Winter Plan 2020: Statements

I welcome this opportunity to address the House on the winter plan which was published last week. Every winter, our healthcare system faces increasing pressures, resulting in difficulties for many people and many patients, particularly older people, in accessing services in a timely way. This becomes most evident, as we know, in the hospital emergency departments in the form of overcrowding, longer waiting times and patients receiving care on trolleys.

Before Covid arrived in Ireland, we already had the longest waiting lists in Europe. Last winter saw the highest trolley counts since records began. That was our starting point. Since March of this year, Covid has caused a substantial increase in waiting lists due to the necessary pausing of many aspects of healthcare. Covid has also caused a very serious fall in our healthcare capacity, due largely to the need for extra infection prevention and control measures. In short, it takes longer and it costs more to provide the same care to the same patient.

For all these reasons, this winter is likely to be the most challenging time our health services have faced in many years. The winter plan is one of the ways that we are responding to this challenge. None of us wants to see patients and staff enduring overcrowded conditions. The problems giving rise to these challenges are varied. Many are rooted in the way services have been historically delivered.

This is why a strategic approach was agreed on an all-party basis to bring about long-term structural reform to our healthcare system, namely, Sláintecare. I re-emphasise the Government’s and my commitment to the implementation of Sláintecare. I know colleagues recognise, and the Sláintecare report itself acknowledges, that these deep-seated reforms, which we need to make, take time to implement. There is no magic formula to immediately fix the various waiting list and trolley issues that we see. Nonetheless, Sláintecare is the strategy we are pursuing and the winter plan is designed according to Sláintecare principles and, I am very happy to share with the House, in a way that substantially accelerates the implementation of Sláintecare.

I welcome the publication of the plan. It is ambitious. Its aim is to deliver safe, efficient and effective services this winter and to do this by reorienting service delivery towards primary care and community-based services. I particularly welcome the HSE's undertaking to reduce the number of patients receiving care on trolleys in emergency departments and the improvement of patient experience times while they are in emergency departments. Both of these objectives are critically important to keeping patients and staff safe in response to Covid-19 this winter.

Last winter, more than 620,000 people visited emergency departments. While anybody who needs emergency medical treatment should, of course, receive it, it is generally accepted among experts that there are many patients who could be cared for in alternative settings other than hospital and who would indeed be better cared for in non-acute settings. Therefore, it is a central part of this plan to provide alternative pathways of care where they are appropriate. This is to ease pressures on the hospital system, including emergency departments, to speed up patient discharge and to provide patients with care as close to the home and their communities as possible and where possible. This will, of course, free up hospital resources for the patients who need to access acute care.

The Government's determination to meet the challenges of winter this year and support the healthcare system are demonstrated by the commitment of €600 million to underpinning this plan. That includes €200 million for the rest of this year and an additional €400 million for next year - that is, the 2021 part of this coming winter. The plan is designed to enable patients to be seen in the community wherever possible.

It does this by providing a better service in the community healthcare settings. The plan supports patients receiving timely care in hospitals when needed and supports patients returning home or to appropriate care settings when they are well enough to leave hospital. It does this by providing home care and step-down options.

I am particularly pleased to share with the House that there are additional supports in the plan for people at greater risk, including elderly people, homeless people, those in addiction, those with chronic illnesses and many more by allowing them to stay home while they are receiving the right level of care.

The plan provides for building capacity and resilience in the system. One of the big challenges facing us is building this extra capacity in the acute hospital system. In 2018, the health service capacity review was published. It sets out the necessity for increased acute and non-acute bed capacity right across the system in the context of major reforms being implemented in the way healthcare is delivered. These major reforms are a critical part of the plan. The plan that has been set and to which we are all working has approximately 2,590 acute beds but it is worth noting that the capacity review states that this is one end of a range and if the necessary reforms are not delivered, we would need in excess of 7,000 beds. These are essential reforms. The programme for Government commits to continuing investment in our health services in line with the recommendations of the capacity review and the commitments in Project Ireland 2040.

The winter plan provides additional health service capacity across a range of services and settings, including acute capacity, to reduce admissions and facilitate egress. Key initiatives include funding for nearly 900 acute hospital beds, nearly 500 sub-acute beds, 631 rehabilitation places and 530 repurposed community beds. Some of those are beds that have been put in place since the arrival of Covid-19 and were funded for several months through the initial Covid-19 response fund. The winter plan will continue the funding of those beds until the end of April and double the number of acute beds in the same timescale. The plan also provides for the utilisation of private hospitals for urgent complex care to reduce waiting lists and for their use in the event of a surge of Covid-19.

Many of these measures are aimed at reducing the number of those over 75 years of age who need to be treated in, or admitted to, acute hospitals. They also aim to reduce the number of patients whose discharge from hospital is delayed because of a lack of alternative care available to them. We saw that happen last winter although it was tackled with some success at the time. It must be comprehensively tackled this year.

The plan also provides additional community healthcare networks, more community specialist teams and additional acute hospital front-of-house teams. This will create the foundation and organisational structure through which integrated care can be provided locally within the community at the appropriate level of complexity. These networks and specialist teams will work closely with the National Ambulance Service to deliver end-to-end care with the aim of keeping people out of hospital or, where they are admitted, to ensure they are discharged without delay. It is anticipated in the plan that these measures could lead to a decrease of 20% in the number of emergency department admissions for people who are over 75.

Having mentioned the National Ambulance Service, I would like to put on the record my acknowledgement of the extraordinary work the men and women in that service have provided. They always do extraordinary work, but their response to Covid-19 has been nothing short of exemplary.

The plan also commits to delivering more diagnostics in the community, allowing patients to be seen closer to home and avoid going to hospital. The plan puts in place supports for GPs, including those in rural practices, to support service continuity. GP access to diagnostics has been coming up for many years. GPs all over the country are firmly of the view that they can reduce admissions to hospital and referrals to consultants and emergency departments by accessing diagnostics and bringing their own patients back to their practices to continuing their care. This winter, we are putting a substantial investment into making that happen and I hope we will see exactly the sorts of results that the GPs intend to deliver.

The plan also aims to double the existing level of home support hours to support the Home First initiative. This is designed to enable those with high and moderate levels of frailty to be cared for in their own homes. With this objective in mind, 4.7 million additional home support hours are being provided for in the plan.

A key action will be a comprehensive flu vaccination programme. The HSE has placed orders for approximately 1.35 million doses of the quadrivalent influenza vaccine as well as 600,000 doses of the live attenuated influenza vaccine, which is essentially a nasal spray rather than an injection for children aged two to 12. I remind people that the flu vaccination for these vulnerable groups is being administered for free, which is an important message and I would appreciate the help of my colleagues to get that message out to people that if they are in one of the vulnerable groups, they should approach their GP or pharmacist for a free vaccination.

Funding is also provided for waiting lists. I would like to acknowledge and support the necessary decision taken earlier this year to defer elective care. I know that this has had an impact on scheduled care waiting lists. Hospital waiting list figures are higher than at the start of the year with the inpatient day case and outpatient waiting lists 17% and 10%, respectively, higher than at the start of January. However, there are some indications of improvement which I think are worth noting. As a result of concerted efforts by front-line workers, the HSE and the National Treatment Purchase Fund, the trajectory of growth in waiting lists has been slowed since services resumed in June. There has been an almost 11% reduction in the numbers waiting for inpatient procedures since May, with early evidence that the rate of growth on the outpatient list has slowed. The HSE has actively sought to improve productivity through the increasing use of alternative work practices. This includes telemedicine, virtual clinics and other alternative settings. Private hospitals, community facilities, atypical outpatient settings, the HSE and particularly community health organisations have been innovative and deserve great credit for their response to Covid-19. They have responded with great creativity and professionalism. The HSE is also currently working to secure access to private hospital facilities for urgent and time-critical procedures for public patients.

The National Treatment Purchase Fund has resumed its activities on behalf of public patients and is currently reviewing strategies to maximise activity and benefit for patients. These include the increased use of private hospitals, funding weekend and evening work in public hospitals, and funding see-and-treat services where minor procedures are provided for at the same time as outpatient consultations. The funding of hybrid services where public and private hospitals contribute to the treatment of patients and the funding of virtual clinics and clinical validation are also included. We need, of course, to acknowledge that waiting lists are at record levels but the combined impact of this work should help to offset to some extent the awful impact of Covid-19 on waiting lists. The HSE and the National Treatment Purchase Fund will continue to work together to address this issue.

I very much welcome today's debate and look forward to hearing from my colleagues their views on the plan. The objective of the Government is to fully implement Sláintecare and I want to work collaboratively with all stakeholders and right across this House to do so. Sláintecare is not owned by this Government, it is owned by the Oireachtas and I hope to see it implemented to a great extent in the coming months and years. In the immediate term, we need to get services back up and running to at least the level they were at prior to the outbreak of the pandemic.

The winter plan is part of that process and is designed to meet the immediate challenges we anticipate this winter. With the ambitious targets in it and the funding provided by the Government, I am confident that we can make inroads into the problems in the system. I hope this is something all Deputies in the House want and will support.

I am sharing time with my colleague, Deputy Patricia Ryan. I will take ten minutes and she will have five minutes.

I have said to the Minister on a number of occasions, and I think he has accepted it because it is a statement of the obvious, that we are facing a very difficult winter. The onset of Covid has been tragic in many ways for our health services, not just in terms of trying to battle Covid and save people's lives but also because of the impact it is having on non-Covid care across a range of areas. We need to get it right as we try to strike a balance between protecting people against Covid and maintaining all critical non-Covid care. We would both agree that we are facing into a very difficult winter for our front-line staff and patients.

The Minister will have seen from the most recent figures from the National Treatment Purchase Fund that we now have record numbers of people waiting to see a consultant and get into the system, and people are also waiting for treatment. We need urgent resources and an injection of serious capacity. We needed a serious long-term plan that would deal with the challenges we face. There is some additionality in the Minister's plan, which I welcome, but much of it resembles more of a wish list. It lacks urgency and ambition.

In the first week of August, I launched the Sinn Féin proposals. We launched a plan that would succeed, not a plan that was designed to fail. We called for 1,100 additional acute beds between now and the end of the year as well as all necessary staff, a proposal that was completely costed and funded. We also called for 2,500 additional staff between now and the end of the year to take the pressure off front-line staff who we know have worked extremely hard and face very real difficulties and challenges. We committed to €50 million in additional spending on cancer services and, separate from our plan, we also talked about additional resources for disability services, mental health and other areas. The Minister's plan for most of those areas has been underwhelming.

I have listened to many stakeholders, including health trade unions and advocacy groups. Over the past week alone, I have met over 20 groups. I have listened to what they have to say because they are on the front line advocating for patients across a range of areas. The one thing that keeps coming up is that this is a temporary plan with temporary sticking-plaster solutions. While that is in part because of the winter challenge, there was an opportunity to make sure all of the additional beds which are being provided would be provided on a permanent basis. In our plan, we provided for 609 modular rapid-build units. The work could have been done during the summer and the beds would then have been ready to be opened in the winter. We would have them on a permanent basis in our health service, which is what we need. Temporary solutions do not cut it and are not what was promised in Sláintecare. They are not what any of us were promised when we canvassed for people's votes in the most recent election.

There are no targets in the Minister's plan in terms of staff. There is no mention of staff in the plan. In the press conference, that information had to be dragged out of some of the people who were there. The plan is still lacking in targets. How many staff will be recruited and how they will be recruited? Will they be agency staff? How long will they be employed for? What type of contracts will they be on? I refer to doctors, nurses, consultants, medical scientists and so on. We know the winter plan is only funded to the end of April and will not, therefore, be a medium-term to long-term solution for all of the challenges we face. In my view, it does not go anywhere near enough to deal with the challenge we have in delivering Covid and non-Covid care. This is a winter like no other. This is a winter when we have to deal with Covid and non-Covid care. However, there should be some opportunity to catch up on all of the missed care.

I have listened to cancer patients who have not had access to their consultants at the times they were promised. Their appointments, procedures and surgeries have been cancelled. I put down a parliamentary question to the Minister on children with scoliosis, a matter which he quite rightly raised with other people when he was in opposition. It is a fundamental issue of children who are in pain and need treatment. There was a 30% reduction in medical procedures for children with scoliosis for the first eight months of this year compared to the first eight months of last year. That is obviously because of the Covid restrictions, but it is all the more reason why we need a catch-up plan, investment and resources to ensure children with scoliosis and cancer patients are not waiting longer for treatment.

The plan made no mention of disability services. It failed to provide additional funding, resources and investment for disabilities and dementia services. The Minister has since announced a meagre €10 million for these services, which was met with shock and disbelief by all of the advocacy groups representing people with disabilities. I very much hope that they will see much more from the Minister, and the Ministers for Public Expenditure and Reform and Finance, on budget day because this is an area that deserves a lot of our attention.

The Irish Cancer Society has said we need €40 million for cancer services. All the Minister has provided in the winter plan is €2.3 million in additional funding next year to deal with what he called restarting or kick-starting cancer services. That falls far short of what is needed for us to be able to make sure oncology services are operating at the same levels that they were pre-Covid.

I do not underestimate the challenge, but there is another important area I want to raise with the Minister. For the past number of weeks I have compiled as much data as I can on dental and orthodontic wait times, which are beyond shocking. Children are waiting four and five years for services. I have received emails from the parents of children who are in extreme pain and cannot get the treatment they need. I do not know whether the Minister has looked at the waiting times recently, but they are shocking. It is one of the areas where there was a pause in treatment. I know people who are not even being referred for treatment; they are instead being told a referral cannot be made because of the lack of capacity. In the Be On Call for Ireland waiting pool of 1,600 staff, there are dentists and dental assistants. Why are they not being hired and brought into the public system to ensure we can treat people and make sure children get the treatment they need? That is the point.

We have to live with Covid, as I said, but we also have to live with it in a way that non-Covid-related healthcare can be delivered. We are saving lives, which we need to do in terms of Covid and taking all of the necessary precautions. On the other hand, people are waiting far too long for cancer treatment, children are waiting too long for all sorts of medical treatment and across whole range of areas, from cardiology to neurology and many others, we have longer and longer wait times. Over 600,000 people in the State are waiting to see a hospital consultant. I can guarantee that by the end of the year, given the lack of urgency in the plan, that will get worse because the Minister has not provided for measures to deal with that.

The plan lacks the detail, ambition and urgency needed to inject the capacity that is needed. The Minister knows full well that if we are to have any chance of catching up or, if we are to be brutally honest, any chance of keeping up we need far more beds than are being delivered in the plan. The Minister has put more pressure on acute hospitals to find whatever space they can in their hospitals to open up beds . There are no new builds whatsoever. There is no reference to modular building, or to medium-term or long-term planning. The plan is about what can be provided by acute hospitals, which are bursting, and putting them under pressure to get all of these beds in place which will of course all be closed at the end of April. We will be back to where we were with a lack of capacity in the system.

I want to finish on an issue I have raised several times with the Minister. It has been raised on the floor of the Dáil with the Taoiseach. I refer to cardiac services in Waterford and the south east. There is very real concern about the second cath lab that was promised which will now only deliver diagnostic services. I attended several meetings with senior officials from the Department of Health, the previous Minister for Health and others where we were promised that the lab would provide interventional and diagnostic care.

That needs to happen.

The final point I will make in the 30 seconds remaining is that I, as a Waterford Deputy, want to work with this Minister for Health, so that he can be the Minister that delivers health equality for the south east, and delivers the 24/7 cardiac care people want. He has it within his power to work with those in the Department and the HSE and with others to make that happen. He knows from his colleagues and others in the south east that this is not just a Waterford issue but that this is needed. I appeal to the Minister to work with others on this issue and to be the Minister for Health who delivers that facility for the people of the south east. Gabhaim buíochas.

Gabhaim buíochas leis an gCeann Comhairle.

I agree with my colleague, Deputy Cullinane. This winter plan is a wish list which is short on targets, on timelines and on ambition. I am very fearful of a winter crisis at Portlaoise, Tullamore, and Naas hospitals. When Covid-19, in particular, is taken into account, the plan is lacking in detail, targets and timelines for staff recruitment and bed delivery. It falls far short of what is required to safely deliver appropriate care in the coming winter months. We need a plan that will catch up on missed care and to build capacity. This plan does not deliver enough ambition to catch up to where we were pre-winter, let alone when the usual barrage of the winter causes our emergency departments to clog up. When I refer to clogging up I mean clogging up in the normal conditions. I fear it will be much worse in the socially-distanced world we now live in.

I spoke last week to a man from Portarlington who attended an accident and emergency department in Tullamore recently. Despite suffering from chronic pain he stood at the edge of a waiting room as this room was too packed, and despite most people wearing masks, he felt unsafe being in such close proximity to a large number of people given the Covid-19 crisis. The man was understandably nervous as he injects a biologic monthly to suppress his immune system in an effort to manage his condition. When he could not stand any more he sat near a window. He had been sent to the accident and emergency department by his doctor who had immediate concerns for his health. He spent eight hours in the accident and emergency department on a Friday evening in September. Imagine how long he might have had to spend in January if he was in that same waiting room.

The Sinn Féin plan which was launched in early August would deliver 1,100 additional acute and subacute beds and 50 intensive care unit, ICU, beds this year. It would provide €40 million to kickstart cancer care and bring on an additional 2,500 staff ahead of winter, not after winter but ahead of it. The Government plan will only deliver 251 acute beds and 89 subacute beds in 2020, and 232 acute beds in early 2021. The 17 ICU beds proposed is far short of what is needed. Additional ICU beds in early 2021 will be crucial but no target has been set.

The HSE has admitted that the so-called new beds will only mitigate Covid-19-related capacity shortfalls and not meet demand. There are hundreds of unfilled vacancies across the health service, including many in Laois, Offaly and Kildare. As the Irish Nurses and Midwives Organisation, INMO, and the Irish Hospital Consultants Association, IHCA, have said, without filling these vacancies new beds cannot be opened. Without clear commitments and rapid recruitment, the burden on existing staff will not be relieved. They are overworked and have worked hard through this pandemic with little or no relief.

There is no mention of disability services. I have spoken with CEOs of disability services as recently as this morning and I can tell the Minister that they are in disarray. There is no funding for mental health services. Why is this the case? There is also no funding to kickstart cancer services this year.

I welcome the investment in occupational welfare supports for front-line staff and investments in community care, in community intervention teams and the winter flu expansion. These were a core part of Sinn Féin’s capacity protection programme, but these alone are not enough. The rest of the plan misses the mark. It is in another missed opportunity to deliver a proper health service for the people of the midlands I represent.

Finally, I am concerned that not enough is being done for carers through the winter plan. Carers are burned out. We need to prioritise carers and day care centres. These need to be reopened and they need this help now. Gabhaim buíochas.

I call Deputy Alan Kelly now.

I thank the Leas-Cheann Comhairle. I welcome the fact that we are having a discussion on this issue this evening. As with my earlier contribution on the roadmap, I would appreciate if the Minister would take on board some of what I am going to say in the limited time available to.

On the flu vaccine, I understand the international issues. Last October some of us were advocating that everybody should get the flu vaccine. We would have had a head start. Unfortunately, we did not do that. While there are international factors, we could have been ahead of the game. Can the Minister, or the Minister of State coming in to sum up, update us on where we are on the roll out of the flu vaccine? Dr. Nina Byrnes and other prominent GPs across the country have been saying that it has been coming in small doses and some people in my own constituency have said the same thing. Are we going to be able to get to the target group? Are we going to be able to get to the over 80s, about whom I spoke earlier and which includes my own parents, and to the vulnerable groups on time?

The second issue I wish to raise is on non-Covid19 healthcare. I want the Minister - I will be asking the Taoiseach next week and he will probably revert to the Minister - to provide me with a table for January to September 2019 and 2020, showing the number of people diagnosed with cancer per month and the type of cancer and the same for coronary conditions. I also want the table to show the treatments. We have to deal with Covid-19 healthcare but we also have to deal with non-Covid-19 healthcare. It is not a case of robbing Peter to pay Paul. I appreciate that the Minister for Health has a very difficult job but we have to look after both of these groups. There is no point saying that, unfortunately, we lost one person through Covid-19 in the past couple of days, if we are losing more people due to other chronic and serious issues like cancer, or heart conditions. It is as simple as that. I want the Minister for Health, through the Taoiseach, to ask that question. It is very rare for the leader of one of the parties in opposition to give the Government a week to get information, and to say that he will ask the same question next week. We need to know this as does the country. We have to diagnose proportionately the same number of people, and probably improve in some categories, as we were last year.

We have all heard anecdotal evidence. I heard of a surgeon in the mid-west who is a specialist in rectal cancers. He has not been diagnosing the same number of patients as he was last year. That means that there are many males, in particular, who do not know that they have cancer. That means delayed outcomes and more mortalities. Put that in an equation versus what we are doing about Covid-19. We must then get these statistics.

I remember the Minister sitting beside me here for years, and also in committee, and he always used the phrase that it is all about the data. Let us find out the data. I have also tabled parliamentary questions on this and I have asked the Taoiseach.

We need more detail on the beds issue. I have said here on numerous occasions that the numbers announced in the plan and the real numbers are different. I will not bother boring everybody by going through it again but the net effect is that there are not as many beds as is being said. I want to see the detail of this plan. Where are the beds going? There is a chronic issue in University Hospital Limerick, UHL. It has to get that 96-bed block and it has to be built using this rapid-build technology. Use the Covid-19 emergency legislation.

I will make a positive suggestion to the Minister. The Covid-19 emergency legislation which allows the Minister to do a whole range of different buildings will run out soon. It needs to be extended because some of the projects may be outside its remit and may face planning or other issues. I know about that because there is a €1.5 million outpatients department being put in Nenagh, and in Thurles there is a €2.4 million facility to deal with elderly members of the community as a hospital prevention measure. Can the Minister tell us where the beds are going to go? We are desperate in the mid-west to know what is going to happen there.

I welcome all the hospital prevention measures being brought in across the country. I have serious questions on staffing. Some 12,500 staff members were mentioned. I was here when questions were asked about this and I could have answered them because according to the plan, there will be 5,000 staff provided before Christmas and 7,500 will be provided after Christmas. I will tell the Minister in a straightforward way that if he can get 12,500 staff members into the health service by next April, I will buy him a good bottle of whiskey.

If he can even get the 10,000, I will buy him a good bottle of whiskey. I know we are being flippant, and it is not a joke, but I want to see a plan and I will work with the Minister on where we will get all of these nurses, and particularly specialists and doctors, that he is committed to delivering.

On cancer screening, I want to see a clinical reason BreastCheck screening has gone to three years. I have asked that question. The screening was always every two years but now, because of Covid-19, it will be every three years. I do not buy that and most people who have knowledge of this do not buy it either.

I want to raise a couple of other issues. As regards the funding that has been announced, I have a huge interest in people with intellectual disabilities. They have been let down. They are our most vulnerable. We need to ensure the plan deals with that issue, and obviously with mental health also.

I want to see more diagnostics going into the community. I refer to all the different doctors who are in co-operatives across the country. We all know they are co-operatives and are private practice but they need extra supports because they are acting in a different way now. They are acting as part of a different type of network in an emergency. They need supports so the Minister should target them.

I have a real issue with what happened with regard to private hospitals. It is not today or yesterday I said that but I will always stand over it. At the beginning of this crisis we should have bought one of the two main private hospitals in Dublin, if not both of them. The Minister will need capacity. That is the quickest way of getting it. People are saying the total amount of public and private beds will be the same but we need public capacity. I believe it would be cheaper in the long term and I still believe the Minister should consider it.

I have heard many promises made in the House over the years but I never heard whiskey promised before.

That is how much it means to me and I hope the Minister delivers it.

We all might get to share it with him.

Yes, we can do that.

I call Deputy O'Connor who is sharing with Deputy Dillon.

The HSE winter plan will see an additional €600 million invested in the health service. I want to recognise that our healthcare workers have worked tirelessly throughout this pandemic and that investment will support them as they care for their patients, both those who have Covid-19 and those who have other healthcare requirements.

I welcome the Home First approach that emphasises reablement in providing extensive home care support packages for those with more complex needs, including people with dementia who are being supported through additional resources that have been allocated towards that area.

The roll-out of community specialist teams to support older people and those with chronic illnesses is also hugely positive. Those teams will help them to stay at home or, if they need hospital care, to get them home more quickly afterwards.

Under the current programme for Government, the commitment towards primary care facilities and recognising that hospitals are often not the best place for people to be in on a long-term basis is a positive move. My home town of Youghal, for example, does not have a primary healthcare centre and such developments in communities such as Youghal would be very welcome in the future. I look forward to working with the Minister to try to deliver that for the people of my constituency.

I would also like to raise a point about funding for communication strategies to communicate the message about Covid-19 to young people. I do so as the youngest Member of this House. Dr. Mike Ryan of the World Health Organization said that there was an ongoing shift in Covid-19 to younger adults. The shift in the disease being detected in our younger population is probably because they are the ones who came back into society at an earlier stage as they were returning to work, college and university. Younger people may suffer a less severe version, in some cases, of the Covid-19 disease but it is not guaranteed that this will always be the case. There is always a risk of passing it on to older populations and more vulnerable members of society. Transmission from younger to older generations can occur, especially if younger people are asymptomatic. If the disease is passed on to older generations again, Dr. Ryan said the hospitals will refill, which is something we do not want to see happen.

I want to highlight the need to target the messaging specifically to young people when it comes to Covid-19. As a young person, I understand that young people do not consume information in the same way as older generations of our society. We need to adapt our approach to ensure every section of our society is aware of the ramifications of the Covid-19 disease, not only for themselves but also for others in the community. I do not want this to come across as young people needing to be specifically singled out and communicated to or, worse, to be lectured but I am conscious that the media consumption patterns have changed so dramatically between generations that this issue cannot be left unaddressed.

I commend the Minister on his hard work, which he has shown since he came into his Department. As he is aware, I have highlighted my concerns around some of the mental health constraints that Covid-19 is placing on our citizens and young people across this country. The lives of many young people have been turned upside down because of this pandemic. They now face very few job prospects in many cases and a very uncertain future, which can greatly impact on an individual's mental health. The general direction of the winter plan is to ensure that we continue to keep the level of deaths from Covid-19 low and that other illnesses are treated also, but in a time of great change for so many across the world it is important that we do not forget to look after our mental health. I refer to measures such as reducing our social contacts. For many young people, not being able to attend university can be draining. I want to say here today that young people are not forgotten in this fight against Covid-19 and that the Minister's Department is looking to ensure that any person who is suffering throughout this pandemic, or at any time, can get the support they need.

Young people need hope that we can get through this pandemic without our health service being overrun, hope that everyone is doing their best to ensure we have a healthcare system in place that will overcome this pandemic, and hope that the future will be better and that we will get through this together.

I thank the Minister for facilitating this debate. It is very encouraging to see that the winter plan has strongly accounted for building capacity and service continuity and ensuring pathways of care during the pandemic era. It is welcome that more than €600 million will be spent as part of the plan, under which the largest spend will be on home support and Home First, totalling in excess of €130 million.

Many of us expressed our support for the healthcare workers on the front line, be it those working in our hospitals, GP services, pharmacies and those providing care at home. However, I must acknowledge the work done by HSE management during the pandemic. They had to respond to a national and international challenge beyond any I can think of in living memory. They have undertaken a public health campaign on a magnitude not witnessed by many. It is inspiring to see such public service values come to the fore during a time when strong leadership and public confidence was most required. While our healthcare system has some long-standing weaknesses and legacy issues, it is important to recognise the strong leadership and to be thankful for such in times of crisis.

I am hopeful this pandemic will also present an opportunity to address some of the long-term capacity challenges in our health service, in particular emergency department overcrowding. I note that the winter plan highlights that in a Covid-19 environment there is a need for zero tolerance of overcrowding in all care environments.

Ensuring the delivery of the long-awaited temporary modular unit planned for Mayo University Hospital is a vital concern for me. While it is due on site by early November, I believe it is important to keep the issue highlighted until it is operational as we enter the winter months. I was recently advised by the HSE that a feasibility study is taking place within the Saolta health care group regarding the development of a 50-bed ward block at Mayo University Hospital. Any further update on that would be most welcome.

In recent months, various other improvement works have been progressing at the hospital, including electrical upgrade works with the provision of a new energy centre along with the installation of additional generator capacity. Other improvements include the reconfiguration and upgrade to the hospital sterile service department as well as the replacement of existing autoclave equipment and building reconfiguration work to achieve compliance with the latest decontamination standards. Such investments are most welcome during the Covid-19 era.

An area of concern which I note is mentioned in the winter plan is general practice support. I am especially conscious of single-handed practices, two-doctor practices and practices with older GPs. Some of those practices are covering huge areas of incredible rural geography, for instance, Belmullet, the Erris region or Achill. I would appreciate it if the Minister could provide further detail on the temporary crisis support to ensure the continued provision of local GP services.

The Minister will be well aware that I have spoken on health issues a number of times, both in this Dáil and many times in the Thirty-second Dáil, so here we go again. I feel I have to do so because of the constituency I represent, which is Limerick city and includes part of Tipperary. We have University Hospital Limerick in that constituency.

I have to speak so often on health because, unfortunately, the issues of overcrowding and low staff levels are ever present in the hospital. The number of patients waiting on trolleys is nearly always the highest in the State. A total of 1,146 patients waited on trolleys in University Hospital Limerick in September this year. The numbers are massive and totally unacceptable. While they are down on last year, the Minister will be aware that the pre-Covid figures for January and February were much higher than those for 2019, which will be a major cause of concern after Covid. In February 2020 there were 1,286 on trolleys, by comparison with 973 in February 2019, and in January 2020 there were 1,215 on trolleys, by comparison with 973 in January 2019. Before Covid, the emergency department was often bursting at the seams and it was clearly unsafe for patients and needed urgent intervention.

University Hospital Limerick is a fine hospital and the staff, from porters to nurses and doctors, do an incredible job, but they often do so in very difficult conditions. I hope the Government's winter plan will provide some remedy for the problems faced by the hospital. These issues will become even more difficult to manage with the onset of the winter flu season, as the Minister is well aware.

I accept that the winter plan was never designed to be, or going to be, a panacea for all these issues. I hoped it would provide some solutions and comfort to the people of Limerick. Unfortunately, it seems my reasonable expectations were overly optimistic. As my colleagues said, we were not presented with a plan but with a fantasy list. The Minister knows, or at least should know, the difficulties faced by University Hospital Limerick. I have spoken about them here often enough and he is well aware of them. We are presented with offers and no remedies. What this plan offers is clearly inadequate. It is inadequate in terms of its ambition to increase the number of beds and, most important, in terms of targets to increase the number of staff needed to deliver appropriate care through the winter.

The plan aims to improve patient experience times in emergency departments and reduce trolley numbers by 30% compared with the winter of 2019. These are good ambitions but, quite frankly, the resources needed are not committed to. The plan proposes to open an additional 251 acute beds and 89 sub-acute beds in quarter 4 of 2020, and a further 232 acute beds in quarter 1 of 2021. I welcome any increase in available beds but I wonder whether the targets can be met. There are hundreds of unfilled vacancies across the health service. I am aware, from speaking to nurses recently, that there are a large number of vacancies in University Hospital Limerick. Without filling these positions, the new beds promised cannot be opened. There is construction in Limerick but there seems to be no real plan to make sure the facility will be equipped properly when the beds are in operation. The plan does not show enough ambition.

Sinn Féin's health plan, Better for Health, is ambitious. It would require significant and sustained public investment but would deliver results, not short-term achievements of metrics. It would result in a long-term commitment to move from a two-tier public-private health system to a universal healthcare system. Our plan targets the delivery of 1,100 additional acute and sub-acute beds and 50 ICU beds.

I have a difficulty with what is in the Government's plan and with the question of whether it can be delivered, but I wish to highlight what is not in it, that is, a commitment on mental health. In fact, not only does the plan not make any commitments on this important issue, it does not even refer to it. Mental health services have been chronically neglected for years. The winter plan is meant to be a short-term tactical plan but it is outrageous that mental health is absent from it. The Minister will be well aware that Deputies of all parties have raised their concerns over the number of mental health issues and suicide levels caused by Covid. Funding and resources for mental health are critical in my city, Limerick. The Covid committee has heard expert opinion and anticipates an increase in the number of mental illness cases due to the stress of Covid but there is no plan for this. Throughout the country, there are some wonderful mental health organisations that for far too long have been carrying a burden that the Minister’s Department should be helping with. I commend them on their often unseen and unreported work. The Minister and his Department have a responsibility in this matter.

There is no reference to disability services and no funding allocated for this year to kick-start cancer services that I can see. The Minister mentioned funding for 2021. I welcome the community specialist teams, however. This is a good idea. If this initiative is used correctly, it could support older people and help manage conditions outside the hospital setting. Visiting a hospital is daunting enough at any age but this is especially true with the added concerns about Covid-19 transmission.

I am deeply concerned about what will happen in University Hospital Limerick, especially the emergency department, over the winter. If I were to grade the Minister's plan, I would give him a low C but I am sure the algorithm of his colleague, the Minister for Education and Skills, Deputy Foley, would reduce this mark further.

There is no doubting that the headline figure for the winter plan, €600 million, is very substantial and dwarfs any amount set aside in previous winter plans. It requires and deserves further scrutiny, however. The small print indicates that only one-third of the amount is to be spent in the current year and potentially two-thirds - the funding has not been secured yet - will require agreement in the budgetary process. Theoretically, just one third of the amount is to be available for spending this year. A lot of digging down has to be done into the details of the figure. It includes expenditure on many services that have been put in place in recent months. Therefore, there will not be new services to the net value of €200 million this year.

On a very positive front, I very much welcome the considerable allocation made for home care. Many of us have been looking for that for years. It makes absolute sense. It should have happened long before now. The amount provided, as I understand it, will address the needs of the 6,000 people at home who have been approved for home care but who have been on a waiting list. Those people, in the main, are in very vulnerable circumstances. They may be on their own or infirm and they desperately need care. I hope all the waiting lists can be cleared with the allocation made. I hope it will ensure that, in so far as it is possible, they will not end up hospital or nursing homes. That is all the allocation will do, however. It will not cater for new people who require care. A very considerable number who are ready to be discharged home from hospital need to be catered for also. These are the two separate groups.

In the time remaining, I wish to concentrate on what I believe to be glaring omissions. Three points arise: the lack of any provision at all for mental health services, the lack of any provision for disability services, and the wholly inadequate position on ICU beds.

With regard to mental health services, many of us have been talking in recent months and years about the underlying underinvestment in mental health services. There are long waiting lists for children, in particular, and adults. I provided the figures here a couple of weeks ago. Thousands of children are on waiting lists for community services, whether child and adolescent mental health services, CAMHS, or community psychological services. That was the situation before Covid. We are aware that A Vision for Change was not funded adequately. There has been a shortfall of €50 million in funding in recent years for the implementation of A Vision for Change. Sharing the Vision has finally been published, and it has a price tag attached to it. It has not been provided for in the winter plan.

That was the pre-Covid position. With Covid, it is significantly worse. We heard the very good contribution of Deputy Lahart, who very eloquently described the circumstances in which people find themselves as a result of the major psychological impact of Covid. Isolation, depression, anxiety, grief and loss are all taking a very significant psychological toll. More than ever, we need to put in place significant funding to address the major mental health problem we are storing up, which is at the point of exploding. Most Members of this House have referred to it as a crisis coming down the tracks very quickly owing to inadequate services. It is just shocking that no provision was made for mental health services in the winter plan. I cannot understand it. I cannot understand what the Minister has been doing, nor can I understand what the Minister of State has been doing. It is deeply disappointing. I urge the Minister to make this a priority in the budget in a couple of weeks.

There is a major omission in respect of disability services. There is no mention of these in the winter plan. There was an announcement of €10 million last Sunday but the Minister knows that falls very far short of what is required.

We now have a situation where large numbers of family carers are looking after their loved ones at home because many services closed during Covid. At this point, some of them are opening, but only gradually and for approximately one day per week or, at most, two days per week. There is a huge level of need in this area. There are 1,250 primary carers over the age of 70 caring at home for somebody with an intellectual disability, 400 of whom are carers aged 80 or more. This is shocking and it has been going on now for over six months and is taking a huge toll on people. Many children with disabilities for whom timely services are essential in order to meet their milestones are being denied access to essential therapies that should be provided at community level, including speech and language therapy, physiotherapy and so on. Many respite services are closed or severely restricted. People with intellectual disabilities are experiencing severe mental health challenges as they struggle to cope in the current circumstances.

The Minister is aware of the cost of addressing the huge gaps in services. He is also aware of the cost of putting in place the additional services that are required as a result of Covid and meeting all of the requirements under public health advice. What he provided last Sunday was a small fraction of that cost. It is not good enough. These are the most vulnerable citizens and they must be catered for and looked after in the upcoming budget.

On intensive care beds, we knew pre-Covid that we were hugely underprovided in this area. We had less than half the recommended number according to European standards. There has been some small number of additional ICU beds provided. The fear last March was around the low level of ICU beds. We had so much catching up to do. What is provided for in this plan in terms of net additional beds is 17. Inclusive of all that is funded under the winter plan, we are still more than 200 beds short of the pre-Covid requirement. I put it to the Minister that this is hopeless.

The next contributor is Deputy Murnane O'Connor, who is sharing time with Deputy Alan Farrell.

I welcome the Minister. The winter plan seeks, in part, to protect services and patient care delivery. I am concerned about the lack of services in the community for those in need of palliative care. Palliative care teams are fantastic but there is not enough of them. People could die without this care because of under-resourced services. This winter more people will die but we cannot allow their families to spend precious last days fighting for care for their loved ones. It is imperative that the Minister properly staffs this resource. We cannot have a family sharing a palliative care team with another family and have one patient die while the team is attending the other patient. This happened in my constituency this week. The family concerned was devastated. I have been working with them since. No family should have that experience because of a lack of resources.

Today marks the beginning of breast cancer awareness month. When will breast screening services resume? I have been told that there is a waiting list of 12 to 14 weeks. While cancer can in some cases be slow to move, anxiety is not. Patients were not able to access screening because of Covid and in some cases they were too afraid to discuss their symptoms with their GPs or they could not access a GP because of Covid. Adding to their anxiety by extending waiting times is not acceptable. I know that this is a priority area for the Minister and I ask that he provide me with an update on it.

I want to comment on the current restrictions in Dublin and Donegal. I think restrictions might be imposed on more counties soon on the basis of the current figures. As things stand today, will restrictions have an impact on services in counties? In other words, if restrictions are imposed on more counties will services be affected? Will people be told to not attend services?

I also want to speak about the impact of Covid-19 on our mental health services. It concerns me that this pandemic exposes the huge gaps in our services. Many more people are seeking to access supports during this difficult time. We know that our mental health system was under serious pressure prior to the pandemic and it is even more stretched now. Our communities are in dire need of funding to support them through this tough time. Mental Health Reform, the national coalition of 70 plus different organisations, launched its pre-budget submission seeking an increase in staffed mental health services, the development of an out-of-hours crisis service to give people quick and easy access to services, investment in primary care mental health and talk therapy to enable prevention and early intervention, support for the community and voluntary sector to continue providing essential mental services , investment in individual placements and support to help people get back to work. We need to resource these services.

Earlier, the Minister spoke about the excellent work being done by our paramedics. I compliment the service in Carlow. We have excellent paramedics who are going to houses to carry out testing. We are two or three days behind. I raised the following issue at the recent meeting of the Covid committee but it is important to raise it again now. For three years now, I have been raising the Department's promised investment of €350,000 for a building to house this service. Currently, it is housed in a prefab with one shower to cater for a number of paramedics. It is important that funding is provided.

My other concern is in regard to staffing in general. It is brilliant to have ambition for the plan. I believe this winter plan is ambitious but I have concerns. Who will staff these beds? How will those staff be paid? Will our student nurses be paid, as our student doctors are paid? How will we pay for these resources in the middle of the pandemic? Are we represented on the national doctors training and planning, NDTP, medical workforce speciality review specific to each area of medicine in Ireland? I am conscious of glaring gaps in our medical workforce. For example, in the south west for a population of over 500,000 there are only 2.4 public health specialists, which is not near enough. I welcome the announcement yesterday that 250 more specialists are to come on stream nationwide. Is the HSE actively recruiting and to what areas will staff be deployed? It is important we know this.

I welcome the €138 million for home care supports and additional hours. I know the Minister of State, Deputy Butler, has been working hard on this provision. I welcome that provision. It is so important. When will the funding be made available and will the Minister of State provide a breakdown of the allocations, in particular for CHO5, which is my area? I also welcome the ten new dementia advisers. When will these jobs be taken up and, again, will any of them be deployed to CHO5?

This is a €600 million plan. We have to welcome it. How we use that money is important. I know from interactions with the Ministers of State, Deputies Butler and Rabbitte, in regard to disability services that a lot of services will get funding, although I note it was mentioned earlier there is nothing much in the plan in regard to disability services.

The flu vaccine was mentioned. We will be living with Covid for a long time and we are heading into the winter, which will be a difficult time for young and old. We are living in a different world. We will probably never see anything like this again in terms of the recession and the changing times. Families are trying to watch out for each other and people are afraid to go outside in case they catch the virus and pass it on to someone else. We have to be careful. Do we have enough flu vaccine and, if not, do we have a plan if we run out of it?

I welcome this debate. As we are all acutely aware, 2020 has presented a monumental challenge for our health services. We have demanded huge sacrifices from our nurses, doctors, paramedics and all of the staff who keep our hospitals and all medical facilities running safely every day. This winter, unfortunately, promises to present even more challenges for our health infrastructure and front-line staff. It is imperative that we prepare in the right way to ensure we have the ability and capability to deal effectively with the obstacles that we will be faced with in the months ahead.

Members of this House will be acutely aware that Covid-19 will remain with us for some time. We will likely see spikes in infection and hospitalisations. We know also that during the pandemic other illnesses do not cease. People still require hospitalisation for a myriad of conditions and we must have adequate resources in place to manage these risks and prevent our health services being stretched insofar as we can. I am pleased that we have a commitment to a significant increase in spending, staff and beds. These will be much needed as our front-line staff endure what is no doubt going to be a difficult winter.

As we continue our fight against Covid-19 in the months ahead, testing will become an important feature for us to understand the direction in which the virus is heading. We must remain ambitious in this endeavour and put in place operational capacity to avoid the development of backlogs and other associated pitfalls. In the early stages of the pandemic there was a large reduction in the number of people attending emergency departments, as has been mentioned during this debate. There have also been reductions in the number of people presenting with other non-Covid related illnesses for fear of contracting the virus. We do not yet know the full extent of the ramifications this will have for the long-term health of the population. Successfully overcoming many conditions requires timely intervention. Providing confidence to the public will be an important feature of avoiding a repeat of this situation, along with the implementation of improved access to healthcare through technology, remote clinics and improved community care, which will be greatly appreciated in my constituency of Dublin Fingal and is included in the winter plan.

It is also vital that there is a significant take-up of the winter flu vaccine, as my colleague just mentioned. Historically, we struggled to have large take-up of the vaccine, even among healthcare professionals. This year, however, there is an obvious need for maximum engagement. The expansion of free access to the vaccine was a very positive step in this regard. As the vaccine is available now, we must encourage as many people as possible to get it, through information and communication campaigns across all media platforms. By doing so, we will avoid the potential for increased pressure on the health services as a result of a bad winter flu season.

I wish to refer to a comment made by Deputy Shortall in a previous debate on a previous day when she spoke about the need for political parties and none to engage collectively in promoting the message of engaging with the health services for ailments that might be worrying people. She referred to influencers and the like. There should be some unity of purpose in the House in terms of the political leadership that is shown to promote the uptake of a winter flu vaccine by collectively messaging the public. Perhaps it could be through a single video to show the unity of purpose of this House and the Seanad. It could also relate to the messaging on Covid-19. It is worthy of our consideration. Success in respect of the availability of the winter flu vaccine may also enhance our ability to encourage take-up of the Covid vaccine, should one be developed and approved for use in the near future. This afternoon, RTÉ published a poll showing that 32% of people expressed an unwillingness to take up the first vaccine for Covid when it becomes available and a further 12% were unsure if they would take up the vaccine.

The winter plan, correctly, focuses on protecting as many vulnerable people as possible. This is the challenge for all of us. We must come together as a nation to protect vulnerable people, their families and friends, our neighbours and even strangers we may never meet. We will survive the pandemic due to the individual sacrifices of people. The Irish people are ready and willing to protect these people again. It is our job to ensure we can provide a strong and capable health service that will have the ability to cater for the demands of this winter and, indeed, repay the sacrifice of front-line workers who are at the coalface each day.

At this point we all accept that the period of time we are dealing with is at least six to nine months. A number of Members mentioned the necessity for test, trace and isolate capacity. I reiterate that somebody must examine areas such as Dundalk and north County Louth, which has problems at present with an increase in cases. However, the test centre is moving to Ardee. That must be examined. In fairness, Deputy Munster has been strongly urging that Drogheda also needs a test centre. These are two major urban areas.

Members referred to the flu vaccine. We must ensure we have the stocks and the capacity. This must happen because otherwise we will create a pile of problems for ourselves.

A number of Members have said that the plan has stop-gap fixes and spoke about the need for more long-term planning, particularly on delivering ICU bed capacity. I hope some of their questions will be answered, be it by the Minister of State, Deputy Butler, or the Minister, Deputy Stephen Donnelly.

I wish to deal with a number of issues regarding non-Covid care. I previously raised the dental treatment services scheme, DTSS. I have been contacted by a number of people who use these services and also use intellectual disability services. There are far fewer dental practitioners using the scheme at present. It is a difficulty for anybody who has a medical card. It requires action and a delivery plan because there does not appear to be a solution at present. We have all heard the horror stories about children in very bad circumstances.

Today, one of my colleagues raised the fact that St. John of God Community Services says it will cease its involvement in the provision of community services by 1 October 2021. It currently provides intellectual, disability and mental health services to more than 8,000 children, adolescents and adults and employs 3,000 staff and volunteers in 300 locations across Dublin, Kildare, Kerry, Wicklow, Meath and Louth. A large number of people will be impacted, including workers. Families are incredibly worried about whether the service provision will happen. We must get some type of solution. I am thinking of the families, the service users and the workers in places such Drumcar and the St. John of God Venegas Centre in Dundalk. Perhaps we could get an answer regarding a plan.

Like many Members, I am worried that this plan does not deal with mental health services. I spoke to the Ministers of State, Deputies Rabbitte and Butler, earlier this week about a number of cases of County Louth that are incredibly important and which will require a follow-up meeting with mental health services in the county. Perhaps the Minister of State would be good enough to meet some of the families to hear about their issues, because it is an ongoing situation and we need to provide some clarity on protocols and a solution that facilitates a service that people deserve. I would be grateful if that could happen as quickly as possible.

I am also curious about another issue relating to St. John of God Community Services. I understand that a system had been set up whereby a portal was to be opened and services were to put in their requests for what they would require to operate in the present circumstances. While I accept that, at times, not every request will be delivered, I am confused about how we went from that to a situation where St. John of God Community Services is saying it is ceasing operations. There should be clarity about that as soon as possible.

As this is my last opportunity to speak in the House this week, I welcome the fact that the European Commission has taken legal action against the British Government due to its illegal action with the Internal Market Bill, which is endangering the Irish protocol, the withdrawal agreement, the Good Friday Agreement and business, society and life across Ireland.

You are wandering outside the remit of the subject matter.

It is his last time to speak this evening.

Unless I get speaking time from another Member.

The Deputy has clocked up a fair few minutes already. I call Deputy Bríd Smith.

We are all acutely aware that there is great fear across the country of the months ahead, the growing number of Covid cases and the dangers many people are facing in the coming period. The conflicting advice, confused rules and regulations and lack of clarity about what needs to be done and what we are doing from the Government are feeding into that fear.

In this context, I would love to be able to say something positive about the announced winter plan. I am afraid I cannot because those at the front line of the health service, our nurses, doctors and consultants, have made it clear that this plan is not addressing the crisis. We could say it is a sticking plaster but in reality it is more akin to a policy of saying a prayer and hoping for the best. It is said that Covid-19 is ruthless in seeking out the most vulnerable, those with underlying conditions or with a fragility. That is one reason the fear in this country is so high. We have over 1 million citizens with underlying conditions and their families and loved ones are also in fear. This pandemic is also ruthless in exposing the weaknesses and underlying conditions in our economic, social and health systems. When this crisis started last March, the then Minister for Health acknowledged that a two-tier, dysfunctional health system was not fit for purpose in dealing with a pandemic. He gave us the impression that the Government was gone all socialist and was going to provide a one-tier system based on need and not on the ability to pay. It is now clear that no such policy was ever planned. Even as the virus ploughs ahead, we remain committed to a two-tier health system. The winter plan will see us repeat temporary purchasing at very high prices from the private sector with no vision of the permanent capacity increase that we need. Of the 1,500 new beds announced as part of the winter plan, which is to cover us from now until April, there seem to be only 528 actual new beds. Will the Minister of State confirm that or is it more PR spin that the Government thinks will fool the virus?

That lack of real vision of a plan to fundamentally change the system is another reason people have real fears. We must compare these details with what the front-line workers are saying. The Irish Hospital Consultants Association says we need an extra 2,000 inpatient beds at a minimum and has called for a doubling of ICU beds. We are getting an extra 17. The INMO has pointed out that many of the 300 beds opened under last year's winter initiative are now closed due to staff shortages. If we cannot keep beds open from last year because of staff shortages - one hospital in the east has 400 nursing vacancies - how in the hell can we be confident that we will staff this plan? In a pandemic crisis such as this we need emergency steps. We need to take over the private hospitals, end agency staffing and bring workers into the HSE in a permanent capacity on permanent contracts to end this two-tier system and to show everybody that we are indeed all in this together and that there is real social solidarity.

Last week it was announced that Tallaght hospital has had to cancel elective surgeries and close operating theatres due to the second wave of Covid and the major threat it poses to our entire health service. This comes on top of the closure of Tallaght hospital's children's accident and emergency department and its rushed downgrade last month. Decades of Government neglect mean our hospitals have a serious underlying condition, namely underfunding. Thousands of hospital beds have been closed. Pleas for more staff have been ignored. The result is that we have a health service that struggles to cope. Winter is coming and our health staff and hospitals need urgent support. We also must learn the lessons of this crisis and vow to reverse the decades of neglect which Deputy Bríd Smith has spoken about, the entrenched two-tier system which is further and further entrenched, and instead build a one-tier, quality national health service in Ireland. Tallaght hospital needs immediate relief but it also needs long-term investment.

It is shameful that mental health services have been completely forgotten in the Government's winter plan. Not a single cent has been set aside in this plan for mental health services. Even before the pandemic, we had massive backlogs and waiting lists for basic mental health services and supports. The Covid crisis has made it much worse. As well as the extra stresses and strains on people resulting in a significant increase in referrals to mental health supports, we have also seen the suspension and delaying of many of those supports. We need emergency funding for mental health services. We need to be investing in remote psychotherapy and counselling services for those in need and supporting our mental health services.

It struck me in the course of the last week with the extra round of announcements of advisers for junior ministers that the Government now employs 64 special political advisers but only 60 specialist public health doctors. It is a Government that has more spin doctors than public health doctors. In the midst of a global pandemic, the Government is finally talking about investing in public health but we need urgent action here. We need significant investment in tracking and tracing in particular. Despite all of the Government's spin, the reality is that Ireland is still testing at about half the rate of similar sized countries like Denmark. We are still not testing many close contacts such as those in schools. We need to invest in public health, testing and tracing as part of a strategy to crush the curve and to eliminate community transmission. Otherwise we will be caught on a merry-go-round of outbreaks and lockdowns which will continue to disrupt people's lives and our society over the course of the next year.

I am sharing time with Deputy Christopher O'Sullivan. I welcome the Government's decision to invest an additional €600 million in health services this winter. Healthcare workers the length and breadth of the country have worked tirelessly throughout this pandemic and we are going to ask even more of them in the coming months. This investment will go some way towards supporting them as they care for their patients. The plan provides more hospital and community beds and significantly increased homecare support. Some 34 new beds are to be opened at Cork University Hospital under this plan and additional beds are also due to be opened at Mercy University Hospital. While this is a welcome and much-needed measure, any extra capacity also requires extra staffing. I note that the INMO general secretary, Phil Ní Sheaghdha, has expressed concern about the lack of detail around the staff planning arrangements. The success of this plan will be contingent on the recruitment of additional staff. I would like to ask the Minister of State whether her Department could provide further clarity or detail on how the HSE intends to recruit the 12,500 additional staff to provide this care. A constituent of mine was due to undergo an assessment in hospital recently but the doctor carrying out the assessment was deployed elsewhere as a result of Covid-19. A few months later another doctor was assigned. It is my understanding that a few assessments resumed but were halted again in recent weeks due to the increase in cases. I would be hopeful that the Minister could put in place a significant and detailed staffing plan to avoid incidents like this over the coming months. We are all too aware that waiting lists are at record levels and Covid-19 is affecting the overall capacity of the system. I have been contacted by many constituents expressing concern that their elective procedures may be cancelled. The winter plan is estimating some 10,000 outpatient appointments, 2,879 inpatient procedures, nearly 18,000 day case procedures and nearly 3,000 gastrointestinal scopes. I ask the Minister of State to do everything possible to ensure these procedures go ahead.

Cancer services have been mentioned by a number of Members this evening. I ask that the Minister of State ensure that reduced cancer services do not become the new norm in Ireland as the Covid-19 pandemic continues. Cancer patients need to be diagnosed and treated at the earliest opportunity. I ask the Minister of State to commit the necessary funding to cancer services. As we are all well aware, the three screening services, BreastCheck, BowelScreen and CervicalCheck were cancelled in March. CervicalCheck reopened in July and BowelScreen in August. I would be grateful if the Minister of State could provide confirmation of when BreastCheck will reopen. In respect of all three screening services, I ask that a huge effort is made to ensure that screening and cancer test backlogs are cleared as early as possible.

I welcome the €10 million that was made available to disability services last week by the Minister of State, Deputy Rabbitte. She met a number of groups in Cork in the past few months including Cope Foundation and various others. It needs to be acknowledged that the additional funding will make a big difference to day services not just in Cork but around the country.

I was listening to the debate from my office before I came down and wish to respond to some of the adjectives that were used by members of the Opposition. We are not even in the middle of winter yet. People are calling for unity on one stage. I do not think it is the time for ideological battles.

There are Members on this side of the House who believe in ending a two-tier service in healthcare. I do not believe now, in the middle of a pandemic, is the time to be talking about ideological differences. We are facing what will probably be the worst winter in our history in terms of healthcare provision and the people need to get behind the Department of Health, the Minister for Health and the various Ministers of State who have a very difficult task ahead. As I said, I was baffled by some of the adjectives used, such as "underwhelming", "fantasy list", "lacking ambition" and "a failure". It is a failure and it has not even started. We all knowledge there are difficulties in the Department of Health and in healthcare provision in this country. In the middle of a pandemic, however, and facing the worst winter we are likely to face in terms of flu and with Covid-19, the people need to get off the stage and get behind the health services and the Ministers.

I am here behind the Minister but I have his back, so it is okay. He need not worry. I very much welcome the plan. It is unprecedented in scale and funding of €600 million. We have never seen the likes of it previously for a winter plan. Clearly, the Minister's fingerprints are all over it with, I believe, close to five million hours of home care. That is huge and it is significant. It is something previous Governments and previous Members, including Opposition leaders, have been calling for consistently, and that is something we will deliver on. I congratulate the Minister on that because it will make a huge difference to families, to communities and, most importantly, to the elderly people who this was intended to help. I congratulate him on that and fair play to him. He came into this role with a lot of passion and fair play to him for fighting for that allocation. It is incredibly important.

Of course, the winter plan was never going to be all-encompassing. There were elements that all of us, Government Members as well, would like to have seen included. Perhaps, therefore, the following could be seen as much as a budget plea as a plea to have it included in the winter plan and that it could be included in aspects of the health budget.

The first topic I wish to touch on is disability services. I appreciate from the announcement that the Minister of State, Deputy Rabbitte, fought tooth and nail for funding towards disability services. She managed to secure €10 million in conjunction with the Minister, Deputy Donnelly. Unfortunately, in terms of the overall scale and the overall picture for disability services, it is only the tip of the iceberg and only scratches the surface. The truth of the matter is that because of chronic underfunding in previous years, the reality is that disability services need a budget of in or around €100 million to bring them up to an absolute acceptable standard. That is just the reality. While I appreciate that €10 million will go some way towards that, we certainly need more allocated towards disability services.

I am aware that the Minister of State, Deputy Rabbitte, was briefed by the National Federation of Voluntary Service Providers during the week. I believe the picture and the story the representatives painted for her was pretty bleak and told a story of where we are at. There are approximately 26,000 users within the National Federation of Voluntary Service Providers. Of that figure, for 400 of the families the main carer is in his or her 80s. I believe it was alluded to earlier in the House. That has massive implications. Obviously, because the carer is elderly, it completely limits the amount of services the actual service user, which is a child in this situation, can avail of. That is worrying. Obviously, the person cannot go out into the community because of the fear of the elderly carer contracting coronavirus, which we know is devastating for people in their 80s and upwards.

A further non-Covid related issue is the fact that many of these children and servicer users are well into their 40s, 50s and 60s. There is a fear and anxiety that goes with the fact that their parents and main carers are becoming elderly and there is no service coming in to replace that. That is a pretty stark reality. There are some users with primary carers in their 90s, so it is pretty stark. That goes further, because another group is coming up behind where the main carers are in their 60s. Unless we put the residential care facilities and day care facilities in place, there will be serious concern and anxiety and those vulnerable groups will be left exposed.

Services obviously have had to be greatly reduced during Covid-19. They are only running at approximately 40% capacity from what I can gather. I know first-hand of a fantastic voluntary service provider in west Cork called CoAction West Cork, and I have spoken to the Minister about this previously. It is fantastic and I have seen first-hand the difference it makes for its service users. The interaction between the staff and the service users is phenomenal. Obviously, over the past six or seven months there has been an absolute void and it has been running at a very reduced capacity. That will have an impact going forward. With that said, to make the disability service sector work properly, it needs significantly more funding, and budget 2021 is an opportunity to do that.

Another aspect of health that could have been more strongly represented in the winter plan, but again this can be taken as a budgetary plea, is the whole area of mental health, which has been touched on a lot here. Historically, it has been chronically underfunded but now, for the first time, perhaps, in the past five or six years we have started to open up and talk about mental health and our own mental health experiences within the family and the community. That is important. However, that conversation exposes the fact that the whole service has been chronically underfunded. As a Government, we now need to step in and address that because so many families and people nationwide are impacted by this. That has been stressed all day in the Chamber during this debate.

I must make a plea for Bantry General Hospital in my constituency of west Cork. I have spoken to the Minister, Deputy Donnelly, on several occasions about this and he is well aware of it. I wish, however, to make this plea in the Dáil. There is a 24-hour acute emergency access service in Bantry hospital at the moment. It is vitally important when one thinks about the geographical nature of west Cork and how big it is. The journey from somewhere like Castletownbere to Cork University Hospital takes hours, so Bantry provides a really important service. There is 24-hour acute emergency access there at the moment. That is underpinned by the provision of an anaesthetist but we need support anaesthesiology there to ensure the service remains. The Minister, Deputy Donnelly, is aware of it but I wanted to take this opportunity to highlight it in the Dáil Chamber.

A previous speaker from the Fianna Fáil Party suggested that we should all put our differences aside and simply get behind our health services and the Ministers. I would like nothing more than to do that. It is very difficult, however, to just simply get behind our Minister and our health services when dealing daily, as I do and, I am sure, as other Members do, with sectoral interests, people who are at the coalface and people who are in need of services and treatment, none more so than those reliant on our disability services.

The failure of the Minister to include additional funding resources or investment provisions for disability and dementia services in the winter plan is astounding. His subsequent announcement of a meagre €10 million for disability day services and home support six months into the pandemic has been met with shock and dismay by the sector. To say it falls short of the urgent needs of the 643,133 people with disabilities in the State today is an understatement of the highest order.

Disability services, as the Minister will be aware, submitted their Covid-related costs to the HSE in June, so the Minister knows that the moneys that were announced on Monday past are just a fraction of the funding needed to deliver services. I should not have to remind the Minister of his Government's commitment under the UN Convention on the Rights of Persons with Disabilities. I cannot overstate the personal toll and long-term impact of the withdrawal of care and supports for people with disabilities, their families and carers. I am calling and pleading again on the Minister of State, Deputy Butler, and the Minister, Deputy Donnelly, to address the funding crisis for disability services in budget 2021 and to bring their funding resources and capital investment needs on a sustainable footing going forward.

On that note, I wish to raise this issue again with the Minister, because every time I try, unfortunately, for one reason or another, I cannot eyeball him across this Chamber, the issue of the group home for people with disabilities in Carrickmacross. This group home was accepted as a very important resource that was warranted back the early 2000s.

From that point on the families of the people who will reside in this group home had to fight tooth and nail every step of the way.

The building was finally completed in 2016 and then disgracefully and remarkably the HSE announced it had no money to run it. Every year we have been told that it will be considered for the following year's Estimates. Unfortunately, at a political level during the terms of several Ministers, the response has been to say that this is a HSE matter. I ask the Minister of State to bring this message once again to the Minister, Deputy Donnelly. This is a political issue and we need political accountability. I ask the Minister of State to ensure that the Minister, Deputy Donnelly, responds to my request. He should bring together the relevant officials in his Department and in the HSE along with representatives of any other bodies involved, such as the Respond housing agency, Monaghan County Council and whoever needs to be brought around a table to resolve this issue. These are young adults with very profound physical and sensory disabilities. Their needs have been assessed and the health services have decided that they are best placed in the long term in this group home.

The group home, which is finished, is a fine building. It needs a few bits and pieces to be changed, but it is essentially ready to become operational. Unfortunately, the HSE has decided that its operation will be outsourced to a private company if it can get somebody to tender for it, which is incredibly disappointing because there was no reference to that before the building was completed.

I ask the Minister of State to ask the Minister, Deputy Donnelly, to convene that round-table meeting as I have suggested, after which I will be the first to commend the Minister and get, as the Minister of State's Fianna Fáil colleague asked us to do, behind the Minister and the health services because we want the winter plan to work. Those at the coalface of the disability services need the cash, the resources and the infrastructure to do it. A key part of that infrastructure in the south Monaghan and surrounding area is the group home in Carrickmacross. I again plead with the Minister of State to ensure it becomes operational without delay.

I want to put on record my support for any measures that will help beat this virus. The Government plan is framed under a number of headings including: building capacity; service continuity; pathways to care; PPE; testing and contact tracing; public health; and e-health.

I agree that we need to address the building capacity in the current climate. The proposal to open an additional 251 acute beds and 89 acute beds from now until December and a further 232 acute beds in the first quarter of 2021 is to be welcomed and supported. It is stated in the plan that we can increase efficiency levels by 30% to 40% through new ways of working. If this can be achieved it will be welcome, but I would be interested to know how exactly this efficiency can be achieved and if successful why it has not been implemented prior to this. I welcome the that intermediate care capacity is to be expanded.

One of the measures being undertaken is the repurposing of some centres through refurbishments and extensions. I ask the Minister to expand on this and give a timeline for these measures. I am concerned that we need the measures now and when I hear that extensions and refurbishments are involved, I fear that these will be drawn out and not delivered on time. However, I welcome the plan for an additional 530 new rehabilitation beds to be operational by April 2021.

I note also that the HSE will once again enter into an arrangement with private hospitals should a surge in Covid cases happen. Again, I would be concerned at the costs involved. Can we be sure that we are getting full value for money? With regard to the service continuity section of the plan, I note that a restoration of services in the community is necessary for the continuation of support of people in maintaining health and well-being and to avoid activity being directed to acute settings.

As the Minister knows I have constantly advocated for the restoration of services to Louth County Hospital in Dundalk. The hospital in Dundalk is a fantastic facility and needs to be supported. Now is the perfect opportunity to increase the services at the hospital with this winter plan. Furthermore, any investment in the hospital is a long-term investment and not just for the winter season.

The Louth County Hospital in Dundalk has the potential to make a real difference to the north east. It can act as a real support to Our Lady of Lourdes Hospital in Drogheda, which as we know has suffered from capacity issues in the past. The investment at the Louth County Hospital will show real results immediately. I once more urge the Minister to consider the potential of the Louth County Hospital to make a real difference in this current crisis. I invite him to visit the hospital and see for himself the real difference it can make.

I note from the pathways to care section of the plan that it is planned to have a total of 20 hubs available from the period January to April 2021 and I welcome this. However, I am concerned that it is anticipated that only 70% of pre-Covid-19 productivity can be achieved with regard to emergency department pathways for non-Covid presentation. We must be aiming for 100% and more.

Unfortunately waiting lists have now reached record numbers standing now at 704,000 in total. This is unacceptable and must be properly addressed.

Cancer treatment services have also been reduced during the Covid crisis. While I understand the pressures that were placed on the health services, it is simply not right that those requiring cancer treatment or diagnosis were left untreated. This cannot be allowed continue. We must prioritise those who require urgent treatment. Cancer treatment must not suffer.

The plan notes that many centres are now struggling to deliver pre-Covid levels of service and this needs to be addressed as a matter of urgency. The plan contains many proposals, but we need real action now.

In the section on PPE, testing and contact tracing, the plan states that the HSE is in the process of developing a sustainable Covid-19 test-and-trace service and that the new service model being developed will strengthen underpinning processes to ensure that the service is sustainable and of a high quality into the winter months and beyond. It also states that the detailed design for the final model is still a work in progress, which is unacceptable. How can a final model still only be a work in progress at this stage?

It is important that the HSE gets value for money in its purchasing of PPE. I am glad to note that this is mentioned in the plan although it only states that the HSE expects to achieve price reductions.

There is little mention of the flu vaccine in the plan other than stating it is to include two to 12 year olds. It is vital that we get the flu vaccine right. Many GPs are complaining that they do not have supplies of the vaccine now. We must not create a new problem with the flu vaccine in our fight with Covid. It is important for the Minister to make a statement on the availability of the flu vaccine and give clarity on the availability now.

I welcome the publication of the winter plan and while I agree with a substantial part of it, it is important that the Minister addresses the issues I have raised today. We need clarity on the value-for-money element of the plan to work with private hospitals, clarity on the continuing treatment for cancer sufferers to ensure that they do not become a victim of this pandemic, clarity on the testing-and-tracing system and why it is still only a work in progress and clarity on the availability on the flu vaccine.

I once more invite the Minister to visit the Louth County Hospital in Dundalk to see for himself the great work that is currently taking place there and the great potential the hospital has for additional services. I have no doubt once he sees the potential of this hospital, he will see how with some investment the Louth County Hospital will once more have the services that people of the north east deserve.

Since the arrival of Covid into our country a clear and present danger has existed not just to the lives of our elderly and vulnerable, but also to the social and economic cohesion of our State. Covid-19 is largely a killer of the elderly and those with underlying medical vulnerabilities. Thankfully our knowledge of dealing with and treating this illness has advanced greatly over the past six months. Despite its dangers, Covid must not be allowed to sideline the many other significant healthcare areas in which patients need support, particularly cancer, trauma, disability, mental health and chronic disease.

The recent Government announcements of increased funding for the winter plan and the overall healthcare sector include the addition of €600 million to fund more front-line staff to develop additional ICU and HDU bed capacity, to provide additional hospital beds and to ramp up to 4.7 million additional home care support hours, which are greatly welcomed. While the funding is welcomed, along with these resources, health service managers must seriously look at how they can reorganise and innovate to deliver increased efficiency in hospital throughput. In our acute care hospitals, the issues of Covid planning pathways must be reviewed with respect to daily case scheduling. We need innovative thinking such as expanding diagnostic services, particularly in scanning and scoping to address the backlog of cancer patients awaiting access to care and treatment. We need increased radiology, diagnostic scoping and biopsies to address the significant waiting times which are emerging in symptomatic and prostate cancer services.

Medical needs extend to my constituency of Waterford, where, as the Minister of State will know, waiting times for diagnostic angiograms have extended up to 12 months again. We must consider the use of the National Treatment Purchase Fund in both public and private hospital settings to support extending these service opportunities. Our first priority must continue to be to secure the health of our elderly, particularly those in residential accommodation. We need to ensure ongoing randomised testing of healthcare workers and strict visitor infection protocols particularly over the winter months.

Rapid diagnostic tests, though shunned by NPHET to date have shown a pathway to increasing random testing elsewhere in the world, and it is to be hoped we will see their use authorised here as soon as possible. The announcement of the additional 700 swabbers and contact tracers is welcome given that is should allow health staff to return to their jobs where they are so badly needed.

The focus in the winter plan on keeping people with physical health needs out of hospital is welcome. However, patients with ongoing mental health and disability issues appear to have been bypassed in the plan as no money has been provided to address their needs or how they can be cared for in the community. This is an area of healthcare that must receive additional priority and allocation of resources. The Government has given us a winter healthcare plan, and although it is extensive in comparison to previous years, the health care needs of our nation have never been greater. We must continue to rely on the truly great legions of healthcare workers in our State who look after our citizens as well as they can. We must persevere in calling all in our community to continue adhering to all of the Covid rules that we have learned in recent months so that, despite intermittent cluster outbreaks and lockdowns as months elapse, we can repair our economy and health services and, it is hoped, steer a path from this global pandemic.

I will make a number of points with respect to the winter plan. First, I welcome the additional funding across a number of areas. The reality is that this must, out of necessity, be a dynamic process as it is responding to a situation that is changing almost daily. However, there are a number of challenges that come with that uncertainty and the need to respond quickly.

I draw attention to those requiring services on a long-standing basis who have found the last number of months incredibly difficult. It is very encouraging that extra funds for homeless supports have been included in the measures. This is an issue that impacts the whole country but is keenly felt in my own constituency. Services were already under pressure from increased numbers in 2019. Dublin Simon Community saw an 18% increase in demand for homeless healthcare services last year and provided access to treatment for more than 1,200 people. There was also an increase in waiting times for access to related services over the previous year. For example, for access to detox services the wait time increased by 84%.

The same organisation has now also warned of a health crisis in the homeless population in the capital due to the pressure on funding and a shortage of suitable accommodation. Covid has brought the entire system for homelessness and addiction supports to the very brink of capacity. I am aware in my own constituency that the constraints of the pandemic mean that many service providers need additional space. They need more sanitation facilities in particular. A lack of facilities has not only impacted the people who need this most basic human right but it also has a knock-on impact in the local community as service providers spill out. I would urge the Minister for Health to consider capital funding and confirmed multi-annual funding for the provision or lease of buildings to those groups to accommodate the increase in need along with the constraints that Covid represents in terms of delivering those services.

Similarly, I very much welcome the inclusion of considerable funding for home care, for community health networks and for GP diagnostics. I am very aware though that Covid has put immense pressure on people's mental health and has had a huge impact on persons with disabilities and their families. I would urge the Minister for Health to consider the long term impact of poor mental health and a lack of disability services within the community and to bear this in mind when making decisions around the budget in the next few days, as the sector needs far more than has been announced or included in the winter plan.

Second, I draw the Minister’s attention to the report this week from the Parliamentary Budget Office on expenditure undertaken this year and its concerns around transparency and accountability. Again, I am aware from my own constituency that private hospitals in many cases provided absolutely vital capacity to the public sector during the Covid-19 crisis and they facilitated the continuation of care in other medical specialties. This was really important and worthwhile. However, the winter plan document outlines that almost 10% of the total winter plan spend of €604 million is going to go to private hospitals. There is, however, scant detail provided on what we are getting for this other than that some of it will be used for elective procedures, which is not in itself a bad idea if it increases capacity in public hospitals, but again we do not really have enough detail. None of it is being used for surge capacity and this would need to be provided separately. If we were going to spend taxpayers’ money with private hospital operators, we need to be clear right now on what exactly we are getting for the amount we are spending and what outcomes we are expecting as a result of that spend.

Covid has changed us and our communities irrevocably, and no winter plan will paper over the cracks of a system that needs reform. The pandemic has been a shock and awe event for our health service. The leadership of clinicians and front-line staff has never been more meaningful or more impactful, and the reality is that our health service for years has focused on servicing the needs of organisations, not always the needs of patients. Covid has allowed us to cut through some of that. We need Sláintecare and we should seize this moment because we need it now. Let us allow our time of adversity also be our moment of clarity. Let us begin the active implementation of Sláintecare. Let us give ourselves a deadline. I think it should be spring 2023. That is 30 months. Let us be ambitious. The NHS in the United Kingdom was established in 1948 at a time when their public finances were in total disarray and the future seemed incredibly challenging and very uncertain. That sounds very familiar to all of us right now but they pushed forward towards their vision of universal health care for everybody and we should push forward with ours.

Sadly, it has been announced this evening that another four people have died of Covid-19. I offer my condolences to their families and to all those that have lost loved ones to Covid-19 here in Ireland.

We have known this winter would be a significant challenge since the Covid-19 pandemic emerged here in March. The pandemic, combined with the flu season, will place enormous challenges on our health service and front-line workers. Pre-Covid, many of our hospitals were already operating at 90-95% capacity. I welcome today's announcement of the €600 million financial commitment made by the Government for this winter plan. In particular, I welcome the plan to provide 892 acute beds with 484 sub-acute beds. The extra capacity will be crucial this winter. The extra 500 isolation beds will provide reassurance that capacity exists if Covid cases continue to increase.

At the heart of the strategy to combat Covid is the strong testing and tracing infrastructure. Extra funding to bring our public health teams to in excess of 3,000 professionals is welcome, as is the commitment to bring the capacity to more than 100,000 test per week. The flu vaccine will be issued to more than 1.5 million people over the coming weeks, starting with front-line workers, schoolchildren and vulnerable members of the community. I welcome innovative plans to allow pharmacists to inoculate people in their cars and other socially distant locations. I am sure all in the House are grateful for the flexibility pharmacists have shown.

I welcome the additional 4.7 million home support hours. People with a disability and the elderly have made huge sacrifices during this pandemic. Many of them lost home care supports during the acute phase of the lockdown in April and May, and this support was gradually reintroduced. Supporting people at home and helping them avoid the need to attend a hospital is critical in this pandemic, particularly as we head into the winter months. The extra support for home help hours is welcome and necessary. Earlier today, we were informed that St. John of God, which provides crucial services not only to my own constituency in Dún Laoghaire but across south Dublin and indeed the rest of the country to more than 8,000 adults and children with disability and their families, would be withdrawing from its HSE contract. The announcement has caused great concern worry in the community, and many people have been in contact with my office today. Covid-19 has been exceptionally difficult for those families, and this is adding an additional stress and strain. I ask the Minister to intervene directly with the HSE. We must ensure continuity of service for this cohort. I hope the Minister can give us assurances this evening.

Deputy Nolan is sharing with Deputy Mattie McGrath.

I wish the Minister of State all the best in her new role. I am sure she will be fantastic in the role because she has been bringing great energy and enthusiasm, so I wish her the very best of luck.

It is vitally important that we have a sufficiently resourced health service, now more than ever. What is of equal if not greater importance, however, is that we have a significantly escalated plan to achieve major increases in staffing levels right across the services and specialties. I made this point recently when I called on the Taoiseach to ensure that sufficient ICU and critical care staff are available to deal with any increase in demand for beds at the Midland Regional Hospital in Tullamore and the Midland Regional Hospital in Portlaoise.

Staff members at the hospital have told me that increasing staff numbers is the core issue that must be addressed. I accept what the plan says about providing 1,500 additional staff at national level but they have to be deployed to areas of most acute need. This debate also highlights how important it is for hospitals and health facilities to be able to engage in future strategic management. Unfortunately, this cannot be said of the Midland Regional Hospital Portlaoise as there is still an absence of clarity on plans for the hospital. In July, I welcomed receipt of confirmation from the Minister, Deputy Donnelly, that he is emphatically committed to securing and further developing the role of Midland Regional Hospital Portlaoise in the Dublin Midlands hospital group. However, it is still a source of significant concern to learn that no decision has yet been made on the draft action plan for Midland Regional Hospital Portlaoise. While I welcome the statement provided by the Minister because at the very least we now have the outline of a real political commitment to the future of the hospital in Portlaoise, we do need further commitments, especially on the status of the appointment of an independent facilitator at the hospital. This is urgently needed if local confidence in the process is to be maintained. What we need to hear from the Minister, Deputy Donnelly, is a substantial level of detail on just what securing and further developing Midland Regional Hospital Portlaoise will mean in real terms. Without that hospital we will not be able to plan for the future and it is affecting the hospital in terms of recruitment of specialist staff and the development of the maternity unit. It is holding up many developments. I hope we will have some resolution and a concrete plan and commitment.

The next issue I want to raise is the absence of mental health facilities and services for children and adults. This is a huge issue throughout the State, which I know the Minister of State is aware of and very passionate about. Services need to be put into Laois and Offaly urgently to try to deal with an escalating situation where people are suffering. The Covid pandemic has not helped and has led to the escalation of many cases.

There is a big hold up in the transfer of cancer patients. I am aware of one man in my constituency who received a shock diagnosis a few months ago. He is still waiting to be transferred to St. James's Hospital in Dublin. He is very concerned as is his family. I would be greatly appreciated if something could be done to curb the delays.

I am very disappointed the Minister for Health is not here. This is the second time today that he has abandoned the Chamber for the later speaking slots. It is no disrespect to the Minister of State and I thank her for coming to Clonmel to see the mental health issues there.

The youth mental health charity, Jigsaw, saw an increase of 50% in demand for its service in August compared to last year. There has been a more than 400% increase in traffic to its online mental health platform over the past six months. Inclusion Ireland, which represents people with intellectual disabilities, has stated day services are running at a rate of 50% of what they were prior to Covid-19. Many people cannot access these services due to transport limitations. This is chronic. It is now crystal clear that mental health needs must be treated as a core element of the response and recovery from the Covid-19 pandemic. It is so unfair on these people. It is all about Covid and all about instilling fear. I said this earlier. The figures need to be explained and the true figures need to be explained. I will not repeat what I said earlier. I ask the Minister of State to insist the figures for self-harm and mental health are collated. The agency stopped collating them in April. We need to know. Why hide them?

The Minister of State's saw St. Michael's unit in Clonmel. Unfortunately, officials have decided not to give us our beds. Since it was closed eight years ago it has been a disaster. We have had more issues and mental health problems. A Vision for Change did not deliver the community response. We need beds in Clonmel. The Department is able to find €700,000 or €800,000 for more beds for Covid. Mention the word "Covid" and money is like confetti or dust falling from the sky. There is no problem. However, the Government cannot look after people's mental health. It is shameful in the extreme. When there are inquiries into this in ten or 15 years' time the fear that the Government, RTÉ and the whole cabal are instilling will be exposed nakedly for what it is with no research. A doctor was sacked last week for speaking out. Dolores Cahill will not be listened to. All those with a contrarian view are all unpatriotic. We are all loony bins. The genie is out of the bottle. Today I quoted figures from Denmark, Hungary and other places. They show they have far fewer issues than we have. They have more borders but our wonderful HSE, which was dysfunctional before this started, is even more dysfunctional now and it is shameful.

St. Bridget's Hospital in Carrick-on-Suir, a wonderful day hospital, which the Minister of State has passed many times, had four hospice beds paid for in the main through fundraising by the people of south Tipperary, west Waterford - the Minister of State's area - and south Kilkenny. It is closed and has been taken off the people because Covid is more important and to hell with the people who need palliative care. They are dying in their homes and they cannot get treatment. It is a shocking indictment of how we have gone down the road like a runaway train with Covid and to hell with cancer patients and stroke victims. One person an hour is dying of cancer and 27 a day are dying of strokes and heart conditions. There are also many other issues growing inside of people's bodies that they are unaware of because they cannot get tests. The Government will be brought to The Hague for war crimes when it is all over because of the abandonment of the people and it is shameful the way they have been treated.

Every time I see or hear the word "Sláintecare" coming from the HSE, the Department of Health or Ministers I become extremely angry because I know, the Minister of State knows and everybody in here knows the Sláintecare report, as a planned approach to achieve a single tier well funded public health service, has been consigned to the shelves to gather dust in the Department of Health. Sláintecare as intended will never be implemented by any Government containing Fianna Fáil or Fine Gael so let us dispense with the pretence.

It would not have taken any great medical expertise to know our public health care system would be overrun by a pandemic of the nature of Covid-19. The lockdown and public compliance with it prevented a catastrophe and we have to recognise that in essence our healthcare system was overrun with the cancellation of many essential services in diagnostics, screening and elective surgery.

All Deputies have received a particular email and I will read from it because it is important with regard to disability services. It is from parents of adults with intellectual disabilities who, since the onset of Covid-19, have struggled with a lack of useful help for them and their adult children. The adult children's day and respite services were drastically cut to the point of being non-existent for most of the time up to September. They had hoped the promised winter plan would start to address some of the issues but instead they find their adult children and themselves once more ignored and neglected. They are bitterly disappointed and join Family Carers Ireland and Inclusion Ireland in expressing their dismay. They state that once again the authorities have let them down and let down the entire disability community. This email is one example and we could all give further quotes from a range of organisations, such as the Irish Cancer Society, urging emergency action. The glaring omission of serious funding for mental health services is hugely disappointing and, as has been said already, I hope it will be addressed seriously in the budget.

Having said that, the measures taken were necessary given the underfunding of the health service over decades. It is also necessary to record the tremendous work carried out under very difficult circumstances by those who work in the public health services, including doctors, nurses, porters, cleaners and all ancillary staff. In this context, a plan that calls for an injection of €600 million over the next six months is to be welcomed, as are the proposals for 570 new beds, 12,500 extra staff, the extension of community assessment hubs and more home help hours. Unfortunately, the €4.76 million for home help will not deal with the issue because many people did not have their home help needs met prior to Covid and they are looking for more hours. There is a huge backlog of people waiting for home help hours. People who were independent prior to Covid now face the need for home help hours. It is a question of having 6,000 new staff to deal with this.

One can only imagine how much better the service would be if the Sláintecare proposals for €600 million a year over five years had actually been implemented over the past three years. It would have made a huge difference.

I thank the Minister of State and wish her good luck in her new job.

Today, we are discussing the HSE winter plan and how it underpins the first pillar of the framework for living with Covid-19. The Minister earlier described the winter plan as ambitious but ambition needs to be underpinned by resources, competence, as well as systems which work collaboratively and efficiently. It also needs to have timelines, not just targets. Within those targets, there need to be specifics and pathways to achieve those specific targets. Unfortunately, I do not see this in the plan which is disappointing.

We must ensure CervicalCheck is fully reinstated and resourced in order that it catches up with those women left behind since March 2020. The waiting time for those who have had their tests and who urgently need biopsies or colposcopies is far too long. I have a constituent who has been told that the waiting time for her urgent cervical biopsy is eight weeks. She is beside herself with anxiety and fear. The service has to be improved.

The winter plan refers to extra beds which is welcome. However, we need to see the specifics, namely, where, when and how. In that context, I want to see real progress on the 42-bed unit for Sligo University Hospital. It has got planning permission and approval in principle. While it is out of the starting blocks, it is painfully slow. If the winter plan is to mean anything, we need to see an ongoing timetable which delivers those beds in the shortest possible time. Four intensive care unit beds are coming to Sligo University Hospital which we are very happy to see.

Every Member has referred to mental health today. I read the plan but there were only two mentions with nothing specific or definite. The GRASP Life, a mental health service foundation in Dromahair, County Leitrim, which services Sligo and Leitrim, recently stated that, during Covid, the number of calls to its service increased by 70%. That is across the board with all kinds of issues. It stated the local county councils and HSE were supportive but its fundraising has dried up. Accordingly, it is caught at both ends. We need to see more supports for mental health. The Minister of State and I know it. People are desperately crying out for these services.

I thank all Deputies who contributed to this important debate today. I welcome the opportunity to make the closing remarks to it. I have taken notes and will pass individual requests back. The suggestions made and the issues raised will be borne in mind as the winter plan is implemented.

I was disappointed that not one Member today welcomed the fact that €830,000 will be spent on ten dementia advisers. I sat on the opposite side of the House for the past four and a half years and I championed the appointment of dementia advisers every week. Up to last year, there were eight dementia advisers in the whole country, meaning getting one could be a postcode lottery. We finally made the breakthrough last year and we managed to get ten more in the budget. To get another ten in the winter plan means we now have 28. The optimum number according to the Alzheimer Society of Ireland is 33. I fought doggedly for the €830,000 to get ten extra dementia advisers. I cannot believe I have been in the Chamber for the past 75 minutes but not one Member mentioned it. Up to 11 people are diagnosed with dementia every day. I chaired the all-party committee on dementia for the past four and a half years. It was a committee at which politics was left at the door. It had members from every single party and none. We all worked together to raise awareness.

As stated by many Members, as well as the Minister for Health, Deputy Donnelly, this winter will be challenging for our health and social care services. It is like a perfect storm. We are heading into the winter. We do not know what is coming. We could have the winter vomiting bug and the winter 'flu. We will have all our usual challenges with capacity, overcrowding and trolley numbers. Coupled with all that, we have Covid.

Last week, I was delighted to launch the HSE winter plan with €600 million funding, 20 times more than what the plan is normally. It is an adequate plan. As I have said many times, the devil is in the detail, however. We will work as hard as we can to ensure those supports are put in place.

We are dealing with a global pandemic which has disrupted the level and the delivery of healthcare since March, while placing significantly increased demands on healthcare staff. I wish to pay tribute to all our healthcare staff and carers who have made such efforts to provide care in such difficult circumstances. I also wish to remember all those, including healthcare workers, who have passed away as a result of Covid-19.

I agree with the sentiments expressed by Members that we need reform. That is why the winter plan is designed in line with Sláintecare principles. We need investment and reform. I take on board the point made by Deputy Joan Collins about the €600 million funding. We need to see more of that if we want to implement Sláintecare.

The €600 million investment in the winter plan represents a significant commitment from the Government which will allow us to commence the process of pivoting care and the required resources towards home and community care. As Minister with responsibility for mental health and older people, I am particularly pleased with the emphasis placed on supports for older people and those groups at greater risk in this plan. This is essential. Older people are more likely to be admitted to an acute hospital following a visit to an emergency department. They are more likely to experience a wait on a hospital trolley. Accordingly, I welcome the additional 47 community specialist teams to support older people and those with chronic disease to stay at home, the 13 additional community assessment hubs, the additional community beds which will allow faster egress from hospital and provide care closer to people’s homes.

This was piloted in University Hospital Waterford last year. Normally, the hospital would have between 20 and 25 beds for people who would be termed as late discharge. A consultant would have deemed them as fit to go home but, unfortunately, there was no place for them to go. Capacity was bought in a nursing home at a cost of €1,000 per bed as against an acute hospital charge of between €6,500 and €7,000 per week. Some of these patients needed respite, others were waiting on home care support packages or on fair deal. They were able to transfer to a nursing home for two to four weeks care, depending on what they needed. Up to 530 of these community beds will be rolled out across the country which should free up capacity in the acute hospital settings.

I especially welcome the 4.76 million additional home care hours which will allow people to remain in their own homes. I welcome the commitment to provide aids and appliances to an additional 5,500 people. Such simple initiatives can make all the difference to an older person. We need to keep our older people at home, safe and secure, with the correct wrap-around supports. There are always waiting lists for those who require home care. However, these extra 4.7 million home care hours should make a big difference. Obviously, there are people on a waiting list or whose needs might have changed during Covid. We want to make sure that the support goes into the home and that somebody does not have to go to an emergency department and wait on a trolley.

It is important to mention nursing homes and the important role they and their staff have played in the care of our most vulnerable older people before the pandemic and, especially, in the last few difficult months. The pandemic bore down very hard on our older people. Unfortunately, 54% of all deaths to date have occurred in the nursing home sector. Our nursing homes are where many of our older people call home and it is critical that we continue our supports to that sector. Our plans for winter will be enhanced by the extension of the temporary assistance payment scheme, which will continue to provide funding to private and voluntary nursing homes and to residential care homes to ensure they are prepared for Covid-19 so they are safe for older people who are transferring out of the hospital system. Enhancements in rehabilitation and home care will also help to ensure that our older people can be cared for in the community, thereby easing the pressure on capacity in nursing homes and providing an alternative care pathway when leaving hospital settings.

I want to touch on mental health because it has been raised by almost every Deputy in the House and it forms a very important part of my remit as Minister. The winter plan, with a focus on those actions which will have an impact on winter, and specifically trolleys, is part of the larger strategic plan which the Government asked the HSE to develop for health service delivery to the end of 2021 in the context of the pandemic. I intend to seek, as part of this strategic plan in the Estimates process, additional resources to implement a number of the short-term recommendations of the mental health policy, Sharing the Vision. It is important for everyone who has spoken today to note that the 4.7 million hours which will be added to the existing 19 million hours that are already there will not differentiate whether one is older or has dementia, a disability or a mental health issue. The carer will not stop at the door and say they are only looking after older people. Those hours are there for everyone: those with mental health issues, those with disability issues, those who are vulnerable, those with dementia and the older generation. It is important to get the point out tonight that those hours are for anybody who needs support in their home. For everyone who has said there was nothing in it for mental health or people with disabilities, those hours will not differentiate. When the carer goes in the front door, he or she will not differentiate whether one has a mental health or disability issue.

The winter plan is about people. It enables patients to be seen in the community and to remain in their own homes. This is the Sláintecare principle of the right care, in the right place, at the right time. However, we have a growing and an ageing population. This Government accepts that we need more acute beds in our hospital system to provide acute care to this growing population. This plan provides for a range of additional beds in acute, sub-acute and community settings along with arrangements to work with private hospitals to deal with urgent cases and waiting lists. I was struck when Deputy Harkin mentioned the four extra ICU beds going to Sligo. Each extra ICU bed needs six nurses and is at a cost of €750,000, so I am delighted Sligo is getting extra capacity. It is great to hear. These additional acute beds and measures to move care to the community will allow hospitals to operate more efficiently and reduce the number of patients receiving care on hospital trolleys.

Finally, I encourage everyone to do their bit to keep themselves healthy this winter by eating well, exercising, getting the flu vaccine, washing their hands, keeping their distance, limiting the number of people they are meeting and following public health guidance. I also encourage everyone to seek medical help if they think they need it. We are doing everything possible to keep our health settings safe for patients and staff.