the country. I have great faith in community intervention teams. The only problem is there is not enough of them deployed throughout the entire country, particularly in rural areas. Care is needed with early discharges from a general or even from a community hospital to take such people back into the communities. It is a welcome development if early discharges can be given, provided the person is sure of having the care he or she needs when they go home. More public health nurses are required to deliver primary care in their own areas.

On mental health and delivery of that service, the lack of a community psychiatric service is grave in communities and more services are required, especially where there is an age gap. If we have young people with psychiatric problems, sometimes they can fall between two stools in that there is no service available for them. They are neither here nor there. We have to ensure that whatever the age of a young person, there is a place for him or her. If the parents or close family of such young people feel, see or know that they are in trouble with psychiatric illness or problems, we must ensure there is at least some place for them to receive the care they need at that critical time.

One service that has developed throughout the country is what we might call pop-up private consultation services. I am not a great fan, quite simply because local GPs always have provided a continuity of care. If a pop-up service is there and if people can go in for a once-off consultation, where is the continuity of care with the original care provider? There may be misdiagnoses or different issues that may arise from those consultations. Nothing will ever beat the good patient-local GP relationship, where a person will have the same GP for many years. That GP then gets to know his or her patient in a very sound fashion. They get to know each other and can get a better outcome of healthcare for the person because of it.

As regards nurses, it is shame that we have a lack of nurses in places such as Dingle, County Kerry. It must be made more attractive for young nurses. We have great, intelligent young nurses who have been trained, are excellent and would provide a significant service, were they here in Ireland. Unfortunately, as they wanted to better themselves, they felt the rate of pay they would get here from the HSE would not be adequate and they left. They are over in England, in America and in Australia. I plead with the Minister of State, for the sake of those young people, to make it attractive for them to come home and to work, regardless of whether it is in Kenmare, Cahersiveen or Dingle community hospitals or in general hospitals like University Hospital Kerry or Cork University Hospital, which service the county or Limerick.

We do not want those jobs to be filled by temporary staff. We want them to be full-time care providers, nurses, doctors or community welfare nurses. They are the people on whom we will be relying.

I want to use my last bit of time to speak about the ambulance service. I could not commend ambulance personnel highly enough. They are the first people who are called out to the home of an elderly person or to the scene of an horrific accident on the side of the road. They are the backbone of first contact between the patient and the hospital and they should be supported by all of us.

I am glad to get the opportunity to speak. We have a duty of care as elected representatives and must ensure all the people who present sick, ill or whatever get a fair and proper assessment and are dealt with in a professional way as soon as possible. The Government has published the national primary care plan. I do not give it much credence. I have listened to too many plans, reports and proposals that never seem to take off. My brother, Deputy Michael Healy-Rae, rightfully, praised the ambulance crews. The ambulance crews themselves are fine and do their job as well and as efficiently as ever they can. In recent times, a 94 year old woman was waiting for two hours for an ambulance in east Kerry. That is a fact and it is not a joke. Likewise, another person in mid-Kerry waited for two hours for an ambulance. That was not happening in Kerry up until a certain thing was done by the HSE, which it called the "reconfiguration" of the ambulance service. That was the word it used. What it actually meant was a reduction in ambulance services. When the ambulance leaves Killarney with a patient for Cork University Hospital, CUH, when it drops off the patient, the ambulance is told to press a button in the ambulance as they are coming out of CUH saying they are available for work. Instead of going back to Killarney to deal with the Killarney people, that ambulance could finish down in Fermoy, Youghal, Mitchelstown, in any part of Cork or even could be sent to Limerick. That is what is happening. That leaves Kerry exposed until some other ambulance comes back to Kerry, which does not happen because the flow of ambulances is to the bigger hospital. We are left waiting for two hours. Then we have ambulances with personnel from Cork and other places struggling to find places in Kerry. When they were asked to go to Lispole they went to Listowel. Simple things like that. I imagine the Minister of State does not know the distance between Lispole and Listowel. Things like that are still happening.

We are talking about patient care. None of us knows the hour when we will get sick. A man rang me yesterday evening about his wife. She is doubled over with pain. She got a letter saying she is on a waiting list to be called for an endoscopy assessment. We went after it and found that if the doctor would say it was serious and urgent, she would be called within eight days but if that did not happen, she would be waiting doubled over for practically three months. That is not good enough when someone is in pain. It is the same with people with pain in their hip or knees. If they are just on a medical card, they will have to wait and stay awake at night with pain. That is not good enough. That is the health service as it is operated at the minute.

I raised the issue of home help here today. The Government is all talk about keeping people in their own homes as long as possible. That is not happening because the home help hours are being cut. In one instance a woman asked the home help, who had just 20 minutes in the evening, if she could cook a dinner for her. The home help said, "I cannot. I can give you a shower and I can give you a sandwich." The woman said to me, "Danny, to hell with the showers. I am showered to death. I am actually hungry." That is God's gospel truth. I am not adding one iota to it. Cutting the home help time to 20 minutes is ridiculous.

I refer to people with disabilities. I am talking about children who are born to a mother and father who are going to have a disability, mental or physical, for all the days of their life. This is a terrible cross and a burden on families to which it happens, but that is nature, that is life, that is the cross they have been given. I feel for those parents when they get elderly. I know a family where the father is 75 years and the mother is 79. They are very worried about where their 57 year old disabled son is going to finish up. They are still taking him in the car to meet the bus to go to day centres. The biggest worry they have now is not the problem of seeing after him but what is going to happen to him when they are gone. That is their worry. That is replicated right around the county of Kerry which I represent. I know so many people in that position. The Government is failing in that regard. It is failing to do anything about it. The Minister of State should not shake his head because I know it is and know the people who are involved. The Government wanted to put some of these disabled people in decongregated settings to put them out into the communities. I told the Minister of State about some of these people before. They are not able for it and will never be. I know one child - I still call her a child but she is 46 years of age - who is blind and is balled up in a little ball. She does not know anything but they have her kept alive in St. Mary of the Angels and the Government wanted to take her out of it. That is very wrong. The Government has some people taken out of it and is paying €600,000 and €700,000 a year to keep them in a decongregated setting. That is where the Government is spending the money wrong.

People in pain are not being seen after and I just do not give credence to these primary care plans and all other plans. There are so many little things the Government could do to ensure that when people are in pain and need help, they should be seen to, no matter if they just have a medical card. The only way we can get some of those people seen to is to send them into the accident and emergency department and tell them not to come out until they are seen. Otherwise they would remain in pain for weeks or probably until they died.

My father fought hard to get a new community hospital for Kenmare. Only half of it is open still, 80 years on. There is only one respite bed and families trying to care for elderly people and doing their best to keep them in their homes for as long as possible. They need a break. The hospital in Kenmare services from Poulgorm Bridge all the way to Caherdaniel, practically as far as Waterford, and back the other end of the peninsula as far as Lauragh. To think that hospital can only cater for 26 patients in a year.

That is what is going on. The lucky patients get two weeks. That is what we get when we divide 26 patients over 52 weeks. That is all that is being catered for, while there are still 18 or 20 beds to be opened in that hospital. There is talk about the difficulty of getting nurses. There would be no problem if they were paid properly. It is the same story in Dingle Community Hospital. There were between 22 and 24 patients on trolleys in University Hospital Kerry, Tralee, in the middle of the roasting summer. That is wrong. I do not think the Government understands this. We have five Ministers responsible for health in the Government and we still do not have a proper health service for people who are sick. I am sorry. I have nothing personal against the Minister of State but I have to point out what the people we represent are telling us.

Tá áthas orm deis a fháil labhairt ar cheist an chúraim phríomhúil. Ar ndóigh, tá coimhlint mhór taobh istigh den chóras sláinte. An cheart an t-airgead a chaitheamh ar na hospidéil nó sa phobal? In all my time in politics there has been a great tension between expenditure in hospitals and expenditure devoted to preventive and primary care medicine. It always seemed to me that the hospitals won out. It is a more high-profile area and much more likely to attract public attention in the main national media. Primary and preventative care is less spectacular but, when analysed, gives much better results. I remember suggesting at one stage that we really need two Departments of Health. Having one Minister means that person is always conflicted between putting money into the hospitals for exciting new medicine and putting it into the much more mundane area of primary and preventative care. That might deliver better results for many more people.

There is definitely this tension. My feeling was that if we had two Ministers, one with responsibility for children and primary care and the other with responsibility for hospital care, at least there would be balance in the debate at the Cabinet table. The reality is that if we look at many of the illnesses causing so many challenges to us as a society, we see how much prevention is actually better than cure. I refer to diabetes or regular testing for cancers as examples. It is noteworthy that we are having this debate on the issue of primary care. I believe a much greater share of resources should be focused in that direction.

If we had properly funded and located primary care teams, I am convinced that many treatments now provided in hospitals could be brought out into the community. These issues date back when we were in government. No matter how often we talk about this, unfortunately, it is always stated that this is the way of the future. It never seems to happen, however. I believe in centres of excellence for high-powered medicine. That makes absolute sense. There has to be critical mass for diagnoses and operations when treating cancers, etc. It does not hold true, however, for subsequent treatments. We need to have a positive policy that everything that can be done more appropriately at the local level will be done there.

We also have to understand that for many people, throughout their lives, the mundane issues of medicine are very important. I will address some related issues in the short time that I have. As I stated in the debate on rural development earlier, there is a huge impetus towards centralisation now. When pressure comes on systems, the first places to lose out are on the periphery. It also seems that when the pressure comes on we do not do the simple things well. I will give some examples. There is an issue in respect of a lack of physiotherapy resources in the west of Ireland. The money has been provided but there seems to be some delay in hiring physiotherapists. The existing resources were not spread equally across the regions to ensure that any reduction in services would be borne evenly between urban and rural communities. A decision was made by the HSE instead to withdraw physiotherapy services from Connemara and to tell people to travel more than 100 km to Galway city for physiotherapy. It is absolute nonsense to be recommending that older people who need these services be brought such distances on bad roads. I recall the old saying about bringing the person to the mountain or the mountain to the person. It seems that in this case we are bringing all of the people to the city instead of bringing the services to the people.

This is a major reversal all of the promises made regarding primary care. I have an example in which the Minister of State may be particularly interested. Someone recently approached me in respect of the child and adolescent mental health services, CAMHS. That person lives seven miles west of Clifden, County Galway. Clifden is about 100 km from Galway city. The suggestion was there be a CAMHS service in Clifden once a month. I asked a parliamentary question on this issue. It was, as usual, referred to the HSE. That agency responded that that was its policy and the patients would have to go to Galway. Is that a humane way to treat a family under stress and the young person with mental health issues? Is it fair for that young person and his or her family to have to spend half a day travelling to avail of a service? Is this what we call progress? We are centralising everything and putting great impositions on people on the edge. We wonder sometimes why the emergency services are jam-packed. We wonder why ambulances are held up in the acute hospitals waiting to disgorge patients. The patients can be brought into the hospital but they cannot be handed over to the staff. The lack of a local primary care service is forcing people who could have been treated in those services into the acute hospitals.

In the time left to me, I want to raise a subject that might not be the exact topic of this debate but I am sure the Minister of State will forgive me. It is his specific area of competence. I am gravely concerned about the dearth of funding for disabilities services in recent years. I am criticising the Minister of State and the Government but I am not doing it in a personal way. I am doing it because a great many parents are coming to me looking for respite care. Some are looking for full-time residential care.

We just opened a respite home recently and €10 million has been provided this year.

That is still not meeting demand.

I ask Deputy Ó Cuív to refrain from stating we are doing nothing in this area.

The figures from the HSE show an extra €100,000 has been provided here and another €160,000 provided there. Those providing services to people with intellectual disabilities are telling me that they do not have adequate resources to provide the services required. I understand the challenge. It is, again, not the high-profile part of medicine. There was much more talk about disability issues in the 1990s and 2000s than there is now. I understand that as a consequence, the Minister of State might be fighting an uphill battle. The reality, however, is that the families of the people with intellectual disabilities are living with this every day of every year and can expect a lifetime of looking after a young person. Most people who end up caring for the elderly will be in that situation for a finite time. People who wind up looking after young people with a disability will be doing that for a long lifetime. That is because, thankfully, survival rates are much better nowadays.

I have been trying to table questions to the Minister for Employment Affairs and Social Protection on the means-testing of disability allowance for those who have never had and never will have the chance to find a job. If parents leave to their children out of what they have saved in a lifetime €100,000, the Department disregards the first €50,000. If they leave them a house, it means that they are ruling their children out of receiving support from the State. That issue must be addressed also.

In summary, we need a greater proportion of the budget to be spent on primary care services. We must ensure the regions and areas on the edge of the country receive the same services as those areas at the centre. We must put a great deal more money into disability services than we have been in recent years.

This is a timely discussion, given the public meeting held last Monday in Monaghan town which was organised by Family Carers Ireland, in particular, Brigid Finnegan and her wonderful staff across counties Cavan and Monaghan. The meeting included families from as far away as County Louth. The title of the meeting was "Carers in Crisis", which is an indication of how carers feel about the support the system provides. The meeting was attended by parents, siblings and people in their later years who continue to have complete responsibility for adult children with physical and intellectual disabilities. They remain the primary carers and try to provide care within the environs of their own home. They made the point that they did so against the backdrop of many challenges, obstacles and a significant lack of support for them in doing the good they did. They want no more platitudes and do not want to be told that they are the heroes of society. They want action, not words.

Family Carers Ireland provides a huge amount of support for families, but it is done on a shoestring and with limited resources. It provides some financial, emotional and mental health support far beyond what could be expected of an organisation of its type. A number of issues were raised at the meeting. For the information of the Minister of State, I note that tomorrow in Buswells Hotel, Family Carers Ireland is launching a report entitled, Paying the Price for the Physical, Mental and Psychological Impact of Caring. The meeting in Monaghan was two hours long and included families at the coalface of the vocation of caring for loved ones. A number of issues recurred with families sitting around the tables. For them, those two hours were a precious chance to step out of family life and the 24/7 care they provided. It was heart wrenching to hear some of the stories and personal accounts of the challenges carers willingly faced on a daily basis. I wish to raise those issues with the Minister of State.

I have spoken to the Minister of State privately and on the floor of the House about the recently introduced transport charges for those with disabilities who attend day care centres for lunch. While it might only be €5 per day or €20 per week, it amounts to a significant sum at the end of the year for people who have a very small social welfare payment in the first place. Parents, families and the clients of day services feel aggrieved about the charges. Not only are they aggrieved at the actual payment, they are also aggrieved at the lack of consistency around it. Some centres charge the transport fee, while others do not. Those who refuse to pay are never forced to do so, while some people pay it anyway. It is not regularised and there is nothing consistent about it. There has been a flood of parents coming to me at my constituency offices across counties Cavan and Monaghan who are deeply upset at seeing some of the most vulnerable in communities being encumbered with this extra charge for transport and lunches.

People at the meeting spoke to me about an issue I had not come across before. We all know about the difficulty in getting carer's allowance and the protracted bureaucratic process involved. However, a matter which I do not fully understand was explained to me. It is that a certain number of people find that the allowance precludes or in some way inhibits their pension entitlements after a lifetime of caring. The chairperson of the meeting said that across Ireland a number of adults and parents providing care and in receipt of the allowance saw their pension entitlements affected and that something needed to be done about that issue. They assured me that there was a very small number of people in Ireland who fell into that bracket. They say it is something that should be very simple to address. While it is a matter for the Department of Employment Affairs and Social Protection, I am sure the Minister of State is in constant touch with the Minister owing to his passion for the area. I ask him to ensure the Department of Health will consider the matter with the Department of Employment Affairs and Social Protection.

Also raised at the meeting was the lack of ancillary supports. I refer to occupational therapy, physiotherapy and something I had never thought about before, namely, mental health supports for families and carers providing care. Providing care is draining and difficult. It is the constant nature of the job. It is another element of the frustration carers face when they take on the job. There is frustration in seeking occupational therapy and physiotherapy, but there is also frustration in seeking services for carers. We talk a great deal here about mental health and well-being, but carers who are doing a very difficult job, with no clocking out time, need emotional and mental health support. The Minister of State knows well from personal experience that the job is 24/7. I ask him if it is something at which he could look in his Department to see what can be done to provide that support.

People at the meeting discussed regular and emergency respite care services. As the Minister of State knows, the Annalee respite care service in Cavan-Monaghan has been a fiasco for months. The most recent reply from the HSE states that, after the service has been closed for months on end, there is an oil leak which, again, is preventing access. Families racross Cavan-Monaghan have been shut out from receiving any respite care service. It is a major loss to families and parents. In recent weeks the parents' action group in Cootehill held a public meeting to voice their frustration. They must go to great lengths to hold a public meeting, given the pressures on their time and the dependence of their loved ones. Taking the time to come to a public meeting says a great deal about their frustration. The subject of regular and emergency respite care services was also raised at the meeting on carers in crisis. The answer is providing more hours and greater access to respite care. Families say that when they have asked for emergency respite care, the Department has said it fears such a service would be abused. It is a terrible answer to give parents and carers seeking an emergency respite care service. It was explained to me that families could not pick up the phone and rely on any service to provide respite care cover in the case of a family emergency. The feedback I received at the meeting was that there was no way an emergency respite care service could or would ever be abused.

Therefore, they will be using that service in a limited way and only when it is most necessary. That is, again, something that the Minister of State could delve into and examine. I know there would be significant appreciation for that from carers.

I refer to the home care packages and know that the Minister of State has heard a number of my colleagues across the House raise this issue tonight. In Cavan-Monaghan, we do not seem to be any different from any other area. Somebody has to die before a client who has been allocated a home care package, who has been recognised as being in need of home care and who has qualified for a home care package can get staff in to provide that home care service. The point being made by parents yesterday was that more home care packages are needed, hours and staff are needed and that skilled staff are needed, rather than just lobbing somebody in to do the job. It must be somebody who is appropriate to the clients they are visiting. That is important for these parents and for carers at large.

I have raised the vast bulk of the points that came up yesterday at the public meeting. I encourage the Minister of State again to take time out if he can and go to the launch of their report on the physical, mental and psychological impact of caring. It would be much appreciated and I look forward to working further with him on the issues.

I am delighted to be able to contribute to this debate. I know how earnestly Deputy Finian McGrath views this topic as the Minister of State at the Department of Health with special responsibility for disabilities. The Department has a budget and he has to try to shoehorn as many things as he can into that budget but our job as Opposition spokespeople is to hold him to account in this particular position.

I will make a number of general points on primary care. One of the major health insurers operates what is known as Swiftcare, which has turned out to be a successful model in saving emergency departments in a number of Dublin hospitals in particular, and perhaps in other parts of the country, from even more overcrowding than they have because they are able to deal with injuries and issues that people often attend emergency departments with. There was a cost for people who attended that but one could essentially be dealt with pretty expeditiously and certainly within an hour in most cases, which would be unheard of in an emergency department or emergency room, ER, setting. The problem is that the health insurer has confined that facility to its policyholders.

In the context of locating primary care centres in as many areas as possible, which I know is the ambition under the primary care strategy, there should be a Swiftcare dimension to this where minor traumas such as ankle twists could be treated. VHI policyholders can go to Swiftcare in Dundrum if their kids have been injured in a football game on Saturday afternoon or Sunday afternoon and it is full with them at those times. They do not end up waiting long periods in emergency departments dealing with minor traumas that could be dealt with in the community. That is a model that needs to be looked at.

I refer to my experience as a public representative that goes back 20 years. In the original local authority area that I represented for many years, which covered Rathfarnham, Templeogue and Knocklyon, the HSE made five or six valiant efforts by to deliver primary care facilities. It turned out that the least difficult challenge was securing planning from the local authority. Some of the difficulties arose with attracting GPs to serve in the primary care centre when it was built.

There was to be one in a particular locality close to me in Rathfarnham village. Planning permission was granted and a lot of work had been done by the HSE to secure the medical personnel who were key to the success of that primary care centre if it took off. When planning permission was granted and the project started to move forward apace, it is my understanding that the GPs withdrew for various different reasons. I am sure they were some good reasons and the building became a preschool Montessori building and, therefore, Rathfarnham has no primary care centre. There is a site at St. Augustine's in Ballyboden. The primary care centre project has been going on there for eight or nine years at this stage and according to the latest parliamentary question responses I have received, it looks like we are looking at a public private partnership, PPP, leaseback arrangement between the HSE and some developer if it can get developers interested in the project because the HSE cannot afford to build the primary care centre.

Elections are a good way of testing the pulse of people. I often tell colleagues that in 2009 two issues simply were not emerging on the doors when I was canvassing in the local elections but by 2014 they had begun to spring up and have been growing exponentially. One was autism, which featured to some degree on the doors in 2009 but since the 2014 local election campaign and up to now, one cannot go through a housing estate without meeting multiple examples of families concerned about autism and the spectrum of children with special needs and the need for their diagnosis. This simply did not feature a decade ago. The other issue is dementia. Dementia did not feature as a need ten years ago when I knocked on doors. Professor Rónán Collins in University Hospital Tallaght has stated we need to prepare for a 20% dementia society.

The Minister of State gets this but I must hold him to account for this and there is nothing more heartbreaking than meeting parents of children, whom they suspect have a special need, who need an assessment, who are going through the most vital development needs of their lives, physically, mentally and psychologically and who are on waiting lists for psychological assessment. Some of the local centres are full and the lists are full but let us use the NTPF and give these parents a voucher in order that they can have the psychological assessment done privately by an approved HSE psychologist. This would mean that they could begin to make preparations for their children and do what is necessary to ensure their children get the help that they need at the earliest stage possible and the interventions that could make that critical difference to their development, educational development and, ultimately, educational attainment.

The same can be said for speech and language therapy and the Minister of State will have heard about if he was out and about during the recent local election campaign. These vital interventions are required at the most vital developmental stages of a child's life. The Minister of State will come back and say he has addressed this but I need to hold him to account on behalf of my constituents. He is in government and in charge of the spread of resources. There is nothing more heartbreaking than meeting parents at clinics who know that their child has a need, whose teachers have concerns, even in preschool stages, and they cannot get access to speech and language assessments or services because there simply are none. The cost to the State of providing something such as a voucher system for these parents that would enable them to secure speech and language assistance privately would be minuscule because a large number of speech and language therapy professionals are available in the private sector. As we speak the clock is ticking on so many of these children.

Home care packages make such a difference, which colleagues which pointed out earlier. Deputy O'Dea introduced a Bill last year in that regard. It essentially provided for a fair deal at home scheme and, according to his costings, it would save the State 66% on each package. Most families I encounter want to mind and care for their loved ones in the family home for as long as they can. He estimated that the cost of a fair deal at home scheme would be one third of the cost of the existing fair deal scheme with all its complications where properties are left unoccupied in Dublin, in particular because of the sensitivities associated with selling a family property where a loved one is still alive who probably cherishes the possibility of returning home at some stage.

There is much to consider in respect of primary care. I welcome the centres that have been rolled out in Tallaght and that form part of a campus in close proximity to the university hospital. In burgeoning areas such as CityWest, however, where a massive amount of development has been undertaken, or Ballycullen, Knocklyon, Firhouse or Old Bawn, where much development has been planned, there is not a primary care centre to be seen, despite a population of thousands. The population feeds into the university hospital in Tallaght and, as a result, the hospital is bursting at the seams.

My statement on the issue mirrors those of some of my colleagues. I appreciate that the Minister of State is doing his best. The debate provides him with an opportunity to return to his Cabinet colleagues and say that Deputies raised many important issues in the House. The Minister of State referred to money. It is his responsibility to secure that money, while it is mine to hold him to account if he does not do so or if he does not provide the facilities my constituents need. That is why I was elected. I look forward to the Minister of State's response.

I thank Deputies Smyth and Lahart for remaining until the end of the debate and their statements. It is obvious we agree on the importance of primary and community care services and that we wish to see more care provided at home in local communities. I accept there are gaps in the service delivery and that long waiting times for access to primary care therapy services are unacceptable. We can and must do better. We must develop a more comprehensive community and primary care system, while the vast bulk of health and social care services must be provided as locally as possible. This will not only reduce the pressure on the hospital system but greatly improve patients' experience. While implementing the change required to shift the focus of care from an acute community setting will not be easy and will take time, we must be careful to ensure the correct balance between the depth of service provision and the breadth of access, and must be realistic about the pressure that ever-increasing demand and the increased complexity of cases place on primary care services.

Despite these challenges, the Government and I remain committed to the further development of services in the community. In that regard, it is important to recognise what has been achieved. In my constituency, there is an excellent primary care service in Cromcastle Road, Coolock. I had the honour of opening that service last year and, therefore, thought it important to mention it in the debate. Primary care centres are being delivered throughout the country, while increased investment supports service delivery and will allow for 170 primary care therapists and community nurses to be recruited in the second half of the year. The strong focus of the interdisciplinary work of community health networks represents the next stage in the development of the sector. I am confident that patients and clinicians will benefit from this improved model of working.

A number of Deputies raised the issue of disability and I am delighted they did. The HSE service plan for 2019 provides for €1.904 billion in spending, or an increase of 7.5%. To listen to some of the comments in the debate, one would believe that nothing has happened on the ground. In the past three budgets, however, there has been an increase in the disability allowance of €15 and the restoration of the respite care grant, which is now called the carer's grant, to 108,000 families, while 11,000 children in domiciliary care have been given medical cards. I have been involved in the opening of 12 respite houses in 2018 and 2019. With the support of the House, we have allocated an extra €10 million for respite services. I do not suggest we have everything we want but we have started the investment and reforms. As I outlined, in recent weeks we have seen agreement on the revised GP contract , the publication of a new oral health policy and the implementation of measures to ease the burden of healthcare costs. These are important developments for the health service, clearly signalling a direction of travel towards a high-quality, integrated and cost-effective system. My focus is to build on the achievements to date in providing improved, faster and earlier access to services, as the Sláintecare action plan sets out. This will mean the following: reconfiguring health structures to deliver care based on the population size; expanding the workforce and infrastructure capacity to provide a comprehensive community based service, including prevention and well-being initiatives, diagnostic services and chronic disease management; and developing resources for primary care professionals, including the full utilisation of technology and e-health systems and the development of new funding models.

I listened to the points made by Deputies Lahart and Smyth on the assessment of need and respite, an issue we have tried to resolve in recent weeks. We are providing extra staff and resources but I accept the argument we must do something about the matter. I ask for the Deputies' support as the next Estimates approach to deal with the issue.

I am pleased to say the journey of reform is truly under way. Investment in primary care infrastructure and services represents the first step in creating a modern and improved health service to which we all aspire. I emphasise that it is the first step but we have started with the reform and investment. We need to do more and will do so.