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Dáil Éireann debate -
Thursday, 31 Mar 2022

Vol. 1020 No. 4

Ceisteanna Eile - Other Questions

Health Services

Neasa Hourigan


6. Deputy Neasa Hourigan asked the Minister for Health the progress to re-establish the provision of transgender child and adolescent healthcare services through a clinic (details supplied) and working with Children's Health Ireland in Crumlin; and if he will make a statement on the matter. [17004/22]

Although I am taking this question on behalf of my colleague, Deputy Hourigan, I emphasise that trying to support young transgender people in Ireland is a strong interest of mine. When might we see the re-establishment of transgender child and adolescent mental healthcare services through the Tavistock clinic's work with Children's Health Ireland at Crumlin? This is about recognising that having access to these conversations with Tavistock is part of the mental health supports that young transgender people need at an early stage.

The programme for Government commits to create and implement a general health policy for transpeople, based on a best practice model for care in line with the World Professional Association for Transgender Health, and to deliver a framework for the development of national gender clinics and multidisciplinary teams for children and adults. The HSE is committed to building services for the transgender community in accordance with international best practice across a number of programmes, including mental health, acute hospitals and primary care. This includes a robust and agreed care pathway for young people with gender dysphoria in line with international best practice.

A decision was made by the UK clinic referenced by the Deputy to suspend new referrals for under-16s following a High Court ruling in England. This suspension impacts on patients who have historically had access to the UK service through the HSE treatment abroad scheme. The office of the national clinical advisor and group lead for mental health is involved in ongoing discussions with the HSE treatment abroad scheme in order to identify alternative gender identity clinics abroad that would facilitate referral, with particular reference to the psychology assessment component of the care pathway, pending the development of a national child and adolescent service. Fidelity to the clinical model of care approved by the HSE is essential in advance of considering alternative referral routes.

I am committed to the development by the HSE of a well-governed and patient-centred healthcare service for adults and children in the transgender community in line with the programme for Government.

I appreciate that update. Last week, I had the pleasure of meeting Ms Sara Phillips from Transgender Equality Network Ireland, Ms Paula Fagan from LGBT Ireland and Ms Moninne Griffith from BeLonG To, an organisation that supports young lesbian, gay, bisexual, transgender, intersex, LGBTI, people, particularly with mental health, which is one of the biggest challenges when young people have questions about their gender identity or know they are not in the right gender relative to their birth sex. So much of this, and what they highlight to me, is about having open conversations, and being able to discuss this with GPs and in clinical settings. They say to me that the capacity to have these conversations about recognition, treatment with respect and treatment with dignity, along with the questions and challenges transgender people face internally, often puts off further medical decisions. Access to these conversations, especially in child and adolescent mental health services, in addition to being able to take it further through the hospital system in a respectful way, is very important.

We are committed to building services for the transgender community with the HSE in accordance with international best practice across a number of programmes. The office of the national clinical advisor and group lead for mental health is involved in ongoing discussions. I hope we will have a clearer pathway in the coming weeks and months.

It is important to note there has been a very divisive debate in the UK about this issue over the past number of months and years.

It is a debate that has not helped anybody. What we need is a very respectful, dignified conversation supporting what is a small but significant number of people who are transgender. There does not need to be a conflict between transgender rights and gender identity rights and other sex-based rights. There is space for everybody. One set of rights does not need to displace another set of rights. We have not had that sort of conversation here. I hope it is not a feature that enters into Irish discourse where that sort of conflict is created between different groups of people or rights. There is no need for it. We had a very respectful conversation about individuals and families throughout the marriage equality referendum. Similarly, there is a sensible, common-sense, decent approach that can be taken to the legitimate questions that people have and that are raised as we look to support transgender people but also acknowledge that there is space in the equality house for everybody.

The Deputy's comments are very appropriate. She spoke about decency and people being informed. In recent years, and with the Citizens' Assembly, people have been informed. We are looking at international best practice. Many years ago, that brought in just the UK but I am sure that the HSE and all the stakeholders will be looking further afield, including the USA. We are very much committed Europeans and I am sure there is much best practice in Europe and across the world too.

Ukraine War

David Cullinane


7. Deputy David Cullinane asked the Minister for Health the supports and plans that his Department has put in place for supporting Ukrainian refugees in the short, medium and long-term; and if he will make a statement on the matter. [16799/22]

We all want to do everything possible to support the people of Ukraine. I think that Ireland had been very generous in its response taking in as many refugees as possible. That is what we should do. We all support that in this House. We also need to look at the individual needs of all the refugees who are coming here. The Minister for Health has responsibility to ensure that their full health needs are met and that there is a full audit of those needs. What are the short-, medium- and long-term plans that are being put in place?

I fully agree. Women and children in the main are arriving in Ireland, fleeing a horrific and illegal war in Ukraine, and it is essential that they receive all the health and social care supports that they need. A huge amount of work is ongoing between my Department, the HSE, other Departments and non-government agencies to ensure access to the services they require. This includes access to acute care, chronic care, services for children's health, mental health, disabilities, maternity care, older people and many more. Additional health supports are provided where required, including mental health and psychological supports, including for PTSD, and services for people with long-term illnesses.

Refugees from Ukraine are granted temporary protection status. This entitles them to a PPS number which allows access to health care services, in line with other refugee groups and Irish citizens. In the short term, refugees are provided with rapid access to basic priority primary care in emergency accommodation. The aim of this service is to identify the need for ongoing clinical care of priority medical conditions, to triage and to provide an assessment of healthcare needs of refugees. In the medium and long term, refugees are entitled to apply for a medical card for each adult and child dependant. At the moment, temporary medical card numbers are being provided immediately. The medical card application form has been translated into Ukrainian and Russian and there are supports for people to apply for the more permanent medical cards too.

I welcome the Minister's response. The response has been good and swift. There is always more that we can do but the generosity shown by Irish people and the speed with which the political system has responded to the needs of those coming from Ukraine has been exceptional.

There are two elements around health. We need to make sure that people who come here get access to the very best healthcare treatments. The Minister has said that primary care is the start and that medical cards will be issued to those who need them, which will be most of them. That needs to happen as quickly as possible. I imagine there are also people coming here who are qualified healthcare professionals. Is work being done to identify who they are and what skills and qualifications they have? That could then accelerate matching those qualifications with the standards here to bring some of them into the public system in the areas they work in, which I am sure they would assist and be more than happy to take part in.

The short answer is "Yes". This is something I discussed when I met the Ukrainian ambassador. We have many qualified healthcare professionals here. We have an amazing group of Ukrainian clinicians here already. We have been working with them to try to send humanitarian supplies back to Ukraine. A lot has been done there and we will continue to work with the Ukrainian community already here. The Deputy quite rightly said that we have doctors, nurses, midwives, allied health and social care professionals coming in. They have full rights to work. We obviously need as many clinicians as we can get in our own service. That will also help with the provision of care to Ukrainians coming in; it helps with language and culture and they will have a better understanding of the models of care that the refugees will be used to and the most appropriate care for them. We are engaging directly with the appropriate agencies to identify them and bring them into the system, and critically, in a way that works for them given everything that they have been through.

That is very welcome. If there are any Ukrainian refugees who want to work here they should be entitled and enabled to do so. A difficulty we have had for people coming from all different countries over many years is in professional registration when matching our regulations with those of the countries from which they are coming. Are there any difficulties there? Are there people who have come already who are now going to work in the healthcare system? If any problems have been identified, will they be resolved? That is really important for those with any medical qualifications. We talked about health and social care and the lack of therapists in the system. If there are Ukrainians coming here who have expertise and qualifications and skills but also language, this is really important because they can work and engage directly with children especially who might not have English, for example. There will be all sorts of difficulties and challenges. There are many opportunities and benefits to bringing as many in as possible and I hope that what the Minister has outlined will happen and very quickly.

On Sunday I met someone who is highly qualified in obstetrics and gynaecology from Ukraine. They have over ten years' experience. Has the Department engaged with the Nursing and Midwifery Board of Ireland and the Irish Medical Council on how the process will be put in place for their qualifications to be recognised so that they can give the support to the people and work in the Irish medical system?

I will get an up-to-date report. I understand that there has been extensive engagement. As Deputy Burke rightly points out, we must have a process whereby the qualifications are verified. We are talking about a highly developed country with a highly developed healthcare system. My assumption is that they will be qualified to a very high level. The Irish Medical Council will be involved but we are not starting from scratch. We already have employed within the HSE a community of incredible healthcare workers from Ukraine. I have met many of them. We are working with them to send supplies out. They were instrumental in working with Lifeline and the HSE in repurposing nine of our ambulances and sending them out as well as a lot more supplies. I will get a note for both Deputies on exactly where we are at around identifying these people, verifying the qualifications and then deploying them in a way which, first and foremost, works for them. For instance, there may be childcare requirements that we need to put in place.

Hospital Facilities

Dara Calleary


8. Deputy Dara Calleary asked the Minister for Health the plans that are in place to further develop services in Ballina District Hospital. [16770/22]

I am very proud of my local hospital, Ballina District Hospital. It has sought substantial capital investment from the HSE for some time. Will the Minister update me on where that process is at?

I thank the Deputy for raising the question. I acknowledge his ongoing advocacy and work for Ballina Hospital.

I very much look forward to meeting the Deputy in the hospital soon and meeting healthcare workers and management there to look at what more can be done in future with respect to ongoing provision for services.

Ballina is a very important hospital. It is 62-bed hospital providing short-stay facilities for those discharged from Mayo University Hospital who require convalescence before being discharged or a long-stay bed in a community nursing unit. I acknowledge attempts have been made to carry out capital improvements in Ballina. The Deputy has repeatedly brought these to the attention of the House. Submissions were received in November 2018 for a 75-bed replacement unit and, in January 2021, for a 30-bed interim build. These have not yet been fully appraised by the HSE. It is not a situation I am satisfied with and I am aware the Deputy is not satisfied with it either. I have asked both the Department and the HSE to move on these more quickly. Some of the delay was down to Covid. However, I am not satisfied with the pace this is moving at.

A new proposal was submitted via the national property steering committee at February's meeting concerning the planned replacement of the current facility in Ballina with a modular build, which is urgent and would make a big difference. Engagements have taken place with the CHO since the February meeting, which is important. We are pushing to get this happening. The HSE is to come back confirming bed numbers, types and costs for Ballina. An amended proposal has been submitted for consideration at the next property steering committee meeting, which is taking place in a few weeks.

The HSE and CHO 2 remain committed to the future provision of long-stay residential care. I know the Deputy does and I assure him I and the Government do as well.

I thank the Minister for his reply and the obvious commitment from him to Ballina Hospital. As he said, it is a 62-bed unit. We want to see that maximised. It is an important step-down facility. The staff there do a wonderful job and there are many proposals on the table. I want to see them advanced. They have been there long enough to be assessed.

The Minister acknowledged during the week there is huge pressure on Mayo University Hospital at the moment. Without the district hospitals in Ballina, Belmullet and Swinford working effectively that pressure will continue. I extend once again the invitation to visit the hospital and meet the director of nursing and staff. We also need to be far more ambitious about our network of district hospitals around the country. I have previously told the Minister I see Ballina as the perfect location for something similar to a minor injuries unit. Mayo University Hospital and Sligo University Hospital are under immense pressure. We are located halfway between them and a minor injuries unit would certainly take the pressure off the two main hospitals. The space is there, the site is there, the staff are there and the willingness is as well. What we need is a commitment from the HSE nationally because regionally the HSE is invested in this. The HSE at national level needs to get on board with Ballina hospital.

I fully agree with the Deputy's assessment. As he said, Mayo University Hospital and Sligo University Hospital are fantastic hospitals but they are under pressure and need additional investment in beds, in their workforces and in diagnostics. As he also correctly said, the hospitals are only as good as the networks and the ecosystems within which they work. That is where Ballina really comes into its own. That is why we need the extra beds and the extra capacity. The biggest challenge in emergency departments now, when we look for example at the intense pressure Galway, Mayo and Sligo hospitals are under, is delayed discharge and transfer of care. Hundreds of patients are in hospital beds and have been discharged but at the moment there is nowhere to send them to. This is partly because more than 60% of nursing homes cannot currently take people in because they are within 28 days of a Covid outbreak. However, as the Deputy correctly said, much more can be done with facilities such as those in Ballina.

That is absolutely so and I look forward to the Minister progressing this. I have a question later on Belmullet Hospital in the same vein . It is a superb hospital with a fantastic standard and history of care. With the appropriate capital investment and working with local GPs in Erris it could do an awful lot more. However, HSE management at national level does not seem to get that. Estate management at national level does not seem to get the very important network of district hospitals in Ballina, Belmullet and Swinford around Mayo University Hospital. The Minister does and I look forward to progressing the development of these hospitals with him in the coming weeks - I am not even going to say months - because we need to move on the plans for Ballina and Belmullet in 2022 and no later.

I thank the Deputy. As he rightly said, though I am not sure we will get to the question, he has consistently raised the issue of Belmullet. He and I have discussed there being an active application in for Belmullet as well. I cannot pre-empt the capital appraisal but I would like to see exactly what the Deputy is advocating for, namely, more beds in Ballina, the modular unit moved on very quickly to alleviate pressure in the short term and more beds in Belmullet. I would then very much like to meet the Deputy in Belmullet and Ballina. I would like to go to these places, meet with the clinicians and ensure the required capital investment is put in place because our whole system is moving towards having patients in the model 3 and model 4 hospitals for the shortest time possible before moving them into community facilities like those in Ballina and Belmullet as quickly as possible. That requires ongoing investment.

Departmental Policies

Niamh Smyth


9. Deputy Niamh Smyth asked the Minister for Health if he will report on the Specialist Group on Women’s Mental Health under the Sharing the Vision plan; and if he will make a statement on the matter. [16772/22]

I ask about the new mental health policy, Sharing the Vision, launched in June 2019. The Minister of State, Deputy Butler, has been doing much good work on this and launched the implementation plan last week. What is the status of the report of the specialist group on women’s mental health under the policy?

I thank the Deputy for this important question. Providing rapid access to high-quality mental health services and the supports needed is an absolute priority for me, the Minister of State, Deputy Butler, and the Government. I would say that is the case for everybody in this House. Sharing the Vision: A Mental Health Policy for Everyone was published in June 2020 and is our national mental health policy. We are now implementing this strategy with a total allocation of €1.1 billion in the current budget. It is the largest mental health budget in the history of the State. It has been put there to ensure this is rolled out. As the Deputy quite rightly said, Sharing the Vision, though an excellent strategy, was not at the time gender-proofed.

One of the issues we are priotising at the moment is women's health. This relates to both their physical health, and we launched the women's health action plan two or three weeks ago, but also their mental health. One of the things we are doing that has come out of the work is to gender-proof the various strategies, with one of them being mental health. As we all know, mental health services are needed by men and women and boys and girls but there are some services exclusively used for women such as perinatal mental health. There are also services where we know the majority of service users are women, young women or girls. I am referring to eating disorders and self-harm, for example.

As part of the national implementation and monitoring committee that oversees the implementation of Sharing the Vision, various specialist groups have been established. The specialist group has a short-term remit to gender-proof the strategy with a focus on gender-proofing and implementation. This is just one of the ways we are embedding and prioritising women’s health.

The group the Deputy referred to is chaired by Dr. Siobhán McHale. It includes a mix of mental health and women’s health specialists. It is supported by a diverse consultation panel involving a wide range of professional and civil society perspectives to inform the process.

I thank the Minister. It is good to see action aimed at increasing mental health supports in response to the Covid-19 pandemic but we know issues were already present. According to the statistics, work-related stress, depression or anxiety account for 44% of work-related sickness and 54% of work days are lost because of it. The number of women who experience mental health difficulties in pregnancy and afterwards is one in five. It is, therefore, important to talk about women's mental health and prioritise action. All aspects of the mental health services are being improved and developed through the implementation of this national mental health policy, Sharing the Vision. The commitment has been given by the Minister of State, Deputy Butler. It is an action plan that will be there for the long term and it is a long-term commitment. That is so important.

The Minister mentioned the different working groups. Has the reference group of service users and family members been established and if not, what is the timescale for that?

The national implementation and monitoring committee specialist group on women's mental health was established by my Department in August last year at the request of the national steering committee. The purpose of this specialist group is to advise the committee on implementation of the following recommendation from the Sharing the Vision implementation plan :

The Department of Health Women’s Health Taskforce and the National Implementation Monitoring Committee will undertake a joint project within 12 months to outline an effective approach to the mental health of women and girls. The project should ensure that mental health priorities and services are gender-sensitive and that women’s mental health is specifically and sufficiently addressed in the implementation of policy.

That is the approach that is being taken. We have ongoing implementation of Sharing the Vision and we now have a very substantial piece of work under way looking at women's mental health within that. I imagine the national approach will be adjusted, updated and improved accordingly. I will get a note for the Deputy on her final question on the service users.

I thank the Minister. As a woman, I welcome the fact that the Minister of State with responsibility for mental health is a woman. That is very important.

What is the status of the recruitment of psychology teams across the HSE? This is an issue that the Minister and the Minister of State, Deputy Butler, have been working on and it comes across my desk regularly. Finally, what is the best avenue for applying for grants associated with the women's health fund announced in budget 2022? I have been contacted by numerous people about this funding. It is really important that this funding is provided for women's mental health but I am finding it hard to get information on how to apply for it.

I fully concur with the Deputy's comments on the Minister of State, Deputy Butler. She has been doing a fantastic job and we really are putting women's health front and centre. We launched a strategy document approximately three weeks ago and every Member should have received a copy in his or her pigeon hole by now. I encourage colleagues to take a look at that strategy, which takes a whole life cycle approach to women's health for the first time. Obviously, part of that is mental health. We are looking very specifically at mental health supports for girls and young women, for example. As part of the national listening exercise, perinatal mental health came out as one of the big unmet needs. I am delighted that the new perinatal mental health teams are now being put in place, which is revolutionary. I was in Galway recently where I met a full, brand new team that includes psychiatry, psychology, social work and therapeutics. It is an amazing team, all of whom are women, as it happens. It is fantastic to see that this is now being built out and making a real difference to women's mental health.

Home Help Service

Willie O'Dea


10. Deputy Willie O'Dea asked the Minister for Health if he will provide a report on the establishment of the national home support office. [16861/22]

I am asking this question on behalf of my colleague, Deputy O'Dea. There is a commitment in the HSE's service plan to progress the establishment of a national home support office by the end of quarter 1, which is today, believe it or not. This follows on from a programme for Government commitment to introduce a statutory scheme to support people to live in their own homes. What progress has been made in this regard?

Approval and funding was provided in 2021 for the new national older persons services offices, encompassing the national home support office to be located in Tullamore, County Offaly. The development of a national office for home support will streamline existing structures, providing enhanced management and administration of home support services.

The HSE has advised that work is ongoing to open the office. Refurbishment works are needed and HSE estates has appointed a project manager to oversee this work. The expected timeframe for completion of works and signed lease agreement is quarter two, 2022.

Funding has been provided for 15 full-time jobs, including nine CHO home support manager or co-ordinator posts. The national home support office will ensure a centralised team is in place to assist with the delivery of home support services in anticipation of the statutory home support scheme. The functions of the office will include the development of the structures and processes through which the new statutory scheme will be delivered, including a prioritisation framework for service allocation and active management of waiting list for services. The office will also monitor demand for the scheme at a national level to ensure the capacity of the scheme is sufficient to meet current and future demand, develop a standardised training model for the statutory scheme, and act as the central point for applications for home support services.

I thank the Minister of State for that reply. As always, the HSE is going to make sure the office is ready but let us make sure that the service is not affected. I note that Deputy Colm Burke is present. Last week, he hosted a very good information session, alongside the former Minister of State at the Department of Health, Jim Daly, with the Home Care Providers Alliance. It is essential to ensure, as we move to this new service, that there is no interruption to service on the ground and that local management and local knowledge is still very much a part of it because that often gets lost in the centralisation of HSE services.

When I was lucky enough to be first elected to this House, the problem was getting hours for a home care service, particularly for home help. Now the problem is getting people to service those hours. Many families are given the hours but cannot get the carers. We need to make sure there is no loss of service as we move to this new structure. I welcome the HSE commitment and the programme for Government commitment but I always fear that when the HSE centralises a service, it loses the local connection. I would like an assurance that this will not happen, and I know that the Minister of State will share my wish that it does not happen on this occasion. HSE and private home helpers do extraordinary work across the country but they are absolutely undervalued. We need to make sure that work is not lost.

I thank the Deputy for raising this important issue. As he said, the programme for Government commits the Government to introducing a statutory scheme to support people to live in their own homes that will provide equitable access to high-quality, regulated home care. It is important to note that progress has been made in this area. At the end of January 2022, 4,836 people had been assessed and were waiting for a carer to become available. This is a reduction from December 2021, when 5,322 people were waiting for a carer to become available. There are issues that need to be dealt with but the total number of people waiting for home support across both categories has reduced from more than 9,000 at the start of 2020 to approximately 5,110 by the end of January 2022. A lot of home care hours were allocated but finding staff to fulfil those allocations has been a challenge.

The HSE needs to invest in staff and in recruiting more staff. I acknowledge the work that the Minister of State, Deputy Butler, has done in this area. Last Jul,y she launched four pilot schemes in CHOs in Galway, Cork, Dublin and Westmeath. How are they progressing and what differences have been picked up between those pilot schemes and the roll-out of the current scheme?

I also want to thank the Minister of State for the work being done in this area. Following on from what the Deputy said, in September 2020 I introduced a Private Member's Bill related to the regulation of home care, including putting it on a statutory footing. I know that work is ongoing on that issue but is there a timeframe for the introduction of legislation to put home care provision on a statutory footing? When are we likely to see the draft legislation?

In 2021, the Government gave approval for a draft general scheme and heads of a Bill to establish a licensing framework for home support providers. The Minister of State, Deputy Butler, is very interested in this area and I will relay the concerns of Deputy Calleary to her. The pilot schemes she set up will assist in determining the way forward but I do not have details on the results of same. I will bring the Deputy's concerns to the attention of the Minister of State.

Hospital Services

Peadar Tóibín


11. Deputy Peadar Tóibín asked the Minister for Health the engagements he has undertaken with staff or management in Navan hospital regarding the future of the emergency department in the hospital; and if he will make a statement on the matter. [16021/22]

Overcrowding in hospitals throughout the State is out of control. While this is in part because of the current wave of Omicron infections, it is also significantly out of control because there are not enough resources in the State. Overcrowding is not new. Indeed, there has been overcrowding in our hospitals for the past 15 years. Last September, the Minister announced that he wanted to gut hospital capacity even further by closing the emergency department in Navan hospital. Will he drop this plan?

I will answer the Deputy's question specific to Navan in a moment. I must first address the statement he made. It is manifestly and verifiably false to say that we are gutting hospital capacity. If the Deputy was being honest, he would know that is a preposterous and verifiably false statement. The reality-----

There were 22,000 beds-----

I did not interrupt the Deputy. With the greatest of respect, the record will show that while there is a huge amount more to be done, over the past two years more beds, more clinicians and more diagnostics have been added to the hospital system than in any year on record. They are verifiable facts. It is unhelpful for the Deputy to make statements that this Government, or indeed any Government, is gutting the hospital system.

I will now speak directly to the very important point raised by him regarding Navan hospital. I am acutely aware that any considerations of changes to health services can cause legitimate and real worry for the populations who are served by those hospitals and for the workforces involved. Any consideration of changes must ensure that we have patient safety and high-quality services at the heart of them such that patients can access the best possible services when they need them, including when they are critically ill and when they find they have to attend a minor injury unit or an emergency department.

The view of the HSE and the most senior clinicians in the area is that the changes to services in Navan hospital are needed for one reason, namely, to support the safe delivery of care on a sustainable basis. This is in line with the smaller hospitals framework. That is not my opinion; that is the opinion of the senior clinicians charged with keeping people safe. As the Deputy will be aware, I instructed the HSE to pause in the planning of these changes to commence an engagement process with the Deputy and other elected representatives and the community. My understanding is that we will be having that session very shortly.

Anybody can point to a year or two and claim increases in those years. Twenty years ago, there were 22,000 hospital beds in this State; today, there are only 14,000. The Minister should do the maths. Ten years ago, it was stated that there was need for 500 ICU beds in this State; today, there are only 300. We have one of the lowest rates of the OECD. The Minister cannot hide and talk around that issue.

One of the reasons the Government has put forward for the closure of the emergency department in Navan hospital is the threat of an adverse incident. I contacted the national incident management system. Its staff showed that in five years there has been an increase from 79,000 to 105,000 in adverse incidents in the hospital system. There has been a 37% increase. I asked which hospitals were suffering most and was told they could not answer that question because they did not want to create a league table of hospitals, but they did tell me which hospital groups are suffering most from adverse incidents. The RCSI Hospital Group had a 47% increase in adverse incidents in that timescale. The Government is looking to close a hospital and an emergency department in the Ireland East Hospital Group and to push it towards the RCSI group. How is that safe?

As I said, and as the Deputy will be aware, I personally intervened to stop the process that had been going on. My view is that any consideration like this must involve the local communities, the healthcare professionals and those elected by the local communities to represent their interests. I would like to acknowledge that the Deputy, as well as other elected representatives for the area, have submitted very detailed questions. The HSE has pored over them and provided very detailed responses. I now want to sit down with the Deputy, all the other elected representatives and the senior clinicians in the area to go through all of these very legitimate questions such as, "Has there been sufficient investment in Navan hospital?", "Are the bypass protocols that are in place working?", "Has there been sufficient investment in the other hospitals where people may go?" and "When we are told that there will be more clinical activity in Navan, what exactly is it that is being proposed?"

There were 105,000 adverse incidents in the hospital system last year. This means people were misdiagnosed, mistreated and given the wrong medication. It means people died or were disabled by those actions and that people are extra sick because of the misactions of the HSE. Which one of the Minister's extremely well-paid staff is responsible for this increase? Is there any accountability? I spoke to senior clinicians in the RCSI Hospital Group. They told me that the closure of Navan hospital emergency department will increase the number of adverse incidents in the group. The excuse for adverse incidents being a reason to close the emergency department is wrong. I ask the Minister to review the decision, to not gut hospital capacity during this time of crisis, to maintain the emergency department in Navan hospital and to invest to make it safer.

There is a question that the Deputy and I, as elected representatives, have to answer. If the Deputy and I, and all of us present, are being told not in private conversations where maybe we can or cannot quote directly and name individuals but on the record by the senior doctors that we need to do X, Y and Z-----

We are being told different.

Okay, but if we are being told in open session by named individuals whom we can hold to account that changes need to be made to the healthcare system, be that investment in the National Ambulance Service, in mental health services, in minor injury units or in more care, to protect the lives of the people we represent, then what do we do? This is a really important issue for Navan hospital and the communities. I am proposing that we all get together with the doctors, who have to put their names and reputations out there, and put the questions to them directly and to inform them of what we have been advised. We need to listen carefully to them and then, as elected representatives, we need to have a conversation around what is the best thing to do for the people of Navan.

The Minister needs to talk to the doctors in the RCSI Hospital Group.

We are way over time.