Carol Nolan (Laois-Offaly, Independent)
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I move:

That Dáil Éireann:

recognises that: — healthcare General Practice, being the patient's first point of contact with health services, provides person-centred and comprehensive care from the beginning to the end of life, often coordinating care between many agencies involved in the treatment of complex chronic illnesses;

— general practice in Ireland, providing professional quality care at the heart of the local community, is the cornerstone of the Irish health service, with General Practitioners (GPs) being the first port of call for most patients;

— over two-thirds of GPs (66 per cent) in rural Ireland are currently unable to take on new patients, with some reporting waiting times of up to two weeks for an appointment, according to a survey by the Irish Independent;

— the Irish Medical Organisation warns that Ireland, having only seven GPs per 10,000 population (one of the lowest in the European Union), falls well below the required minimum of 12 per 10,000 to ensure a safe and effective healthcare service;

— Government policy and planning has failed to ensure Ireland is training enough GPs for the population increase, leading to many GPs emigrating due to better pay, terms, and conditions abroad; in 2022 alone 442 Irish doctors were issued temporary work visas for Australia;

— the recent Irish Independent study highlights a mounting health crisis in rural Ireland, whereby a severe lack of healthcare accessibility is causing strain on residents and leading to delayed diagnoses and treatments;

— over two-thirds of GPs are currently not accepting new patients which signifies a shrinking healthcare horizon in rural Ireland;

— medical services in rural communities are currently unsustainable, as evidenced by patients reportedly waiting up to two weeks to secure a GP appointment;

— despite warnings from the Health Service Executive (HSE) years ago, little or nothing has been done at senior Government levels to address this unfolding crisis; and

— modelling suggests that by 2025 Ireland expects a shortage of between 493 and 1380 GPs, mainly in rural areas; this, coupled with an aging population and the likelihood that many GPs are due to retire by 2026 (expected to be around 700), paints a grim picture for a rural health service that is being hollowed out due to a lack of political support; notes that: — according to the Irish Independent study, 68 per cent of medical practices outside the country's main cities are not open to taking on new patients, reflecting a clear urban-rural divide;

— the urban-rural divide in healthcare access has stark implications, with rural patients facing significant barriers to timely medical care, despite rural areas having an older population compared to urban centres in Ireland;

— the cumulative effect of a lack of access to GPs in rural areas has led to an alarming rural health crisis, which is exacerbated by limited or absent public transport services making health services less accessible to rural people;

— the Irish Independent study found that, on average, patients in Dublin can be seen on the same day as a request for an appointment, while those in the midlands looking to book a non-urgent appointment with their GP could be waiting up to two weeks;

— the rural health crisis extends beyond patients to GPs in rural Ireland, with many practices closing down and the remaining ones grappling with overwhelming workloads due to a lack of support from the Department of Health and the HSE, resulting in onerous working conditions that deter new GPs;

— GPs often cite high insurance costs, overheads, and an overly bureaucratic system as obstacles to their patient-centred role, all of which are issues that the Government can address;

— the rural healthcare crisis extends to an emergency in dental care provision where children are forced to wait up to ten years for treatment and less than half of eligible children were seen under the school screening programme last year;

— the rural healthcare crisis is further exacerbated by a severe shortage of home helps, a worsening crisis in every accident and emergency department, an almost non-existent mental health care service, and a severe lack of residential places for people with physical and mental disabilities;

— the Irish Dental Association has previously highlighted to the Oireachtas Joint Committee on Health that children are waiting up to ten years for treatment and less than half of those who were eligible for the school screening programme have been called for treatment;

— the number of dentists registered to treat patients under the Dental Treatment Service Scheme is in freefall, requiring a complete overhaul of the contract governing the scheme; and

— the failure of the Government and the Minister for Health to address the unfolding rural healthcare crisis will likely have a grave negative effect on the health and life expectancy of the rural population; and calls on the Government to: — accept that the leading cause of the severely diminished access to healthcare provision in rural areas is Government neglect and inaction in adopting a strategic rural healthcare framework that incorporates increased resources by the Minister for Health and the HSE;

— end the policy and practice of addressing all healthcare policy problems through a narrow Dublin-based approach, and recognise the healthcare problem in rural Ireland, accepting that rural residents deserve equal access to healthcare;

— explain how, despite an increased national health budget, the country is witnessing a steady deterioration of health services, especially in rural communities;

— urgently address the rural health crisis by establishing a high-level Ministerial working group or Cabinet sub-Committee to generate immediate, medium-term, and long-term solutions, and report to the Dáil within four weeks from this day with a strategic roadmap to reverse this decline;

— immediately implement a strategic 'rural proofing' and 'patient first' approach to all healthcare policies;

— acknowledge that trying to recruit more GPs or allied health professionals from abroad is unlikely to succeed given the global shortage of both these groups of professionals;

— increase the number of GPs through sustained Government funding and a long-term GP workforce strategy and plan, addressing the unhealthy work climate for GPs by improving support, reducing their administrative workloads, and tackling their patient workload intensity and volume, as well as long hours;

— implement policies that will make the provision of rural healthcare attractive for young doctors, such as offering scholarships to medical students from rural areas to return and practice in their home areas;

— ensure the HSE changes policy and puts in place new salaried GP posts where vacancies remain unfilled in rural areas, along with providing premises and staff in areas where the patient list is small; and

— recognise that action is long overdue and the fact that Ireland does not have enough GPs to meet patient numbers, especially in rural Ireland, which constitutes a national health emergency that needs to be treated as such.

I am delighted to move the motion on my behalf and that of my Rural Independent Group colleagues. Before I begin, I convey my sincere condolences and those of the group to Deputy Michael Collins and his extended family on the death of his nephew, which is no doubt a devastating tragedy for them all. Our thoughts and prayers are with them all at this very difficult time.

It is absolutely clear that for many years now rural communities have been struggling to attract and retain GPs and locum GPs. The HSE's own modelling suggests that by 2025, Ireland expects a shortage of between 493 and 1,380 GPs, mainly in rural areas. This is coupled with an ageing population and the likelihood that many GPs will be due to retire by 2026. I understand that the figure for GPs due to retire by 2026 is 700. This paints a stark picture ahead for the rural health service. The emigration rates for young qualified medical graduates, which continue to grow alongside this rapidly ageing population profile, means that unless we get to grips with this emergency now, we are facing catastrophic outcomes in the years and decades ahead.

10 o’clock

We have all seen the recent Irish Independentstudy highlighting the mounting health crisis in rural Ireland, where a severe lack of healthcare accessibility is causing strain on residents and leading to delayed diagnoses and treatments. The study found that over two thirds of GPs are currently not accepting new patients, which signifies shrinking healthcare on the horizon in rural Ireland.

What does that mean in real terms? In the worst-case scenario, it means an early or avoidable death or more intense and prolonged treatment. Those are the facts and what we are talking about here. The lack of GPs in any area and even my own area of Offaly, rural or urban, logically means people who need to be seen quickly for a referral or initial diagnosis are not being seen. This can lead to the development of conditions that might have been addressed more effectively if a GP or doctor had been available to diagnose or assess. From our perspective, all of these issues are being disproportionately felt in rural communities where we live and work.

What is truly alarming is that, looking around the world, the same is true in rural communities almost anywhere. Even in Australia, where so many of our emigrants are and are heading to, we have seen rural GP services and rural medical provision described as a professional wasteland. Indeed, in the UK, the Royal College of Physicians warned that just 13% of consultants appointed in England last year went to hospitals serving mainly rural or coastal areas, with the other 87% being hired by those with mainly urban populations. Examples from other countries could be multiplied with ease.

Coming back to our own country, what this reveals to me is that while Ireland is far from unique, rural communities must be prioritised with the delivery of a rural healthcare strategy that fundamentally addresses these kinds of geographical inequalities. I have no interest in getting up here and simply complaining about this horrendous situation. I want at the very least to point towards some solutions such as those outlined in the Shaping the Future discussion document from the Irish College of General Practitioners, ICGP, last year. In it, the ICGP outlines the ten potential solutions it believes will help relieve the GP workforce crisis, as well as the non-EU rural GP initiative.

What do we need to do? We need to expand GP-led multidisciplinary teams. We need to at least double the number of GP practice nurses, which is key. Many people think they need to see a GP, but a professional practice nurse can take the pressure off GP waiting times. We need to resource the career expectations of future GPs. Local GP roles can be seen as not very exciting or fulfilling from a career perspective, whereas many local GPs who actually take up the role feel that it is at the heart of good medical practice and can be deeply rewarding when properly resourced. We must provide suitable premises for GP-led multidisciplinary teams. We must support suitably qualified GPs to take on General Medical Services, GMS, scheme and medical card lists. We must have increased remote consulting, but this may be more difficult where unreliable broadband unfortunately is still an issue. Many older people still prefer the personal touch. The final point the ICGP gave as a solution was to increase exposure to general practice in medical schools.

These are just some of the many ways and solutions that have been put forward that we can put in place to help to rejuvenate rural GP services. I am aware that the non-EU rural GP initiative is aimed at addressing the issue of brain drain faced by the Irish healthcare sector by attracting non-EU doctors to rural general practice, and that this has led to about 50 participants. That is to be welcomed. The ICGP, as we know, has stated that it wishes to attract at least 100 such doctors to Irish rural practice throughout 2023. While this is welcome to some degree, there appear to be real ethical issues with taking away medical professionals from what may be already poor or underdeveloped areas, particularly when we have a substantial number of our own graduates who could be motivated or incentivised to stay at home and work here.

I accept there are no easy solutions, but at the same time the policies that have been adopted to date unfortunately have failed. There is a myriad of complex and intersecting issues relating to this crisis. Among them is the sheer unattractiveness of living and working in Ireland, with the lack of housing, sky-high rents and an insurance sector that seems almost designed to exploit. All of these things make it more difficult for GPs who are private practitioners to be able to choose a professional life here. The longer these issues prevail, the worse the situation becomes, because existing pressures are then deepened, which in turn leads to professional burnout and to even more pressure on the GPs who are available.

Mention has also been made of the capacity constraints that now exist. We have a Government prioritising free universal access when the capacity of the system to absorb those numbers is just not there. We need targeted supports for the vulnerable in rural and urban communities. What we absolutely do not need are more of the same failed and failing policies, the only outcome of which has been to deepen a GP availability crisis that shows no sign of abating.

Michael Healy-Rae (Kerry, Independent)
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I, too, pay my sincere sympathies to Deputy Michael Collins, his brother, Councillor Danny Collins, and to the mum, Kay Lynch, of the late Michael John Lynch, who would be a nephew of our colleague in the Rural Independent Group, Michael Collins. We are sorry for his sad passing. To his friends, his family and his neighbours in the Durrus area in Cork, I send my heartfelt sympathies.

I thank the leader of our group, Deputy Mattie McGrath, and his excellent staff, including Brian Ó Domhnaill, Triona and others, for their work in putting together this important Private Member's motion. I remind the House what we are actually looking for. We are saying that healthcare general practice is the patient's first point of contact with health services. It provides person-centred and comprehensive care from the beginning to the end of life, often co-ordinating care between many agencies involved in the treatment of complex chronic illnesses. General practice in Ireland, providing professional, quality care at the heart of the local community, is the cornerstone of the Irish health service, with general practitioners being the first port of call for patients. Over two thirds of GPs, 66%, in rural Ireland are currently unable to take on new patients, with some reporting waiting times of up to two weeks for an appointment according to a survey by the Irish Independent. I acknowledge and thank theIrish Independentfor the work it has done in recently reporting this serious situation, as did the Irish Examiner.

The Irish Medical Organisation warned that Ireland having only seven GPs per 10,000 population, one of the lowest levels in the European Union, falls well below the required minimum of 12 per 10,000 to ensure a safe and effective healthcare service. I want to highlight this and remind the Minister of State of those words about 12 GPs per 10,000 persons. I want to explain exactly where the Iveragh Peninsula is. I have been saying it here now for many years but I will say it again because it is where I started out on Kerry County Council.

I am talking about going from Killorglin, on through Glenbeigh and heading over Mountain Stage, down into Portmagee, Kells, Cahersiveen and Foilmore, over the water and down to Valentia Island, Ballinskelligs, the Glen in Emlaghmore, Waterville and up to Dromod, then out to Coomakista, Caherdaniel and Castlecove. When you are talking about the Iveragh Peninsula, that is where you are talking about. It is open terrain, with places that are very far from care centres of excellence. It is very far away from University Hospital Kerry, Limerick hospital or CUH, and if it were not for the advent of air ambulances in recent times, many deaths would not have been avoided.

I thank the people working in healthcare there over the years, but in the past, we had up to six GPs. Now, we are down to three, with another GP retiring. Our indigenous population in the Iveragh Peninsula was 7,000 but we have now gone over 8,000 because Ukrainian families are living there. Look at how far short of the recommended safe numbers we are. If we go down to two or three GPs, that will be for 8,000 people but, at the same time, the statistics tell us it should be 12 GPs for 10,000 people. My goodness, the people in the Iveragh Peninsula and elsewhere in south Kerry are having their lives put in danger because of the lack of GPs. I thank every one of them I know personally going back over 25 years working politically in that area. I know the GPs and the excellent service they have given. I know about the late nights, the weekends and the full cover they have given and I thank them for it. Of course, some of them have gone to their eternal reward, while more have retired or are going to retire, which they are entitled to do.

In recent times, I met the local coiste and I have been talking to the Minister for Health. I publicly thank him for the hearing he is giving me with regard to the Iveragh Peninsula. We are looking for a bespoke arrangement to be put in place because we are finding it so difficult to attract doctors there. Between providing the premises, the insurance and the backup staff and what they will earn, it is not financially viable for them. One shoe does not fit all sizes, so we desperately need a bespoke arrangement for the Iveragh Peninsula. I acknowledge the work of the Minister, which I discussed with him only in the past ten days. I want the people of the Iveragh Peninsula to know I am working on that. I am working to ensure we will have full cover with SouthDoc, which we did not have previously because we were missing Tuesday and Thursday nights when we did not have full cover. To the people who have come to me with horror stories, including over Christmas when a young boy's life was put in danger because there was no service at the time and the child had to be moved out of south Kerry late at night, I want them to know I am giving it the attention it needs.

There is an urban-rural divide in healthcare access and it has stark implications, with rural patients facing significant barriers to timely medical care despite rural areas having an older population compared with urban centres. The cumulative effect of the lack of access to GPs in rural Ireland has led to an alarming rural health crisis, which is made a lot worse by limited or absent public transport services, making the healthcare service less accessible to rural people. An Irish Independentstudy found that, on average, patients in Dublin can be easily seen on the same day as a request for an appointment, while those in the midlands or other places looking to book a non-urgent appointment with their GP could have to wait for up to two weeks.

Coming back to the issue in Kerry, if we do not have GPs working in rural Kerry, whether that is south, north, east, mid or west Kerry, and if we do not have easy access to a GP, patients are going to go to the emergency department. I thank the excellent people working in Kerry University Hospital, in particular in the emergency department because they work in very stressful circumstances. Even so, an elderly person could have to wait 14 hours to see a doctor. I have said previously in the Chamber, and I will reiterate, that if an animal needs care, there is no way in the world that its owner should be waiting for more than two hours for a vet to come to their yard. In Kerry, if you ring Padraig Teahan, Mike the vet or any of the other local vets we have, they will be into your yard within two hours to look after a calf that is in trouble after calving, a ewe lambing or whatever the difficulty is. If there is speedier access to treatment for animals than for people, something has gone radically wrong.

We have never spent more money than we are now spending on healthcare. The spend per head of our population is frightening, yet we have not got it right. We are talking about the pressure our emergency department is under. For goodness’ sake, is it any wonder? If you cannot get a GP, whether it is for a child or a middle-aged or older person who needs care, you are going to put them into the car, ring for an ambulance, land in the emergency department and take up more space there, and the case might not need to be in a hospital at all. The accident and emergency department is what it says - it is for accidents and emergencies - but in many cases it is being used for something it should not be used for.

When I was growing up in the parish of Kilgarvan, where I am from, we had an excellent doctor, Dr. Boland, who was our local doctor. Like many other parishes, we all had a local doctor. They were busy people, they were kept going and they were able to make a living. Why is it that we have gone so far from that? We are trying to attract foreign doctors and I am so grateful we have foreign doctors working in our hospitals, but we have not been able to make it profitable for a doctor coming in from abroad who is weighing up whether to become a GP in a local community or to work in the local hospital. They will want to work in the local hospital, because they know they will get a wage there and they can see where they will be able to survive and so on. If they have to go to a rural area, however, they will have to provide a house for themselves, provide a premises for the business and the surgery to be run from, sort out the back-up staff and work maybe seven days and nights a week or at least be on call. Why can we not make it profitable for those people? If it were profitable in the past and made sense in the past, why can we not go back to that system whereby in every community, you should not be far from a doctor? You are not far from a vet, but why is it easier to access the care of a vet than it is to access the care of a GP?

On that note, I thank the excellent GPs in County Kerry, who have given us Trojan service. One man I have to mention is Dr. Gary Stack in Killarney. I thank him and his team for the work they do in SouthDoc, and all the other GPs and their back-up staff throughout Kerry for their excellent care. They are working in difficult and tough circumstances. This is not to be critical of them but of us as politicians. Why are we not getting it right?

Mary Butler (Waterford, Fianna Fail)
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I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following: "recognises that:

— access to effective and sustainable general practice services is a cornerstone of the delivery of healthcare;

— the Government, recognising the importance of general practice and acknowledging the challenges faced in some areas to maintain sustainable general practice services, has significantly increased investment in general practice in recent years;

— expenditure on general practice has increased from €561 million in 2019 to €784 million in 2022, with expenditure in 2023 likely to exceed €800 million;

— some areas are experiencing challenges in attracting General Practitioners (GPs);

— the implementation of the 2019 GP Agreement increased the Rural Practice Grant by 10 per cent, increasing the financial support to rural GPs;

— the Government has increased the number of GP training places from 258 in 2022 to 286 in 2023 and 350 in 2024;

— applications to join the GP training programme in 2024 reached the record-high level of 1,311 medical graduates;

— research undertaken by the Department of Health indicates that for every GP retiring over the coming four years one and a half to three GPs will enter practice;

— the Government has provided funding to the joint Irish College of General Practitioners/Health Service Executive (HSE) non-EU Rural GP initiative that resulted in the recruitment of 112 GPs from outside Ireland in 2023, with 75 already in place by year-end;

— the Government has provided funding to increase the number of GPs recruited under the non-EU Rural GP Initiative to up to 250 in 2024;

— Irish College of General Practitioners surveys have demonstrated that a large majority of GPs graduating from training intend to remain and to work in general practice in Ireland;

— the role of general practice is continually evolving to include new and innovative services, such as the Chronic Disease Management Programme which helps patients living with chronic obstructive pulmonary disease, asthma, chronic heart disease, and diabetes to proactively manage their conditions in the community, improving quality of life;

— the Government has put in place the resources to allow GPs to refer patients directly to diagnostic services, resulting in reductions in waiting times and earlier diagnosis;

— this Government has consistently made significant increases in expenditure on health services, resulting in an increase of 26,000 staff in the HSE, an additional 1,126 acute hospital beds, 25 per cent more intensive care beds, and a fall in hospital waiting lists for two years in succession in 2022 and 2023;

— there has been considerable additional investment in oral healthcare services in recent years, including an expansion in 2022 of care available within the Dental Treatment Services Scheme for adult medical card holders and a 40-60 per cent increase in fees paid to dentists across most treatment items; and

— sustained investment in recent years has reduced the numbers of children waiting to access public orthodontic care by 47 per cent between 2019 and 2023; and

agrees that:

— the Government is committed to fundamentally reforming dental services through implementation of the National Oral Health Policy, Smile agus Sláinte and that the HSE’s Strategic Reform Lead will drive service reform for adults and children in line with policy in 2024;

— increased investment is making general practice in both urban and rural areas a more attractive career prospect for medical graduates;

— the initiatives taken by the Government to increase the number of training places and to recruit non-EU GPs will result in an increase in the number of GPs providing services in both urban and rural areas; and

— the measures supported by this Government will result in an increase in the ratio of GPs to population and improved services for patients.".

I join the Rural Independent Group in offering my condolences to Deputy Collins and the extended Collins family, including his brother Councillor Danny Collins, on the death of his nephew. I am sure all Deputies will join me in expressing that sentiment.

I thank the Rural Independent Group for raising this important issue. I welcome this debate regarding the challenges with the provision of doctors, especially in rural communities. The programme for Government commits to transforming health and social services in the State in line with Sláintecare, recognising the importance of the expansion of community-based care to bring care closer to home. Access to effective and sustainable GP services is a cornerstone of the delivery of healthcare generally, and in particular the delivery of care close to the home and close to the people who need it. The Government is actively working to increase the number of GPs and GP access for patients throughout the country. We have significantly increased expenditure on general practice in recent years.

The Deputies spoke about the fact that it is not always cost effective for some doctors to run a service. In 2019, fees and other supports paid to GPs amounted to just over €560 million. In 2022, this increased to €784 million, with expenditure in 2023 likely to exceed €800 million, an increase of €230 million, or 41%, compared to 2019.

The 2019 agreement provided for a significant increase in expenditure on general practice, including a 10% increase in rural practice supports. Improvements to GP maternity and paternity leave arrangements were also made under the 2019 agreement. The 2023 GP agreement included a total financial package amounting to €130 million. This included enhanced capitation rates across various age groups and improvements in payments relating to the provision of contraception services under the GMS. The 2023 GP agreement also included measures to specifically support GP capacity, including €2 million to support GP out-of-hours services and a further €30 million in additional capacity supports to assist GPs to retain and recruit additional staff to meet patient demand. These measures make working as a GP in Ireland increasingly more attractive to doctors.

The number of GPs entering training has more than doubled from 120 in 2009 to 286 in 2023, and the Minister, Deputy Donnelly, has worked with the Irish College of General Practitioners, ICGP, and the HSE to further increase the number of places to 350 this year. We are already seeing the impact of the increase in training places in recent years. It is estimated that for every two GPs that currently retire, we now have three to six new GPs entering general practice. In addition, medical graduates are showing an unprecedented level of interest in general practice. A record number of 1,311 medical graduates applied for GP training in 2024. This notable increase, surpassing all previous years, underscores the strong interest in entering general practice among medical graduates and the growing confidence in the future of general practice. The ICGP has stated that the number of GP training graduates emigrating has been decreasing since 2017, with fewer than 6% of GPs now choosing to emigrate. I think everybody will welcome that.

As well as preparing for the medium- and long-term demand on general practice by increasing training places for medical graduates, the non-EU rural GP programme which commenced last year is already increasing the numbers of GPs in practices in the community. New doctors under the programme will work in general practice for a two-year period, following which they can take up an Irish GMS contract. The normal GP training period is four years. The initiative is targeted particularly at rural areas - Deputy Nolan referred to this in her speech - and those difficult to fill posts in various geographic locations across the country. This will further increase capacity in general practice and access to services in these areas. Some 121 non-EU GPs were recruited by the end of January 2024 under the training programme, with 84 non-EU GPs already in place in various practices across the country. The Government has provided funding to bring up to 250 more non-EU GPs to Ireland by the end of this year.

Notwithstanding the positive actions taken by this Government, I want to recognise that the provision of GP services in many areas has been challenging, including in some rural areas. The financial uncertainty associated with smaller panel sizes in some of these areas is often greater than elsewhere. Combined with the growing trend among GPs to seek to work as part of a multi-GP team in a larger practice, this can make it more difficult to fill certain GMS vacancies. When vacancies do arise, the HSE engages and takes all reasonable steps to recruit a GP to the vacant GMS panel. When a vacancy has not been filled before the departure of the existing GP, the HSE puts in place locum or other appropriate arrangements to maintain continuity of services. Rural practice supports increased by the 2019 GP agreement support GPs in these areas and help to increase the attractiveness of vacancies when they arise.

As of January there are 23 GMS vacancies across the country, approximately 1% of the total number of GMS panels. I am happy to report that the number of GMS vacancies fell from 34 in April 2023 to 23 in January 2024 as a result of HSE recruitment to vacant GP practices. Five of the vacancies that were filled were long-term vacancies, that is, vacant for over 12 months.

We all know that GPs are private practitioners, most of whom hold a GMS contract. I understand the points Deputies have raised. I am dealing with a situation in Lismore in Waterford where a doctor retired and the HSE advertised the contract. A person was offered the job but did not accept it so it has to be offered again. A locum is in place. When a locum is in place, patients do not build up the continuity they have with a GP who is serving over many years. I am sure we are all very familiar with what happens when a doctor retires or chooses to move to another area.

As I said, GPs are private practitioners, most of whom hold a GMS contract. In accordance with that contract, the HSE can assign medical card or GP visit card holders who have trouble finding a GP to accept them to a GP's GMS panel. People who do not hold a medical or GP visit card access GP services on a private basis and make inquiries directly to any GP practice. As we know, some practices are full and it has proven difficult for some to access them. I am working with a few people on this issue.

There has been considerable additional investment in oral healthcare services in recent years, including an expansion in 2022 of the care available under the dental treatment services scheme, DTSS, for adult medical card holders and a 40% to 60% increase in fees paid to dentists across most treatment items. Sustained investment in recent years has reduced the number of children waiting to access public orthodontic care by 47% between 2019 and 2023. The Government is committed to fundamentally reforming dental services through the implementation of the national oral health policy, smile agus sláinte. The HSE has appointed a strategic reform lead, who is driving service reform for adults and children in line with policy.

Finally, with respect to the future of general practice, in April last year the terms of reference for the strategic review of general practice were published. Following a delay in commencement due to the Covid pandemic, the review, as committed to in the 2019 GP agreement, is now underway. The Department of Health is leading on the review, with support from the HSE and input from key stakeholders, including the IMO and ICGP. The review will examine the issues affecting general practice, including GP training, GP capacity, out-of-hours services reform, the ehealth agenda, the financial support model for general practice and, of course, issues facing rural general practice.

The review will identify the arrangements necessary to improve the current system of GP care as part of a primary care focused health service and in line with the Sláintecare vision on access. This will include the consideration of innovative solutions, such as a possible role for HSE-employed GPs. As a result of the 2023 GP agreement, the HSE is already engaging with practices to develop a satellite surgery approach to ensure continuity of sustainable GP services within communities. The HSE is also looking at how it can improve locum support for rural GPs who have been finding it difficult to secure locum cover for holidays and other needs.

I looked at the figures of projected graduates over the next three years. In 2024, there will be 209 graduates. In 2025, there will be 226 and in 2026, there will be 257. It is estimated that for every two GPs that currently retire, we will have three to six new GPs entering general practice. In light of the above, it is the Government’s intention to propose a countermotion to this Private Members' motion, agreeing that the Government is committed to fundamentally reforming dental services; that increased investment is making general practice in urban and rural areas a more attractive career prospect for medical graduates; that the initiatives taken by the Government to increase the number of training places and recruit non-EU GPs will result in an increase in the number of GPs providing services in urban and rural areas; and will result in an increase in the ratio of GPs to population and improved services for patients.

Danny Healy-Rae (Kerry, Independent)
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I am glad to have the opportunity to speak and thank Deputy McGrath and his staff for putting this important motion together. At the outset, I want to convey my deepest sympathy to Deputy Michael Collins, a member of our group, Councillor Danny Collins and the mother of Michael Lynch. Michael was a nephew of Deputy Collins and tragically lost his life in the last few days.

We pass on our condolences and sincerely wish them strength and that God will assist them in this very difficult time they are encountering.

This motion is basically about the lack of GPs. People cannot get a satisfactory service with GPs at present. Elderly people cannot get appointments. No GP is in a position to take on local families, including those returning to Killarney and many other parts of Kerry, because they are so overstretched. I remind the Minister of State that up to 5,000 new people with medical cards have been placed in Killarney. As these people have medical cards, the doctors have to take on so many of them. This is putting a severe strain on the service. I have dealt with many cases of people, including those returning to the area, who cannot get a doctor to take them on.

I would also like to speak about ambulance delays. I know of a little baby of three months old who stopped breathing and the doctor could not attend. The doctor did the next best thing and organised an ambulance. It took an hour an a half to come and that is not satisfactory. A young life could have been lost. It is only by the grace of God that this child is still alive. That is serious stuff. What the reconfiguration of the ambulance service in 2012 has meant to local areas is a reduction in the service. The word they used at that time was "reconfiguration", but what it has meant is a reduction in the service.

When people take family members into University Hospital Kerry, they have to wait many hours for doctors there. I had a call from a family whose mom was taken in there in the last few days. It was many hours before the doctor could attend to this elderly lady. She spent many hours on a trolley before she actually got a bed. One of the sons rang me again yesterday to say that the family have been advised by the hospital that some family member must come in to feed their mother and to attend to the tablets she needs to take. That this is happening brings it home to me in a very real way that there is a lack of medics, nurses and staff in University Hospital Kerry. A couple of years ago during Covid times - God help us - family members were not allowed to go in to feed their people. We can say that this left them seriously compromised without being fed properly. That was very wrong. It was a dark hour in our history when family members could not go in to visit their elderly people in the last days of their lives. When they became unconscious, everyone was let in.

We have a serious problem in rural areas in getting a GP service. I thank Dr. Gary Stack and others who set up SouthDoc some years ago. My father, the late Jackie Healy-Rae, worked very hard with Dr. Stack and others to provide an out-of-hours service, but we do not have enough GPs in that service now. If you get sick on a Friday evening, it is a long wait until Monday morning. People cannot organise that they will not get sick during those hours because people do. Gone is the day when Dr. O'Callaghan or Dr. Boland would come to the house to the elderly person or whoever was sick. That time is long gone. We depend on SouthDoc but we need that service to be enhanced because the doctors start out in Killarney on one side and have to travel all the way through Kilgarvan and Kenmare back to the county bounds in Lauragh, down through Templenoe and Blackwater as far as Sneem and over Moll's Gap down into Killarney. They travel massive distances and they are under savage pressure to see after people. We need more GPs. As has been said already, they are the first point of contact for any family member who has someone sick or for an elderly person living on their own who is sick and needs a doctor. Sometimes it is desperately hard to talk to a doctor - to get one on the phone - because they are so busy. As I have said, families are being advised to come in to feed their elderly family members in the hospital. That shows how understaffed the hospital is.

So much money is going into the HSE but we still do not have a proper service. I see all the people going out in the country early every morning, working hard and paying their taxes. This is one of the things their taxes are for. They are not getting the rewards for the taxes they are paying in this regard.

The rural healthcare crisis extends to emergency dental care provision. Children are forced to wait up to ten years for treatment. Less than half of eligible children were seen under the school screening programme last year. This is terribly serious because if children outgrow the time for getting the treatment, their mouths may not be perfect anymore. They get one chance and we should be doing a lot more there.

The rural healthcare crisis is further exacerbated by a severe shortage of home helps, the worsening crisis in every accident and emergency department, the non-existent mental healthcare service and the severe lack of residential places for people with physical and mental disabilities. Too often, I have heard stories from people who tried to get a place for their son or daughter. I have met those people. I feel very hurt when I am at the door looking for a vote and they tell me what happened. They tried to get their child kept in a residential place because they were worried, but it did not happen. As much as they minded them and tried - people know when a youngster is in trouble - they could not get the proper care for them and they lost them. That is a sad reflection of our healthcare system.

I call on the Government to explain how, despite an increased national healthcare budget, the country is witnessing a steady deterioration of our health services, especially in rural communities. If all things were equal, we would still need more doctors to travel the expansive and extensive areas that they have to cover in rural places like the Iveragh Peninsula, the Dingle Peninsula and the Beara Peninsula on the south side of Kenmare Bay.

Michael Ring (Mayo, Fine Gael)
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Thank you, Deputy.

Danny Healy-Rae (Kerry, Independent)
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We need more GP services. I appeal to the Minister-----

Michael Ring (Mayo, Fine Gael)
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The next slot is Sinn Féin. There are eight speakers with two and a half minutes each. I ask people to respect each other and stick to the time.

Pauline Tully (Cavan-Monaghan, Sinn Fein)
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I wish to be associated with the expressions of sympathy to Deputy Collins and his family on the sad passing of his nephew.

I commend the Rural Independents on bringing forward this motion. Rural health services are under major pressure from a stretched and ageing workforce and from demographic changes. The Government has abandoned local communities. It has underfunded the health service, making it more difficult to deliver reform and improve local health services. When there is a situation when more than two out of three GPs in rural Ireland are not taking on new patients, there is a very big issue. Others have waiting times of up to two weeks for an appointment. I know people who have moved into an area and cannot get a GP to take them on. They end up retaining a service, which might be an hour or two away from them in order to have access to a GP. Others do not have access to a GP and resort to using the accident and emergency department in the local hospital, which is not a solution and not something they want, or should have, to do.

I will raise the issue of the GP service in Swanlinbar in my county. I have raised it in the Dáil already but there has been no progress, to my knowledge. The GPs there, a married couple, retired towards the end of 2020. A rolling locum contract has been in place on a three-monthly basis since. It has been the same locum. He has actually moved into the area and he is willing to take on this contract. The local people like him. They want him to stay and he can provide a five-day service to them rather than what was suggested, namely, a three-day service from another local GP who is already overstretched with their own patients. I believe this man's wife is about to be qualified as a doctor so there would be two doctors who would be willing to provide a service in the Swanlinbar area. The local development association has requested a meeting with the HSE to explore this. I have inquired as to whether something is precluding this doctor from taking on this contract and have not received a reply. I ask that the HSE would engage with the local people.

Mary Butler (Waterford, Fianna Fail)
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Will the Deputy confirm the area?

Pauline Tully (Cavan-Monaghan, Sinn Fein)
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It is Swanlinbar in County Cavan. I have sent the details to the Minister of State's office on the back of last week's Questions on Policy or Legislation, QPL.

Mary Butler (Waterford, Fianna Fail)
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Yes, okay.

Pauline Tully (Cavan-Monaghan, Sinn Fein)
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I think it has been forwarded to the Minister for Health, Deputy Donnelly's, office as well.

This motion also makes reference to the extreme shortage of carers for older people and disabled people. A woman in County Cavan, named Marilyn O'Connor, was diagnosed with motor neurone disease approximately two years and the condition has progressed quite rapidly in recent months. She felt compelled to chain herself to HSE headquarters in Monaghan. She fought for a care package. She was finally allocated a sufficient care package but it was not fulfilled. The carers were not there. She was being left for three nights on her own without carers. She does not have the use of her arms or her legs. She said to me, " I did not just do this for myself. I did it for others as well because it is not fair on people who find themselves in this position."We need to see a situation where people with the most need are prioritised for care as this is unfair.

Martin Browne (Tipperary, Sinn Fein)
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From the inability to find a GP with the capacity to take on new patients, to dental services being unable to provide the most urgent procedures within an acceptable timeframe, to home support hours being inadequate, rural Ireland is being left behind. After being contacted by yet another constituent who is experiencing difficulties in getting orthodontic treatment for their child I was told that in the second quarter of 2020, 859 children classed as being in grade five of that index were waiting for orthodontic treatment for 48 months or more. In quarter 2 of 2023 that figure increased from 859 children to 1,474 with nearly half of those in the south east. This indicates the scale of the problem that is not just affecting these children now but will affect them in the years to come, unless they get the treatment abroad.

At a time when our emergency departments are coming under increasing pressure, especially UHL, we find that more than two out of three GPs in rural Ireland are not taking on new patients, while waiting times increase. At the end of last year I asked the Minister, Deputy Donnelly, what his plans were to increase GP capacity in Tipperary. The second line of his response was shocking. He said that there is no prescribed ratio of GPs to patients, yet the IMO outlined there are seven GPs per 10,000 of population and that this figure needs to get to at least 12 GPs per 10,000 to ensure a safe and effective service. What data is the Department applying to its plans, especially in rural Ireland given its geographical makeup?

On this issue, Sinn Féin would implement a multi-annual strategic workforce plan to meet rising demands and would develop this plan with healthcare workers, the health service and the higher education institutes to address short-, medium- and long-term workforce challenges. In addition to this, we would directly employ GPs to support local community health services rather than taking the Government's arms-length approach.

The current challenges also indicate this Government's failure to prepare the most basic approach, matching ageing and population growth with increased resources. This affects dental services not just GPs given that the number of dentists providing services for medical card patients have more than halved since 2019. This Government had failed to plan and failed to prepare. Sinn Féin has a plan it is ready to put in place because the people of rural Ireland deserve more.

Rose Conway-Walsh (Mayo, Sinn Fein)
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First, I express condolences to Michael and the Collins family at this heartbreaking time. I thank the Rural Independents for bringing forward this motion.

Rural communities face unique barriers to healthcare. We have one of the lowest rates of GPs in Europe. I commend the people of Lahardane this morning on what they have done to retain the GP service within their community. They are an example to communities across this country but they should not have had to do that.

Those problems are even more acute in rural areas. Dental care for people on medical cards has collapsed. There are ambulance waiting times, emergency rooms waiting times, people in pain on trolleys, the loss of step-down beds in communities, such as Belmullet, and the fact the people of Ballina are still waiting to have their extension.

I will again raise the issue of rural transport for healthcare. I have been dealing with the case of a 46-year old disabled man who is non-verbal and has been in a nursing home for the past four years. He is on the fair deal scheme and it is topped up by his disability payment. He needed urgent dental treatment in Mayo University Hospital last summer. Keep in mind he has no source of income or savings due to his disability. He cannot agree to any decision on his health costs. He was transported by ambulance to Mayo University Hospital - an ambulance that had to be sent from Galway. Invoices for €2,275 arrived at the home of the man's elderly parents. This was all because he needed dental care. The parents were not consulted, yet they were sent the bill. Naturally, they were distraught. In desperation, they turned to social welfare for the exceptional needs payment. They were sent back to the HSE because it was not an exceptional need. I am now waiting for a response from the HSE. This is no way to treat the most vulnerable people. If I ask the Minister of State for one thing today, it is to please sort out transport for access to dental care and healthcare in rural communities.

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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I thank the Rural Independents for bringing forward this motion. Rural healthcare, and particularly GP services, is in crisis across every constituency. Certainly across my constituency, we continually have people contacting our office. These are people who have moved into the area or who have moved from Dublin or abroad but they cannot get a GP. All of the GPs are full. That is the message we hear everywhere. It is really at crisis point and needs to be dealt with, with great urgency.

Dentistry was also mentioned and I know that in the past five years the number of dentists accepting medical cards has halved across the country. That is also a service which is equally in absolute crisis. We need to get the services in place. In some communities which are growing and where more people are coming to live in an area, that is not being matched by an increase in services. That is the real problem we have.

We had a little bit of good news yesterday. I see that Ballyshannon Community Hospital is due to open, which is good news. There is a list of all the services that will be provided, such as speech and language therapy, occupational therapy, dieticians and all of these things. It looks great on paper. However, the problem is that when people go looking for those services, they are not there. That is a really serious issue across every constituency, and particularly across my constituency of Sligo-Leitrim and south Donegal.

We need to recognise that if the Government is going to be able to provide these services, it must invest in them. The Minister of State mentioned in her speech that more people were going through the service and that more people were being recruited - GPs and so on - but it simply is not enough. What needs to happen is that the HSE needs to directly employ GPs in communities where they are not able to sustain them because of the present system. An awful lot of GPs do not want to become self-employed contractors. They want to be employed properly. That is something the HSE needs to do with urgency because it is the only way we will resolve these problems.

Another issue is physiotherapy. In Manorhamilton hospital, which deals an awful lot with elderly people, particularly across north Leitrim, the physiotherapy service there, which was a five-day service, has been reduced to a part-time with a person who comes two days per week to deal with both inpatients and outpatients. It is a hospital which specialises, in many cases, in rheumatoid arthritis and people who are recovering from strokes and issues like that. To see the service being cut to such a level means that this creates huge waiting lists and anxiety, particularly among elderly people in that region. I ask the Minister of State to deal with those couple of issues in particular.

Claire Kerrane (Roscommon-Galway, Sinn Fein)
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There are chronic shortages in general practice right across the State, including in many of our rural communities. They have been worsening in recent years. I see it throughout many towns and villages in Roscommon and Galway. People are unable to see their GP and are waiting for weeks for an appointment to see their GP and more and more GP surgeries are running waiting lists and are unable to take new patients.

It is obvious that the situation is getting worse and that the Government is not doing enough. There is also an issue whereby when word goes around that the local GP is either leaving or retiring, there is widespread fear in rural communities. I was contacted just this morning by a resident of Williamstown. Their local GP is leaving and they are concerned for the future of the GP service in their rural community. That should not be the case. They feel that they will have a battle on their hands in order to make sure that a GP is retained in their area. That should never be the case for any rural community, or any other community for that matter.

Not being able to access a GP can have serious consequences for a patient's health. There are a number of short-term measures that can be taken by this Government immediately. My party has repeatedly called on the Government to develop a directly hired GP contract so that directly hired GPs can cover areas where they are needed, that this can be targeted and that they can also provide cover in respect of vacancies and absences in understaffed practices. This is something that can be done immediately. Additional primary care staffing supports can be put in place, particularly around public health and practice nurses. Those supports would take the pressure off GPs. There should also be a greater role for pharmacies. Again, we have repeatedly called for a minor ailments scheme as a first port of call for minor illnesses. That could be done through our pharmacies.

These are the measures that are needed now. I acknowledge that the Minister of State has referenced that the numbers undergoing training are increasing. That is great, but it takes four years to become a GP. We need measures that will make an immediate difference because patients cannot wait.

What is being done in respect of dental care, such as the changes and the contract, has not been enough. Not a single dentist has taken up the contract in Roscommon or Galway. Clearly, this matter needs to be looked at again. I ask that the Minister of State would do that.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I thank the Deputies for bringing forward this motion and for giving us an opportunity to discuss the dire state of access to GP care across the State. I represent north County Dublin. My constituents are no different from the people we have heard described here. They wait for GP services and appointments, and they cannot get onto lists. Only last week, I spoke to a woman who has three children. Two of her kids are registered in Balbriggan but her third child cannot get to see a GP in the town. She now has to go to Malahide, which is a fair old trek for someone who has three kids registered across two practices.

Likewise, access to dentistry is a massive issue throughout my constituency. At one of my clinics, I met an elderly gentleman who was on his way down to the credit union to get a loan in order that he could pay privately for dental care that he desperately needs because he is in pain. He cannot access a dentist either in his local area or anywhere else. The man is absolutely desperate and is putting himself in debt for what is very basic dental care. Access to a dentist should not require someone to get a credit union loan. It is an absolute disgrace.

All the while, we have a bright and shiny primary care centre in Balbriggan. That centre came into being in controversial circumstances. The Minister of State's own party was very critical of it at the time, if I recall. Notwithstanding that, the building is there but there are no diagnostics on site. Balbriggan is the biggest population centre in north County Dublin. The centre serves a massive area. If we need diagnostics in my area, however, we have no choice. We have to travel for that. We have campaigned in Sinn Féin for many years for access to diagnostic facilities for people in my area. The population there is already massive and is growing fast. The people who live in Balbriggan deserve access to proper medical treatment and diagnostics.

Patricia Ryan (Kildare South, Sinn Fein)
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I also want to sympathise with Deputy Collins.

Dia is Muire dhaoibh, agus míle buíochas to the Rural Independent Group for bringing forward this motion. I welcome the opportunity to speak on it. Yet again, the fact that the Government is failing when it comes to the health service has been laid bare. Rural health services are struggling to cope - not because of the dedicated and overworked people involved, and we must thank them - because the Government has abandoned local health services. Chronic underfunding by successive Fine Gael and Fianna Fáil Governments has decimated the number of GPs, dentists, public health nurses, occupational therapists, etc., available to provide services. As a result, people have been left in need of services. Waiting lists have got worse and people are not able to access services at all. For example, in my constituency of Kildare South, one poor woman in her 80s, who is the sole carer for her severely disabled son who is himself in his 50s, in absolute desperation contacted me for help. My staff and I had to fight tooth and nail to get a hoist to help her lift him out of bed, not to mention the battle we had to get respite care to give her a break. Why? There was no community care available for this woman and her son because the Government has failed to fund it, failed to plan for it and failed to deliver it. Imagine an elderly woman at that age with no care and saving the State a fortune. It is absolutely unreal.

We need more GPs in rural areas so people do not have to travel miles to get a doctor. We need more occupational therapists, OTs, in rural areas in order that our elderly people do not have to wait for months for occupational therapy reports to allow them to access vital disability aids or home adaptations. They are waiting months to have their homes adapted. What we need are more GPs directly employed. We need more OTs, public health nurses and dentists. The list goes on.

I am going to finish on this. The Minister of State mentioned that there has been an increase of €230 million, or 41%, in funding in comparison with 2019. Where is the value for that money? Yesterday, I had a little girl who is 12 years of age and who needs to have her tonsils removed. She was told that the waiting list will be three years but that if her parents could pay €1,700, she could have the procedure in Clane next Wednesday. That is incredible.

Pa Daly (Kerry, Sinn Fein)
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I thank the Rural Independent Group for bringing forward this worthy motion. This may well be the seventh anniversary of the Committee on the Future of Healthcare's Sláintecare Report. Despite the commitment to ending the two-tier system contained within the health service, little progress has been made. This is especially the case in the context of GP care.

The Sláintecare Report states:

A new GP contract is due to be negotiated in 2017. The new contract provides an opportunity for the GPs to provide the core leadership role in delivering care outside of hospital in multidisciplinary primary care teams.

I get slightly jealous when I hear some of my colleagues from the cities talking about primary care centres because there is a big absence of them in rural areas. The report goes on to state

Potentially, GPs will be hired as salaried HSE staff in areas where it is hard to attract them. In order to extend primary care to the whole population more GPs and primary care staff are needed ...

It is obvious that in some rural areas, qualified GPs do not want to work five days a week. They do not want to work weekends, but they will work two or three days a week. Directly employing them would find a solution in order that they could go in. In recent years, I have seen, in Ballyduff, Milltown and other areas around Kerry, how it has been difficult to attract a GP who wants to sign up to the HSE contract. The lack of progress that has been made in the past seven years with regard to GP cover is disappointing. County Kerry has a high degree of rural isolation and peripherality. In that context, appropriate GP care is key. Campaigns such as the one in Clare - known as No Doctor, No Village - highlight the importance of GPs to rural communities. The most recent Sláintecare progress report up to May 2023 merely states that there is a strategic review of GP services, setting out measures to ensure that sustainable services into the future should be approved. Terms of reference have been published but little else seems to have occurred. All the time, communities suffer, and some right-wing forces have then stirred division by pointing out the lack of services in rural areas. I would like to say that there have been difficulties in the Ring of Kerry, Killarney and other areas around Kerry long before 70 people arrived at the Muckross Road. It is very divisive and irresponsible of some Deputies to raise this as an issue that is only caused by migrants.

With GP care under pressure in County Kerry, there are other solutions to salaried GPs. Pharmacists, as has already been stated, could be engaged to ensure late-night options are available across the State. I was interested to see that the NHS in England made similar suggestions so that in specific conditions, patients can be prescribed medicine by pharmacists without the need to see a doctor.

There is also a constant demand for patients to avoid accident and emergency departments. It came to my attention recently that a constituent from Ballybunion who had a heart difficulty went into an accident and emergency department. The following day, some 11 hours later, they left and went to a hospital in Dublin instead. That cannot continue. Pharmacists can be suitable for some of these functions, and it should be explored to free up GP appointments and accident and emergency departments for more urgent care. I know that the hospital in Kerry has a capital submission in to have a minor injuries clinic on the same campus but outside of the accident and emergency department, which will free that up, in addition to some other capital submissions.

I will finish on this point. The minor injuries clinicin Gurranabraher in Corkhas been very successful.

Michael Ring (Mayo, Fine Gael)
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I thank the Deputy. His time is up.

Pa Daly (Kerry, Sinn Fein)
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What is happening there should be looked at.

Duncan Smith (Dublin Fingal, Labour)
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11 o’clock

I also want to extend my sympathies and those of the Labour Party to Deputy Collins on his loss. I thank the Rural Independent Group for bringing forward this motion on GP numbers and rural healthcare.

I will send the Minister of State a note on this, but there is a situation with a community nursing home in Nenagh that has been in development for seven years. My colleague Deputy Kelly has been instrumental in pushing this forward. The facility has been built and is ready to go. The Deputy received a communication from the HSE stating that it is not in a position to say when the home will be open or what the timeline in that regard is. This is because it cannot provide the whole-time equivalent staff who are needed there. This is what the recruitment freeze is doing. Also in Nenagh, St. Conlon's Community Nursing Unit is not going to meet the new HIQA standards. We have a community healthcare facility ready to go that we cannot get staff.

There is a crisis in the provision of healthcare services in rural and, indeed, all other communities, including my own. The previous speaker mentioned not having enough primary healthcare centres in Kerry. We do not have a primary healthcare centre in Swords, which is the largest town in Ireland that does not have such a centre. I was on the radio this morning making the point that it is the largest town in Ireland that does not have a rail link. We are at the top of a few lists that we do not want to be at the top of. It is incredible that we do not have these services. Like other places throughout the country, we have problems in relation to GP services. GPs are often people's first point of contact with the wider health service. For many years, they have been a cornerstone in towns, villages, communities and cities all over the country. Many families will have had the same GP for decades. It is not unusual for a GP to take care of multiple generations of the same family. For many people, GPs feel like an extension of the family. They are a constant and someone they trust who provides them with a positive and trusted gateway into the wider health service. This is people are so concerned by the fact that they cannot get access to GP services. Even when they do, they face a long wait. According to a survey carried out for the Irish Independent, two out of three GPs in rural Ireland are not taking on new patients. Some have waiting times of more than two weeks for appointments. While some people in Dublin can get same-day appointments, there are others, including in my constituency of Fingal, who also have to wait for up to two weeks to be seen.

There are irregularities in the context access to care across the country. This needs to change. There can be no postcode lottery when it comes to access to health services. The Irish Medical Organisation, IMO, has outlined that we have seven GPs to every 10,000 people at present. This is despite the fact that we need at least 12 per 10,000 to ensure a safe and effective service. This is another metric in respect of which we are failing. The people of Ireland are rightly angered by this. Rural communities have been especially impacted. Many people have been served successfully for many years by GPs with small practices who are now retiring. It is expected that 700 GPs will retire by 2026. A critical situation is developing rapidly before our eyes. We need to see action in respect of it now.

The Government has facilitated more training places for GPs, but it will take years to see the results of this. There is no guarantee that these GPs will be able to set up services. The statistics we have in respect of young medical professionals here moving abroad are a cause for extreme concern. They speak to what feels like an overall collapse of the system. In 2022 alone, 442 Irish doctors were issued temporary work visas for Australia. Questions need to be asked about how attractive we are making the healthcare sector to our young healthcare professionals. The Government needs to take responsibility for this. All young workers hear about chronic understaffing in our health service, which is worsened by the recruitment freeze in the HSE, as I just outlined with the examples relating to Nenagh. Understandably, workers do not see working in the Irish healthcare system as a viable or prosperous career path. When we couple that with the guarantees they receive when moving abroad about safe staffing levels, decent salaries, better weather and a better quality of life, it is understandable, albeit very sad and lamentable, that so many of our young medical professionals travel abroad.

In 2022, the Irish College of General Practitioners, ICGP, reiterated its consistent call for a working group on future general practice to plan for serious GP workforce pressures in a submission made to the Joint Committee on Health. The ICGP knows better than anyone just how of much of a tipping point GP care is at in this country. According to its statistics, we will need an estimated 2,000 GPs over the next decade in order to meet impending retirements and population growth. This is a massive jump. Without serious intervention and a proper plan, we have no chance of meeting that challenge.

I take this opportunity to highlight an initiative started by the ICGP last year. This initiative aims to attract at least 100 qualified doctors from overseas to rural practices as part of a two-year supervised work programme. At the end of it, the plan is that they will be fully qualified as GPs in the Irish system, that they will stay in their new communities, if they want to do so, and that they will hopefully want to treat publicly funded patients in practices of their own. This is a fantastic initiative. The impact of the GPs who have travelled from all over the world to help the people in this country, particularly those in rural Ireland, cannot be understated. This story was covered by The Irish Times, and those who did make the move to rural communities commented on how they felt the desire to help those they felt had been neglected by a service that was under pressure. Dr. Omair Latif Naz who moved to Clonaslee village in County Laois noted that the welcome they received was superb. This only further supported his desire to stay and help the community. He said, "They’re lovely people and they need us". He also said that people do not want to drive 30 km or 40 km to go to hospital if they have someone they can walk to see in the village.

It is worth noting the positive impact of initiatives to attract overseas workers into rural Ireland. It behoves all Deputies, when we are talking about immigrant workers, to remember the positives they bring to all our communities, including those in rural areas. The example to which I refer is one of many. We know that immigrant workers are the glue that keeps our health service together, not just in our major acute hospitals but also in our rural services. I would like to see that level of understanding and acknowledgement in all debates when it comes to immigration.

Ultimately, we need to see changes and we need to see them now. However, these changes have to be sustainable for GPs in the areas to which I refer. We can no longer expect GPs to forgo holidays, sick leave or time off in order to try to keep up with the growing demands of the local population. Support needs to be provided by the Government in order that GP practices in all communities, including those in rural areas, can grow and be an attractive option for young workers to want to join and thereby be part of that element of our healthcare sector.

A record health budget, by the Government's own measure and which it is so fond of mentioning, is no good for the people who simply do not have access to the most basic services. There is no more basic a service in the Irish healthcare system than having access to a GP

Holly Cairns (Cork South West, Social Democrats)
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I want to extend my sympathies to Deputy Michael Collins on the tragic loss of his nephew. My thoughts are with Michael's family and friends and the wider community.

I am grateful for the opportunity to talk about the provision of healthcare and GP services in rural areas. In Cork South West, we are very familiar with the pressures on and failures relating to health services in rural communities. The blunt truth is that the current GP model is not working and has not done so for a very long time. The GP contract is more than 40 years old and is completely unfit for today's world. It requires GPs to set up private practices. The medical work of GPs is hard enough without their also being forced to deal with the pressures of running a small business. It puts medical graduates off the role. In 2019, an ICGP survey showed that only 26.9% of graduates wanted the responsibility of running a small business.

The HSE cannot just keep hoping that this problem will fix itself. We need an alternative model. The HSE has to take responsibility for community healthcare and provide salaried HSE positions for GPs who want to do the work, but do not want to take on the incredible workload of running a practice. We also need to see multidisciplinary GP teams, consisting of nurses, pharmacists and healthcare assistants all working together within general practice, to be built up. This is especially important in the context of rural areas.

There are GP practices in my constituency that are two hours away from the nearest trauma centre, obstetrics unit and surgical unit in Cork city. Putting that pressure on lone GPs is completely unfair and unrealistic, and puts patients at risk.

Out-of-hour GP services throughout the country, but especially in rural areas, are running on a skeleton staff. A salaried model would mean that salaried GPs could work those out-of-hours shifts instead of the expectation that GPs who are already running services during the day, potentially five days a week, would also do that work at night on a completely ad hocbasis. It would also offer a flexibility that GPs do not have at the moment and would include basic things such as part-time contracts, four-day weeks, the option to work a couple of evenings per week, maternity cover and holidays. GPs need a better work-life balance and this is the measure that would provide it.

We cannot keep expecting doctors to carry on like this. Last year, Dr. Fiona Kelly, a GP in my constituency in Castletownbere, tried to take her first holiday in over a year. She tried everything she could to get cover but could not and was forced to close her practice for the day. That is the level of pressure GPs are under. They are never able to take a holiday or sick day or take a break without having to cancel appointments for patients. These working conditions are ridiculous. Dr. Kelly told the Irish Examinerthat a typical day for her means dealing with 70 to 100 patients, with consultations in person, by email and on the phone. The European Union of General Practitioners recommends that the safe level of patient contacts per day is no more than 25. A salaried model would also make it a much more attractive career for young people. A serious concern in GP services is replacing local GPs as they retire. More than one quarter of GPs in Cork and Kerry are over 60 and it is incredibly difficult to replace them in rural areas because of the pressures to provide those out-of-hours services. When these practices lie empty and when SouthDoc services, such as those in Skibbereen, close their doors and reduce their hours, it is a recipe for disaster that forces people in medical emergencies to travel even further to reach an open clinic in areas in which a person would have to wait a long time for an ambulance.

Everyone in rural Ireland knows the pressure GPs and out-of-hours services are under, but what does not help is the absolute lack of transparency on the part of the HSE with respect to these reductions in services. Last summer, when I was first informed that patients from Skibbereen and its surrounding areas were being diverted to Bantry for SouthDoc, I was at my wit's end trying to get a straight answer from the HSE. Officials from the executive swore there was no reduction in services in Skibbereen SouthDoc while the call centre operators were telling my staff they had been diverting patients to Bantry for weeks. These are vital services in rural areas and the absolute least that communities deserve is clarity around the operational status and their capacity. Healthcare must be available to everyone 24-7 regardless of their postcode, but it is getting more and more difficult every year to access medical care and pharmacy services out of hours in west Cork.

This all comes down to a complete absence of Government planning and investment, which has brought the service to a crisis point. The GP training programme needs to be massively expanded. Figures released to Deputy Shortall last September showed that of 964 eligible applicants for GP training, only 286 were taken on. That is disgraceful. We are crying out for GPs throughout the country and nearly 700 potential GPs are being turned away from training.

Another health service under considerable pressure in rural areas is dentistry. There are currently only two public dentists serving the whole area of west Cork: one in Bantry and one in Clonakilty. I am contacted repeatedly by desperate parents whose children are in pain and cannot access dental care. The Bantry clinic is under extreme pressure with cuts, forcing it to operate on a three-day week with staff expected to cover the entire west Cork peninsula. The situation is desperate. We need to provide affordable dental care to people in our communities. It used to be that children in west Cork would see a school dentist in first, third and sixth classes. Appointments are now only available for those in sixth class. Are primary school children supposed to wait eight years for any dental treatment?

There is a severe shortage of dentists participating in the schools scheme. In response to a recent parliamentary question, the HSE told me there were 28.3 full-time equivalent dentists serving 380 schools across Cork. That is tens of thousands of children being covered by 28 dentists. Is it any wonder parents cannot get appointments? The HSE seems to be blaming the failing services on a lack of private dentists participating in the scheme, which is another example in the long list of the State outsourcing its own responsibilities to the private sector.

The HSE needs to provide these services itself with public dentists. This all comes down to a complete absence of Government planning and investment, which has brought rural health services to a crisis point. I know there is a strategic review of GP services ongoing and I join my colleague Deputy Shortall in appealing to the Minister of State to include the possibility of salaried GPs in that review. The Government needs to act quickly to increase capacity in the GP and dentistry systems, to make the professions more accessible to young doctors and to ensure GPs can access cover when needed.

Verona Murphy (Wexford, Independent)
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I thank the Rural Independent Group for tabling this motion. I also pay my sympathies to Deputy Michael Collins on the loss of his nephew.

Where to start? The reality is we have a very serious problem within our GP sector and within rural Ireland in general in the provision of healthcare. Our GPs do not feel supported, as we have heard a number of times. I noted the comments of the Minister of State, Deputy Butler, in respect of the number of GPs who will qualify in the next three years. There is no guarantee those GPs will enter our system. We have heard similar figures quoted with respect to An Garda Síochána and our teachers but we do not seem to be able to recruit them when the time comes. I ask for some scheme or incentive to be put in place such as the one that exists in the UK. As I have mentioned before, when GPs or dental practitioners undertake training in the UK, they sign up to the public health service for two years. They do two years' mandatory service within the public health service before they escape the country for their fling of travel or whatever else. We need to seriously consider an approach that would allow us to recruit all of the GPs who are qualifying.

I am discouraged by something I received in the post from a dentist. It refers to something of a letter of hope from the Department. We all know that prevention is better than cure and any GP will tell us that dental care is the essence of anybody's entire health. If people do not have a dental practitioner or are not looking after their dental health, they are likely to be sick in general. This letter went out on 31 January and is addressed, "Dear dentist". I am not going to read it in its entirety but I will refer to its last paragraph. It states that the Department regularly updates the list of dentists which it provides to medical card patients. It states that, as outlined in the dental treatment scheme, it is difficult for patients if the HSE is providing them with a list of contract holders who are not actively involved in providing care under the scheme. It further states that the Department hopes the dentists to whom the letter is addressed will reconsider accepting new patients under the dental treatment services scheme, DTSS, so as to maximise the opportunities for medical cardholders to access the care they need.

A note was included in the correspondence that was addressed to me. It states that the letter from which I have quoted reflects the attitude of the HSE towards the dental profession and that attitude is what has led to the mass exodus from the scheme in recent years. It states that while the fee structure reflects charges of 15 years ago, the reality is that most dentists are reducing their exposure to these schemes with a view to exiting at the earliest opportunity.

I am sure the Minister of State shares my concerns about that correspondence. Some people who are in need of a hip replacement have come to my office. They cannot have the anaesthetic without the all-clear from a dentist, and because they are new medical patients, they do not have dentists and cannot get appointments.

Quite often, I have gone to a dentist myself and asked if they would undertake to see a patient so the patient could have the more serious healthcare treatment. This is going under the radar entirely. It is predominant in rural towns and, for GPs, in villages. I am from the Hook Peninsula. It is very difficult for a GP there to get a replacement to undertake holiday care or anything like it. I will not start on CDNT and CAMHS because my colleague is going to speak, but we could have ten debates on this.

Seán Canney (Galway East, Independent)
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I, too, wish to be associated with the vote of sympathy to Deputy Michael Collins and his family on the passing of his nephew. I welcome the opportunity to speak on this motion, whose subject matter is close to my heart for the simple reason that, in Galway East, which is predominantly rural, people trying to find a GP contact my constituency office weekly. This is not an issue in rural areas alone because it is also happening in Tuam, the largest town in the county. Mothers come to my office distressed because they cannot not get a GP for their newborn child and the vaccinations. What is happening is wild.

We talk about the recruitment and retention of staff in the service. It is important to remember that one of the biggest problems faced by young doctors and nurses who have spent four, five or seven years studying is that they must work in a powder keg, under constant pressure. They need to have a proper work–life balance. Those going into the medical profession in the public service find it very hard to cope and, within a short time, they seek an alternative or seek to get out.

In Tuam, we have built a fantastic primary care centre. We have renovated the old Bon Secours hospital at a cost of €30 million to include mental health day services. We have put our children's disability network team, CDNT 7, into it. The facility is totally understaffed. Before Christmas, it got to the stage where the parents protested on the streets outside the newly opened facility.

I receive conflicting reports on the number of staff approved. For some reason, the approved number seems to have been reduced, according to two reports. I have taken this up with HSE. There is manipulation in reports. Even on the day of the official opening in Tuam, a senior person from the HSE stood up and claimed bravery for having so many staff in the disability network service. He was challenged on the floor, in front of the Tánaiste, with a statement that if he divided the number in two, he would be nearer the mark.

I do not know whether the issue is that people are unaware of what is going on. Staff are trying to deal with all this. It is no wonder staff go off sick. They need to have their holidays. They just walk away and go into the private sector, where they get a better quality of life. If this keeps happening, we will have fine buildings that are half empty, as at present in Tuam. The primary care centre was built for about €20 million but we never included an X-ray facility. In 2009, or maybe 2017, the then Minister for Health, Simon Harris, provided €700,000 for an X-ray facility to be installed in the building. This is 2024 and the facility is still not operational. All we needed to do was convert a room by lead-lining it, put in a door and put up a gantry.

The Minister of State knows what needs to happen in Galway. We are working on that, but if projects are to be carried out at the rate to date, we will not see the facilities built in Galway for the next 20 years. We need radical change to attract staff into the facilities and provide the most modern facilities, which people deserve.

Thomas Pringle (Donegal, Independent)
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I am thankful for the opportunity to speak on the extremely important topic of healthcare provision in rural communities. I start by welcoming the opening of the new Ballyshannon Community Hospital yesterday. This is great news for the people of south Donegal, who have suffered from a lack of healthcare services for many years. A new hospital equipped to provide professional services for older people in south Donegal, north Sligo and north Leitrim is certainly welcome and well overdue. Unfortunately, however, there is still a long way to go in addressing the lack of services in Donegal.

Hospitals like Killybegs Community Hospital have the potential to provide much-needed community healthcare to rural communities if given the necessary funding. Unfortunately, the services in community hospitals like that in Killybegs are suffering due to a lack of staff and funding. I was recently contacted by constituents who were unable to receive any physiotherapy because the only physiotherapist available was on annual leave. It should never be the case that an entire hospital must rely on one physiotherapist such that the whole system collapses when that person goes on a deserved holiday. This is completely unacceptable and puts immense stress on our community healthcare workers. One constituent told me they were concerned that the lack of physiotherapy would have a negative impact on both their physical and mental health. During what is a severe mental health crisis in this country, we cannot afford to exacerbate this issue any further. Patients' mental health must be taken into account and prioritised. Community health services need better support and funding. We need to ensure the healthcare services in rural Ireland are on par with city services.

It is important that community healthcare services divert people from the hospital service. The costs crisis in hospitals would be eased if people received care where needed and could avail of it the most.

We must not underestimate the importance of our community paramedics, who provide a vital service to communities throughout Ireland. I have previously raised the issue of lack of support and appropriate training, and I urge the Government to take this issue seriously as our paramedics do an important job in bridging the gap between our community services and hospital services. They divert patients from hospitals and keep them in the community, where they can be treated most cheaply, which is vital.

I support this motion's call for the Government to increase the number of GPs through sustained Government funding and a long-term GP workforce strategy. It has become clear in recent years that Ireland does not have enough GPs to meet patient numbers, especially in rural Ireland. This is not a new issue. It has been the case for some time and the Government's lack of action is not acceptable.

I have highlighted a recent incident in a Garda station in Donegal. Gardaí were forced to hold a man with severe mental health issues for 12 hours because there were no GPs available to assess him. This was unfair not only to the man being held but also to the gardaí, who were unable to do anything else while he was in their care. This is just one of many examples of how difficult it can be to access a GP in rural Ireland. Many people in rural communities must wait for years to become a new patient, with many GPs simply not accepting new patients.

The lack of healthcare access in rural Ireland is a crisis and is leading to many delayed diagnoses and treatments. This must not go on any longer. I support the calls in this motion and sincerely hope the Government starts to address the severe issues in rural healthcare. This would help to address the problems in our hospitals, where accident and emergency services are constantly under threat. It is because people cannot get access to care and treatment in their own areas that they end up going to hospital for it.

Marian Harkin (Sligo-Leitrim, Independent)
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I sympathise with Deputy Michael Collins and his family on the tragic death of his nephew.

I thank the Rural Independent Group for tabling this motion on the significant and ever-increasing gaps in healthcare provision in rural communities. Over two thirds of rural GPs are unable to take on new patients and there are waiting times of up to two weeks for non-emergency appointments.

In my limited time, I want to raise three issues, the first of which affects both rural and urban patients and relates to the shocking change in HSE policy on post-mastectomy products, including mastectomy bras, prostheses and swimwear, announced in recent days. So many people have been in contact with me about this.

They are shocked, angry and distressed about this mean-spirited, cruel cut to post-mastectomy services. It is important to say that mastectomy bras, prostheses and swimwear are not underwear or swimwear. They are medical devices necessary to help women's recovery from the perspective of lessening the risk of lymphoedema and for giving breast cancer survivors a little bit of confidence to face the world.

Back in 2017, the HSE attempted to cut back on post-mastectomy products, but a public outcry ensued and the decision was reversed. Deputy Harris was the Minister at the time and he ensured the HSE deferred the introduction of this mean-spirited cut to services, but it seems to have sneaked back in again in recent days. A 50% cut in funding is proposed. Women are entitled to two mastectomy bras, one or two prostheses, depending on need, and one or two swimming prostheses, again depending on need. For that to be cut in half is unacceptable. Many women, their partners and their families are really upset about this decision. Will the Minister of State immediately contact the Minister for Health to ensure this totally unacceptable cut to women's post-mastectomy services is immediately reversed and is finally and fully taken off the table?

The second issue I wish to raise is the loss of a GP in Swanlinbar in County Cavan. This GP service treats patients along the Cavan-Leitrim border. The local GP, Dr. Cristian, has been there since 2021, working four days per week in the health centre. He bought a house in the village. He and his wife are both doctors and they are part of the community. He is appreciated as a great doctor. However, now it seems that the Swanlinbar Health Centre will be serviced by the Ballyconnell Health Centre, which is an excellent service, but bursting at the seams and is 16 km away. I am told it is so busy that it takes two weeks to get a routine appointment and two to three days to get an emergency appointment. This is madness. As one person said to me, the decision-makers in Dublin are so far removed from life in rural Ireland that they do not understand the knock-on effects of this decision. I ask that it be reversed.

I raise the appalling situation, where, according to a response I received from the HSE less than a week ago, there is only one contractor providing care to medical card patients under the dental treatment services scheme in County Leitrim. This letter also confirmed that there has been significant reduction in the number of participating dental contractors in Sligo and Leitrim, with dentists already in the scheme not taking on any new patients. In effect, there is no dental service for medical card patients in Sligo and Leitrim.

Michael Ring (Mayo, Fine Gael)
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On the issue the Deputy raised, it is Government policy that if a service can be retained, it should be retained, like it was in Lahardaun. The people of Cavan should know that.

Violet-Anne Wynne (Clare, Independent)
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I also extend my deepest sympathies to Deputy Collins, his family and friends on the very sad loss of his nephew.

I commend the Rural Independent Group on tabling this important motion on an issue that affects every community in my constituency of Clare. As I have mentioned in this House on many occasions, GP availability in Clare is 33% below the national average. Meanwhile, we saw in the recent census results that Clare is on a par with the national increases in population. People from all sides of the county contact my office every day to say they cannot find a GP or they are waiting a long time for an appointment. Ennis GP, Máire Finn, was on Clare FM yesterday and she stated she feels cruel having to refer patients to University Hospital Limerick, UHL. There are practices in Kilrush, Newmarket on Fergus and other areas that have significant question marks over their long-term sustainability because the pipeline of GPs is not there.

Last year, I called for the rural general practice grant to be increased; it was not. I have called for the General Medical Services scheme to be reformed; it has not. I have called for greater oversight of the €2 million of public money that we give to Shannondoc almost every year and that has not happened. If we want more GPs in rural Ireland, we need to move away from treating GPs as private contractors, bring them under the HSE, have the HSE provide the premises and the nursing and administrative staff to support them, and overhaul the IT system to cut their paperwork in half. In areas where GP sustainability is not guaranteed, we need the Minister to put in place financial incentives that are greater than the rural practice grant to make those posts more attractive. We need to do all of this quickly to make care in the community a reality for my constituents in Clare and all the people of rural Ireland and not just a slogan or a line in a manifesto.

I wish to mention briefly the availability of dentists. Almost three years ago, I organised with a dentist in a neighbouring county to secure appointments for my constituents. That worked for a period until that dentist reached capacity. Having no access to a GP or dentist has been leading to delays in care and, more often now, no care whatsoever being provided.

Hildegarde Naughton (Galway West, Fine Gael)
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I also begin by adding my condolences to those of others to Deputy Michael Collins on the loss of his nephew.

I thank Members of the House for their contributions to this discussion on general practice in rural communities and for their interest in and commitment to the issue. I acknowledge the issues various Members raised, such as the delays patients are facing in getting appointments with GPs and some GP practices not currently accepting new patients.

The Government has substantially increased investment in general practice in recent years in an effort to increase GP capacity. Expenditure on fees and other supports paid to GPs has increased by 41% since 2019, with expenditure in 2023 expected to exceed €800 million. These fees and supports include a 10% increase to rural practice supports, improved GP maternity and paternity leave, and enhanced capitation rates. It also includes increases in payments for the provision of contraception services under the GMS, €2 million to support GP out-of-hours services, and a further €30 million in additional capacity supports to assist GPs in retaining staff and recruiting additional staff to meet patient demand. These measures are making general practice an attractive option for medical graduates, as can be seen in the record levels of applications to enter GP training in 2024 and the decreasing number of GP training graduates who now intend to emigrate.

It is acknowledged, however, that the provision of GP services in some rural areas is more challenging than in others. The pattern of work in general practice is changing and there can be financial uncertainty in setting up a practice in a rural area as the size of the GMS panel available may be smaller. GPs increasingly favour a multiple-GP team model, with some GPs developing sub-specialisations such as in chronic disease management or women's health. While the overall anticipated increase in GP numbers is expected to help to address the challenges of service delivery overall, including in rural areas, it is accepted that some difficult to serve areas require additional supports to ensure access to general practice services in the community. To address this, the 2023 GP agreement included specific supports for rural practices. In addition to the 10% increase in rural practice supports, a ring-fenced fund of €600,000 is being made available to support the delivery of an initiative to support rural GPs to source locum cover for approved leave periods. The HSE is currently exploring how to implement this solution. The HSE is also in the process of implementing a programme to improve the sustainability of GP services in rural areas by working with a larger practice in a nearby town to take on a smaller practice as a satellite entity. It is hoped that, if successful, the programme could be rolled out elsewhere and help to ensure the ongoing provision of services in rural communities. These are examples of creative solutions which will make rural general practice more attractive to GPs. Increasing GP training places will increase GP capacity in the medium to long term, and the number of GPs entering training has more than doubled, from 120 in 2009 to 286 in 2023, with a further increase to 350 places planned for this year.

While there may be some concern that the planned retirements of some GPs will result in GP capacity issues, the replacement rate for retiring GPs is very encouraging for the future of general practice. Due to the increased number of GP training places over the past several years, it is estimated that for every two GPs who currently retire, we now have three to six new GPs entering general practice.

As regards more immediate measures to address rural GP capacity, the non-EU rural GP programme is already placing GPs in rural practices across the country with 121 non-EU GPs recruited by the end of January 2024, of which 84 were already in place in GP practices. The Government has provided funding to bring up to 250 more non-EU GPs to Ireland by the end of this year. The strategic review of general practice is under way and will identify the arrangements necessary to improve the current system of GP care as part of a primary care-focused health service and in line with the programme for Government and the Sláintecare vision of access.

There has been considerable additional investment in oral healthcare services in recent years, including an expansion in 2022 of the care available under the dental treatment services scheme for adult medical card holders and substantial increases in fees paid to dentists. Sustained investment in recent years has reduced the number of children waiting to access public orthodontic care. The Government is committed to fundamentally reforming dental services. The HSE has appointed a strategic reform lead, who is driving service reform for adults and children in line with policy.

The Government is committed to delivering the enhanced community care programme, which is designed to deliver the reorientation of service delivery towards general practice and community-based services, thereby providing health services closer to people's homes - the right care in the right place at the right time. Therefore, I support the Government's amendment to this motion, which agrees that the Government is committed to fundamentally reforming dental services, that increased investment is making general practice in urban and rural areas a more attractive career for medical graduates and that the initiatives taken by the Government to increase the number of training places and recruit non-EU GPs will result in an increase in the number of GPs providing services in urban and rural areas, in an increase in the ratio of GPs to population and in improved services for patients.

Mattie McGrath (Tipperary, Independent)
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I thank the Deputies of all parties who have supported this motion. I wish to express my sympathies to Deputy Michael Collins on his tragic loss and to his brother Danny and the mother of the young man. I thank Tríona and Brian Ó Domhnaill in our office for putting this motion together.

I am disappointed because, as usual, the Government has put forward a countermotion. Everyone knows that something is wrong. Somebody quoted figures earlier and said that spending has increased by €800 million, or 40%, since 2019. It might be true but this is not about money. It is about mismanagement and pure neglect of rural and urban areas. GPs are not valued or respected. They have an ever-increasing workload. In my county, there are advertisements on Tipp FM and other radio stations asking people not to attend Limerick University Hospital or Tipperary University Hospital, and instead to go to their GPs, but you cannot get a GP appointment. Somebody phoned a GP practice last week to be told there is a waiting list of two and a half weeks and it was not an emergency. This woman wanted her blood pressure checked so this could very well become an emergency. There is unbelievable pressure on GPs.

This motion is fair and balanced. It is calling for an interdepartmental group to be set up to report back in a short number of weeks, and to do something about this rather than just turning paper and speaking volumes of words. Deputy Harkin raised the case of women who have had mastectomies being unable to access post-mastectomy services. There is shocking cruelty and inhumanity inside the HSE. We know there are thousands of good people working in the HSE and thousands of good things happen there. We saw the poor unfortunate young adults suffering with scoliosis in the Public Gallery last night. They have been suffering for so long and have had to come to protest outside the gates of Leinster House and come into the Public Gallery to appeal. This has been going on every year but has not been dealt with. Why is the system so inhumane that it cannot realise that it has to deal with these children with scoliosis. I could talk about a plethora of areas.

Former TD Dr. Michael Harty was elected here on a "no doctor, no village" ticket. It was a wonderful campaign. How right he was. The Government asked him to chair the Oireachtas Committee on the Future of Healthcare, which he did. He spent hours and months of dedicated time. As we approach the seventh anniversary of the announcement of Sláintecare in May, nothing has really happened under Sláintecare. That is what is wrong in this system. We keep producing reports and carrying out investigations and inquiries, and we keep making the system bigger and fatter and doling out largesse, but there are no services on the ground. We were told recently that the HSE recruited 1,000 people last year. I would love to know how many were pen pushers. I would say 92% of them were. This is the problem. It has just got bigger and bigger, has cannibalised itself and is unfit for purpose.

We have heard our colleagues here mention many areas around the country. I remember that when I was a young fellow, GPs could come out to you but now they are overwhelmed. The Government has rolled out different schemes, such as free GP care for the under-sixes, and after that for those under the age of 12, and the free contraception scheme. It rolls out any scheme it likes without proper consultation. There are the two GP associations, but they are like all the others - they are organs of the Government. When they arrive in Government Buildings for negotiations, they cave in and forget their members on the ground.

I salute GPs up and down the country and their staff, including nursing and ancillary staff, for the way they deal with people and try to manage the situation. However, I am critical of diagnosis by receptionists, which has been happening since Covid and involves a person being diagnosed over the phone or by someone standing in front of them through a glass screen. They have suddenly become GPs and can diagnose you just by asking questions. This is very poor practice, but it is happening wholesale. I hear awfully embarrassing stories about receptionists asking awful questions in front of a full waiting room, shouting through a screen, asking where somebody has a pain and how they feel, throwing the person a urine bottle and asking him or her to fill it up. That is inhumane. That is the pressure GPs are under. People cannot get to see them.

The figures are there. The Minister of State quoted them. We know the number of doctors who are going to retire. The Minister of State has figures regarding having so many doctors per 12,000 population. The Government is failing in respect of every figure it has nominated. It is failing the people. Two iarthaoisigh, Bertie Ahern and Brian Cowen, told me at different times that they were going to abolish the HSE but instead it has got bigger and more powerful and there are more cover-ups. It has become more unaccountable and disrespectful to the people and to public representatives.

I would like to speak about the primary care centres that are built. We closed a hospital in Carrick-on-Suir but a primary care white elephant was built on a flood plain and is three quarters empty. I have heard stories today about primary care centres. Money was spent on a brand-new nursing unit in Nenagh. It was built and kitted out but there is nobody to staff it. What kind of lack of joined-up thinking is going on? This is the problem.

The ongoing issue of the construction of the national children's hospital is having a damaging effect on children. First of all, it is in the wrong place. It will never be a proper hospital. It will never be accessible, with only a small helipad on the third floor. There is blackguarding, waste and unaccountability. CEO after CEO comes in and gets huge remuneration packages with no accountability. If you ask a question of the Minister here, he will tell you that it is a matter for the HSE. It is a handy stalking horse to fob people off - to hell or to Connacht, or go where you like. We do not have the resources we should have.

I also want to mention dental care, where there are significant pressures under the GMS system. Dentists just cannot take patients on anymore. Any time I visit my dentist on the quay in Cluain Meala, he is so concerned. He is a wonderful man. He is getting on in age like any of us but there is nobody to replace him and the system is being abandoned. We will see the Minister addressing the doctor's conference in early summer.

We will hear about the great things that are happening. The Minister is sent out to read scripts, as the Minister of State, Deputy Naughton, does. I acknowledge there are good things happening, but our GPs are the lifeblood of our community. What is going in Swanlinbar, as Deputy Harkin mentioned, is happening everywhere. Practices are being taken out of rural villages. Bigger primary care centres are taking them over but they have no interest in them really. They want the people from rural areas to go in to the town - isteach go dtí an baile - which means that there is less and less service.

The rural GP services, the nurses in them and the different dispensaries all over the country did a valuable job for decades. Now the HSE will not give them any proper supports. If a place is closed down or a doctor is retiring, they have to build a new centre themselves. There is no proper funding for that. They have insurance. They have health insurance, obviously, or mitigation against claims. They have all kinds of issues - light, heat, you name it. Really, they are small businesses. They might have up to ten staff.

The Minister of State's eye is not on the ball here, and neither is the Government's. I do not know what is to come over the Government, as I have said here. Sláintecare is a grandiose and glamorous document. The former Deputy Harty chaired that committee, but the report is not being implemented. We keep doing reports. We keep doing more and more reports and renting office space all over the country to store these reports instead of taking action. It is time that the Ministers ponied up.

The Minister, Deputy Stephen Donnelly, did not deem it worthwhile to come in to address this motion today, nor did any of the Ministers of State say why he was not here. If he was out of the country or if he is sick, it is fair enough, but he has not even the interest in listening to us. The Minister knows it all and he does not want any solutions.

This motion is calling for practical solutions and for a task force to be set up to decide, once and for all, how to deal with this problem. It does not call for pushing paper and everything else, or for voting on motions only to let them fall into oblivion. In the past while, it has been the practice of the Government to accept motions and then put them into some pigeon hole somewhere and leave them there. Their job is to govern here. Their job is to deliver services for the people.

We have migration into the country. Everywhere you go, in every town and village, there is a huge explosion in population and no services for them - GPs, hospitals, dentists, schools, etc. It puts more pressure on. The Government has a will to destroy the public services we have out there for the public and to deny our people public services they are entitled to, such as basic fundamental healthcare. These are human rights. We have doctors going out to field hospitals doing cataract operations. Deputies Danny Healy-Rae and Michael Collins are bussing people up to Belfast to do them. We cannot do them here. The Government can find the money under that scheme. That scheme is operating on the reverse as well where people from the North and other countries are coming here for those operations. It is farcical in the extreme.

I ask the Government not to oppose this motion, to listen to the voice of reason - everyone who spoke here this morning - and to try to do something for the country to ensure we have some modicum of GP service again and take the pressure off the overworked GPs we have.

Alan Farrell (Dublin Fingal, Fine Gael)
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That concludes-----

Danny Healy-Rae (Kerry, Independent)
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Before we close this-----

Alan Farrell (Dublin Fingal, Fine Gael)
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Sorry, the debate is finished.

Danny Healy-Rae (Kerry, Independent)
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-----debate, could I just say that I am very disappointed-----

Alan Farrell (Dublin Fingal, Fine Gael)
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Deputy, you cannot.

Danny Healy-Rae (Kerry, Independent)
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-----that no member of-----

Alan Farrell (Dublin Fingal, Fine Gael)
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Deputy, take your seat.

Danny Healy-Rae (Kerry, Independent)
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-----People Before Profit saw fit to come to this debate today?

Alan Farrell (Dublin Fingal, Fine Gael)
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Deputy, take your seat now.

Danny Healy-Rae (Kerry, Independent)
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Certainly I will, but I am-----

Alan Farrell (Dublin Fingal, Fine Gael)
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Take your seat then.

Danny Healy-Rae (Kerry, Independent)
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-----very disappointed at their non-attendance.

Alan Farrell (Dublin Fingal, Fine Gael)
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Deputy, you can express your disappointment all you like but you may not do so outside of the orders of the House. You are here long enough to know better.

Alan Farrell (Dublin Fingal, Fine Gael)
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The division will be deferred until the weekly division time this evening.