Nithe i dtosach suíonna - Commencement Matters

General Practitioner Contracts

I welcome the Minister to the House. I have asked him here today to discuss the state of negotiations with general practitioners regarding a new contract, to outline a timetable for the reversal of cuts under financial emergency measures in the public interest, FEMPI, legislation to general practitioners; and to ask what contingency plans are in place to ensure the retention and recruitment of GPs, especially in rural Ireland.

GPs have suffered cuts of up to 38% under the FEMPI legislation and meanwhile patients with medical cards and GP visit cards have increased to almost half the population with the introduction of the under-sixes and over-70s schemes.

The FEMPI legislation was introduced as an extraordinary financial measure but it is now having dire consequences for the healthcare sector as a whole. FEMPI is a key factor in the high rates of emigration of GPs as the profession becomes untenable and unviable in this country. FEMPI cuts have destroyed general practitioners practices especially in remote areas and deprived urban areas. FEMPI has not affected Ballsbridge in Dublin 4 but it has in those two types of locations I mentioned, where the majority of patients have medical cards. For example, in my own rural area of north west Mayo, GPs work up to an hour and a half away from a hospital. GPs face social issues such as drug abuse and addiction problems in deprived urban areas. FEMPI has been damaging in those two types of areas. It is not possible to take €2 billion out of general practice without having a devastating effect on the entire health service. We know that every €1 that is spent in primary care saves approximately €5 in the rest of the health service.

FEMPI has, in effect, halved the funding available per patient in general practice over the past ten years. The cuts have reduced the capacity of family doctors to provide a safe service for patients. They cause thousands of patients to attend emergency departments unnecessarily every week. The health service cannot function properly until general practice is fixed. I wish politicians, and the Minister in particular, would accept this. I am not making this up, it is a hard, cold fact. We need general practice fixed. GPs are the gatekeepers of our health system and we need them for our total health system to function properly.

General practice is viewed as unviable by newly-qualified doctors. We need the FEMPI cuts reversed and a new general medical services contract.

There are 63.1 GPs per 100,000 people in this country. Those figures are well below the international best practice of 80 GPs per 100,000 people. A survey by the Irish College of General Practitioners, ICGP, found that upwards of 40% of GP trainees indicated they would emigrate after graduation. We must stem the tide of emigration or the manpower crisis will continue and both GPs and patients will continue to suffer the effects.

I support the GPs' campaign for better terms and conditions through the undoing of FEMPI. Many hundreds of GPs will march on the Dáil today. As I can attest, if the current situation is allowed to continue, practices will struggle to remain open and to keep GPs employed, especially in rural areas, which is my main concern.

Dr. Padraig McGarry, chairman of the Irish Medical Organisation, IMO, GP committee, said there is a threat that some GPs will not be replaced and that areas in rural Ireland, particularly west of the Shannon, will not be able to attract GPs. A decade ago positions in rural practice often attracted up to 30 applications. In my own practice in Belmullet, when I applied for the job, there were 12 applications. Today, substantial practices struggle to get just one applicant and, in some areas, there is no interest at all. Young GPs are not prepared to come in under the present circumstances of excessive hours and poor supports. There will be situations where elderly, sick and vulnerable patients have to travel unjust distances on a poor road network, or depend on a public transport system that might not be efficient, to see a GP because their local GP practice has closed. They will be met with different locums week after week, which is not fair on the elderly patient, who has to try to strike up a rapport with a new GP on an ongoing basis.

We need to encourage young GPs to come to rural areas, not dissuade them. A new contract for GPs will be an important step forward in addressing this issue but while GPs have been working for years to get the basis of a new contract, little or no progress has been made. I implore the Minister of State to redouble efforts in this regard and I look forward his response.

I thank the Senator for raising this issue. I assure the House that the Government is committed to engaging with GP representatives on the development of modernised GP contractual arrangements. Discussions with representatives were progressed on a wide range of items throughout 2017 without reaching a conclusion. A new phase of discussions commenced in May 2018 based on the mandate set by Government in March. Officials from the Department and the HSE met IMO officials, as the established GP representative body, at the beginning of May to set out the State’s position in regard to the GMS contract and to progress this important issue.

The State side set out the mandate agreed by Government under which the consultations were being conducted and the package of measures to be agreed. The Department subsequently wrote to the IMO, at the organisation’s request, setting out these proposals formally. The IMO responded to the Department by letter on 20 July. Talks resumed in October 2018 and there was intensive engagement, particularly in the weeks leading up to Christmas. While some progress was made, a number of outstanding issues need to be progressed before any agreement can be secured.

The State’s negotiating team is keen to bring a renewed focus to the engagement with the IMO and talks are continuing in an effort to bring matters to a conclusion. I look forward to positive and productive engagement with all parties concerned. Agreement on the delivery of service improvements and contractual reform would facilitate a substantial increase in the resourcing of general practice on a multi-annual basis. In line with the long-established approach to such processes, and by agreement of the parties concerned, I am not in a position to give further details while engagement between the parties is under way.

The Government is aware of workforce issues facing general practice, including the influence of demographic factors, and has implemented a number of measures to improve recruitment and retention in general practice. GP training places have been increased from 120 in 2009 to 202 places in 2019. The objective is to continue to achieve annual increases in the number of training places available while ensuring all places are filled.

The entry provisions to the GMS scheme have been changed to accommodate more flexible GMS contracts and the retirement age for GPs has been extended to 72. An enhanced support package for rural practices has been introduced, with improved qualifying criteria and an increased financial allowance of €20,000 per annum. Some 257 GP practice units, encompassing 347 individual GPs, are now in receipt of financial supports under this framework, a significant increase on the 167 GPs who received a rural practice allowance prior to the introduction of the 2016 measures.

The Government remains committed to the continued development of GP capacity to ensure that patients across the country continue to have access to GP services and that general practice remains an attractive career option.

I note the Minister of State did not comment on any possibility of reversal of FEMPI, which I mentioned in my opening contribution. There seems to be an air of secrecy regarding the new contract, which is a cause of deep frustration for many GPs throughout the country. Why was the National Association of General Practitioners, NAGP, excluded from the contract discussions, bearing in mind it was part of the discussions in 2017? Will it be a totally new contract or is it just intended to amend the current contract?

I am not directly involved in the negotiations; the Department and the HSE are involved. However, I will ask the Minister, Deputy Harris, to address the Senator's two questions on the involvement of the NAGP in the talks and on FEMPI, which is more a matter for the Minister for Finance.

Health Services Staff Remuneration

I need to raise with the Minister of State the failure of the Department and the HSE to honour the public service stability agreement, PSSA. It is deeply ironic that, at a time when the Minister is citing this agreement as a reason for not negotiating with the nurses - incorrectly, by the way - he and his Department are in breach of the agreement.

The Minister of State will know from the Commencement matter I have raised that I am referring to the job evaluation process which was carried out under the terms of this agreement and which was completed on 4 October in respect of up to 7,000 support staff. I have a personal interest in this matter because, for years, I had the great honour to work with these support staff from time to time in University Hospital Limerick, UHL, and I am aware of the incredible work they do. I know how much these jobs have been changed, enhanced and broadened for healthcare assistants, porters, lab staff and central sterilising supplies department, CSSD, operatives.

These people waited seven years to even have a job evaluation take place because of FEMPI. They worked through the hardest of times in our health service and, God knows, it has worsened rather than improved. Finally, under the terms of this agreement, the process took place and was completed on 4 October. Under the terms of the agreement, the awards made under this process should be made within six weeks, and that is noted in the job evaluation document itself. Yet, for these healthcare assistants, porters and lab staff, nothing has happened. Worse than that, the Department refused to sit down with their union, SIPTU, and refused to engage with the union prior to the Estimates for the health service being completed for this year. Right now, not only is the Department in breach of the PSSA, but it has not allocated moneys to fulfil this agreement in the budget for this year.

We are talking about the people who keep this health service going from day to day, alongside our courageous nurses, who, quite rightly, have made the decision to take industrial action. What the Government is doing by ignoring the PSSA is forcing another union, SIPTU, to take industrial action, and that is just what will happen. I cannot believe the neck of the Minister, Deputy Harris, to quote the PSSA while being blatantly in breach of the same agreement. I am hoping the Minister of State will confirm that the Government will honour the terms of this agreement and pay the moneys due, which are pay rises of between 5% and 7% for these workers. No other answer will be appropriate.

I thank the Senator for the opportunity to address this matter. As part of the talks which took place under the Lansdowne Road agreement, a chairman’s note was agreed by all parties on the reintroduction of a job evaluation scheme in the health sector. This scheme had previously been in place but was discontinued in 2008. SIPTU sought the introduction of the job evaluation scheme for the support grades along the same principles that operated in 2008. The support staff grades are categorised into four pay bands, which have different pay scales attached.

SIPTU held the view that the roles of support staff grades needed to be evaluated as, in some cases, due to the type of work they carry out, the grades may warrant placing in a higher band category. This scheme examines a grade rather than an individual post in isolation. If, for example, the work of a porter is found to be more appropriate to a higher band, then all porters will fall within the new band. The scheme allows for posts to be evaluated in a cross-section of approximately 25 locations, including acute hospitals, services for older people, intellectual disability as well as other specialised areas.

The chairman’s note provided that all parties would agree on the scope and conduct of the scheme. On this basis, discussions commenced in 2016 between the HSE and the relevant unions - SIPTU and IMPACT, now FORSA - regarding the re-establishment of the schemes. Successful engagement with FORSA led to the approval of a job evaluation scheme for the clerical and administrative grades in August 2016. However, as agreement on a scheme for the support staff grades could not be reached, the issue was referred to the Lansdowne agreement oversight body in early 2017.

The chair of the body issued a recommendation stating that the parties should proceed with the scheme as planned but that the question of its implementation would be considered at the conclusion of the exercise. The Workplace Relations Commission, WRC, agreement provided that the scheme was to be carried out in four phases. Phases 1 and 2 included support staff in the laboratories and the theatres. Also included, were the larger categories of support staff grades, the healthcare assistants and the multi-task attendants.

In October 2018, a report was produced setting out the results of phases 1 and 2 of the exercise. The report recommended that a significant proportion of those grades evaluated should move to a higher pay band.

While the WRC agreement states that any payments arising as a result of the exercise would apply no earlier than the completion of phases 1 and 2 of the exercise, there is no agreement at this stage to the implementation of the result of the exercise. This is a matter that falls to be discussed and agreed with the Department of Public Expenditure and Reform within the context of wider budgetary considerations.

Is it any wonder people are cynical about politics? Furthermore, is it any wonder that the nurses have taken the justified decision to go on strike when even if one complies with this agreement, goes through the processes and waits seven years for the job evaluation to take place, we have a Department that turns around and says that one is owed that money but that it is not going to implement this, that it will have to have further talks about it, even though there is a note regarding the job evaluation form which states that within six weeks those moneys should be paid? The refusal of the Department of Public Expenditure and Reform to even sit down with SIPTU, which it was requested to do before the Estimates were settled, shows the completely cynical attitude towards the employees in the HSE. Is it any wonder there is industrial relations chaos in our health service when we have a Department and a Government that are so cynical regarding the people who keep our health service going?

I would like to make it clear that I fully recognise the valuable and fundamental role many of the support staff grades make to the efficient delivery of many of our healthcare services. I am aware that in December 2018 SIPTU announced that it will ballot more than 7,000 support staff members working in hospitals and for healthcare providers. In my view, this ballot is premature. SIPTU is claiming that the Government has breached the terms of public service pay agreement but this is not the case. As I already outlined, management agreed to the terms of the scheme in 2017, but the question of its implementation was always intended to be subject to further discussion with my colleagues in the Department of Public Expenditure and Reform.

Hospitals Building Programme

I seek an update from the Minister of State on the planned new 50-bed unit for Portiuncula University Hospital in Ballinasloe. I have been raising this issue for some time. I first met the then Minister for Health and now Taoiseach, Deputy Varadkar, in 2015. It is important this project is funded under the 2019 capital investment plan. These are much-needed facilities for the hospital to replace wards which are unfit for a modern healthcare setting. Much of the nurses' strike is about working conditions in our hospitals. This project is key to improving conditions for patients, nurses and other staff within the hospital.

As the Minister of State is aware, this is a shovel-ready project and it is important we get shovels in the ground on this project. I have been in touch with hospital management recently and it continues to confirm the urgency for this project to be delivered.

I want to make the strongest possible case for this project this morning. I understand the capital investment plan is currently being finalised. It is important this project is included in it for 2019. As an occupational therapist, I am very aware of the need for modern health infrastructure. We know that in terms of standards a number of the wards at Portiuncula University Hospital are not fit for purpose. It is important we see movement on and funding provided for this replacement unit.

The hospital has completed the design stage along with full costings. They were submitted to the HSE Estates in 2017. Our biggest issue is the funding of this project. I look forward to a positive response from the Minister of State regarding this 50-bed unit at Portiuncula University Hospital.

I thank the Senator for raising this issue and giving me this opportunity to outline to the House the position regarding the proposed capital developments at Portiuncula University Hospital, Ballinasloe, including the provision of a 50-bed ward block to replace existing ward accommodation and other works such as fire safety upgrade works and the replacement of the existing fluoroscopy room.

Planning permission has been received for a new 50-bed replacement ward block to provide replacement ward accommodation at Portiuncula University Hospital in Ballinasloe, County Galway. The HSE has informed the Department that tender documents are being prepared with a view to progressing the procurement process and commencing an enabling works contract in 2019. Progress in respect of these and all other capital projects are subject to the availability of capital funding.

The health capital allocation in 2019 is €567 million for the construction and equipping of health facilities. Following the publication of the Health Service Executive's national service plan for 2019, the Health Service Executive is currently developing its capital plan for 2019. The HSE capital plan will determine the projects that can progress in 2019 and beyond having regard to the available capital funding, the number of large national capital projects currently under way, the cashflow requirements attaching to each project and the relevant priority. In developing its capital plan for 2019 and future years, the HSE must consider a range of issues, including the expenditure that is contractually committed, the HSE’s annual requirement in regard to meeting risks associated with clinical equipment, ambulances and healthcare infrastructure and the total capital Exchequer funding required for the new children’s hospital in 2019.

The impact of the increased costs for the completion of the new children’s hospital will, based upon the HSE’s analysis and Government priorities, see the timing of non-contracted capital commitments managed within the available health capital allocations. In line with statutory requirements, the Department of Health and the HSE are currently engaged in a process to finalise the HSE capital plan for 2019, informed by the Government decision on the children’s hospital. Details of total capital investment for 2019 will be set out in the plan and the HSE will be required to manage its capital expenditure within the agreed plan.

The future requirements of Portiuncula University Hospital and other health capital projects, currently at various stages of development, are being considered as part of this process. Once the HSE has finalised its capital plan for 2019, it will then be submitted to the Minister for consideration.

As the Minister said, work on the projects to be included in the plan is currently being finalised. I emphasise the need for urgency on this issue. I am happy that the HSE has informed the Department that tender documents are being prepared with a view to progressing the procurement process and commencing an enabling works contract in 2019. It is important we would see enabling works commence but further urgency needs to be given to the delivery of this new 50-bed unit to replace wards the condition of which are not fit for purpose in a modern health care setting. I urge the Minister of State and thee Minister, Deputy Harris, to work closely to ensure this project for Portiuncula University Hospital is included in the 2019 capital plan.

I acknowledge the Senator's representations on the matter and her sincerity in pursuing it. A project that is advanced as this is a long way ahead of others that are awaiting planning and design. A project that is proceeding to enabling works has been significantly progressed. I note the Senator's concern and her insistence that it proceed unhindered. I will pass on her remarks in that regard to the HSE.

Post Office Network

This issue relates to the post office network. I have been endeavouring to raise it in the House since November. I am delighted to have the opportunity to do so today. I understand and appreciate that the matter is outside of the brief of the Minister of State but I hope that he will have some news regarding the Government's commitment to the post office network.

Last August, An Post announced that 159 post offices were to close. By and large, under the agreement reached between An Post and the Irish Postmasters Union, many post offices in rural areas have been closed. Engagement by An Post management with community organisations and public representatives has been dismal, disgraceful and completely unsatisfactory. Local concerns across the country have not been heard. Community groups and local residents have expressed their concerns but they have not been listened to by An Post.

The Government is the only shareholder of An Post. Ultimately, it could direct the company to take an alternative course of action but, regrettably, this has not happened. The Government is culpable when it comes to the closure of post offices. I accept that some post offices may not be economically viable but the criteria being applied by An Post leave a lot to be desired, including, for example, those relating to the 15 km rule and population centres of 500. An Post is being selective in its examination of the criteria. I will provide an example. In the context of the post office in Dunfanaghy, County Donegal, which closed on 31 January last, An Post used the figure relating to the settlement population rather than that relating to the electoral area. An Post is being disingenuous. People in most rural areas live in the hinterlands, not the towns. In this case, the hinterland population comes within the electoral division of 1,645 yet An Post deems it does not meet the criteria of a minimum of 500 people. There is selective use of the criteria on the part of An Post. Its procedure has been disingenuous. I made contact with the CEO and management of An Post and the responses I received were, to say the least, flippant. I received responses outlining that a review has taken place and An Post cannot provide any concrete information under that review process. Meanwhile, the post office has closed and the opportunity to have it reopened has passed.

I will provide another example regarding the post office in Dunfanaghy. The former postmistress, Ms Bríd Gallagher, wrote to Mr. Gerry Whelan of An Post before she retired on 31 January offering a stop-gap solution whereby she would continue in her position and keep the post office open until the company negotiated with the local community and local businesses to find an alternative solution. She received no response, which is disgraceful. It is deplorable that An Post did not respond. This is a town with a population approaching 2,000. People in this rural area are being asked to make a 30-minute round journey in order to post letters. While many people use email, the vast majority of older people in rural areas where there is no broadband cannot avail of online services and are obliged to depend on the post office network. The decision to close rural post offices is wrong. The business model and decision-making processes of An Post are wrong in this instance. I am very disappointed with the lack of input on the part of the Minister for Communications, Climate Action and Environment on behalf of the people who, after all, are shareholders in this company.

I am not expecting that the Minister of State will have any answers for me but I hope that there will be some reflection by the Government on this issue. If the approach being taken continues in respect of other State services, we will be on a road to nowhere. Rural Ireland is losing out. The Minister of State, who comes from a rural area, will appreciate that.

I welcome the opportunity to address the issue of Government policy on the post office network on behalf of the Minister for Communications, Climate Action and Environment, Deputy Bruton, who has responsibility for the postal sector, including the governance of An Post. It is important to remember that An Post is a commercial State body with its own board. Decisions relating to the post office network are an operational matter for An Post directly.

Two years ago, Government was presented with a future for An Post and the post office network that was very uncertain and extremely bleak. The environment in which the post office operates is changing and the network needs to change to thrive, particularly with the move to digital transactions. These changes are impacting on the revenue being generated by the network as a whole. In the face of serious declines in the volume of mail and post office business, An Post faced growing losses and has had to undertake a major restructuring of its business to continue to be able to provide its services. The sharp decline in the activity made it inevitable that the size of the network would be affected.

In regard to the post office network, An Post agreed an exit arrangement allowing postmasters to retire if they so wished. It established a protocol which set out how the company would facilitate the continued provision of post office services where this occurred. Its aim is to make as many post offices as possible viable. It takes account of minimum service levels, as well as a range of other issues. Reflecting its commitment to sustaining a nationwide post office network and daily mails service, the Government made €30 million in State funding available to An Post in 2017, of which €15 million is being used to support the renewal of the post office network, with the other €15 million being used for the continued fulfilment of a five-days-a-week mails delivery service. This, in turn, will secure the future of mail and post office services for local communities throughout the country in rural and urban areas.

There is widespread acceptance that the post office network requires modernisation to build, maintain and protect a service that meets the needs of communities across the country. An Post's renewed vision for the post office network centres on the availability of new services in a modernised, revitalised network. These services must include a better range of Government services, financial services and e-commerce services for shoppers and small businesses. As part of its consideration of the financial position of An Post the Government agreed that further opportunities for Government business through the post office network should be explored. The first practical step that the Government has taken is the launch of the digital assist pilot initiative. Government funding of €80,000 has been allocated to the scheme which has seen ten post offices kitted out to assist citizens with online Government interactions. All ten post offices went live in the week beginning 20 October 2018 and the pilot scheme will finish in April this year. The pilot will provide data and insight in relation to the provision of offline Government services to citizens. A review of the initiative will be carried out in quarter 2, 2019 and feedback from this review will inform consideration of further offline services.

On 4 September 2018, the Government approved the establishment of an interdepartmental group to Identify options, including procurement frameworks, for delivering services to those citizens who do not wish to use, or are unable to use, digital services. Where a business need is identified, it has been agreed to develop a procurement framework which would allow for the central provision of offline services by Government. The group will provide a report on its deliberations this year. The findings of this group may be of use to An Post in the longer term.

On 17 January 2019, the Minister for Employment Affairs and Social Protection, Deputy Regina Doherty, renewed her Department's contract with An Post to provide pensions, child benefit and other social welfare payments in cash at post offices. The social welfare contract accounts for over €51 million in payment services. In addition, the Department paid over €10 million for postal services to An Post in 2018. The current terms of the contract between the Department of Employment Affairs and Social Protection and An Post were agreed in 2013 for an initial two-year period, with an option to extend annually up to 2019. This reaffirms Government policy which sees the post office network as a key piece of the country's financial and social infrastructure, particularly in rural areas. Accordingly, the programme for Government commits to actively encourage payment at post offices. Investment of €50 million in the network by An Post is based on getting communities to use the enhanced services that their local post office will provide through a modernised network. Key to the survival of the network is the willingness of the public to use the service the post office provides. In light of the challenges it is facing, the company will have to pursue an ambitious agenda across its business areas and there is likely to be significant change and new business models implemented in the coming years.

This should be viewed positively as it will result in a solid, sustainable business future. Two years later, critically important decisions have been made. An Post has been stabilised because of the action that has been taken. All avenues are being explored to ensure services available through the post office network are enhanced such that we have a strong, customer-focused, viable network.

I thank the Minister of State. This is the general response from the Department of Communications, Climate Action and Environment. I understand that the Government is committed and has provided resources but to say that the additional supports have been given to An Post and practical steps have been taken to launch a new digital assist pilot initiative, with Government funding to be provided through the post office network, is little consolation to people losing post offices in their own towns or villages. They will not be able to access those services because their post office is gone. The manner in which this happened is all wrong. The forward thinking should have happened before any decision about closing post offices took place. The door is now closed, the horse has left the stable and people are losing out. It is very poor public policy and the Department has really got this wrong. The level of engagement with An Post was very poor.

An Post has to be financially viable but there were many other options of providing additional State services through the post office network to assist with the viability of post offices that could have been looked at first. That did not happen and we are here now. I am not making a political point on the issue since it has been going on for many years. It should have been dealt with and was not. Will the Minister of State ask the Minister for Communications, Climate Action and Environment to instruct An Post to engage with communities that contact it? That is not happening at present.

I thank the Senator for raising this issue, which is important to many of us who represent rural areas, but we have to be real in our commentary. I acknowledge the Senator's desire not to be political. Some 30 post offices were closed in Donegal between 2002 and 2010 when Fianna Fáil was in office and two when Fine Gael was in office between 2011 and 2016. The politics of this do not interest anybody and I accept that the Senator has posited that himself. The reality is that human behaviour has changed and people have voted with their feet, choosing to go online in large numbers. We cannot continue to subsidise something that is not viable and have to work collectively towards its future viability. I have outlined efforts to do that. I will take on board the Senator's request. In defence of An Post, as a politician in Cork, I have found it to be extremely co-operative in engaging with us and with local communities. I will pass the Senator's comments regarding An Post on to the Minister.

Sitting suspended at 11.15 a.m. and resumed at 11.30 a.m.