Health Services: Statements (Resumed)

I welcome the Minister of State, Deputy Jim Daly, to the House. There are so many issues in respect of our health service at the moment that it is very hard to know where to start. However, I will start on a positive note and mention that yesterday was World Diabetes Day. I thought of Senator Butler and how he successfully managed to take his health care into his own hands in order to avoid having to take up to nine tablets a day for the rest of his life. Senator Butler lost six stone and turned his life around in doing so. We all commended him at the time and World Diabetes Day is a timely reminder that diabetes is a most serious disease which will affect an estimated 640 million people by 2040. The majority of those 640 million people will be affected by type 2 diabetes, or adult-onset diabetes. Some 70% of these cases could be prevented through lifestyle interventions, just like in Senator Butler’s case. In these cases, it does not take tablets or operations but a lot of hard work and encouragement to do so. In July, Senator Butler called on the Government to provide for diagnostic testing which would alert people to the fact that they are in danger of developing type 2 diabetes. This testing is currently too costly for many and so I echo Senator Butler's call and urge the Government and the Minister for Health to introduce testing which we all know would save money in the long term.

On an entirely separate matter and one which I was bitterly disappointed to hear about, parents of children with scoliosis have been informed that the planned outsourcing of procedures to France is now not to go ahead. Parents had been told initially that the plan was for 20 children to travel to France for surgery. They have now been informed that treatment in France was offered to some families but those families turned down the option and that, "[u]nfortunately as families declined this offer this will not proceed at this time." I would be very interested to know why there is not a system in place to offer a declined position to another family with another child who is suffering while awaiting a life-altering procedure. According to the Scoliosis Advocacy Network, with which I have been in contact, it has asked other parents and not one family out of approximately 600 has ever had France mentioned to them. In fact, there are many on lists who were never contacted about outsourcing at all.

The goalposts are moving and it is not acceptable. We have gone from a situation where no child was to wait longer than four months for surgery by the year end to a situation where children will be offered a plan. The year 2017 is drawing to an end and still too many children remain on surgery wait lists. For some there is no hope of a date for their surgery before Christmas. They end 2017 as they started it: waiting for scoliosis treatment. I sincerely hope there will be no attempt to spin the figures when the targets at the end of the year are not met.

While I am on the topic of parents having to fight tooth and nail for health care for their children, the initial decision made by the HSE not to fund the life-changing drug Vimizim for children with the ultra-rare disease such as muchopolysaccharidosis is utterly devastating, in particular for the two families whose children are currently in receipt of the drug. BioMarin has agreed to continue providing Vimizim compassionately until 5 December 2017. After this date, vulnerable patients will no longer have access to this life changing drug. The numbers here are minute and I encourage the Minister for Health and the Minister of State to leave no stone unturned with regard to funding this drug. It is a ticking time bomb for these vulnerable patients.

One such patient who was brought to my attention is a girl called Grace McIntyre. Grace is a nine year old girl who has not really known life without Vimizim. She is one of two children in Ireland who are participating in the compassionate programme provided by BioMarin. Grace’s parents are extremely fearful for her future and are living in limbo not knowing what will happen to their daughter after 5 December and the turmoil they are facing is compounded by the fact they do not have any other medication to turn to. Vimizim is, effectively, their only lifeline. Why is it that the HSE cites a lack of clinical data when Vimizim gained licensing approval from the European Medicines Agency in April 2014 and is currently funded by more than ten European countries, including Northern Ireland, which is less than 90 minutes from Dublin?

I welcome the Minister of State's comments on district hospitals and the nursing home sector. It is important to distinguish the two. I would welcome investment in the district hospital network. Those hospitals are a valuable cog in the delivery of a modern health service and should not be seen as a relic of a bygone era. As the Minister of State knows, they facilitate discharge from the acute hospitals sector and prevent admissions to the acute hospitals sector. They often act as an interface between the acute sector and the fair deal, where a person is waiting to go into a nursing home. Not to be too parochial, while the treatment in our own district hospital in Belmullet is excellent - we recently had a HIQA inspection - the building is crumbling. I have been speaking to the Minister about this and lobbying him. We need a new hospital given our distance from Mayo University Hospital, which is more than 50 miles away in Castlebar. These facilities should receive investment, especially given most of them have a quick turnaround time. Patients are not languishing in them for long periods. They are a vital cog that will take the pressure off the acute sector.

The Minister of State mentioned €25 million provided in the 2018 budget for primary care, which is welcome, but it really is a drop in the ocean. I have spoken about this to my niece, who is in her final year of her medicine degree in Limerick. If we want our young graduates to enter the specialty of general practice and to entice our young GPs back from abroad, we need to see at least a partial reversal of the FEMPI cuts. The whole sector has been decimated since the introduction of those cuts. It is a scary figure but 900 GPs will retire in the next five years and young GPs are not there to replace them.

We try to be solution-driven. Will the Minister of State consider one proactive initiative, namely, the establishment of a 24-hour emergency line for general practitioners to enable them to access the CAMHS for adolescent patients who may be suicidal? It is a service that is badly needed. In some parts of the country children can wait over a year to access the CAMHS. The service would not be abused. In my busy practice I would not expect to have to ring it more than twice annually. It would ensure young vulnerable patients would be seen within 24 hours and be able to skip the queue because they were suicidal. Far too often they end up in emergency departments, which is wholly inappropriate in terms of their assessment by a psychiatrist. I would appreciate it if the Minister of State would consider that initiative.

I welcome the Minister of State and his officials and thank him for such a comprehensive report. Health is a wide brief and he has chosen to focus on particular issues which Senators have raised in the House.

A service which is close to my heart and to which I have referred regularly in the House is the national rehabilitation service. There is a real need for a master plan or to receive an update on previous plans. What might happen in County Roscommon or in Munster? I was present a number of weeks ago at the National Rehabilitation Hospital in Dún Laoghaire when the Taoiseach and the Minister for Health, Deputy Simon Harris, turned the sod for the development of a new 120-bed facility. It will replace an existing 120-bed unit. It is important, therefore, that we do not get too excited over it. The Minister of State referred to upgrading. It is right that we do so to ensure facilities are fit for purpose. I acknowledge that it is a real start. Of greater concern, however - this is a matter I have raised in the House often - is that on 1 January this year 12 beds were closed in the hospital. I have engaged regularly with hospital management, the Minister and the Department and been drip-fed responses and answers. First we were told that all of the beds would be open by the middle of the year. That did not happen but two were opened eventually. We were then told that the problem was the lack of staffing resources. Where the staff had gone? In recent days the hospital authorities have confirmed that there are now four beds open, which means that eight still remain closed since 1 January. It is frightening to look at the huge waiting list for the service, but the patients in question are not at home but in other acute beds in other hospitals that could be freed up for others. They have been identified as patients who require intervention in the National Rehabilitation Hospital, yet there is no facility that will take them When I spoke to hospital management again this week, I was told that there were four beds open. I appeal to the Minister to produce the necessary resources or explain the reason he is presiding over a situation where eight beds remain closed at the National Rehabilitation Hospital because it is unacceptable.

In his acceptance speech on becoming leader of Fine Gael, the Taoiseach promised leadership in the health service. Today I looked at his speech again and one of the things he emphasised was the need to lead from the front in the health service. I acknowledge the hard work done by the Minister who is very diligent and keen to deliver within the limits of the resources available to him, but it is not an easy brief but a tough one.

Will the Minister of State clarify something about Sláintecare? Originally, it was to be centralised in the Department of the Taoiseach rather than the Department of Health but now we hear reports that it will be centralised in the Department of Health. What does that tell us about how health services will be prioritised? How is that leading from the front and recognising that this is an important issue? It is important that we be told in coming days what is the future of Sláintecare. Who will co-ordinate it? Who will lead from the front? Who will assess it? Where will the unit and its funding be based? There is an issue in that regard.

In press reports yesterday we heard from the consultants' association that there were 400 vacant posts. Why is that the case? This is an issue we must explore in detail. Research which was published recently showed that in 2016, 83 consultant posts were advertised but no applications were received. We must ask why people do not believe they can expect to have a meaningful job with proper remuneration and everything that goes with it. What is the problem and how can we address it?

There are ongoing issues in hospitals. I single out Tallaght hospital since there were reports in several newspapers this week that there were 425 patients on trollies there this month. At one point, there was not a single senior consultant in place to oversee the emergency department in the hospital. That is serious. It is a question of having confidence in health services. One does not really engage with the health service until a loved one or a family member or oneself is sick and needs to access services. The ongoing trolley delays are unacceptable and we have not even faced the worst of the winter problems that occur annually. It is not acceptable that there are hundreds of patients on trolleys in hospitals. Someone told me recently of how they had not been lucky enough to be even on a trolley; they had been put in a wheelchair because there were no trolleys available in the hospital in question.

The Minister of State has covered matters such as the health budget, the HSE and the national service plan. I referred to Sláintecare and hope we will receive clarification on the matter in the coming days. I welcome the funding for the National Treatment Purchase Fund. It is interesting that when the Government has a focus and sets targets and budgets, things seem to happen. Therefore, I welcome what the Minister of State set out on the National Treatment Purchase Fund. Once treatment is provided and we deliver the service, I do not care who does it. I have no ideological hang up about who should provide the service, once it is professional and responds to the needs of patients. We need to get over that hurdle because people ask about the policy. If it is possible to have something done outside the public system for patients on waiting lists, we should proceed.

I am somewhat disappointed by the figures for scoliosis patients. A few days after a sad and harrowing documentary produced by RTÉ's "Prime Time" programme, the Minister responded. He organised an interview to give a response. He needs to return and honour and deliver on the promises and commitments he made. We must deliver on the promises made to scoliosis patients because it is important that we do so.

I again thank the Minister of State and his officials for being here.

I welcome the Minister of State and thank him for the comprehensive overview. It is important to thank everyone in the Department, across the HSE and everyone involved in the provision of health care which is always demanding.

It is important to begin on a positive note. We regularly speak about waiting lists. It is right that we raise the matter and try to deal with it to make the service more efficient. Nevertheless, we should recall the figures. There are 3.2 million attendances in outpatients departments annually, or 63,000 weekly.

There are 1.2 million attendances in accident and emergency departments, which is 23,000 weekly, and 16,000 patients attend hospitals each week for day care procedures. Although a large amount of health care is being provided across the board there are still bottlenecks in some areas so it is important that we deal with them.

While I welcome the increase in the budget, my concern is the use of that increase. We must ensure that we deal with the areas where there is an urgent need for reform and improvement. I have raised this issue previously. There was an increase in the budget over the last two years, but there was also a substantial increase of over 2,000 in administration and management from December 2014 to April 2017. At the same time there was an increase of only 39 in the number of public health nurses. That imbalance should not arise. When we provide additional funding it is important to ensure that we are also providing additional people on the front line. There is a need for an urgent examination of management within the HSE and of why certain places appear to have difficulty with retention and continuity. As I have pointed out previously, I am aware of one hospital that has had ten managers in 18 years. There is a problem if that is occurring. Either the pay or the supports are inadequate, but nine people have moved on and the hospital is now on its tenth manager. This is not a small facility. Something must be done so that when such an issue arises management at senior level in the HSE can respond to it. If there is no continuity in management, there will be a problem.

Another huge concern for me is the development of further facilities in the Cork area. My colleague spoke about the rehabilitation services. It is 15 or 20 years since we first talked about opening a rehabilitation unit in Cork. There is a need for such a unit in the Munster region. It could be included in the development of a single major new facility in Cork. The Fitzgerald report in the 1960s suggested that Cork should have two major hospitals. We built one but we appear to have forgotten about the second. The national development plan should include the provision of funding for a new state-of-the-art medical facility that not only caters for the increase in population in Cork, which has increased by over 130,000 in the city and county over the last 30 years, but also for the increase in population in the Munster region. That is extremely important. Rather than obliging people to transfer to Dublin where the expertise is, we should also grow that expertise in Munster. The Dublin facilities are already under substantial pressure.

An issue that has come to light and been discussed extensively over the last two or three years is support for general practitioners. The report published by Trinity College in the last few days must be carefully examined. It studied a number of jurisdictions and how to develop and provide the necessary supports for general practitioners so they can provide services and, as a result, keep people out of hospital and reduce the number being referred to hospital. It also examined the issue of e-health. This is now in the Cork area and is also being introduced in the rest of the country in respect of maternity services. The system is becoming computerised. It is up and running in Cork and Kerry and there is talk of developing it in Dublin. It is about ensuring that all the management of this area would be computerised. I am aware that there was an initial problem in Cork. While the system was put in place and was up and running for the patient and the hospital, there was a disconnect in the system for general practitioners.

The report, which was published last Monday, highlighted the need for connectivity between hospital services and GPs. In one of the countries studied, Israel, patients can go online and get access to their files. Denmark and Germany were also studied. We are way behind in that regard. While the roll-out of new services is important, it is also important to engage with modern technology and ensure it is in place so GPs can get access to it. That access is not just about referral and getting the results of the work done in the hospital, it is also about getting diagnostic reports. In a huge number of cases the GPs know exactly what is wrong with their patients but they must have it confirmed by getting access to diagnostic services. This must be given priority.

We also must consider the funding for GPs. My understanding is that it is 4.5% of the overall health budget. That must be examined if we wish to keep GPs in this country. My colleague, Senator Swanick, raised the number that will retire from the service. I was in Plymouth recently with the National Association of General Practitioners. We were in one area where all the GPs who were serving 20,000 patients handed in their contracts and walked away from the practice. They could afford to do it because they knew they could get jobs somewhere else. The local hospital was forced to employ other GPs to ensure some level of cover was provided. That is a challenge this country will face in the next five to ten years unless we start to deal with the concerns of GPs. It is extremely important to deal with those in the new contract for GPs.

Finally, I wish to raise the issue of respite care. I received a report from the HSE in the last two weeks. I refer to respite care not just for elderly people but particularly for people with intellectual and physical disability, where parents are caring for children who are now adults. We have a huge ageing population of carers who have been looking after their children for 30, 40 and 50 years. The HSE has identified a need for 2,244 extra respite places between now and 2021. We must prioritise that and see where we can develop at least 500 new places per year between now and 2021. I ask the Minister to give priority to that.

I am sharing time with Senator Warfield.

I welcome the Minister of State. I wish to record my dissatisfaction with having statements on this because they appear to prevent action. Yesterday in my local hospital, St. James's Hospital, there were 15 patients left on trolleys. The national number was 428. One does not often think of this with respect to children but in 2016 Our Lady's Children's Hospital in Crumlin had the highest number of children on trolleys. By the end of this year it will have had more than 1,000 children on trolleys. Up to November, almost 10,000 elderly people have been left waiting for over 24 hours for accident and emergency treatment.

These problems and a myriad of others, and I can give many examples, are directly linked to the fact that overall public health service employment has decreased since 2008. Recruitment and retention in the public health service are the core reasons the sector is on its knees. I wish to focus on that and I seek clear answers from the Minister of State on the Government's plan to tackle these issues. In November 2014, Dr. Stephen Thomas of Trinity College Dublin's centre for health policy and management said that we had experienced the biggest proportionate drop in health care across Europe as we had lost almost 20% of our health funding and at least 12% of our staff.

The IMO quoted that we have a "manpower" - maybe it meant woman power - crisis within hospitals. It rightly acknowledged that the HSE is no longer an employer of choice, and the skills of a growing number of doctors, nurses and midwives are actively sought by European and international health organisations.

Some facts that the IMO has identified about this issue include that at any one time there are up to 400 vacant consultant posts. Those posts, when advertised, often attract no applicants. Nursing is the backbone of the health service. A total of 78% of final year nursing and midwifery students have already been offered full-time permanent posts in other countries. They have more attractive terms than those available here. Pay, training supports and career progression, along with poor working environments, are the key factors in decisions to emigrate. The shortage of doctors, nurses and midwives is leading to unsafe work practices and negatively impacting on patients. We are not replacing those staff who leave and young nurses without experience are being left to cope.

In a recent response to a parliamentary question from the HSE we learned that the number of nursing students has increased since 2008, which I welcome, but the number of staff nurses has decreased by 10%. We are not striking the balance well in terms of recruiting those who are newly qualified and retaining the experience and expertise required to keep the health service running smoothly. We have a brain drain and we have a massive haemorrhage in the experience we need.

Many times in my nursing career my experience served me well and that is then passed on to younger nurses who will then take over the helm, but that is not happening at the moment. It is part of the informal training and sharing with the newcomers and shaping all the talent they have into being a good practitioner. However, if we are not fostering conditions to incentivise experienced nurses to stay in their posts we will end up with a young nursing workforce left with no elders from whom to learn. That compromises the duty of care and endangers the lives of patients.

The reality is that Ireland cannot compete with the UK, Australia and others to retain new graduate nurses. The offer a few years ago of the insulting yellow pack graduate scheme began the exodus of nurses who said they had enough. We also have incentives and bonuses provided by private companies of between €3,000 and €5,000 for signing up with them. The impact of the shortage of staff is enormous and results in the curtailment and closure of services. I invite the Minister of State to comment on the proposed closure by the end of this month - we have two weeks - of the high observation unit in Tallaght Hospital. Cappagh hospital has a nine-bed unit but six of those beds are permanently closed, although there is a massive waiting list because of staff shortages.

There is a curtailment in the development of psychiatric services. I ask the Minister of State to also explain why we do not even the basic maths involved in our spending on the child and adolescent mental health service, CAMHS. The HSE does not do budgetary oversight.

In order to work as a nurse or a midwife in the Republic of Ireland one must obtain a certificate of registration from An Bord Altranais, the governing body, but there is a real problem with highly skilled experienced staff. More than 100 nurses unsuccessfully tried to obtain registration. I raised the issue previously and it has been discussed. I spoke to those nurses who are now working in non-health care settings because of the inflexible criteria of hours that must be divided between theory and practice by An Bord Altranais. We must examine the issue and add flexibility that does not compromise patient safety or care. It is a short-term objective and it is doable. The Minister of State should meet with An Bord Altranais to progress the issue.

Sinn Féin seeks to propose increasing nursing numbers by adding 500 each and every year over a five-year period, bringing the total to 2,500 which would be followed by further recruitment. The more people one has that are active and excited about working in pleasing and satisfying conditions the more people will want to join. Sinn Féin is often unfairly and wrongly accused by other nasty Senators of not offering solutions to problems. We have given several solutions, including the comhlista initiative and this morning Deputy Louise O'Reilly launched on our behalf an approach to the trolley crisis, which sets out comprehensive proposals and analysis on tackling the problem. I ask the Minister of State to outline in detail the Government's approach to tackle the issues I have addressed. I also urge him to work with the trade unions on staffing so as to make the health service fit for purpose.

I thank the Minister of State, Deputy Jim Daly, for coming to the House. I wish to talk about sexual health. In 2016, HIV transmission rates in the State rose to more than 500 new cases in a year for the first time this century. We are going in completely the opposite direction to our European counterparts. As part of the Department of Health's national sexual health strategy from 2015 to 2020, two of the key recommendations were to develop and implement guidelines for the appropriate use of antiretroviral therapy in HIV prevention.

We must ask what is driving the increase in HIV rates because it is not due to those who know their status; it is due to terrible sexual education in schools, poor access to services and a lack of availability of PrEP, pre-exposure prophylaxis. I was in Baggot Street clinic last night. The place is condemned. Paint is falling off the walls. One is required to go to the bathroom to conduct part of the test but the lights are not working in the bathroom. It is not a pleasant place for a sexual health service to be located, although it is quite a good service.

As the Minister of State is aware, PrEP has been hailed as a step forward in the fight against HIV and it is the most suitable response to the HIV crisis we are in at the moment. Two years on from the launch of the high profile strategy the PrEP working group is assessing PrEP for HSE availability and it recently announced that it was conducting a cost-benefit analysis of Truvada. Last week in the High Court, Gilead lost an injunction case which will allow generic manufacturers to produce PrEP and provide it to Irish users, but the drug will need to be assessed by the HSE. My question is about if and when it will happen. As I indicated, 500 new cases of HIV are being loaded onto an already stretched health service every year. The longer that goes on the more embarrassing it is for Ireland and the longer it goes on the further we will fall behind our European counterparts. Not only are we not being proactive in tackling the issue we are literally stopping people buying the drug online as it is being picked up by Customs at ports. I urge the Minister, Deputy Harris, to speak publicly about sexual health. His silence has gone on for too long.

I welcome the Minister of State and his officials to the House. The Minister of State began his contribution by setting the debate in the context of the budget for 2018. We have gone from 2014 until 2017, and we are into the fifth year post-recession, since the troika left Ireland. I do not enjoy saying that the recession has not ended for people with disabilities and mental health needs when it comes to the health service. It is very interesting that the Taoiseach said on the night he was elected on 14 June that we are renewing our commitment to ratify the UN Convention on the Rights of Persons with Disabilities this year. There are six weeks to go to the end of this year. He also committed to improving services available to people with disabilities, especially respite care and emergency residential places. They did not figure in any obvious way in the Budget Statement.

It is quite interesting that two issues the Taoiseach named, two among many, have been raised again by Senator Colm Burke and others. There is a real issue if something the Taoiseach prioritised the day he was elected does not turn up four months later in the budget.

Several areas were mentioned in respect of needs of people with disabilities, for example, personal assistants, a range of community and home supports such as home help, and access to various therapies. We could call that a basket of community supports. The Minister of State mentioned in his extensive speech that there are 23,000 people in nursing homes. Approximately 5% of them are young people with disabilities who should not be in nursing homes. There are 1,200 people our age and younger in those nursing homes. A person's average length of stay in a nursing home is two years and the next location is a grave. It is absolutely unacceptable by any metric that young people with disabilities, regardless of their critical needs, are in that situation. Part of the reason for it is that all the instruments in the community, home supports and personal assistants have been shaved, year in year out. When people from the HSE come along the only tool in their box is an application for a nursing home. That costs the State money.

The UN Convention on the Rights of Persons with Disabilities refers to deprivation of liberty and changing legislation to deal with that. If we just changed how we provide services we might not deprive people of so much liberty, not only their own but that of their family members. These are young people, many of them in family situations. They are real issues. I am grateful that I can depend on Senator Boyhan to mention the 12 beds in the National Rehabilitation Hospital, NRH, four of which are now open. These are for the same group of people who are locked away in acute hospitals which have huge pressures. They cannot get into the NRH and the problem is how to get from there to their homes and all that involves.

I was in Longford last night at St. Christopher's Services for Persons with Intellectual Disabilities. The Minister, Deputy Harris, was there a few days earlier. I thought they had spruced the place up because I was visiting, then I realised the Minister had been there. The critical areas were mentioned to him, such as access to psychological and behavioural support services. They are trying to get through with one tenth of a professional per week to support people. That is just an example of the problems.

A councillor who spoke to me during the week had made representations on behalf of a 40-year old woman with multiple sclerosis, MS, whose situation had deteriorated significantly in the past year, from being ambulant she is now using a motorised wheelchair. I am not slagging the HSE but somebody said the only way that woman would get a service is when somebody else who has MS dies. That is not an isolated case. There are many such cases. There is a crisis but it is behind people's doors and does not burst into the open. It is important for the Department of Health to own up to the fact that there is a real problem, then let us see if we can work towards fixing it. That will take time. The demographics are going against us. People are living longer. The census has told us the number of people in the State with disabilities has increased by 0.5%, from 13% to 13.5%.

I have tried, time out of number, on the Oireachtas Joint Committee on Health to get estimates or guesstimates of the projected need for people with disabilities and mental health needs in this State. An estimate may change. It is like budgeting but there is a reticence to say these are the issues that we have. We cannot deal with them if we do not put them up front. Does the Minister of State or the Department have figures and estimates for waiting lists, the closing of waiting lists and some sense of the issues confronting this country? I will be the happiest person in the world and will come back here and go on my knees if I am wrong and apologise. The whole problem of disability and mental health needs is going to burst open on us. This is surfacing and people are taking it on the chin in their homes in every town and townland in the country. Please give us the estimates and figures. Let the people of Ireland know what we are dealing with so that we can say honestly we will or will not do something about it. Right now, the situation is totally unacceptable.

I welcome the Minister of State and his officials. I also welcome the fact that there has been an increase in the health budget this year, after several years of increases. That is truly welcome because for many a year when I was Minister for Health all we had was a diminishing budget. Health is such a huge area that it is not possible in five minutes to address it comprehensively in any real way so I will focus on an area that is on people's minds, namely, primary care and community. It is of note that in a recent survey by Professor Tom O'Dowd mental health services were top of the list for 1,000 people interviewed. That is a very important area. On-site X-rays were next, followed by minor surgery, blood tests and lifestyle advice. I will come back to that last point because I often said when I was Minister for Health that I felt I was Minister for ill-health as we seemed to talk only about illness and disease, instead of about keeping people well, prevention and early intervention.

Reform remains key and capacity in our hospitals is an issue but we need a transitional fund if we are going to move the focus from hospital care to primary care. I welcome Tony O'Brien's comments in this regard. If we do not have that we cannot achieve it. Any time we want to change things it requires energy and resources. We did not have the money in the past to do that but we do now and I welcome the fact that this is acknowledged in the ten-year Sláintecare report. I firmly believe that we need to treat patients at the lowest level of complexity that is safe, timely and as near to home as possible, and affordable for the patient. I see that echoed in the report and welcome it.

In his report on primary care, Professor O'Dowd also says that the secret sauce at the centre of successful outcomes for patients is regular contact with a good and caring doctor. That brings me back to the old definition of general practice, which still holds true for me, namely, primary, personal continuing care. The two words in the middle are very important, "personal" and "continuing", that patients go to the same doctor who know them and their history, so that particularly in respect of mental health issues they do not have to open up to somebody new and go through their whole story again.

I have met many patients who have been frustrated by this and cease going to their clinic because there is a different doctor there every time they go and they do not have the energy to go through it all again, whereas meeting somebody on an ongoing basis who can help to manage a patient's condition, knows his or her story, family and community is very valuable for him or her.

As everybody understands, we need a new GP contract. I heard Senator Keith Swanick mention the FEMPI legislation. This will be a sore point for many doctors because while we had to take these measures during the financial emergency, they see many sectors coming out of it but do not see any progress at their end. That will be a problem. That aside, a new contract needs to focus on well-being and health. I again refer to the survey of lifestyle advice about keeping people well.

We also badly need more day hospitals. The Minister of State is familiar with the hospital in Bantry which is in his neck of the woods. There are also Nenagh, Ennis and Louth county hospitals. We need more day hospitals in Dublin where patients can undergo inpatient procedures for a hernia, gall bladder, etc. We need one in Swords which would be convenient for people living on the north side of the city who would come out against the traffic. It will allow Beaumont and the Mater hospitals to run outpatients' clinics which would be much more convenient for patients. In the new primary care centre in Balbriggan, which is up and running, we need diagnostics. Patients want to access X-ray facilities. It is included in the survey but doctors know it. There is nothing new in this. In County Donegal where a high value has always been placed on primary care services because of the geographical spread of services, there were X-ray facilities in four areas. There was one in Killybegs, but I cannot remember the others now. I heard Senator Keith Swanick talk about one in Belmullet. That is the way forward. We cannot keep doing the same things in the same way. Reform is key.

We need to expand primary care teams with more allied health care professionals. When I had a physiotherapist in my practice, instead of reaching for the prescription pad to prescribe a non-steroidal anti-inflammatory, I reached for the pad to refer a patient to the physiotherapist and the outcomes were better. If we have these facilities in the community, we would keep people well. It is never as sexy politically or as attractive for politicians to be involved in good public health policy as it is to launch a new MRI scanner or a new hospital wing, but we have to focus on public health policy. I welcome the tobacco and alcohol control Bills and the sugar tax, but we need joined-up thinking across the board. From the point of view of the health budget, we need this transitional fund to make these changes happen because acutely ill patients take precedence, rightly so, but if we keep doing this, we will never address the flow into hospitals.

While I am disappointed that the Minister for Health, Deputy Simon Harris, is not present, everything I am about to say I have said to him directly and have put in a letter to him. He has been in County Donegal on several occasions, but I will reiterate the points made today.

Letterkenny University Hospital is the sixth largest hospital in the State. It caters for over 23,000 inpatients every year, but one would not know it from its budget. The budget allocated to it is one third of that allocated to the four major hospitals in Dublin. I appreciate that they deal with specialties and deserve more money, but a sum three times more cannot be justified.

The implications for Letterkenny University Hospital are profound. The number of patients on trolleys is the highest ever in the history of the State. Sick and elderly patients have to wait a long time and are then left in the undignified situation where they are left on a trolley or in a bed which is not specific to their needs. Many are forced to be on trolleys in the hospital. The waiting list runs to almost 17,000. If we include those waiting in south Donegal to access Sligo hospital, one in eight people in my home county is on a waiting list that is growing all the time. I note that the previous Minister, now Senator James Reilly, acknowledged that there had been years of under-investment in the health service. Now we have a crisis. The recent budget was an opportunity. Deputy Pearse Doherty and I put together a document entitled, The Need to Invest in Letterkenny University Hospital, which we submitted to the Government, the HSE and Saolta. We expected to see a clear signal in the recent budget that in 2018 there would be a serious attempt to address the crisis in Letterkenny University Hospital and elsewhere, but no new net investment was provided for. Given the expenditure already committed to and the need to allow for growth in the population, there is no new investment. The crisis in Letterkenny University Hospital will continue. Fianna Fáil and Fine Gael supported the budget. Both parties need to take responsibility for the continuing crisis in the health service and the fact that it will not diminish in 2018 because of the failure to provide adequate funding. Instead, the Government has provided for marginal tax cuts across the board. That is wrong when there is a crisis and people are suffering throughout the State.

A short stay ward with 20 beds in Letterkenny University Hospital has not been deployed for a long time. The hospital has asked for approximately €2 million to open the ward to take the pressure off the emergency and other departments, but that funding has not been forthcoming. It really needs investment justice in order to receive a fair share of investment that will reflect the number of patients for whom it caters. It is a major hospital; it is the sixth largest in the State, yet it is getting a fraction of the investment hospitals in Dublin receive. The funding allocation system for hospitals is totally wrong. There is no good in Fianna Fáil and Fine Gael politicians speaking on their local radio stations and pleading on this issue when they have just passed a budget that will not address the crisis in 2018. That was a huge mistake, but it was a choice they made. I believe the implications of that choice will be evident in the hospital system in County Donegal and elsewhere this winter and in 2018. That is completely unacceptable and wrong.

I welcome the Minister of State, Deputy Catherine Byrne. Many of my questions would be more appropriate to the Minister of State, Deputy Jim Daly, who has departed. If the Minister of State, Deputy Catherine Byrne, is not in a position to reply to them, I would be grateful to receive a reply in writing. I acknowledge that a commitment to provide for dual diagnosis was given in the Minister of State's statement, Senator Frances Black will want more specific detail on the improvements that will be made.

I am concerned about the provision made in the 2018 HSE service plan for the 55,000 people with dementia and the specific priorities and commitments given. The statement was light on detail on services for people with dementia. Does it include an expansion in the number of dementia service advisers to build a national network? The all-party Oireachtas group on dementia services, for which I am co-convener, called for an investment of €1.6 million to move from eight dementia service advisers nationally to 30 and to build on that figure year on year. When we met the Minister last week, he said he would get back to us, but I have still not heard from him. I would like to know where we stand.

I am also seeking an update on the call for €6 million ring-fenced dementia-specific home care funding. There was mention of home care but not dementia-specific home care. The all-party group also asked for money to be set aside for assistive technology innovations, the continuation of the general practitioner prepared project as well as €1 million support for people with Down's syndrome and dementia. People in that group get early onset dementia and they are not really catered for either in the disability or older people's sectors. I would be grateful for some specifics and if the Minister of State cannot give them to me now I appeal to her to write to me.

Will the Minister outline proposals for the extension of home care? I heard this morning that €37 million is being allocated for older people. The allocation is not all going to home care. One of the officials at the Joint Committee on Health said two thirds of the allocation would be for home care. I am seeking a transparent figure on the budget for home care for 2018 versus what it was for 2017.

I also heard this morning at the Joint Committee on Health that it will take two to three years to roll out home care under the statutory scheme and regulation. That is too long for the people who are waiting for home care. There are 195,000 carers waiting and the wait is simply too long. I call for a greater sense of urgency.

Will the Minister for Health outline progress in his Department on adult safeguarding? Since the Adult Safeguarding Bill passed Committee Stage considerable development work has been undertaken, including two hearings at the health committee, new research from the Institute of Public Administration published in October and newly-commissioned research currently under way at UCD. Will the Minister for Health give an update and note my readiness to work with his officials on this important aspect of public policy? I have written and offered. I am doing a good deal of work on this, but I cannot simply talk to myself.

What provision is the Minister for Health making to tackle the waiting lists in the Central Mental Hospital? The Minister of State, Deputy Byrne, was here to hear me speak on the matter last year. Some progress is being made but the lists are still among the highest in the country. I know the doctors there are looking for €2.7 million to maintain progress for running costs. I want to know the position with regard to that figure.

The first issue I wish to raise is the crisis in physiotherapy in Mayo. Hundreds of children and adults are waiting for physiotherapy. Some are waiting for an initial appointment while others have been clinically deemed as desperately needing physiotherapy on a weekly basis but they have not had physiotherapy for months. I appeal to the Minister of State and the Minister to address this. It has been going on for months.

Whole swathes of the county have been left without any physiotherapists. That is not right either on a social or humane level or a financial level either. We have people who cannot be discharged from the acute hospitals, either Mayo University Hospital or University Hospital Galway, because they do not have the necessary physiotherapy services in the community. There was a panel of physiotherapists. It is not as if we could not recruit them. I know this because I have seen a physiotherapist myself for months. They were all on a panel waiting to be appointed but they were not appointed by the HSE. This happened even though the positions were there, whether it was a case of maternity leave or those on long-term illness. The HSE would not actually appoint people in the positions to provide the medical attention that others needed. It is not right to leave these people in pain. It also means that they cannot be discharged to the district hospitals.

I heard my colleague, Senator Swanick refer to Belmullet District Hospital earlier. I was surprised and puzzled by this promotion of district hospitals. I have a deep belief in the value of district hospitals, including the hospital in Belmullet, but the truth is that Fianna Fáil cut half the beds in the hospital in 2010. This was in spite of a local action group begging and pleading for the beds to be left open. I find it somewhat perplexing that those in Fianna Fáil now say they value our district hospitals and that we need to have them upgraded and so on. Why then did that party cut the beds by half only a couple of years ago? That perplexes and bamboozles me. Perhaps there has been a change of policy and they now realise that these services have to be delivered locally or that as many services as possible should be local to the people.

We have seen how centralisation and privatisation has not worked. The centre of excellence in University Hospital Galway hospital is good but we still have people sitting on chairs and dying of cancer while begging for treatment. That is the reality, I am not making it up. Indeed, it has been the reality for many years. Wards have been closed because ceilings are falling in. Everyone knows that we need proper capital investment and a proper refurbished purpose-built hospital with parking and everything else that is needed at Merlin Park University Hospital. The grounds are available. All that is needed is the capital. We are told that we are in the recovery and that things are going well. Those of us in the west deserve a hospital and proper treatment. We deserve a hospital that will meet the needs of the population in the west. We will not let up until we get that hospital. We deserve it.

I wish to raise the issue of the approval of Translarna. I thank the Minister for Health, Deputy Harris, for agreeing last Friday to meet Anne Marie Harte and Lewis Harte, her son. He is one of the little boys who desperately need Translarna. He is six years old. Only two little boys in the country need this drug. It has to be approved. As I said to the Minister the last day, I am begging with him not to get entangled in the legal process. There is a window of opportunity for negotiation between the drug company and the HSE. They need to sit down for the sake of these two boys who are eligible at the moment. Only three other boys will become eligible. I appeal for a commitment from the Minister or the HSE to meet the drug company. I know the Minister has agreed to meet Muscular Dystrophy Ireland. That is important. He should also meet Dr. O'Rourke, who is an expert in Translarna. The drug must be made available sooner rather than later because time is of the essence for these boys.

I could cover many other issues on health, including the other topics referenced this morning such as home help and carers and so on, but I will keep those for another day. I want to secure a decision on Translarna and proper physiotherapy services in Mayo.

The Minister of State will respond. While she is gathering her thoughts, this is something we might look at in the Committee on Procedure and Privileges. I noted on the monitor that the Minister of State, Deputy Daly, spoke for 35 minutes. That is probably his entitlement but several Members are confined to either eight or five minutes. Then the Minister of State, Deputy Byrne, has only five minutes to respond. We should look at the possibility of greater time to respond to the queries of the Senators. That used to happen under the last Government and probably the one before that, when I was Leas-Chathaoirleach. It is not your fault, Minister of State, but it is something we should look at. When Members call for a debate on an issue and raise pertinent questions, then the Minister who responds should be in a position to respond. I am not saying it is your fault, Minister of State. It is a general problem that I see and we should look at it for future debates. You have five minutes to answer many questions. You were probably not here to deal with some of them but ar aghaidh leat.

I thank all Senators for their input to this afternoon's debate. There are many issues that I will be unable to address, unfortunately. I have taken numerous notes. The Minister of State, Deputy Daly, was here before me and I know he has committed to follow up on some of the points as well. I will proceed with my statement and then after that I might be able to address some of the other points raised.

I thank the Senators for giving us the opportunity to speak today. I note that my colleague, the Minister of State at the Department of Health, Deputy Jim Daly, updated the House on a wide range of topics, including budget 2018 and the Sláintecare report as we move towards the implementation phase. He also updated the House on developments in his areas of responsibility, older people and mental health. I know he listened with interest to the contributions, which covered a wide range of issues. Where an undertaking was given, Senators will be provided with the necessary follow-up or any addition information requested.

I can assure the House that the Government is committed to making tangible and sustainable improvements to our health services and as the Minister of State, Deputy Daly said, the Sláintecare report provides a framework within which this can be achieved. I know that the Minister, Deputy Harris, is dedicated to use the levels of support and consensus around the report to build a health service where people feel valued, respected and well cared-for.

Of course we cannot underestimate the challenges we face. Too many patients continue to wait on trollies for admission to hospitals in cramped and overcrowded conditions, though Deputy Daly did note some improvements in this area. An ageing population will bring increasing pressure, as we all know, on our health services in the years to come.

I would now like to touch briefly on matters relating to my own responsibilities. As Minister of State with responsibility for Health Promotion and the National Drugs Strategy, I am determined to improve health outcomes and address health inequalities for the most vulnerable people in our society, including those with addiction issues, the homeless, Traveller and Roma communities, and refugees and asylum seekers. It is generally accepted that people from diverse marginalised groups experience poorer health outcomes than the general population. They tend not to access health services readily and often only present to services when their health has deteriorated. This is especially true of people affected by homelessness, who can present to services with complex needs, due to poor physical and mental health and problems with drugs and alcohol addiction.

I secured €7.5 million in budget 2018 for new developments, which will support a range of measures to improve access to health-related services for these vulnerable groups. Regarding homelessness, the emphasis in 2018 will be on supporting housing-led solutions and providing people who have experienced or are at risk of homelessness with the supports needed to secure and sustain permanent tenancies in line with the Rebuilding Ireland action plan for housing and homelessness.

My main focus this year has been on putting in place a new strategy to respond to drug and alcohol use in Ireland. The new strategy, known as Reducing Harm, Supporting Recovery, will cover the period from 2017 to 2025. It promotes a more compassionate and person-centred approach to people who use drugs, treating addiction first and foremost as a health issue. As part of this approach, I brought forward legislation earlier this year to enable the establishment of a pilot supervised injecting facility. This facility will provide a clean, safe, health care environment where people can inject drugs, obtained elsewhere, under the supervision of trained health professionals.

The HSE is currently leading a procurement process to provide a medically supervised injecting facility in Dublin city centre on a pilot basis. I chair the National Oversight Committee which will oversee the implementation of the strategy and includes members from the statutory, community and voluntary sectors, as well as clinical and academic experts. The committee held its first meeting in September and will meet on a quarterly basis to keep progress in implementation under review during the lifetime of the strategy.

On behalf of myself and my ministerial colleagues in the Department of Health I would like to thank Members for the opportunity to speak here today and for their contributions. I will turn to one or two of the contributions. I was not here for the first part of the debate, but I know a number of issues have been raised, particularly from Senators Swanick, Boyhan, Burke, Devine, Dolan, Reilly and other Senators.

I will reflect on what Senator Kelleher has asked for. I have taken down a number of notes, and unfortunately, the health issues that the Senator raises are not under my remit. I will speak to the Minister of State, Deputy Daly, on them and ask him to come back to the Senator on a personal basis. I apologise if in the past the Senator has been told that people would contact him and they have not. That is wrong. If we give a commitment to people, we should come back to them. The same applies in my own role. When I am asked a question when taking any Topical Issue matter in the Dáil or during a debate here, I make it my business to come back to people, particularly on issue that has been raised.

In response to the Senator who has raised the issue of Translarna, I will raise that with the Minister, Deputy Harris. A number of people have called into my office regarding this drug, thinking that it is part of my remit but it is not. On many of the other issues that have been raised, I hope Members are not offended if I do not individually answer their queries. I appreciate that Members have been present at this debate for a lengthy period. I was asked to appear here at short notice because the Minister of State, Deputy Daly, had to go somewhere else.

I apologise again to the Cathaoirleach and to Senators that the Minister, Deputy Harris, Harris unfortunately could not be here for this debate. However, I will confer with my colleagues here from the Department to try to provide answers on some of the major issues that have been raised and address Members' concerns around the different issues, which we have noted.

You are here so frequently-----

I will be back in another half an hour.

We should make you an honorary Member of this Chamber.

I thank the Minister of State. Any comments I made were not in any way directed at you, it is a general comment about how things work here.

Senator Colm Burke, would you move to suspend the House until 5.30 p.m?

I move to suspend the sitting until 5.30 p.m.

I thank the Senator.

Sitting suspended at 5.20 p.m. and resumed at 5.30 p.m.