Ceisteanna ar Sonraíodh Uain Dóibh - Priority Questions

Hospitals Building Programme

Stephen Donnelly

Question:

38. Deputy Stephen Donnelly asked the Minister for Health the status of the relocation of the three Dublin maternity hospitals to new sites; the planned dates for when the new hospitals will be open; and if he will make a statement on the matter. [49072/19]

The Government has promised to deliver three maternity hospitals in the greater Dublin area. Holles Street hospital is meant to move to the St. Vincent's site. The Coombe is meant to move to the St. James's Hospital site and the Rotunda is meant to move to the Connolly Hospital site. Could the Minister provide an update on the progress that has been made? When will the hospitals be up and running on the new sites?

I thank the Deputy for his question. In line with best international practice, it is the policy of the Government and Oireachtas, as set out in the national maternity strategy, that stand-alone maternity hospitals will be co-located with acute adult hospitals. We should not have stand-alone maternity hospitals anymore.

Project Ireland 2040, our capital plan, provides €10.9 billion for health capital developments across the country, including funding to relocate the hospitals.

The Government is fully committed to the maternity hospital projects. The new maternity hospital at the St. Vincent's University Hospital campus will be the first of these to be developed. The transfers of the Coombe Women and Infants University Hospital, the Rotunda and University Maternity Hospital, Limerick, will follow.

The relocation of the National Maternity Hospital at Holles Street to the St. Vincent's University Hospital campus is progressing. A number of enabling works contracts in regard to the pharmacy block and the extension to the car park are in progress and are due to be completed next year. Let me be very clear, however, that the tender documents for the maternity hospital development will not be issued until such time as a legal framework to protect the State's significant investment has been agreed. I have heard much commentary on this in recent days. The Government's position is that it will not press "Go" on the full project until all the outstanding issues are resolved.

The relocation of the Rotunda to the Connolly Hospital campus is one of the key infrastructure projects to be funded. It is important that we carefully plan all projects to meet population health needs and achieve value for money. This work is ongoing. I have engaged with the Master of the Rotunda, RCSI hospitals and the HSE on the relocation of the Rotunda to Connolly Hospital. This included a meeting with these parties in July of this year.

A site for the proposed maternity hospital is identified in the St. James's Hospital campus master plan, and the new children's hospital design has allowed for the required operational links and clinical adjacencies with both maternity and adult hospitals to be provided. Trilocation for the Coombe will facilitate the transfer of critically ill mothers from the maternity hospital to St. James's.

Project briefs will be progressed in 2020 for the relocation of the Rotunda, Coombe and Limerick hospitals to acute hospital campuses. I acknowledge something the Deputy called for in the capital plan. We have now provided funding for the project briefs to be progressed for each of the projects in 2020. All our maternity hospital projects are required to progress through a number of approval stages, in line with the public spending code, which includes appraisal, planning, design and tender stages before a firm timeline or funding requirement can be established.

I asked for funding for the project briefs to be progressed this year, but next year is better than not at all. I want to go through my points one at a time. The Holles Street project is meant to have started by now. I understand that was the original plan. The Minister, fairly or unfairly, has been blamed for part of the delay by a chief justice at an Irish Hospital Consultants Association conference in Galway, on the basis that there was some spat between the Minister and the hospital and that he was blamed.

The work has not happened and the car park is not of much use to the patients.

We were promised by the Taoiseach, when he had the Minister's job, that the Coombe project would happen at the same time as the national children's hospital project. That has not happened. As I am sure the Minister is, I am talking to the clinicians involved and learning that the conditions are not safe. The Rotunda was promised that, at some point in the far distant future, it will end up on the Connolly Hospital site, but before that happens, there will have to be a model 4 adult hospital. In that context, the Rotunda has repeatedly asked for pretty modest funding to upgrade its existing facilities.

Does the Minister agree that the current conditions in all three hospitals are unacceptable for mothers, babies and clinicians? Does he accept that the delays are unacceptable and that they are delays rather than instances of everything proceeding according to plan? Most important, the only question that matters is whether the Minister has a date, even a year, for when the building of each of these hospitals will begin and, much more important, for when they will open.

The phrase "fairly or unfairly" is pretty loaded because one believes the accusation is either fair or unfair.

I do not know. That is why I asked.

As Minister for Health, I believe it is very fair. I hope that if the Deputy were in my position, he would adopt this approach also, such that we will not press "Go" on the building of the new national maternity hospital at the St. Vincent's campus until all the issues, including that of the religious orders leaving and all those associated with governance, are resolved and the hospital is in public ownership. I believe all of this can be achieved. There has been a lot of misinformation and scaremongering in this regard but I believe all these objectives can be achieved. My position is very clear in that regard.

That is not delaying the project, however, because the enabling works are ongoing on the pharmacy and car park, both of which will benefit our acute adult hospital anyway. Those works are due to be completed in 2020, at which stage we will go to tender for the national maternity hospital proper. We will press "Go" on that tender only after a Government decision and once the thee clear commitments I have set out have been met. It is possible that the hospital could go to construction late in 2020, subject to the conditions being met.

While the Deputy is correct that it was always intended to proceed with the Coombe project alongside the national children's hospital project, it was never from a construction point of view. The children's hospital must be built first, and then the Coombe. The Deputy is correct that we should be preparing to go ahead with the construction of the Coombe. That is why the project brief will be produced.

With regard to the Rotunda, I agree there is a need to listen to Professor Malone on the interim works that should be carried out. I have asked Professor Malone and the HSE to come up with an agreed project concerning what could be done in the interim. I believe this work is almost finalised and I look forward to those concerned coming to see me in the coming weeks in this regard.

I thank the Chair and the Minister. On the promise on the Coombe, the exact wording of the Taoiseach was that the work would happen "in parallel". If the Minister tells me building A is going to be progressed in parallel with building B, it suggests to me that bricks will go up at the same time. That is pretty reasonable.

I would like to return to the core question again. We can go back and forth on the detail, which is fine, but ultimately the only question that matters to mothers, fathers, babies and staff is when. There must be a project plan for each hospital. Does the Minister have one for each? If so, will he share the date for when the new hospital will be open on the St. Vincent's site? When will the Coombe be opened on the St. James's site and when will the Rotunda be opened on the Connolly Hospital site? Ultimately, this is all that matters. Will the Minister commit to starting to provide funding in the next year's budget, in the service plan for the Rotunda? As the master said, and as we both know, it is only a matter of time until a baby dies because of the overcrowding the hospital is dealing with.

It is a very Dublin-centric question because the Deputy keeps on leaving out poor old Limerick. I am sure Deputy O'Dea would not be happy with that. We do intend to co-locate the four maternity hospitals, including the one in Limerick.

To answer the Deputy's question bluntly, Holles Street is the first in the queue. That is our intention. I hope, subject to the criteria I have set out being met by all involved, that construction can begin on it towards the end of 2020.

With regard to the Coombe, we need to go to tender. If I start giving out dates on the floor of the Dáil on the tender process and the construction project, the Deputy will come back to me in ten years saying I said this or that. We need to allow the tender process to proceed. That is fair. The Coombe will go to construction, but when the children's hospital is finished. What we will do in the meantime is proceed with all the planning and development that needs to be done in this regard.

With regard to the Rotunda, my priority, while I am committed to the bigger move, is to see how we can help the master with the interim works that need to be carried out. I wish to see funding provided for this. I need to meet Professor Malone and representatives of the HSE on this in the coming weeks. I have asked them to present their agreed plan formally to my Department and I will endeavour to respond positively.

Primary Care Centres Staff

Louise O'Reilly

Question:

39. Deputy Louise O'Reilly asked the Minister for Health the staff, by occupation, working in each primary care centre run by the HSE; and the vacancies in each. [48902/19]

We know there are significant vacancies in primary care right across the State. I do not expect the Minister to dispute that, but perhaps he will. Some of those vacancies exist because GPs have retired or because we simply cannot get GPs to fill the vacancies, but there is a number of vacancies in primary care centres that are run and staffed by the HSE. That is a matter that falls within the remit of the Department. It is something I believe more effort could and should be made to resolve.

I thank Deputy O'Reilly for the question. The development of community and primary care services is a key priority for the Government and primary care centres support this goal by providing a setting in which a range of health professionals can deliver better care, closer to people's homes in their local communities.

Data, as requested in the question, on the number of staff working in individual centres are not compiled centrally by the HSE, nor are vacancies identified within a specific building. There is a rationale for that, as I am sure the Deputy will appreciate, namely, that staff work across their local community and are not assigned solely to a particular centre. Nonetheless, I have asked the HSE to endeavour to get the information as best we can for the Deputy. However, the HSE does acknowledge the requirement to develop integrated reporting systems that would support timely reporting of staff both by service area and location.

Nationally, there are more than 10,600 staff working in primary care and it is estimated that around 1,800 of these staff were working in primary care centres as of November 2018. Many other staff will provide visiting clinics or other services at primary care centres, while some centres may also house mental health or social care staff and others will host visiting clinics run by consultants from acute settings. In addition, centres are used for training, education and other staff or community development programmes. As such, I have no doubt that investment in primary care centres and primary care staff is benefiting local communities.

Alongside infrastructure - this is a crucial point - we are also investing in staff. Deputy O'Reilly makes the point to me regularly that we can have all the shiny buildings we want but we need to staff them properly. I am pleased that in budget 2020 we received a multi-annual commitment for €60 million for what I call the Sláintecare workforce. That will provide 1,000 additional staff in community settings by 31 December 2020. That is a commitment the CEO of the HSE has given me. Roughly speaking, we need about 4,000 additional staff in the community if we are to reach the Sláintecare goals and to achieve the Sláintecare targets. The 1,000 staff is the first tranche and I hope we can build on that with 1,000 each year in the following budgets.

With the greatest respect, if the Minister is not identifying where the vacancies are, it strikes me that he is making it very difficult for himself to plug the gaps. I have asked parliamentary questions on this matter 17 or 18 times. The question relates to my area, which is a microcosm of what I believe is happening throughout the system. When I ask if we are getting additional staff in the primary care centre in Balbriggan, the youngest town in the State, which is in the fastest growing constituency in the State, the answer I get is that services will be provided from within existing resources. That is a very polite and nice way of saying it will not be getting any additional staff. The Department can come back with that answer and be clear that services will be provided from within existing resources, meaning there will not be any additional staff, and yet the Minister tells me that those staff have not been identified. Sláintecare is very clear on where the staff should be, what type of staff are needed, such as physiotherapists and occupational therapists, but we are also talking about directly employed GPs. Let us not forget that a motion was passed here in the House, with unanimous support, calling for the employment of directly employed GPs where that is necessary. If the Minister is not looking at the needs in areas and identifying where the gaps are, then it strikes me that it will be very hard to fill the gaps and to deliver the service. We have a plan and it should not be that hard to stick to it.

The Deputy's comments are reasonably fair, except that perhaps they miss out on one point. For the first time we are now beginning to map out the actual requirements in each of the new regional health organisations. As the Deputy is aware, we will be setting up the six new regions to slim down the HSE nationally and to devolve more to the regions in line with the Sláintecare report. That does mean a mapping exercise, and one not based on the buildings but on the population health needs. In Deputy O'Reilly's regional health area, the question is how many people are required to fill positions in speech and language therapy, occupational therapy, physiotherapy and public health nursing to meet the needs of the community in a timely fashion. That exercise is already under way. The 1,000 additional staff we will hire in the community will comprise the first tranche of that significant investment.

It is fair criticism to say that we have invested a lot in buildings and now we need to catch up in terms of investment in people. Usually, every budget day we get asked how many extra nurses and doctors we have hired in hospitals. I do not suggest that is not important, but this year is the first year that we have put forward a budget that has a very significant increase in the number of staff that are going to work in the community.

On the issue of directly employed GPs, I agree it has happened in some areas but I accept not many. I visited one area in the north inner city where directly employed GPs are providing a service that was never previously provided. That option remains open to the HSE in any area.

It is my contention that there is not a primary care centre in the State that is fully staffed with a multidisciplinary team in operation. I do not believe there is one offering a full range of services. It is a little bit disingenuous that time after time, when we question the Minister for Health or the Taoiseach about long waiting lists or overcrowding in accident and emergency departments, we are told that people should not go to accident and emergency departments if they do not need to. However, it is the only door that is open to them. We are not identifying where the staff are needed, by virtue of the population and its needs, and trying to shore up some of that deficit now. In north County Dublin, children wait 33 months for early intervention. We could just stop calling it that because it is insulting to wait 33 months for early intervention. Therapies such as occupational therapy and speech and language therapy can and should be provided within a primary care centre but they are not being provided at present. I do not hear anything from the Minister to give comfort to the parents that are waiting at the moment. What we really need to know is when the HSE will start to provide the staff. How will the staff be put in place if the gaps have not been identified?

The appointment of directly employed GPs must be ramped up because the GP is the heart of the primary care centre and if GPs are not coming in on the basis of the small-business model, their appointment must be accentuated directly by the HSE.

I agree with Deputy O'Reilly. I have had conversations with the HSE about that and it is clear in its mandate in that regard.

Deputy O'Reilly used the word "disingenuous" and I do not wish to use it back, but perhaps she is choosing not to listen to what I said in that regard. We got funding in last month's budget to hire 1,000 additional people in the community. We are now carrying out the mapping exercise. We are setting up a discrete programme of work in the Department and the HSE to monitor that. I am sure Deputy O'Reilly will, rightly, table a parliamentary question on how many of the 1,000 additional staff have been hired. The answer needs to be 1,000 by 31 December 2020. Whoever is here for budget 2021 - I hope we all are - will need to continue that. I am being very honest. I have asked how many extra staff the HSE believes we need in primary care to achieve the Sláintecare vision and the estimate is approximately 4,000. The next body of work is to map that out across the regional health organisations by specialty as well. That work is ongoing in the Department and in the HSE and the provision of those 1,000 additional posts will be the first real evidence-based example of that.

Question No. 40 replied to with Written Answers.

General Practitioner Services Provision

Michael Harty

Question:

41. Deputy Michael Harty asked the Minister for Health his plans to address the failure to fill the vacant general practitioner posts in Newmarket-on-Fergus, County Clare, Milltown, County Kerry, Macroom, County Cork and in many other locations nationwide; and if he will make a statement on the matter. [48817/19]

What are the Minister's plans to address the failure to fill vacant general practitioner posts in Newmarket-on-Fergus in County Clare, Milltown, County Kerry and Macroom, County Cork, and in many other locations around the country?

I thank Deputy Harty. As of 1 November, there are 22 vacant General Medical Services, GMS, general practitioner posts nationwide. These vacancies account for less than 1% of all GMS panels. The HSE is actively recruiting to fill the vacancies referred to by the Deputy in Newmarket-on-Fergus and Macroom, and is considering available options with the local community in Milltown. I believe there is ongoing active engagement in that regard. In the case of each vacancy, a locum or other appropriate arrangement has been put in place to maintain GP services in the communities in question.

The Government is aware of the workforce issues facing general practice, including the difficulties in filling certain GMS vacancies. I assure the Deputy that the Government is committed to the continued development of GP capacity, so that patients across the country have access to GP services, and that we have taken a number of measures to improve GP recruitment.

The recent agreement on GP contractual reforms, which was endorsed by 95% of GPs who participated in the consultative Irish Medical Organisation, IMO, ballot will see an increase in expenditure on GP services of €210 million annually by 2023, providing for significant increases in capitation fees, the effective full reversal of financial emergency measures in the public interest, FEMPI, plus additional supports for rural practices and, for the first time, practices in urban areas of deprivation.

In addition, I am very encouraged to see that the number of medical graduates undertaking GP training has increased from 120 in 2009 to 192 filled places in 2019, with a further increase expected next year. In a recent press release, not from me but from the Irish College of General Practitioners, it stated the good news that it had received the highest ever number of applications for its 2020 GP training programme. Our job is to make sure that we keep those GPs working in communities in all parts of the country. I believe the changes to the contract are attractive in that regard. I am confident that these measures help make general practice more sustainable and a more attractive career option for doctors. I am aware there is ongoing work in each of the three locations referenced by the Deputy. The HSE is very engaged in trying to find a full and sustainable solution in each of these regards and it has provided locum cover in the interim.

I believe there was a lost opportunity for the sustainability of general practice in respect of the deal that was brokered between the Minister, the HSE and GPs earlier this year. As the Minister has often said, 95% of GPs have signed up to that deal. Of course they would because it is returning financial emergency measures in the public interest, FEMPI, money that was taken from them over the years. However, it has not addressed the issue of GP recruitment. The contract underpinning GP recruitment is out of date. It was introduced in 1972 and has undergone so few changes since then that it is not fit for purpose. It does not recognise the changing and expanded role of general practice. It does not attract new entrants into jobs such as in Newmarket-on-Fergus. That was a perfectly run practice yet it could not attract a GP because of the contractual commitment that a GP has to engage in is so onerous when running a small business. GPs want to work. They are inflicted with a responsibility they do not want to take on as a result of the contractual arrangements they are offered. The fundamental issue in respect of recruitment is the fact that we do not have an up-to-date, modern contract.

I assure the Deputy that I do not consider our engagement with the GP bodies to be done. I very much consider the measures we have taken in recent months to be about initial sustainability after a number of difficult years for GPs. They did not just all sign up; they went out and voted in a ballot that they thought this was a good deal. We are providing significantly more funding and not just returning what was owed to them, as is sometimes said. We are going well above and beyond that and providing for the first time additional supports in respect of paternity and maternity leave, a fund for areas of urban deprivation where we sometimes have difficulty attracting GPs, and increased rural allowances. I accept there is more to be done.

Regarding the three areas the Deputy mentioned, in Newmarket-on-Fergus in County Clare the GP post has been re-advertised with a closing date of 12 December. It is planned to hold interviews for this post early in the new year. In Milltown, County Kerry, in light of the community reaction to the announcement, Cork Kerry Community Healthcare rightly had a meeting with local community and public representatives to listen to concerns. They have postponed the closure of the practice to provide time to the local community to work on additional measures. Finally, in respect of Macroom, this post is currently being advertised again both in Ireland and internationally. A locum GP is in place as of 16 September and is providing services for both general medical services, GMS, and private patients. All other practice staff such as the nurses and secretary remain in place and remain funded by the HSE. The locum doctor will continue to be funded until the post is filled.

I am sure all the Minister's Fine Gael colleagues have similar stories to the ones I outlined in my question. This is a national issue, which is not just confined to the three practices I mentioned. When a list is unfilled, as these and many others are, there is great anxiety within the community. When a GP position is unfilled, there is a loss of community cohesion and an unravelling of the fabric of a rural society. There is a loss of pharmacy services. It is impossible to sustain a pharmacy in a town or village if there is no doctor. No village or town in Ireland has a pharmacy without a GP. There is a loss of support to the ancillary services within the community. There is a loss of community intervention team support, public health nursing support and home help support. When these lists are left unfilled for a substantial period, by the time somebody is appointed, very few remain on the list. When a community loses a GP, there is decreased access to primary care services and to the supports patients get within the community. House calls to the frail and elderly and palliative care work are removed from that area and transferred to the nearest town, where it is not sustainable to deliver that service. There is a lack of sustainability also in out-of-hours services. As GPs are lost, the out-of-hours service struggles to continue. The result is increased attendances at emergency departments because patients cannot get primary care services when a GP is not there. Once the list is gone, it is gone forever. The Minister talks about 22 vacancies. At least 200 practices have closed over the past ten years, which are not counted. They no longer exist. GP services will not return to those towns or villages.

I do not disagree with some of the comments the Deputy has made. However, I need to be clear that as Minister I have brokered an agreement with GP representative bodies and will restore every cent that was removed in capitation fees during the recessionary years by 2023. The agreement will provide more than that as well. It is providing additional funding that GPs sought for rural areas; funding for urban areas of deprivation for the first time ever; and paternity and maternity cover. We have been responding to many of the issues, although we have more to do as we have heard directly from GPs. I have also listened to GPs regarding eligibility issues. They have asked me to make sure I sequence this correctly and invest in general practice before I swamp them in respect of eligibility. Those are their words as opposed to mine. I have listened to them on the phasing in of the introduction of free GP care for children, and not going in one swoop to cover under 12s but introducing it in two-year intervals. We are seeing in recent weeks more people applying to train to be a GP than ever before in the history of our State. That news has been welcomed by the Irish College of General Practitioners. I accept that we have a lot more to do and that in particular parts of the country we have challenges. The HSE is engaging on the ground in that regard. We are training more GPs than ever. We need to make sure they want to remain GPs in Ireland. That is why it is important that we do not just pat ourselves on the back and say we have negotiated a good deal. We must look at how we continue to build on the relationship.

Healthcare Professionals

Róisín Shortall

Question:

42. Deputy Róisín Shortall asked the Minister for Health the timescale for the full reversal of financial emergency measures in the public interest, FEMPI, for GPs and the ending of the two-tier pay scales for consultants; the other steps he plans to take to address the issue in view of the severe shortage of GPs and hospital doctors and the serious impact which this is having on patient care; and if he will make a statement on the matter. [49074/19]

The health services faces many major issues, which combine to deny people access to basic healthcare. Whether at hospital or community level, there are very significant problems. One of those major problems is the shortage of GPs and hospital doctors. This has now reached crisis point in my view and in the view of many working in the HSE. What precisely is the Minister doing about that crisis?

I thank the Deputy for her question. It raises queries in respect of doctors in general, both GPs and consultants. I will try to take them both. I have outlined a number of the measures in respect of general practice. In the interests of time, I will not elaborate on them, other than to say we reached significant agreement on contractual reform and service development in May this year in return for co-operation with a number of measures. Those measures include some the Deputy pushed for and advocated in respect of chronic disease programmes and a number of reforms concerning multidisciplinary working and e-health medicines. We will increase expenditure on general practice by approximately 40% or €210 million by 2023. We will also bring in more flexible contracts, allow GPs to hold contracts until their 72nd birthday, train more GPs and introduce enhanced supports for rural GPs. More people are now applying to train as GPs.

Regarding consultants, I want to be clear. I believe we are going to need to pay our consultants working in the public health service a lot more money if we want to keep the there. I intend to sit down and engage with the consultant bodies on this, namely the Irish Medical Organisation, IMO, and the Irish Hospital Consultants Association, IHCA. However I have no interest, in that process, in worsening the divide between private medicine and public medicine in our public hospitals. I think the Deputy and I agree on this. I agree that the de Buitléir report needs to be implemented in full. Everybody else who has had a conversation about more money or reversals of recessionary measures - GPs, nurses, midwives, SIPTU workers - everybody else has had to do that alongside a programme of reform. Consultants are no different in that regard. I want to pay our consultants working in public hospitals more for doing public medicine. I want to look at how we can end the two-tier reality in that regard. I do not want to do anything that would worsen that divide and that would embed further a practice that I genuinely want to end. The Deputy Sinn Féin and the Labour Party want to end it but I have yet to hear the Fianna Fáil position on it. Every party should come out in this House and say if they want to end the practice of private medicine in public hospitals. As the Taoiseach outlined recently to this House, progress has been made between my Department and the Departments of Public Expenditure and Reform and the Taoiseach on an approach to negotiations with our consultants and the implementation of the de Buitléir recommendations. I expect to bring forward concrete proposals to consultant bodies in that regard.

We have had some discussion on GPs already. It is reported that approximately 70% of GP lists have closed. Many GPs report being under great strain. Stress among GPs is a significant issue. Increasingly, it is difficult to recruit GPs to replace those who are retiring. It is all very well for the Minister to say he is rewinding FEMPI but he is doing so slowly. Deputies and most other public servants did not have to wait four or five years for FEMPI to be rewound.

This is an agreement that the Government reached. That is all very well but as the Minister knows and as we on this side of the House have been saying for a long time, a new GP contract is needed.

We expect GPs to take on new work yet we are not providing the kind of supports necessary for them to do that including ancillary staff, to address the whole issue of chronic disease management.

The Minister talked about the increase in the number of people applying for GP training. That is great but how do we hold on to them? We know that GPs themselves have said this. New GPs want to be working as part of multidisciplinary teams and they want to be operating as doctors not as businesspeople. That means that accommodation must be provided for them.

The Minister promised salaried GPs in the programme for Government. These have not been seen yet. He also promised part-time contracts for many trained GPs, including women, in particular, who want to work for a certain period of their lives as part-time GPs. What is he doing about this? It is hard enough to provide cover during the day. The whole question of out-of-hours coverage is very fragmented because of the dire shortage. What is the Minister going to do about those commitments that he has given for a new contract, for salaried GPs and for part-time GPs?

I do not agree that it is being done very slowly in the unwinding of this. I believe it is being done in quite an equitable way, favouring lower-paid public workers and people who have contracts with the State first. We are not just returning the money that was taken through the Financial Emergency Measures in the Public Interest Act 2009, FEMPI, which was taken by many Governments, 75% of which was taken by Fianna Fáil when in government. We are returning an extra €80 million on top of that which is paying handsomely for new services to be provided in chronic disease management. We are phasing that in, starting with over 70 year olds people with a medical card in the new year, rather than bringing everybody in in one go. This recognises the need to allow our GPs to see the benefit of additional investment before a significant extra workload.

Salaried GPs are now in place in Ireland. I accept there is a need to ramp it up. There is no need for any legislative change to make that a reality. The HSE already has those powers and is already funding a number of salaried GP practices. I share the Deputy's point that could be a lot more. The HSE already knows that it has a clear mandate in that regard as well.

On the out-of-hours services, GPs are contracted under the general medical services scheme and must make suitable arrangements to enable contact to be made with them or with a locum for emergencies outside of normal practice hours. As part of their regular obligations our GPs are contracted provide all-hours access for General Medical Services, GMS patients. The HSE supports the provision of these services with infrastructure, call-handling, recruiting nurse staff and currently over 90% of our population has access to out-of-hours GP service. The HSE and the Department of Health were made aware during the summer of this year of a particular difficulty being experienced by some co-operatives in recruiting GPs from abroad to provide services as a result of the terms of the atypical working scheme visa. The Deputy may have seen the announcement by my colleague, the Minister for Justice and Equality, and myself on that in recent days.

On the question of consultants, how long is the Minister going to stand by and watch the haemorrhaging of consultants from the Irish health service? The situation is now at crisis point. There are over 500 vacant consultant posts. Many aspects of the health service are crumbling and in crisis as a result of this. People are dying as a result and are experiencing and enduring life threatening conditions. There are reasons why this is happening. The reasons have been set out by various reviews and surveys that have been done about hospital doctors. There are issues in relation to bullying, for example, inhumane working hours, awful working conditions for many people, no payment of overtime - a whole range of issues. One needs to look at career structure and the over-concentration on specialisation with hospital consultants. We should be training many more generalists, as they do in other countries.

There have been long promises to tackle this issue. The cuts that took place in 2012 and the creation of the two-tier system has been devastating.

The then Minister, Deputy Varadkar, promised in 2014 that he was going to reverse this. The Public Sector Pay Commission has said that it has to be reversed. When is he going to take action to end the two-tier pay system among hospital consultants, which is doing so much damage?

I agree with the Deputy on the generalists' model. We have already seen this begin to work in the new facility in Connolly Hospital Dublin in our new model of care around children. I do not see why that cannot be extended to other areas.

I need to point out when discussing any issue that one would sometimes get the impression that there are fewer doctors working in the health service. There are in fact more. More consultants are working in the Irish health service this year than last year, and there was more last year than the year before that. There are many more now than when I became Minister for Health.

We have a bigger population.

I fully accept that we need more.

The Deputy is correct that the Public Sector Pay Commission said that we need to address the issue of pay parity. I expect in the coming weeks - I am being quite specific in that regard - to have concrete proposals to put to the consultant body. What I am saying very clearly in this House is that the de Buitléir report said very clearly that we should offer a Sláintecare-type A contract, with pay parity for new entrant consultants who take up this contract. I have no interest no interest - none, nada - in using taxpayers' money to further embed a practice that neither I nor the Deputy believe in, which is using public beds in our hospitals to profit private health insurance companies. I am happy to say that on the record of this House. My counterpart in Fianna Fáil will not do so. We need to get serious about radically overhauling work practices regarding private medicine in our public hospitals. We will pay for that and will bring in pay parity for that as part of any talks.

When will that happen?

I will bring forward concrete proposals in the coming weeks.