HSE Winter Plan: Statements

I welcome the Minister of State, Deputy Butler, and congratulate her on her appointment.

I thank the Acting Chairman for his kind wishes. I welcome this opportunity to address the House on the winter plan, which was published by the Health Service Executive on 24 September. Every winter, our healthcare system faces increasing pressures on it, making it more difficult for people, particularly older people, to access treatment as quickly as we would wish.

This is particularly noticeable in emergency departments, which see overcrowding, longer waiting times and patients receiving care on trolleys. This year the Covid-19 pandemic is likely to underscore and increase these existing pressures.

The €600 million investment in the winter plan represents a statement of the Government's intention to work towards moving care and the required resources towards home and community care, in line with the principles set out in Sláintecare. As Minister of State with responsibility for mental health and older people, I particularly welcome the plan's focus on supports for older people and those groups at greater risk. This is fundamental. Older people are more likely to be admitted to an acute hospital following a visit to an emergency department and they are more likely to experience a wait on a hospital trolley. Of course, other areas of our health system also need attention. I will advocate for increased funding for mental health services in our budget discussions.

I welcome the addition of further community healthcare networks, 36 community specialist teams and 11 acute hospital front-of-house teams. These will create the foundation and organisational structure which will allow older people to be treated in their own local community while still receiving the required standard of care. These networks and specialist teams will work closely with the National Ambulance Service to deliver end-to-end care with the aim of keeping people out of hospital, or where they are admitted, ensuring they are discharged without delay. The plan expects that this could lead to one in five of our older family members, neighbours and friends over the age of 75 not needing to be admitted to hospital at all.

I welcome the additional community beds, which will allow patients to leave hospital earlier and provide care closer to people's homes, as well as the 4.76 million additional home support hours, which will allow people to remain in their own homes. I also welcome the commitment to the provision of aids and appliances to an additional 5,500 people. Simple interventions like this can make a vast improvement to an older person's quality of life and independence.

I want to mention mental health, which is a very important part of my remit as Minister of State. As many Members of this House have noted throughout the pandemic, the outbreak of Covid-19 is giving rise to significant stress, anxiety, worry and fear for many people. This arises from fear of the disease itself, as well as from increased social isolation, disruption to daily life and uncertainty about employment and financial security.

During this period, acute inpatient and community residential facilities have remained open and patients have been provided with services throughout the pandemic, although numbers have been reduced in some settings and telehealth services also have been used to protect both staff and patients. Further improvements to mental health services are included in the overall HSE pandemic plan, Delivering Health Services in a Covid-19 Pandemic, to address HSE service delivery to the end of 2021 in the context of the pandemic. I would like to add my congratulations to various State bodies, including the HSE and the Department of Health. Some 90% of mental health supports have been maintained during the Covid-19 pandemic. Services have obviously had to move to a more blended approach, with many supports delivered online. For anyone already receiving services, 90% of supports were retained. That did not happen in all sectors, but I am delighted that the most vulnerable were able to receive those supports.

I wish to assure Members that I am working to secure additional direct funding for mental health services in the context of the main pandemic plan, a matter which is being considered as part of the Estimates. As part of this strategic plan, the additional resources I am seeking through the Estimates process are intended for the fulfilment of several short-term recommendations of the new national mental health policy, Sharing The Vision.

Full implementation of the Sláintecare reform programme continues to be our goal, but the impact of the Covid-19 pandemic has presented us with the more immediate task of resuming our services to the level they were at before the outbreak of the pandemic, in a prioritised manner. At the Government's request, the HSE developed a strategy for health service delivery to the end of 2021 in the context of the pandemic. The winter plan, which is a part of that strategy, focuses on the immediate problems we will be facing this winter. As I said at its launch, I welcome the publication of the plan by the HSE. I particularly welcome the HSE's recognition of the importance of reducing the number of patients receiving care on trolleys in emergency departments and improving patient experience and waiting times in the context of Covid-19. It is also important to point out that although this year has brought unprecedented challenges, the €600 million pledged under the winter plan is also unprecedented, amounting to 20 times the figure pledged in any previous year's plan.

Last winter more than 620,000 people visited emergency departments. While I encourage everyone who needs emergency medical treatment to seek it, experts generally agree that many patients could be cared for outside of the hospital. Where appropriate, the plan therefore provides alternative pathways to care with the aim of easing the pressures on the hospital system, including the emergency departments, and ensuring more timely egress from hospitals. This will free up hospital resources for the job they should be doing.

The plan is designed to enable patients to be seen in the community wherever possible by providing a better service in community healthcare settings. It is intended to allow patients to receive timely care in hospital when this is necessary, and return home or to appropriate care settings when well enough to leave hospital through the provision of more home care and step-down options.

The plan provides for building capacity and resilience in the system. One of our core tasks is building extra capacity in the acute hospital system. In 2018 the health service capacity review was published. This outlined the requirement for increased acute and non-acute bed capacity in the system alongside major reform in the way healthcare is delivered. The programme for Government, Our Shared Future, commits to continuing investment in our healthcare services in line with the recommendations of the review and the commitments in project Ireland 2040. This winter plan provides additional health service capacity across a range of services and settings, including in our acute hospitals, to help reduce admissions and allow earlier discharges. Key initiatives include an the addition of 483 acute hospital beds, 89 sub-acute beds, 631 rehabilitation places and 530 repurposed community beds to support the pathway to home care. These community beds are absolutely essential. In a pilot scheme in Waterford last year, 20 beds in a nursing home facility were bought at a cost of €1,000 each. Persons deemed by their consultants to be fit enough to be discharged but not well enough to go home were transferred to community beds for three or four weeks. This provided a respite for patients waiting to receive home care or to go into a nursing home. This is a great model and should be rolled out everywhere. I really welcome the 530 repurposed community beds, which will support the pathway to home care.

The plan also provides for the utilisation of private hospitals for urgent complex care in order to reduce waiting lists. This capacity can also be used in the case of a surge in Covid-19 cases. The plan commits to delivering more diagnostics in the community, allowing patients to be seen closer to home and avoid going to hospital. It puts supports in place for GPs, particularly those in rural practices, to support service continuity. The plan also aims to deliver twice the current level of home support hours to support the home first initiative, designed to allow even those with high and moderate levels of frailty to be cared for in their own homes. To facilitate this, 4.76 million additional home support hours are being provided for in the plan, at a cost of €139 million.

A comprehensive flu vaccination programme is essential this winter. The HSE ordered approximately 1.35 million doses of the quadrivalent influenza vaccine as well as 600,000 doses of the live attenuated influenza vaccine, which will be made available to children between the ages of two and 12.

Finally, I would like to address the question of waiting lists, for which funding is provided. I recognise the necessity of the decision taken by the National Public Health Emergency Team, NPHET, to defer elective care procedures earlier this year. I know this has had an impact on scheduled care waiting lists and on the lives of the people waiting for these operations. Hospital waiting list figures are higher than at the start of the year, with the inpatient day case and outpatient waiting lists 17% and 10% higher, respectively, than at the start of January. However, there are some indications of improvements. Due to the joint efforts of the HSE and the National Treatment Purchase Fund, NTPF, the growth in waiting lists has slowed since services resumed in June. Since May there has been a reduction of almost 11% in the numbers waiting for inpatient day case procedures, with early evidence that the rate of growth of the outpatient waiting list has slowed.

The HSE has actively sought innovative new ways to increase productivity through the increasing use of alternative work practices such as telemedicine, virtual clinics and alternative settings including private hospitals, community facilities and atypical outpatient settings.

The HSE is also currently working to secure access to private hospital facilities for urgent and time-critical procedures.

The National Treatment Purchase Fund, NTPF, is currently reviewing strategies to maximise activity and benefit for patients, including increased use of private hospitals; funding weekend and evening work in public hospitals; funding "see and treat" services, where minor procedures are provided at the same time as outpatient consultations; funding hybrid services where public and private hospitals contribute to the treatment of patients; virtual clinics; and clinical validation. While acknowledging that waiting lists are at record levels, the combined impact of this work should help mitigate the impact of Covid-19 on waiting lists and the HSE and the NTPF will continue to work together to address this issue.

I welcome the Seanad's consideration of the winter plan today. The Government is fully committed to its implementation and the Minister, Deputy Donnelly, and I want to work collaboratively with all stakeholders and across the Houses to do so. Right now, we need to get the services back up and running to at least the level they were at prior to the outbreak of this pandemic. This winter plan is part of that process and is designed to meet the immediate challenges we anticipate this winter. The ambition of the plan, and the significant funding provided by the Government, gives me confidence that we can start to address the problems in the system. I hope that is something all Senators in this House want and that they will support the plan.

I remind Senators that on the Order of Business today, it was agreed that each Senator would have five minutes of speaking time. I call Deputy Seery Kearney.

I congratulate the Minister of State on the HSE's winter plan. It is a very ambitious plan which takes into account the very challenging and potentially competing demands of Covid and non-Covid healthcare. I am proud that our Government has circled in red additional supports for those in the increased risk category, the elderly, homeless people and those with chronic illnesses, and provided them with home supports. Well done. I am very proud of that.

Much was done by the Government to support older adults with intellectual disabilities and mental health challenges in public and private long-term residential care facilities from the beginning of the crisis. Area crisis management teams were established, which were a vital component in the management of outbreaks within long-term care facilities through upskilling staff in infection control procedures and implementation, providing PPE and public health advice, the provision of staff and support for own governance. I note that this provision is being extended within this plan. Again, well done.

There always has to be a "but" and I have a little one, although it is a significant issue for those affected by it. I want to draw the Minister of State's attention to the disability non-residential care sector, which has been mentioned frequently in these Houses over the past 24 hours. I advocate for urgent additional supports for organisations in the voluntary and not-for-profit category, which support more than 26,000 people with intellectual disabilities and their families. While day care services have resumed, they are still at a reduced level. We need to urgently address the clients' and their families' needs for additional supports, as the current situation erodes all of their resilience. Families have been stoically and intensively supporting their family members for months while experiencing their own levels of frustration. Some felt they had been forgotten or left behind when additional supports were announced.

In my constituency of Dublin South-Central, there is a super organisation called WALK, which is headed up by its director of services, Catherine Kelly. It believes that people with disabilities have the right to live and contribute to the everyday life of their community. It supports the development and maintenance of relationships which lead to the attainment and sustainability of socially valuable roles and natural support networks, providing employment, training and community living opportunities and supports. However, it cannot do that work part time. In response to the lockdown in April, it began to develop online sessions for its day service attendees and while it has reopened in a limited capacity, observing social distancing and providing services to people with disabilities and their families, those individuals and their families need this service to run five days a week as that is the most appropriate way of tailoring to their needs. Nadine Vaughan, a mother whose adult son Sam is a service user with WALK, has commented to me that, while everyone is suffering with the effects of the pandemic and their lives have been curtailed, for people with special needs and their families, their only outlet is the day services. Their lives have not just been curtailed but they cut off at the waist. I ask the Minister of State to give urgent attention to disability day services.

My apologies, I think I should have called Senator Clifford-Lee first.

I am sharing my time with my colleague, Senator Fiona O'Loughlin. I thank the Minister of State for her very comprehensive statement on the winter plan. It is so important this winter, more so than ever before. I am happy to see that acute beds have been more than doubled and that there is a significant increase in sub-acute beds as well.

Home support packages are the most important thing that stands out from this winter package. We all know people who have suffered greatly and lost home supports over the years. It is great to see them being introduced again and the supports being increased. That was a key component of the Fianna Fáil election manifesto and I am delighted to see that home packages are once again being prioritised.

I am also happy to see the support for GPs, who are the unsung heroes in this pandemic. They adapted their GP surgeries very quickly to deal with the new reality. We have all done phone and video consultations with them at this stage and they have been absolutely fantastic in dealing with an ever-increasing workload, given that they were already overstretched as it was. I pay particular tribute to the GPs of Ireland.

I am also glad to see the emphasis on vaccinations in this package. It is essential that everybody gets their vaccination, particularly those in a vulnerable group. I thank the Minister of State for making such funds available.

As the Minister of State is responsible for mental health and older people, I take this opportunity to address one specific matter with her, on which I hope we will be able to make some progress. I refer to the mental health and well-being of the women of Ireland who have given birth or been pregnant during the pandemic. They have gone to appointments and scans alone and often received some very bad news. They have miscarried on their own, been told there is no heartbeat alone and given birth alone. These matters are going to impact on the mental health and well-being of those women for evermore. If we are going to live alongside the virus for the next number of years, the Minister for Health needs to address this issue. I would like to hear the Minister of State's comments on that. I pay tribute to everybody working in the HSE and wish them the very best of luck for the winter.

We will have to make the Minister of State an honorary member of the Seanad at this point. We are all aware that this will be the toughest winter we have ever faced in our health services and in society. We all need to be prepared for the huge pressure that will be placed on our health service at every level. I acknowledge the Government's determination to meet the challenges head-on, the huge investment of an additional €600 million and the very concrete actions outlined in the winter plan. I recognise that all our healthcare workers have worked tirelessly throughout the pandemic and they deserve every support we can give them as they face into their busiest and most difficult time of the year. I also recognise the huge mental health effects Covid-19 has had on so many people of all ages in all sectors of Irish society. We have to be mindful of how a winter of restrictions and anxiety will affect people who struggle with mental health.

The Minister of State spoke about GPs. In many developing towns, when new people arrive they cannot get access to a GP. That is happening quite a bit in Newbridge, Kildare and Athy.

Ballymore Eustace is in the Kildare South constituency and the medical centre there has been closed for six months, with no sign of it reopening. People who live there are forced to go to Blessington, which is in another county. Bearing in mind all the restrictions, this seems absolutely ridiculous. Two new housing developments are planned and we absolutely need that centre open.

I again welcome the ten additional dementia advisers provided for under the winter plan, which will bring their numbers to 28. I know that absolutely comes from the Minister of State's influence. The roll-out of community specialist teams to support older people and those with chronic diseases is a major positive and the number of acute beds has doubled. We also have doubled the number of home support hours, which is positive.

I raise the matter of breast and cervical cancer screening under the winter plan. We are all aware of the hidden health cost of Covid-19 and the unfortunate delays in care for cancer patients. There are backlogs and lengthening delays in hospital waiting lists for appointments. I am aware that Dr. Colm Henry, chief clinical officer with the HSE, has said this will be cleared by spring next year but I am concerned that the pace must be increased.

I thank the Minister of State for her time. I am absolutely happy to support the winter plan.

I welcome the Minister of State and congratulate her on her appointment. At the outset, I should say that the winter plan is being presented to the House on a day when the Government is also asking An Garda Síochána to create havoc on the roads for many people, which is a very bad idea. It verges on the unlawful and all we must do is think for a moment what it would be like to be in a 4 km tailback with an older relative being brought to hospital, a nurse on the way to hospital or somebody opening a shop or other place of employment. How would it feel to be stuck in a queue of that kind, deliberately created with a view to members of An Garda Síochána giving the public a short, sharp shock? It is deplorable and the Garda Commissioner should reconsider the tactic immediately. It is demeaning to An Garda Síochána and it will set ordinary people against gardaí if they are inconvenienced in this cruel way.

I note and welcome the increase in the number of acute beds as indicated by the Minister of State. NPHET zoned in on the unavailability of ICU beds in particular and on the pressure that would be on them in the system. There is nothing in the Minister of State's comments about extra ICU beds. I understand, from indications not contained in her statement, that the plan is to increase the number by 17 in the winter programme. The number is currently 282, meaning the total will be approximately 300. I noticed that the Minister announced his intention to bring the number north of 300 in the future. We are talking about 17 additional beds.

Over the past five years, successive Governments have been warned about the major shortage of ICU beds. We have had severe acute respiratory syndrome, SARS, and other episodes and this is not the first major problem for public health. Nothing of significance has been done. Going back to the emergence of this crisis in March, people were told that the shortage of ICU beds, which was particularly acute, was the reason we had to close the country. It was to avoid that pressure on hospitals. It is not sufficient for the Minister of State to come here and not even mention ICU beds. I do not necessarily blame the Minister of State for the script supplied to her but there was no mention that this very serious constraint on our health system has been ignored and that reports advising successive Governments to do something about it have been shelved. It is not good enough to say a number is north of 300 when it will be 299 or 300. It is not good enough to speak about 17 beds as being sufficient in the current circumstances.

I do not want to be critical of any individuals but I took an opportunity today, because a long-standing friend of mine asked me to do so, to look at the structure of NPHET. The relevant information is available on the Government website. The simple fact is that NPHET is not a new body that exists separately from anything else. It is a single body, the membership of which comprises approximately 30 people. The great majority of those individuals are either HSE employees, Department of Health employees or members of other statutory bodies. There is a point that must be taken on board. NPHET, the HSE and the Department of Health are all part of the State's apparatus to manage the health crisis we are experiencing. I do not remember NPHET mentioning ICU beds at any stage except to indicate that capacity was a restraint earlier this year. I do not remember anybody in the HSE or the Department of Health, between March and August, saying that in a national emergency we must increase the numbers of intensive care unit beds as quickly as possible. I do not remember that happening. One of the problems that emerged with the weekend's conflict has been that people on NPHET have been party to the failures that have created this shortage of acute hospital beds. In effect, they are defending the indefensible with silence.

I do not want to trespass on the time allotted to others. There are aspects of the statement from the Minister of State which I regard as unsatisfactory. It is welcome that she gave statistics on the number of flu vaccines that have been ordered but we have encountered major delays in administering those vaccines. The statement did not cover such matters. Some Senators may welcome this statement and the programme, and I agree that any resources will be welcomed where they are needed, but we have much more to do and we must demand more frankness from our Government.

I welcome the Minister of State. She is here to present the plan but it is a little late in the year to be doing so. She is aware that Sinn Féin made proposals in August and there are many people wondering why months were allowed to elapse over the summer when this work could have been done. The plan has some good points but it appears that these are mostly aspirational rather than being part of an effective strategy. It lacks detail and, in some ways, it is a little underwhelming.

The plan is full of temporary measures. I am sure the Minister of State would agree that our health service has been in crisis for many years and that this plan needs to be about more permanent solutions, capacity and expansion. I am sure she agrees that we need beds but the announcements in this plan simply replace the capacity that existed before the Covid-19 pandemic. I am sure everyone agrees that we are heading towards a potentially catastrophic winter for our health service and that we desperately need greater bed capacity, particularly critical care and ICU beds.

It is somewhat a scandal that we are in the middle of this global pandemic with a health service that in any given year during winter is already bursting at its seams and yet we still only have half the number of critical care beds as compared to the European average. In 2009, there were 289 critical care beds and we were told then that we needed 579. Move forward 11 years and, in the middle of a global pandemic - the biggest health crisis this generation has faced - we have nine fewer critical care beds.

We also desperately need staff, including doctors, nurses, consultants, medical scientists and other health and social care professionals. Those people need investment. The plan does not go far enough in respect of any of that.

I welcome the ambitious targets for community beds but, again, there is a lack of detail. The broad suite of community and home supports is welcome but there is also a lack of detail in this regard.

The plan does not go far enough to address outpatient waiting lists or funding to fully resume disability and mental health services.

Since the beginning of the pandemic, Sinn Féin has been calling for an all-Ireland approach to dealing with Covid. We do so not to make a political point but because it makes perfect sense when trying to deal with a virus such as this. It was very encouraging in the early days of the pandemic when we saw the signing of a memorandum of understanding between the two states. Unfortunately, however, there have been significant gaps in implementing it. There is, without a doubt, far more work that could be done.

I wish to raise a very serious and concerning situation which I have raised previously in the Chamber and with the Minister, Deputy Donnelly, and which my party has raised with the Northern Ireland Minister of Health, Mr. Robin Swann, and that is the serious concerns around the lack of cross-Border contact tracing. My party also raised this issue last week at the North-South Ministerial Council. However, I have been less than impressed with the length of time it has taken for this issue to be considered, let alone addressed, because, as far as I am aware, it still has not been fixed. Time is of the essence. It is no coincidence that the number of cases in Border constituencies are the highest on the island. People need to wake up and smell the coffee. We need to get this issue addressed now. What have the Minister, Deputy Donnelly, and the Northern Ireland health Minister, Mr. Swann, agreed in terms of a way to get the issue of contact tracing in Border constituencies addressed once and for all?

In the middle of the pandemic, with the worst winter that we will face in a long time to come, I am underwhelmed by the plan presented to the House. It is obvious that NPHET has concerns around bed capacity, and ICU capacity in particular. That is clear from the recommendations it made this week. However, much as the Minister of State's colleague, the Tánaiste, Deputy Varadkar, tried his best to portray otherwise, NPHET is not to blame for a broken health system that will struggle to cope if hospitalisations go up. That is on the Tánaiste and the Minister for Health, Deputy Donnelly, as well as the Government and previous Governments. If this plan is anything to go by, there is no political will to be part of the solution in the health crisis we all face. We had a broken health service before the virus. The problems did not stem from the virus but, rather, from decades of bad government, bad decisions and poorly equipped winter plans such as this one. I wish I could be more positive about the plan that has been announced.

Winter is always an extraordinarily difficult time in our health service, whether one is a healthcare worker, a patient or one who is anxious about a loved one in hospital. My party colleague, Deputy Kelly, raised the issue of the flu vaccine in the Dáil. We are seeking an update on that issue because there is serious concern among general practitioners and many other sectors of society. Pharmacies are advertising the flu vaccine online but when one fills out the form, one realises that one cannot get the vaccine. We have been told that pharmacies should be receiving the vaccines in advance of the winter season. What is the position regarding the volume of vaccine we will be getting? It was flagged quite early that there were concerns around the volume of vaccine and that we needed to ensure we had a supply coming in. Where are we at with regard to the supply of the vaccine and how will it be distributed to healthcare professionals? Over what timespan will we have the vaccine this year? We are obviously up against a deadline given the crisis in terms of non-Covid and Covid healthcare.

The Labour Party has been raising the issue of Covid healthcare taking priority over non-Covid healthcare for many months. I have deep concerns on this issue, especially after speaking to people working at various levels of the HSE in the past two weeks. All Members have heard of the issues with the volume of people who may not be diagnosed this year. The situation is worrying because the longer a person's illness remains undiagnosed, the less chance that person has of survival, particularly in the case of those with seriously acute conditions.

The winter plan makes certain commitments on beds. The Government has been trumpeting that there will be 1,500 new beds, but 409 of the 830 new acute beds , 45 of the 62 new critical care beds and 395 of the 484 new sub-acute beds are already in place. In reality, there will be 89 new sub-acute beds in the run-in to a winter when we will grapple with the Covid-19 crisis in addition to the usual acute care demands. That is a little less than reassuring.

Of course, the number of beds is not the sum total of this equation. The other key component is staff. It is all well and good to promise extra beds and, goodness knows, we need them, but it is an entirely pointless exercise unless safe staffing is in place. There are ambitious plans for recruitment and health, with more than 12,500 staff to be recruited, including 5,000 before Christmas and 7,500 afterwards. From where are those staff going to come? Ms Phil Ní Sheaghda of the Irish Nurses and Midwives Association has pointed out that some nurses who came home from abroad have been unable to get full-time jobs. What is going to radically change? How will this work? Where will we get the consultants we require? From where will all these staff come? How will the Government deliver on this commitment? Where will the staff be placed?

I wish to briefly mention the issue of student healthcare professionals, many of whom are working without pay. I know of at least one student nurse who is working on a Covid ward as part of her placement but is not getting paid and is unable to take up paid work in another setting due to concerns about cross-contamination. That situation is extremely disheartening for student nurses, who are front-line healthcare workers. Those students and unpaid workers cannot eat the candles placed in windows or survive on the public clapping for them. This issue is of deep concern for those student nurses.

We need an update on cancer screening. The drop in the number of cancer screening tests since March will have a profound effect. This week, I was briefed by the Irish Cancer Society on the drop-off in services for breast cancer patients. As Members are aware, October is breast cancer awareness month. With regard to Breastcheck, we know its services are not resuming in the way it was indicated they would. The Irish Cancer Society is concerned that there are 600 people with undiagnosed cancer. They do not know they have cancer and are unable to start treatment because of the drop-off and delay in services.

I ask the Minister of State to explain the slightly baffling decision to move from an interval of two years to an interval of three years in the context of mammograms. If an interval of two years was previously the standard, I would like to know the new medical evidence indicating that an interval of three years should be the new standard. I do not think Covid-19 is an acceptable reason for that decision. I wish to know why the interval between screenings has changed. Nobody has explained the reason for that decision or why we were using an interval of two years in the first place if there was a different standard. I ask the Minister of State to outline the position in that regard.

On CervicalCheck, some 6,000 letters have gone out but there has not been sufficient uptake, which is a real concern. The low level of uptake needs to be tackled because otherwise there will be severe consequences down the line. We know there are an extra 50,000 people on waiting lists because of Covid. Never before in the history of the State have there been so many people on hospital waiting lists. Frankly, unless the Government takes action, this issue will spiral further out of control. It is clear from these figures that the reopening plan for non-Covid healthcare is inadequate and needs to be significantly beefed up. What will be done to tackle the waiting lists and ensure no further delays are faced?

I warmly welcome the Minister of State to the House. In her previous term in the Oireachtas, she showed real and genuine commitment to health, and mental health in particular. I was delighted to see her take up her current role.

When we started discussing these issues in March, April and May, much of the focus was on flattening the curve. I remember thinking about how I could be of assistance. I decided that as lots of people were focusing on flattening the curve, I would focus on the issue of what we do with the time we are buying. Let us be clear that flattening the curve is only the buying of time in order to increase and support capacity. I am concerned that the time gained by flattening the curve has not been well used.

It seems to me that the lowering of the level was seen as a lessening of pressure. We know that some of the social supports which I believe should have been beefed up were removed or eroded and that we did not see the scaling up that was needed in terms of ICU care. Pre-Covid, bed capacity in ICU was 225. The temporary surge capacity was approximately 350 and now our permanent capacity is just 280. A move from 225 ICU beds to just over 280 beds is not an adequate response.

One of the issues on which I focused at the time was ventilators. As the Minister of State will know, certain companies in Galway were among the key global manufacturers in terms of ventilators. They have shown great responsibility by sharing and open-sourcing some of their plans. In March, the HSE ordered 900 new ventilators.

It is not clear whether they have arrived. Where are they in the system? Are they in high-dependency units, HDUs, or ICUs? Intensive care and high-dependency units do not simply comprise ventilators - there are also ICU staff.

I echo others' concerns about the failure to drive recruitment. We should never be in a situation of people walking away because they feel that they are not valued or being offered meaningful contracts in respect of their work. For example, we want to ensure that student nurses do not leave our health system because they feel undervalued through not being paid properly.

I am concerned about ICU capacity. Were other staff retrained to acquire ICU skills? It has a specific set of skills. The Minister of State referred to increasing home care hours. When will there be a statutory entitlement to, and regulation of, home care? I asked numerous questions but received unsatisfactory answers around the provision of PPE to those working in home care and in community and voluntary services that support people directly in their homes. Will the State guarantee to provide them PPE?

Regarding those who wish to transition from residential care to home care, the Minister of State mentioned step-down services. Was she referring to people who were leaving hospital or did she mean a potential route out of residential care for certain persons?

These are my key issues. Other Senators have spoken about the flu vaccine. I have asked questions of the Department about public sanitation and been told that it was a matter for local authorities. Will the Department engage with local authorities on ensuring that there is public sanitation and that, accordingly, people can access sinks, toilets and spaces? That has always been part of ensuring an appropriate response. It is an issue, and not just for those with disabilities.

Mental health matters are a key focus for the Minister of State. Waiting lists were already extraordinarily high, with 2,000 children awaiting child and adolescent mental health services, CAMHS, and 10,000 people awaiting primary care. The amount of €30 million is not enough, and the Minister of State knows that there have been demands for €80 million. What can we do to step up?

Other Senators have spoken about home care and disability services. Rehabilitation and recovery services for those with addictions are essential care and I hope that they will form part of the winter plan.

I realise that I am coming to the end of my time. I wish to address a cost-cutting issue. When we debate the HSE's winter plan, it has to be based on health and scientific advice. That is fundamental. I urge the Minister of State and her ministerial colleagues in the Department of Health to ensure that health is the driving factor. While it is not within the remit of any Minister to produce a cure or treatment for the coronavirus, we see health concerns being set against supposed concerns about poverty and so forth by those who previously in the Seanad did not show particular concern for poverty. Poverty and income, employment and business supports are issues to which we actually have the answers. The IMF is urging us to borrow. We have a large capacity. We can spend our way out of those problems,-----

-----but we cannot do the same in respect of a health crisis. I call on the Minister of State to please not let a bogus argument be set up between the health of the nation and its economic well-being. They are certainly linked, but we need to prioritise health. The other issues can be addressed through borrowing and intensive spending, all of which we have the remit to do.

My apologies for straying.

The Minister of State is becoming a regular visitor to Seanad Éireann. If she keeps arriving with the good news that we got this morning, she will be a very welcome one. I listened as she outlined the ambitious winter plan. As the Acting Chairman knows, we have debated winter plans down the years where there was not a significant spend. However, the mindset around healthcare has been recalibrated so that healthcare is not at the top of our political priorities.

This time last year, we were discussing Brexit, which was the largest political challenge in our country's recent history. While it remains a major political challenge, it is fair to say that all observers and commentators now realise that health is our single greatest political challenge. We will not have a vibrant economic future unless we and our people are healthy. Health and our economy are intrinsically linked - they are two sides of the one coin and deserve the same commitment in terms of resources, priority, effort and determination. Since January, we have seen how our country and our people respond "when our backs are to the wall".

Currently, we are dealing with a worldwide pandemic that has infected nearly 39,000 of our citizens. On the island of Ireland, more than 2,000 people have, sadly, lost their lives. Any winter plan has to reflect that backdrop, and this one does. We are discussing spending hundreds of millions of euro in this winter plan and making beds available in accident and emergency units. In the mid-west, an extra 60 beds will be opened on 9 November for patient treatment. These are new beds and their opening is welcome. I am not 100% sure whether it was a year ago today, yesterday or tomorrow, but 93 people were on trolleys in University Hospital Limerick, UHL. The 60 beds will make a major difference when they open. That is just one element of the winter plan, but it is a key component.

Colleagues have alluded to other issues. For example, the Minister of State is aware of mental health issues from her work in the previous Dáil. I agree with Senator Higgins that the Minister of State's work was genuine, determined and focused. In politics, it is great to see someone with that determination getting the opportunity to execute it from a position of authority. I do not doubt that, if the Government lasts the four and a half years, the Minister of State will be able to turn around and point to significant achievements in the fields of older people and mental health. We wish her well and will stand in solidarity with her in her efforts to achieve those.

The winter plan is appropriate and proportionate. It has to be welcomed, but it also has to be implemented. I look forward to standing in the Chamber in six months' time to review how the winter plan worked and the impact I hope it will have had.

I will conclude by referring again to the pandemic. As Oireachtas Members, we all have a responsibility to use our social media platforms to keep hammering home the message. We are in level 3 and the situation is not easy. There are people who this morning were told they would not have jobs until such time as we moved back to level 2. We have a collective duty as leaders in our communities and society to encourage everyone to reboot his or her efforts. I appeal to business people to do the simple things like keeping their hand sanitisers topped up. The number of hand sanitisers one finds empty when going into buildings is amazing. Regardless of whether we like it, complacency has sadly set in. People became fatigued, but we must reboot and recalibrate now. The only way that the Minister of State's winter plan can be successful is if we can break the coronavirus chain and reduce the number of people getting infected.

With that, I wish the Minister of State well.

I welcome the Minister of State to the House and congratulate her on her elevation. My colleagues have already addressed the issue of critical care bed capacity so I will focus on some of the other risks that exist within the HSE. I will add that hearing the Minister on the radio the other day talking about building bed capacity over the next two years did not really inspire confidence in where we are going. God help those who are sick with anything other than the coronavirus if things continue to spiral out of control.

The winter plan states that a key underlying risk in its implementation is the risk of not being able to attract and retain the appropriate number and calibre of staff for key posts. A significant number of such staff is required. These posts cannot be offered on a permanent basis. We attracted hundreds if not thousands of medical care workers back to this country to put on the green jersey during the Covid-19 pandemic and then we offered them nothing. Some were not even offered jobs. Meanwhile, I heard the director of a nursing home complaining yesterday that the HSE was stealing her staff, both special care assistants and nurses. We cannot do this. We have to treat the entire healthcare system as one unit. This is the plan's Achilles' heel. Having identified the risk, the plan should go on to mitigate against it. What plans have been made to attract these staff? They are highly qualified people. We cannot offer them rubbish contracts. If we are going to bring them in, we have to give them decent contracts.

Additional funding for bed capacity is all well and good. My colleague, Senator Annie Hoey, mentioned the Irish Nurses and Midwives Organisation, INMO, in the last few minutes. The plan sets out several ambitious targets but does not outline the number of extra staff that will be needed and recruited to achieve them. For example, just five days ago there were 80 vacant nursing posts in three main hospitals in Kildare. Some 25 of those posts were in Naas. For months the INMO has sought a funded workforce plan for the HSE. Where is it? As far as I can see it is not in the winter plan. It was forthcoming at the end of last month but it has been referred to the Workplace Relations Committee. Do we have to go through a workplace relations dispute in order to solidify or create decent jobs for these people?

What steps have been taken by the HSE to provide clarity for the nursing unions? I fully support the proposal to care for those with high and moderate levels of frailty in their own homes. That is welcome. I also welcome the 4.7 million additional home support hours provided for in the plan. Again, this is an ambitious target. It is predicated on the ability to recruit staff, with Family Carers Ireland estimating the required figure at about 800. We have to find 800 support staff for care in the home. Fórsa is meeting the HSE today and the Services, Industrial, Professional and Technical Union, SIPTU, has already raised the issue. It is frighteningly late in the day for the HSE to be discussing this when we know that healthcare workers have been severely and disproportionately affected by Covid-19. A director of nursing in one nursing home was on the radio yesterday afternoon. A neighbouring home had staff with Covid-19, including both care assistants and nurses. She went over and volunteered in that nursing home. The movement of caring staff from house to house will be a problem.

Family Carers Ireland has concerns about additional pressures on its members and the need for vital supports such as daycare, personal protective equipment, PPE, transport and essential therapies. I could go on and on, but like most other people I am running out of time. I appreciate our position regarding this plan but as in every other area affected by Covid-19, the chickens have come home to roost. Years of underinvestment have left us facing into a hard winter. This is not the Minister of State's fault but that of successive Governments. God knows what is coming down the line if the measures being taken by the Government do not get public buy-in. Today I read about nurses trying to get into Dublin facing a five-hour tailback because of the roadblocks Senator McDowell referred to earlier. That is simply not good enough. I apologise to the Acting Chairman for going over time.

The Government has been in existence for more than 100 days but this is the first time I have had the opportunity to congratulate the Minister of State and wish her well in her new role. It may be her first time in this House. She is very welcome. At the time this Government was being formed, people were crying out for a Government. Fine Gael might not be the best friend of the Minister of State's party, although it is certainly its most competitive friend. However, party differences were set aside. Many would not step up to form a Government but the coalition parties put people before politics. I hope history will be kind to the bravery of Fianna Fáil's membership in providing stability in the teeth of a pandemic. I am sure it will.

I broadly welcome the plan the Government has outlined in recent days. I have three concerns, which I hope the Minister of State will take on board. The first is the problem which many doctors and pharmacists have reported, that is, a shortage of the flu vaccine. It is a shame that this winter, of all winters, many practitioners are crying out for enough doses for their patients. They are perplexed and worried. They have received some supplies so far, but nothing like the amount required. Perhaps a better explanation is due to those practitioners and their patients. If there is a worldwide shortage I ask the Minister of State to say so. Did this issue arise because the HSE did not order the vaccine in time? This is not necessarily a criticism of the Minister of State.

My second concern pertains to the Covid-19 assessment hubs. We know about testing centres, but the assessment hubs play a vital role after a full consultation with a GP. Many cases may not justify referral to an emergency department for further medical examination. As such, we set up assessment hubs for those with respiratory symptoms at the beginning of the pandemic. However, as I said in the House last week, we do not have any similar facility for those under the age of 16. For those over 16 a third option exists, a safe place for further examination which cannot be carried out in a GP's surgery for obvious reasons, namely, the need for intensive cleaning and concerns about the safety of patients and medical practitioners. I worry that large numbers of possibly unnecessary referrals will be made to paediatric emergency departments because there is no such facility for children.

The third concern, which the Minister of State might take on board in due course, relates to beds in intensive care units, ICUs. Before Covid-19 we had 225 such beds. In April, at the peak of the first wave, we had approximately 354 beds. I am open to correction on that point. Those included makeshift beds in theatre recovery areas. I understand that we now have 280 fully staffed beds. In 2009 the HSE said that 579 ICU beds were required. We are often just a little bit behind England, where hospital admissions have increased by 25%. That figure does not refer to ICU admissions. I am concerned that we do not have enough fully staffed ICU beds to ratchet up our response as necessary. I hope the Minister of State can provide reassurance on that point. I am concerned about overcrowding due to the toxic combination of the winter flu season and the challenge of Covid-19.

Have we a sufficient number of ICU beds?

Overall, I welcome this significant injection of moneys. The Government is obviously taking this crisis very seriously and putting people's health first, which is only right and proper, and of paramount importance to us all.

I would be very grateful if the Minister of State took on board all of the issues that I have raised.

Six more speakers wish to contribute but we have to conclude at 4.37 p.m. to allow the Minister of State to speak for eight minutes. Senators Cassells and Byrne have agreed to share time in the Fianna Fáil slot and they are next. After that it is Senators McGahon, Currie, Dolan, Keogan and Buttimer unless others indicate a wish to contribute. Senators Cassells and Byrne will speak first and then Senator Keogan because there is a ratio of 3:1 but in terms of the Government Opposition it is 2:1.

I believe that is wrong.

I suggest that the Senator speaks for only three minutes if she can as I am conscious that the Minister must have an opportunity to contribute.

I welcome and congratulate the Minister of State. I am delighted that she was appointed to the role because her dedication and passion for her portfolio, when in opposition, was second to none. She is going to be a reforming Minister of State.

A very famous television show called "Game of Thrones" had the tagline "winter is coming". For us in this country it really is and it will be a winter like no other. For us, the coronavirus is our reality of the White Walkers and just as deadly. The winter programme will be critical in so many aspects of society in keeping our systems functioning and our citizens healthy so I am glad of the extra €600 million on top of our normal funding for this particular programme. The medical card for the over-70s was a huge and very significant announcement. With the coronavirus there is so much noise in our media and on the airwaves that hugely significant statements such as that by the Minister of State which are reforming and will make a huge difference may not be heard.

The initiative is about keeping people safe in their homes, which is a huge issue that the Minister of State is passionate about. I ask her to touch on home care support in her closing remarks. We are all very conscious that there was already a backlog in the system. Have the Minister of State and her Department analysed the anticipated surge that could arrive on top of the backlog? In terms of GPs, I would like to know what services are under pressure in all of the constituencies and I would like to hear statistics on waiting times as a result of Covid. I am very conscious that all of this plan, even things like community beds, are contingent on a large numbers of additional staff. It is a wholetime equivalent of 868 new staff in terms of staffing the community beds initiative. Is there a recruitment process in place to make sure that, come spring, the Department has time for that?

I have been inundated with representations about disability services because people are anxious that their loved ones get the full-time care they had prior to Covid. It is causing a major strain on families. I ask the Minister of State to address these matters and I now hand over to my colleague, Senator Byrne.

I welcome the Minister of State and I know she is passionate about this issue, particularly her concern about people's mental health and well-being over the coming winter.

The winter plan addresses the role of GPs. GPs have been under pressure and working on the frontline has meant many of them are exhausted. GPs and their teams of nurses and other workers deserve a lot of praise.

I agree with the concerns about the flu vaccine expressed by Senator Martin. We must ensure that there is an adequate supply. I know from talking to GPs in Wexford that there are still some concerns about supply.

I wish to raise two specific issues about the plan. The first issue concerns the community intervention teams. Most counties are covered by community intervention teams with the exception of counties Longford, Westmeath, Mayo, Donegal and Wexford. There is a plan to put community intervention teams in place but a commitment in the winter plan says that they may not be in place by March. I hope that we will be out of our winter by March. One of the big problems is that one in four GP practices in rural Ireland has only one GP and local cover is essential. Therefore, community intervention teams must be in place to provide adequate access to healthcare.

I wish to comment on GP access to diagnostics. Due to the fact that there is limited access many patients are being referred directly to hospital emergency departments, which is an inefficient use of resources. The significant number of proposed additional diagnostics is welcome. It will be nearly 34,000 by the end of this year and more than 45,000 in the first quarter of next year. Who will perform the scans and X-rays? Where will the staff be located? How will GPs access all of the additional diagnostics? That information must be clearly spelled out.

Senator McGahon is next and I urge him to stick to just two minutes.

Some Members spoke for 1 minute and 20 seconds more than their allotted time, which was rude, but I will stick to the time in deference to the Acting Chairman.

As we have been delayed again because Senators spoke for too long I will scrap what I was going to say and focus on one issue. Senator Elisha McCallion is absolutely correct in her call for an all-island approach to tackle Covid. That is the one and only time in my career in this House, however long I will be here, that I will agree with Sinn Féin. The Senator, like myself, is a Border politician so understands what the Border area is like and I only live a few miles from the Border. We have seen huge increases in Northern Ireland and in Border constituencies so unless we have a dedicated Border plan to reduce Covid then there will be a really difficult winter experienced by communities like mine in Dundalk and north County Louth. It is essential that our public health requirements and restrictions mirror as closely as possible the same restrictions in Northern Ireland. It is madness. There is no reason the South should be on level 4 and Northern Ireland on level 2 because it will lead to a lot of people criss-crossing the Border due to different restrictions. At the minute there is good co-operation between the HSE, the NHS and various Departments but we need to massively increase that communication otherwise people living in Border communities will have a very dark winter indeed.

I welcome the Minister of State to the House. Last week, I addressed a number of issues concerning the flu vaccine and I welcome the measures that were brought in then.

The winter plan is a step in the right direction but the journey is far from complete. In its current form the HSE's winter plan is deficient in certain respects. I refer to the gross under-utilisation of the 1,800 community pharmacists who serve communities across the country and never closed their doors to people in need during lockdown. The Government gave a commitment to expand the role of community pharmacies in the programme for Government. The Government pledged to include pharmacies as part of the initiative to enhance primary and community care, thereby making the vast majority of healthcare services available to people in the home or close to home rather than in overcrowded hospitals. Now is the time to make good on that promise in the midst of a pandemic, when the need is so great, to maximise the use of all available resources and expertise. This is imperative not only to protect the health of the public but also to ease the burden on our overworked GPs, hospitals, doctors and nurses. There are a number of measures that could easily and quickly be introduced to improve the winter plan and further these objectives.

In terms of vaccinations, pharmacists are allowed to administer the pneumococcal vaccine to members of the older population. However, there is an issue both with the provision of the vaccine doses and the funding to roll it out through community pharmacies. I suggest that Connolly Hospital and even the HSE should sign a statutory declaration to supply and reimburse pharmacies for such work.

If the Minister, Deputy Donnelly, is sincere in his intention to protect the vulnerable, then he must act on this proposal without delay. There is no excuse for any such delay. The Minister must act now, as the flu season approaches and the Covid numbers continue to rise.

I am not sure if the Minister of the State is familiar with the proposed minor ailments service. Its introduction was announced in 2016 but the proposal seems to have sat on the shelf ever since. There are other steps being taken to expand the role of pharmacies and relieve the ever-growing burden on GPs and hospital emergency departments. This effort would be enhanced by the immediate establishment of the minor ailments service, which would provide accessible healthcare for a variety of common ailments via the existing network of community pharmacies. We are lagging behind our neighbours in Northern Ireland, Wales and Scotland in this regard, where valuable primary care services are already provided through the pharmacy network. There is further evidence of the value of the proposal in a study undertaken by the home medicines service in the UK, which indicated that a comprehensive pharmacy-based minor ailments service could take on up to 1 million unnecessary GP visits annually. In the midst of the Covid pandemic, I know the Minister of State will see the value of introducing this scheme as a priority.

I apologise that I cannot give the Senator any longer to speak but we are under pressure of time. I am mindful that there are only six minutes remaining and three Senators wishing to speak.

I was going to raise three issues but will confine myself to just one. The Government's resilience and recovery plan is premised on doing everything we can to keep schools and childcare provision open. As it transpires, minding children is the glue that keeps us together, except when it comes to maternity services. I am sure the Minister of State has heard the expression "happy mama, happy baba". There are many unhappy mamas at the moment because of the hospital restrictions that mean they have no one by their side during early pregnancy scans, anomaly scans, throughout the duration of the birth process and for post-partum services. Expectant mothers are staring into a winter of more of the same.

The Government made a decision on Monday to base our approach to Covid-19 not just on public health numbers but also on wider important social factors such as emotional well-being, mental health, which the Minister of State knows all about, and a holistic duty of care. Can the same approach not be taken in regard to maternity services? In response to a parliamentary question last week, the Minister said that any decisions on restrictions are made, implemented and reviewed at hospital level and that the national women and infants health programme has developed a guidance document on restrictions which seeks to provide a more consistent national approach to visitor restrictions. It proposes, for example, that hospitals should review visiting arrangements every week. Will the public have access to those reviews by way of hospital risk assessments and safety statements? Is it possible for maternity hospitals to be brought into the resilience and recovery plan by way of the imposition of stepped restrictions from level 1 to level 4? Surely women in such vulnerable positions can be prioritised rather than pushed to the back of the queue when it comes to reopening society.

I recognise that these are very challenging times for maternity hospitals and I appreciate everything their staff do and are doing. All I am asking for is communication, clarity and compassion. I spoke yesterday to Claire Hanna, MP, who has raised the same issue in the House of Commons. She has stood up for women in the North and I am doing the same today for women in this State. The Royal College of Midwives has stated that having a trusted birth partner present throughout labour is known to make a significant difference to the safety and well-being of women during childbirth. At a time when the coronavirus is heightening anxiety, that reassurance is more important than ever. I ask the Minister of State to stand up for these women because they are busy and cannot do it for themselves.

I welcome the Minister of State to the House. As per the Acting Chairman's instructions, I will keep my contribution brief. I very much welcome the investment in the HSE winter plan and acknowledge the fantastic work being done by our healthcare teams in primary care and in hospitals. The investment in community healthcare networks is particularly welcome, as are the additional 4.76 million home support hours provided under the home first initiative.

I want to raise an issue that is local to me. Social services in Ballinasloe have had a HSE nurse allocated to them but day services are not fully open at this time. I would like to see the resources that were allocated to contact tracing and testing returned to social services so that they can avail of access to a HSE nurse.

In terms of innovation, it was great to see such things as e-referrals of prescriptions during the Covid crisis. It has taken many years to get across the barriers to that type of innovation. I welcome the focus in the winter plan on telemedicine. I would like to see much more of that type of innovation happening in order to reduce face-to-face contact.

Access to the winter flu vaccine is crucial but we are hearing that some people in vulnerable groups have not been able to avail of it. In my area, for example, I know of a young pregnant woman who has not yet been able to get it, which has made her very anxious. We are now hearing that people will have to wait until the end of October before there is availability.

Recruitment of healthcare personnel in regional areas can be challenging. I ask that consideration be given to offering incentives in hospitals in more regional locations to recruit staff.

Finally, I draw the Minister of State's attention to the fact that the red-eye Westdoc service is not currently available in Ballinasloe, Clontuskert, Laurencetown and south Roscommon to support local GPs.

I welcome the Minister of State to the House. In the brief time remaining, I will home in one point in the winter plan, namely, the provision of 4.76 million additional home support hours. I pay tribute to all the carers in houses throughout Ireland who look after both elderly people and those with disabilities. I am seeking a commitment that these additional hours will actually be made available. Additional hours were announced in last year's winter programme but there was no evidence of them for the people who need them. We certainly did not see them in my area of Longford-Westmeath. Families need to see them coming on stream. I ask for a commitment that the hours will be made available throughout the country.

I apologise again for the time pressures. I am conscious of the agreed Order of Business and the need to allow time for the Minister of State to respond. As it turns out, we are right on time and I thank colleagues for their co-operation in this regard. I invite the Minister of State to reply and she has eight minutes to do so.

Eighty minutes would be more what I need.

I thank the 16 Senators who spoke for their contributions. Some strayed outside the remit of the winter plan but I will confine myself in my reply to addressing the questions that related to specific aspects of the plan.

An issue raised by several speakers was the availability of the flu vaccine. I was in the Seanad on two occasions last week to address matters raised by Senators Keogan and Paul Daly in the Commencement debate. We had a very good debate in both instances. I am happy to restate the situation in regard to the flu vaccine because I know there are worries in that regard. Last year, 1.35 million vaccines arrived in Ireland, compared with a figure this year of close to 2 million. A total of 600,000 of the vaccines are for children aged two to 12. They will be administered free of charge and inserted through the nose, with no requirement for an injection. That is very welcome and we hope it will be rolled out through the schools. The remaining 1.35 million doses are of the quadrivalent vaccine, which is the one any of us will be administered. I encourage everybody to avail of it. Following a delay in delivery from the manufacturers, almost half of the vaccine doses have now been received. By 18 October, 75% will have been distributed throughout the country. The flu virus is not only in Ireland but worldwide and there is a huge demand for the vaccine. We are on target to have 75% of our delivery distributed by 18 October. That will make a huge difference.

There were many questions on the disability sector. I was in the Dáil Chamber last night with my colleague, the Minister of State, Deputy Rabbitte, for a two-hour debate on disability services. As Senator Cassells noted, sometimes good initiatives can be lost in the business of the everyday. Senators will all be aware that the disability sector was in line for a 1% cost-cutting measure, which would have reduced its budget by €20 million. That decision was reversed since the Government came into office three months ago. In addition, extra provisions of €10 million and €7.8 million were allocated in recent weeks for the delivery of disability services.

Those services all stopped during the pandemic and it has been extremely hard on parents, carers and the people in receipt of care. I am the first to admit that the situation for many people has been awful. I held a round-table discussion with carers three weeks ago. It had to be done online and the number of participants had to be reduced but it was a good opportunity to speak with carers. Many of them told me that they had been housebound during the Covid crisis and had found it really hard. To date, 40% of all disability supports are now back in place. Most people who avail of those supports are getting two days one week and three days the following week. There is a plan to increase that provision from October to December and another plan from January to March. A huge amount of work is going on in this area.

That will also be addressed in the Estimates.

Many Senators raised critical care capacity. It is a huge factor. ICU beds do not grow on trees. Every ICU bed has a cost of €750,000 and needs six qualified nurses with specific skills. It is very important to recognise that. The HSE advises that between 280 and 285 critical care beds are fully staffed and open with the precise number on any given day fluctuating due to staffing or other operational factors. We should note that our critical care units have coped well so far largely because the curve was successfully flattened at early stages, which meant they were not overwhelmed, and because of the incredible work carried out by critical care staff. As a result, outcomes for Covid patients in ICU here compare well with other jurisdictions including the UK. Mortality for Covid patients in Ireland's ICUs is reported at 21.5% whereas the figure in the UK is 41%. We are very aware of the importance of ICU acute beds. It is not simply a matter of putting the beds in tomorrow, however, because they must be accompanied by staff with a specific set of skills. That is why it is quite difficult.

Many Members spoke about recruitment and retention. Many doctors and nurses move onto other countries when they qualify, as they are entitled to do, where they hone their skills. There will not be a movement of staff this year and we are hopeful that will help us to fill some of the issues.

I sat on the other side of the House for four and a half years. Just one Senator referred to the inclusion in the winter plan of ten additional dementia advisers. That is a very important feature of the plan. When I was first elected to the Oireachtas, there were eight dementia advisers in Ireland. As a result of pushing really hard with others on the all-party Oireachtas group on dementia, where members left politics at the door and worked really hard to secure more supports, we got ten posts in last year's budget. I was very happy to speak at the launch of the winter plan two weeks ago when we announced ten more dementia advisers. There are 65,000 people living with dementia here, with 11 people diagnosed every day. It is very important to acknowledge there are many positives in the winter plan.

When I sat on the Opposition side of the House for four years, I criticised other winter plans that had a spend of €30 million. This year's spend is 20 times bigger. That shows how seriously the Government is taking the need to keep our older people out of hospital this year, and to keep our older people at home with the correct wrap-around supports. We need to ensure the people who need re-ablement can get it at home and can get the respite they refquire. That is why €139 million was spent on home care hours alone, with 4.7 million extra hours. I have spoken to some of the private companies and the HSE and it will be a challenge but it is already happening. Before the election, there were 7,900 people waiting on home care supports. Yesterday, I was briefed that this number is now down to 4,300. That is hugely significant. We are already rolling out the hours. I was told this by the person in charge of older person services in the south east. It is a significant reduction, although it is not enough and I will not be happy until no one is waiting.

Diagnostics were raised by several Senators, who asked who will provide them. Some of the details are yet to evolve, but GPs will be able to access 79,000 diagnostics, some of which will be acquired through the NTPF because we will be able to buy diagnostics for the first time ever. Previously, it was possible to do this only in the case of treatments such as hip or cataract operations. Primary legislation will be required to enable the purchase of diagnostics under the NTPF. That will be very important.

I was surprised we did not hear much about nursing homes today. It is a matter close to my heart. Members will have heard in the last week or so that there has been a surge in Covid cases and clusters in nursing homes. Every single nursing home has a sufficient quantity of PPE. There have been challenges about staff moving to other areas, as Senator Keogan observed, but I have spoken to the HSE and we have asked the homes actively not to do that.

I wish to reassure people that the temporary assistance payment scheme, which supports nursing and residential homes, will be continued until next April. That is significant.

I am sorry if I did not answer everything. I could stay here for an hour and answer questions. I thank Senators for their respect and their constructive approach this afternoon. I hope they will all support the plan. All we want to do is keep our people safe as we face the winter.

Sitting suspended at 4.46 p.m. and resumed at 5.05 p.m.