Ceisteanna ar Sonraíodh Uain Dóibh - Priority Questions

Vaccination Programme

David Cullinane

Question:

80. Deputy David Cullinane asked the Minister for Health if he will address outstanding concerns regarding the availability of the flu vaccine; his plans to ensure there is a right to any Covid-19 vaccine the State intends to procure free of charge at the point of use; and if he will make a statement on the matter. [33737/20]

My question relates to issues regarding the availability of the flu vaccine, not just for adults but also for children. I have been contacted by a number of pharmacies and GPs and they say that demand has certainly exceeded supply. I discussed this issue with the Minister personally in recent days. It is important, and I take this opportunity to encourage people to get the vaccine if they can, especially for children. However, there is a concern that we do not have enough vaccines to meet the demand. Can the Minister outline exactly how many doses were ordered for both adults and children? Is it the case that, this year, there is more demand than supply?

I acknowledge the Deputy's and his party's support in encouraging people to take up the vaccination programme.

The expanded flu vaccination campaign is a substantial advance on the campaigns of previous years. Some 1.95 million doses of vaccine, about twice as much as was administered last year, have been made available for those in at-risk groups and children aged from two to 12 years old. The total amount includes 600,000 doses of the vaccine delivered via nasal drops to children aged from two to 12 years old. This is the first time this vaccine, which is easier to administer, has been made available to children in Ireland. It is also the first year that children in this age group, who represent a risk group in their own right, have had access to vaccination without charge, which is welcome.

Some 1.35 million doses of the injected vaccine are being made available for those in the HSE-defined at-risk groups, including healthcare workers. For comparison purposes, just under 1 million doses - 950,000 - were administered last winter. Notwithstanding the large increase in available vaccine this year, it is likely that the full supply will be used. This will represent an increase of 35% in uptake in the adult population over last year. This is expected to increase the population health benefit from the vaccination campaign, as well as help to reduce the pressure on the health service, particularly when combined with the uptake among children.

Deliveries of the vaccine from the manufacturer have not been as quick as we would have liked, due to the very challenging international market for flu vaccines and given the global context of Covid-19. However, I can confirm that the HSE has now received all 1.35 million doses. A total of 950,000 have already been distributed to GPs, pharmacists and other vaccination locations and the remaining 400,000 doses are being distributed for use. The introduction of an effective and safe vaccine against Covid-19 will assist in curbing the pandemic’s spread and may facilitate the return of normal social and economic activity.

I accept that the numbers this year are greater than last year. Some 950,000 doses were available last year for adults and it is 1.35 million this year. However, the anecdotal evidence, and the Minister has just confirmed that it is not only anecdotal but a fact, is that we simply will not have enough for those who need it. I read the ministerial brief in detail and it referred to a very ambitious programme this year and ensuring, insofar as possible, we have a general roll-out of this vaccine in the population. I imagine it was hoped that whatever number of people wanted the vaccine would get it. What was the target and ambition? How is it that we are left in a situation in which, unfortunately, there will not be enough for those who need it? Is it possible to order more now? We are hearing there is a worldwide shortage. Is there a process ongoing in which the Minister and the Government are trying to get more doses of this vaccine to meet demand?

The orders for the flu vaccination are made at the start of the year. I believe the orders for this winter were made in January or February. The HSE took a new approach. It identified the at-risk groups, and it was calculated that totalled 1.35 million people. Children aged from two to 12 years were added to that and the 600,000 doses were procured. I believe, and the figures confirm, that there is very high demand, which is positive. It appears that almost all 1.95 million doses will be administered. As to whether there will be enough vaccine for those in the at-risk groups, the demand for the vaccine remains strong and the vaccine is being distributed. As a consequence, however, for the next round of distribution, which is the 400,000, GPs and pharmacists are being asked that priority be given among the remaining patients in the at-risk group to those over 65 years old and healthcare workers with direct patient contact.

It is unfortunate that we simply will not have enough for those who need it. Of course, those who are at risk should be protected. I wish to make a final point about vaccines and it relates to the possibility of a vaccine for Covid-19. My party supports the Right to Cure campaign, an EU-wide campaign that calls for all treatments, therapies and vaccines related to Covid-19 to be universally and freely available. Can the Minister inform the House what orders have been made for any of the trial Covid vaccines? How will they be rolled out and will we have sufficient stock, given that there will be worldwide demand, to ensure we can vaccinate people as much as possible against Covid-19? There is no vaccine at present. The Taoiseach has talked up the possibility of it being available in early 2021, and the Tánaiste spoke about it being a possibility before the end of this year. If and when one becomes available, what preparations has the State put in place to ensure there is free and universal access?

Ireland is currently involved in the EU procurement exercise being operated by the European Commission on behalf of member states to procure a portfolio of stable, safe and effective vaccines in sufficient quantities to combat Covid-19. I am sure the Deputy has seen that we are involved with the WHO and the Gavi global response, which is in a spirit with which the Deputy would agree. It has a global justice view to make sure that the vaccine is distributed globally.

The arrangements are intended to ensure co-ordinated action at European level to vaccinate the EU population. As part of the exercise, Ireland has already opted into two advance purchase agreements with the British-Swedish drug maker AstraZenica, which is partnering with the University of Oxford and Johnson & Johnson. Ireland will also be opting into another agreement reached by the Commission with Sanofi Pasteur, but is not required to do so formally until late December or early January. The short answer is that there are three so far and, in line with the Commission, we are keeping that under careful watch.

Cancer Services

Alan Kelly

Question:

81. Deputy Alan Kelly asked the Minister for Health the reason he commenced the CervicalCheck tribunal while still negotiating with a group (details supplied) in view of his assurance that it would be postponed to allow time for its concerns to be addressed; and if he will make a statement on the matter. [33478/20]

My question relates to the CervicalCheck tribunal. On 26 October the Minister said he would postpone the tribunal when he met the 221+ group on Zoom. However, it was commenced the following day. The Minister signed the order on 23 October. Vicky Phelan, has announced, unfortunately, that her cancer is back.

Lorraine, Stephen and all the members of the 221+ group are watching the Minister tonight for his answer. The Minister thinks he has more time than he has. We need all of these issues to be solved. They are very solvable. I presented some of the solutions myself. I urge the Minister, please, to give them confidence that these issues will be resolved this week.

As Deputy Kelly is aware, it was originally intended that the CervicalCheck tribunal would be established at the end of March. Both Deputy Kelly and I voted for the Act to set that up, and we debated some of the various parts of it in this House. The establishment was delayed due to Covid and then a further delay arose, as Deputy Kelly is aware, due to issues concerning membership when two of the judges were called on to do other jobs. The 221+ group has consistently raised its concerns over the delay in establishing the tribunal and its members have stressed to me the importance of establishing it without further delay. The group wrote to me in July, very shortly after I was in situ to ask that the tribunal would be set up immediately and with no further delay. In September, the group sought confirmation of an imminent start date. I have always made clear that I accepted the urgency of setting up the tribunal and my focus has been on its establishment as soon as possible. In July, I announced two new tribunal members and I also progressed work to make the tribunal facilities as safe as possible, or as Covid-proofed as possible, in the current environment.

There has been very in-depth and ongoing interaction between the 221+ group, me and the Department. The group has raised a number of concerns in respect of the tribunal, and progress was made in addressing these at our meeting at the beginning of September. I committed to consulting the Attorney General on some of these issues and to responding to the group before the establishment of the tribunal. I wrote to the group on 20 October, with the benefit of the Attorney General's advice, and informed the group of my intention to proceed with the tribunal's establishment on 27 October.

To effect the establishment of the tribunal, a number of steps were then taken, including the signing of the establishment orders, as Deputy Kelly referenced. I met with the group on 23 October and 26 October and further progress was made on its concerns. The most substantive of the concerns is one Deputy Kelly and I debated with the then Minister in this House and related to recurrence. I believe Deputy Kelly tabled an amendment at that time. The second concern, which Deputy Kelly and I discussed previously, was in respect of the Supreme Court judgement in the Morrissey case. I have more to say, which I might come back to in the next response.

To refresh my memory, I have read everything the Minister ever said in regard to this matter, so I know what commitments he made. Second, he did meet with the group, but he did not take on board what was said. Two months passed, and he did not take on board what was said. He just commenced the tribunal without addressing the main issues. One or two of the smaller issues have been addressed since.

I do not know why the Minister made a commitment on 26 October, having signed an order on 23 October, without rescinding it, for the tribunal to commence on 27 October. The Minister's excuse here is just not believable. It just does not help for a Minister to sign an order on the 23rd for the tribunal to commence on the 27th but to meet a group and tell it on the 26th that it was being postponed.

The Minister knows the main issues. They relate to the State Claims Agency joining as defendants and the Statute of Limitations. The most significant issue that the 221+ group wants sorted is the provision whereby a woman can return to the tribunal if she suffers a recurrence of cancer. They are the three outstanding issues. They have always been the three outstanding issues. I have discussed them with the Minister. There are solutions. I have even produced a Bill and sent it to the Minister, which, amazingly, his private secretary asked me for again last week even though I had sent it to her with a briefing note. When, this week, will the Minister give the assurances the 221+ group needs? Otherwise, the members of the group are going to ask publicly that people do not engage with the tribunal. The Minister and I do not want that.

I accept Deputy Kelly's bona fides on this. He and I have worked on this together on the committee and in this House. I hope he appreciates that I cannot get into a negotiation here with him that I am having in private with this group.

I do not want the Minister to do that.

It has been my intention from the very start to do right by this group. The group wrote to me and asked that the tribunal would be set up immediately, and that is what we moved to do. The group reiterated that in September. Deputy Kelly said that a few small issues may have been resolved but I am afraid that is factually incorrect.

The Minister would want to stop with that attitude.

The single biggest issue is the Supreme Court ruling in the Ruth Morrissey case, and they said themselves that that was a game changer. The group asked for an undertaking that the labs would not be joined as co-defendants in the tribunal. That has been supplied not just by me but in a letter furnished by the chief executive of the State Claims Agency.

Has the Minister read his letter?

So, with the greatest of respect, that has been done.

The Minister's attitude is appalling. He will not solve this issue with that attitude. He got a letter today explaining to him why that will not work. He obviously has not read it, or else he is choosing to ignore it. He is being quite ignorant on these issues. At this stage I have gone in-depth on all these issues for many years, specifically in relation to the tribunal. I know exactly what is needed. I have even supplied legislation to the Minister in regard to it, which he has ignored. I do not mind if he even takes the Civil Liability (Amendment) Bill on board, amends it and uses it as Government legislation. It does not bother me, but it sorts out the issue that we know we have to sort out regarding the re-occurrence of cancer for these women.

The Minister has very little time. I do not think he gets that. Vicky Phelan is watching this now as we speak. She has put her heart and soul into solving these issues in recent months. It is one of the last things she wants done. I urge the Minister, please, to honour that. There are comprehensive solutions here regarding the three issues that I believe everyone in this House would support. The Minister should just do it. He should not adopt an attitude like that. It is not appreciated and it will not work, with me or with them.

We can all make comments about people adopting attitudes with each other. With the greatest respect, what I say to Deputy Kelly is that I, the Department and the Government are in detailed discussions with the 221+ group. Various issues have been raised. A lot of them have been dealt with comprehensively.

The Minister received a letter today.

Good progress has been made on the others. I cannot get into a negotiation with Deputy Kelly in the Chamber about this. I need to respect the process that we are going through with the 221+ group. I have received the letter today, and I read it.

If he did read it, the Minister would not say what he has said.

I am sorry, but with the greatest respect, it is being looked at. It is a seven-page, detailed legalistic letter. It raises a lot of very detailed issues and we are going to afford it the respect it deserves. We are seeking legal advice on it. We are going to discuss it and we are going to see what progress we can make. The only thing we are bound by is the law.

The Minister can change the law.

My position going into this is exactly my position today. The only thing we want to do is what is right by these women. Deputy Kelly and I voted in this House for the Act that sets this tribunal up.

I produced legislation to deal with this issue.

What I want to do and what I believe Deputy Kelly wants to do is get this tribunal set up. We have made progress right across the board, within the bounds of the law, which we obviously have to follow.

No, the Minister has not. He does not realise how serious this issue is.

I thank the Minister. I am moving on.

The Taoiseach-----

Deputy Kelly should please not interrupt. I am moving on to the next question.

Covid-19 Tests

David Cullinane

Question:

82. Deputy David Cullinane asked the Minister for Health his plans for enhancing the testing and tracing system to make it more robust and proactive; and if he will make a statement on the matter. [33738/20]

This question seeks an outline from the Minister on his and the Government's plans to enhance testing and tracing, to put in place a more proactive and robust system, and to have a system in place that is fit for purpose and that can be used to hunt down the virus but also stay ahead of it so that when we get to a situation, which I hope we will, where the numbers are much lower and we can come out of this current lockdown, we will have strength in numbers in terms of a robust system to aggressively keep the virus in check.

I agree wholeheartedly with the Deputy. The answer may be a bit long but I will supply the Deputy with the full text if we do not get through it.

On the advice of the National Public Health Emergency Team, NPHET, the HSE developed the capacity to conduct 100,000 tests per week. I subsequently met the HSE and requested that it look at increasing the capacity. This is now in place and the HSE currently has standing capacity to test 120,000 people every week and progress is being made on looking at going higher than that should we need it. The testing and tracing regime compares very favourably internationally in terms of tests per size of population. Ireland ranks eighth highest out of 24 EU countries and the UK in terms of the number of tests being completed at the moment.

The median time it takes from a swab being taken to the communication of a laboratory result is now 29 hours in community testing, 28 hours in serial testing and 28 hours in acute settings. In the week to 27 October, the median time to complete all calls for contact tracing was 1.8 days.

A significant number of staff from other areas of the HSE were deployed to assist in the testing and tracing programme. The HSE is now moving these professionals back and redeploying them to their front-line posts, which is important.

My focus is on what must be done to minimise the risks of future large increases in positive cases. One of the really important tools is an effective testing and contact tracing programme. The HSE is currently running a nationwide recruitment campaign for swabbers and contact tracers. Some 180 additional swabbers have been appointed to date, while additional candidates are currently going through the process. Some 500 additional contact tracers are being hired to provide sufficient capacity for contact tracing with 280 already in place and a further 60 to 70 being appointed every week. By way of comparison, by mid-September, there were 292 people deployed to contact tracing. By 30 October, this had gone up to 683 people deployed to contact tracing and it is rising.

Additional information not given on the floor of the House

At the request of NPHET, HIQA recently undertook a rapid health technology assessment, HTA, on the use of alternatives to laboratory-based real-time RT-PCR to detect cases of current infection with SARS-CoV-2, the virus causing Covid-19 disease. HIQA’s report was published 21 October. HIQA advised that adoption of alternative approaches to testing requires consideration of factors including clinical performance, sensitivity and specificity, turnaround time, and ease of use. However, while rapid antigen detection tests have the potential to expand test capacity, reduce test turnaround times and improve access, the antigen tests available or currently in development show lower sensitivity than that observed with the rRT-PCR Test, the current gold standard.

I have asked the HSE to put in place a systematic and robust process for the rollout of a series of clinical validation exercises across a range of targeted settings and population cohorts. The HSE has established a group to review the antigen tests currently available and how they might be deployed in clinical and non-clinical settings.

The HSE has worked intensively over the past number of months to put in place a comprehensive testing and tracing operation. We will continue to pursue a robust testing strategy. This will include continuation of my Department’s work with the HSE to improve turnaround times, consistency and our end-to-end testing pathway. This ensures the system is responsive to nature of the current and expected future demand for testing and tracing. Testing and contact tracing continues to be a key component of the Government’s response to the pandemic.

We need more capacity both in testing and tracing. On the testing side, we need to increase lab capacity. We can have more swabbers but if we end up with a bottleneck in the labs to do the testing, then we have a problem. With regard to tracing, the problem is the system collapsed for a couple of days and more than 1,900 patients, unfortunately, became contact tracers themselves. When the head of testing and tracing was before the health committee, she said that the metric used to ascertain how many tracers are actually needed in this State showed the figure is 800. However, on the day she was at the committee, and when we are in the middle of a second wave, she said we only had 581 tracers.

This proved the point that many of us had been making for some time, namely, that we wasted the summer months by not putting in that capacity. The temporary collapse of the tracing system was due to lack of capacity and that it became overwhelmed. The Minister should not waste the next number of weeks in the way the summer was wasted. He must ensure the numbers are brought up to the levels to which the Government committed.

We discussed this in the Chamber before. I do not accept the system collapsed. I absolutely accept that what happened should not have happened. Many people were asked to contact their own close contacts. That is not what we want. I would not see that as the system collapsing, however. In some European countries where cases rose, one essentially saw contact tracing stopping. We did not see it stop, however. It was a one-off event.

It now has the capacity to rapidly contact trace up to 1,500 new cases per day. In the current situation, the highest number was just short of 1,200. It is falling now thanks to the work of people across the country.

I absolutely agree with the Deputy. What needs to happen now, as the numbers come down and when we come out of level 5, is that we must make sure the contact tracing system in place is quick and comprehensive, as well as doing both forward and backward contact tracing for the very reasons the Deputy laid out.

Several Members here attended the committee hearing with the head of testing and tracing. There was much spin beforehand in terms of the public commentary from Ministers and even the press statements from the Government that we would see an additional 800 tracers. As it turns out, it was to bring us to 800. We were going to go from 581 to 800.

We were told by the head of testing and tracing at the committee that the number needed to ensure we had a safe service, according to the metric used, was 800. At that point, we were in the middle of a second wave with 1,200 cases a day at its height. We were left only with 581 tracers, however. How did that happen? It happened on the Minister's watch because he did not use the summer months to recruit the staff necessary to ensure we had at least sufficient capacity.

I do not buy it even that 800 would be enough. The Minister must not leave us exposed again. When we get the numbers down, we must have a testing and tracing system that we can use to hunt down Covid, to keep ahead of it and that we do not lose control in the way we lost control this time.

We will just have to agree to disagree on the system collapsing. As I said, obviously one does not want people having to contact their own close contacts. As a one-off event in nine months or so of a global pandemic, I certainly do not believe that constitutes a collapse at all.

I cannot speak to people saying an additional 800. I am pretty sure what I have been saying is that it is scaling up to 800. It will have gone from 231 in mid-September to 800, a significant increase. What is important now is that the capacity is there to rapidly contact and trace 1,500 cases a day. We all need to make sure we never get close to 1,500 cases a day. While we do not know what the future will hold, the cases are certainly coming down now. The focus for the short term, but, hopefully, for the medium and longer term as well, will be less on having to do the high numbers and more around speed, getting to people, getting to their close contacts, going deep and doing both the backwards and forwards contact tracing.

Health Services Staff

Róisín Shortall

Question:

83. Deputy Róisín Shortall asked the Minister for Health the number of public health doctors required and the number of these posts which will be at consultant level in respect of his undertaking to increase the numbers of public health staff; his plans in respect of the recruitment of additional public health nurses; his plans in respect of other public health staff; and the timeframe to which he is working for the filling of these posts. [33889/20]

Prior to Covid, most people had not heard of public health doctors, although they did essential work in terms of population health, prevention, screening, vaccinations and all of that key work. Since Covid, many of them have been occupied entirely with critical Covid work. At the same time, they have been treated as the poor relation of medicine. It is now time to address that and to fund this critical service properly. Does the Minister accept that?

I do. There are many different things going on. The first of two of the big ones, of which the Deputy will be aware, is moving the public health doctors to consultant status, which is important. The Department is currently in preliminary talks with the IMO about how that might work. I am meeting with public health doctors this Friday. The second is an expansion of the workforce. I have sanctioned a doubling of the workforce. We are working through exactly how that might be deployed. There are public health doctors, public health nurses, data specialists and scientists. The Health Protection Surveillance Centre, HPSC, is looking for them as well.

Like the Deputy, I want to pay tribute to our public health doctors. They have worked incredibly hard. We have a small number of them but they are doing a huge amount of work in the community with testing and in the national response with the schools. They have been working damn hard and they are tired. They most definitely deserve our thanks and respect. More importantly, they deserve an investment in public health.

There are currently 72 public health doctors permanently employed as specialists and-or directors in public health medicine in the HSE. I have committed to the early introduction of a new framework for public health, as provided for in the programme for Government, as well as the establishment of a consultant-led public health model. Budget 2021 provides for recruitment of up to 250 additional permanent staff. The HSE is looking at hiring up to 400 temporary staff during the pandemic response. They will support the public health teams.

The public health doctors have been advocating for many years for consultant status, which we are moving on. They have also said they need support staff around them. They are having to do a huge amount themselves that support staff should be doing. We are looking to hire and deploy, first on a temporary basis around the pandemic, but also on a permanent basis to support them.

That all sounds fine. The reality, however, is that the discussions with the Department have not been successful. The Minister is talking about a framework which is all fine. We need commitments on this, however. Ireland is an outlier. There are 72 public health doctors who are specialists. They have the same qualifications as all other consultants and yet they are the only specialty that does not have consultant grade.

Will the Minister give a commitment tonight that those 72 specialists, with all the qualifications to become consultants, will be upgraded to consultant level? Will he agree that this is part of his plan? It is critical, as well as introducing the additional support staff but also other doctors and consultants.

We are an outlier also in terms of having such a low number of public health doctors, 72. The number is double or nearly treble that in other countries of comparable size such as Scotland or New Zealand. Will the Minister give that commitment tonight?

I thank the Deputy. I share her views. The 72 doctors she has mentioned include 15 public health specialists and 17 directors of public health, who obviously have wider remits. The public health doctors we have on the ground are even more stretched.

They are not consultants.

We are negotiating the consultant contract. Discussions are ongoing between the Department and the Irish Medical Organisation, IMO. With the greatest respect, I cannot get into the detail of those negotiations because they are ongoing. As the Deputy noted, various statements have been made. The public health doctors are considering a ballot, which I fully appreciate is their right. However, given the situation I am not in a position to get into details that are being worked out through these conversations in the House. I am sorry about that. It would not be fair to the IMO or to the process that is taking place.

A very important principle arises here. Does the Minister accept that these 72 doctors, who are specialists with full consultant qualifications, should be upgraded to a consultant grade? That is a straightforward question. Is there any justification for continuing to treat them less favourably than their colleagues in all other specialties? Is it not an absolutely shocking comment on the very valuable work of public health doctors to tell them that the Government is not prepared to upgrade them to the level of their colleagues in other specialties? There is no justification for not doing that. There have been umpteen reports recommending that since 2002. This is the way to deal with the issue. Let us not get to a point where industrial action is threatened and possibly taken by public health consultants in the midst of a pandemic while the Minister is making up his mind on whether to do the right thing by these doctors. Will the Minister make that commitment and agree to provide the additional posts and support staff? It is the least those doctors can expect.

I thank the Deputy. I can commit to a doubling of the public health workforce in consultation with the public health doctors, and to the creation of the public health consultant contract. The Deputy is quite right. This is something they have been seeking for decades. There is a process under way between the Department and the IMO. For me to make the definitive statements the Deputy is looking for would not be respectful of the process which the doctors' representative group is going through with the Department. With respect, I will leave it to the IMO, the Department and the Government to continue those conversations. I want to see those doctors respected and recognised as specialists. I want to see consultant-level contracts established for public health doctors as soon as possible.

That could happen on Friday. That is what they are looking for and that is what will prevent industrial action.

Nursing Education

David Cullinane

Question:

84. Deputy David Cullinane asked the Minister for Health his plans to address the pay and working conditions concerns of student nurses; and if he will make a statement on the matter. [33739/20]

I hope I get a better response on the issue of pay and working conditions for student nurses than the previous Deputy got on public health specialists. I agree with the points that were made. That is an issue that needs to be resolved. The Minister committed to doing so when he was in opposition.

We have a very real problem concerning student nurses on first, second and third year placements. They are the glue holding our public health system together. They are operating on the front line and they are doing a first-class job but they are not being paid. Can the Minister address this issue urgently?

I thank the Deputy. I recognise the importance of student nurses and midwives completing their essential clinical placements in a safe environment. I also recognise the potential hardship that might arise due to Covid-19 for students on placement, such as maintaining part-time employment, increased travel and additional accommodation costs.

Student nurses and midwives are not paid for clinical placements in the first three years of their studies and this supernumerary status is critical for learning in complex environments. Financial supports for non-intern student nurses and midwives are governed by circular 9/2004, which provides an accommodation allowance of up to €50.79 per week, to be paid where it is necessary for a student to obtain accommodation away from their normal place of residence, and a refund of travel expenses. Both are paid as refunds on production of receipts.

In the immediate term my Department is reviewing the current accommodation and travel allowances that apply to this year's first, second and third year students on clinical placements, taking into account the impact of the Covid-19 pandemic on such placements. The revision is expected to conclude shortly and I look forward to bringing proposals forward thereafter.

Regarding fourth year nursing and midwifery students, the HSE continues to fund the internship employment of these students who are on rostered work placements. It is very important to me that the training element is protected for students. This includes those scheduled to commence in the coming weeks and those due to commence rostered work placements in 2021. These fourth year student nurses and midwives on rostered work placements are paid at the approved rate, that is, €22,229 on an annual basis for psychiatric nursing specialism and €21,749 for all other nursing disciplines.

I will say again that some nurses on clinical placements get an allowance of up to €50 per week, but many do not. It is simply not good enough. In the early stages of the pandemic, many of those student nurses were getting a rate equivalent to that of a health care assistant, HCA. That was discontinued. The Minister must reinstate that rate. He needs to deal with this very urgently. As I said, these people are doing a first-class job on the front line. They should be rewarded and respected and they should get paid for it.

I also wish to ask the Minister about a separate issue to do with a previous negotiation between the State and the IMO. I refer to the IMO contract which was the subject of discussion earlier this evening. When he spoke in the Dáil on 16 April 2019, he made it very clear that it was his understanding that the document which we have been told was agreed was not widely known or shared with GPs. Is that the Minister's position? Can he also confirm to the House that the Department of Health will make all communications between the National Association of General Practitioners, NAGP, the HSE and the Department between April and May 2019 available to Deputies who seek it? We have sought it and we have not yet got it.

I thank the Deputy. I fully agree that nursing students need support. He refers to the HCA wage which was paid during the first wave of the pandemic. The Deputy should bear in mind that when that happened the student nurses were essentially asked to move from education to work. They were working full-time. They stepped up when they were needed and did a fantastic job in a crisis. They were paid the HCA wage. That meant they were working as HCAs and their line managers in the hospitals deployed them as HCAs. It is very important to remember that these are educational training placements. We do not want these students working as HCAs. That is not the point. These educational placements are a really important aspect of the nursing degree which was set up in 2004. I want to make very clear that they are fundamentally different. We are not asking the nurses to work as HCAs. We are asking them to do their educational training placements. We are looking at the current stipend and considering what can be done in the short term, in the context of Covid-19.