Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 1:

To delete all words after “That Dáil Éireann” and substitute the following:

"notes that: — this Government recently announced a record €25.8 billion budget for the delivery of health services in 2025, and this represents an increase of over 43 per cent from the €18.1 billion allocated in Budget 2020;

— there has been an unprecedented level of investment by this Government in the health service workforce since taking office, and as of August 2024, there were 27,901 more staff working in our health service than there were at the beginning of 2020, which equates to a 23 per cent growth in staffing numbers in this period and includes:

— 9,375 additional nurses and midwives;

— 6,184 managers and admin staff;

— 4,092 health and social care professionals; and

— 3,330 doctors and dentists;

— growth in the number of health service staff has never been so high, with recruitment in 2023 being the highest since the foundation of the Health Service Executive (HSE);

— the HSE has been funded to continue to expand its numbers by an additional 4,210 staff in 2024, and by more than a further 4,200 in 2025;

— according to the most recent Organisation for Economic Co-operation and Development (OECD) annual report, Ireland had 12.8 practising nurses per 1,000 population, which was the second highest number amongst reported European Union countries (second only to Finland), and the United Kingdom had 8.7 nurses per 1,000 population;

— Ireland is recognised as a global leader in pioneering Advanced Practice for nursing and midwifery, which is an important tool for optimising the capacity of the existing health workforce, supporting the development of career pathways, and supporting workforce retention;

— €5.5 million has been allocated in Budget 2025 to support continued growth of Advanced Practice in nursing and midwifery, and for the first time to also enable its roll out to Health and Social Care Professionals;

— the Pay and Numbers Strategy is a normal feature of how the HSE manages the funding and allocation of staffing each year, it is not a new thing, and it does not constitute a recruitment moratorium;

— a recruitment pause was initiated late last year, as the HSE had hired 4,000 extra staff, over and above what it was funded to hire;

— the recruitment pause ended in July this year, and any obstacle to normal recruitment or replacement of staff has been removed, within budgeted levels; and

— recruitment and budgetary controls are normal and proper in the running of any public service body; further notes, regarding overall recruitment and funding, that: — an agreement was reached between the HSE, Department of Health and the Department of Public Expenditure, NDP Delivery and Reform, on funding and staffing levels within the HSE for 2024, and the main details of which are:

— an increase in core HSE funding of €1.5 billion for 2024, on top of the €22.5 billion already allocated to Health in Budget 2024, and a further €1.18 billion in core funding for 2025; and

— the funding of 4,000 previously unfunded posts (Covid-19 and over recruitment in 2023);

— funding has been provided for the recruitment of an additional 4,210 staff into the HSE in 2024, 3,310 funded by Department of Health, and 900 whole time equivalent (WTE) funded by Department of Children, Equality, Disability, Integration and Youth (DCEDIY);

— since January 2020:

— National Ambulance Service staffing has increased by 22 per cent, from 1,933 to 2,363;

— Health and Social Care Professionals working in radiography have increased by 27 per cent, from 1,143 to 1,451;

— the filling of vacancies within the Children's Development Network Teams (CDNTs) remains a Government priority; and

— under Budget 2025, new development funding of €2.841 million has been allocated for further new posts within CDNTs;

further notes, in relation to the recruitment pause, that: — the HSE Pay and Numbers Strategy is not a continuation of the recruitment pause, and while a recruitment pause was necessary, it has now ended;

— the recruitment pause arose on foot of concerns about the level of recruitment in the HSE;

— the HSE was funded to recruit 6,010 staff in 2023, but actually hired 8,239, meaning it exceeded what it was funded to hire by more than 2,200 staff;

— during Covid-19, a further 2,000 staff that the HSE was not funded to hire, were recruited by hospitals and other community healthcare organisations across the country; and

— the recruitment pause came into full effect in November 2023, but came to an end in July 2024, and there is no longer any impediment to normal recruitment and replacement of staff taking place; further notes, on the Pay and Numbers Strategy, that: — the strategy has guided the HSE's recruitment policy since July 2024, and the main features of the strategy include:

— the allocation of funding and recruitment ceilings to each of the HSE's regional health areas; and

— Regional Executive Officers (REOs), will have the ability to prioritise recruitment and replacement within their approved staffing number and payroll cost; and

— the approach of devolving autonomy to the regions adopted in the Pay and Numbers Strategy is in line with the Committee on the Future of Healthcare, Sláintecare Report of May 2017, which states that "the HSE and the Department of Health must develop their integrated workforce planning capacity ... to deliver care in the most appropriate care setting and ... that staff recruitment should take place at regional level, or at a more local level if practicable..."; further notes, regarding the safe staffing framework, that: — the Framework for Safe Nurse Staffing and Skill Mix (the Framework) provides an evidence-based flexible approach to determine the number of nurses and Health Care Assistants (HCAs) required to provide safe and quality care based on patient need;

— there has been extensive engagement and agreement with unions and international experts in establishing this framework;

— the Government has provided significant investment since 2020, with over €56 million allocated to the HSE for implementation of the Framework on a phased basis nationally;

— it was calculated that an additional 2,000 registered nurses and healthcare assistants were required to achieve implementation, and as of August 2024, 1,500 of this 2,000 had been recruited, and with further funding provided in 2024, for agency conversion and direct recruitment, achievement of full baseline implementation is progressing as planned and expected to be complete this year;

— in August 2024, the HSE reported that the total nursing and midwifery workforce was approximately 47,584; and

— the number of nursing and midwifery staff recruited to our hospitals has increased significantly since the beginning of 2020, for example:

— St. Vincent's University Hospital increased by 49 per cent (+ 498 nurses / midwives);

— Tallaght University Hospital increased by 53 per cent (+ 521 nurses / midwives);

— Cork University Hospital increased by 37 per cent (+ 599 nurses / midwives);

— Mater Misericordiae University Hospital increased by 39 per cent (+ 488 nurses / midwives); and

— Waterford University Hospital increased by 51 per cent (+ 381 nurses / midwives);

further notes, on overcrowding and waiting list challenges, that: — the Government accepts that waiting lists remain a challenge, and importantly, this Government has made extensive progress on waiting lists, with significant reductions in the number of patients waiting long periods;

— waiting times for outpatient services has reduced from an average 13.2 months in July 2021, to just over 7 months today;

— since the Covid-19 pandemic peak, there has been a 23 per cent reduction in the number of people waiting longer than the Sláintecare targets, 10 weeks for an outpatient appointment and 12 weeks for an inpatient and day case procedure, and this equates to over 147,000 people; and

— there are 17 per cent fewer patients waiting over 12 months since this time last year, and this equates to 23,974 people;

— there has been a significant reduction in the cumulative daily 8 a.m. trolley count over the first nine months of 2024, with numbers down 12 per cent (over 10,000) when compared to the same period in 2023;

— this reduction has been achieved despite an increase in the number of patients presenting to emergency departments, with comparative analysis for January to September 2024, versus the same period last year, showing an 8 per cent increase in overall attendances (91,000 patients); and

—the improved performance follows a reduction in the trolley count in 2023; further notes, regarding Radiation Therapists and Cancer Treatment, that: — the Government accepts that there are Radiation Therapist vacancies in radiation oncology centres, and these vacant posts are still available to be recruited, and posts are being advertised for filling;

— a recent independent review of the Radiation Therapist profession published recommendations which aim to help and support the profession into the future, and overcome the current challenges faced by this service;

— measures have been taken to address international recruitment of Radiation Therapists, including a recent change to CORU's requirements for practice hours to bring Ireland in line with international practice;

— additional training places were introduced for Radiation Therapists during the 2023/24 academic year, with plans to further expand courses in Trinity College Dublin and University College Cork, to meet expected future demand; and

— funding for advanced practice posts for Radiation Therapists was recently announced in Budget 2025, as recommended in the Review; further notes, on agency and management consultant spend, that: — the agency spend in recent years has been higher than the Government would like, and steps are being taken to address this;

— the 2024 Pay and Numbers Strategy includes provision to convert agency staff to permanent HSE employees; and

— the HSE set a savings target of €34 million in Management Consultant costs, and the HSE is scheduled to meet this target by the end of 2024, with further savings being targeted in 2025; and finally, in summary: — the Pay and Numbers Strategy is not a recruitment moratorium;

— the Government has provided extensive funding for recruitment both this year and next; and

— safe staffing targets will be met this year.".

I thank the Deputies for the opportunity this morning to discuss recruitment in our health service. I will start by paying tribute to our healthcare workers and the improvements they have made for patients over the past four years. They have halved the time people wait for an appointment. I know we all talk about the number of people waiting, but what we are all signed up to under Sláintecare is not a number, it is a period of time. As the population grows, as the number of hospital consultants grows and as the number of services we provide grows, there are more and more opportunities for people to be referred into care. That is why Sláintecare quite rightly did not set a number in terms of the number of people waiting. It said no one should wait longer than ten to 12 weeks. That is what we have been focusing on and what we all need to focus on. Our healthcare workers, to their credit, have halved over the past three years the time people wait for an outpatient appointment. To Deputies Smith and Bacik, they quite rightly talk about the hundreds of thousands of people waiting for an outpatient appointment, but we need to acknowledge the achievements of our healthcare workers in halving the average time people are waiting. It is a remarkable achievement, and they have done it at a time when more and more people are referred onto the waiting lists. While overcrowding is obviously still a real problem in far too many of our hospitals, this year is the second year in a row they have reduced the numbers of patients on trolleys. That is at a time when there is an unprecedented extra number of people coming into our emergency departments.

They have rolled out a lot of new services in women's healthcare, genetics, stroke, cardiovascular, cancer care and many other areas. Something I believe the Deputies will welcome happened yesterday in children's spinal care, which we have been working on as a priority for years, where we were able to share the information that it is forecast this year that the number of children waiting more than four months will fall from 86 to 20 and all 20 of those, in consultation with their surgeons here in Ireland, will be given an offer to avail of care in the United States. I thank all of our healthcare workers because we here, quite rightly, focus on what is not working. The Deputies have focused, very understandably, on the areas of pressure. The reality is our healthcare workers are doing something remarkable. They are turning our healthcare service around for patients. Waiting times are falling rapidly. The number of patients on trolleys is falling. The number of new services that are being rolled out is increasing. In more and more areas now, the time people are waiting has gone from years to months and even weeks. Our healthcare workers have achieved that and I know we all thank them for it.

One of the things that has helped is a record increase in our workforce. I want to give colleagues a sense of the unprecedented increase in our workforce in the time of this Government. From 2015 to 2019, the average increase in the HSE workforce was 3,300 per year. In 2020, 2021 and 2022, the average increase was 6,000 new posts, nearly twice as many, and last year, as we know, it was in excess of 8,000. Last year alone, the HSE hired the equivalent of two and a half years' worth of hiring in previous years. In fact, last year was the highest level of recruitment into the HSE in the 20 years since it was founded. The motion suggests the HSE's pay and numbers strategy is part of some embargo or pause. That is not the case. The pay and numbers strategy is an annual feature of how the HSE runs. The pay and numbers strategy is simply the mechanism the HSE uses to say this is the number of staff that are funded, this is the growth and this is how the executive will fill those posts.

It is true there was a temporary recruitment pause initiated within the HSE last November, and that is because the HSE, which was funded to hire 8,000 extra people, actually hired 8,200 and showed no sign of slowing down. The pause ended in July of this year but there were many exemptions in place. Even during the recruitment pause, the number of HSE workers continued to go up. In fact, during the period of the pause, which was November 2023 to July of this year, the number of health and social care professionals went up by 250, the number of doctors went up by 400 and the numbers of nurses went up by 2,000. The narrative is that, during the pause, the workforce decreased. In fact, even during the embargo it continued to go up by several thousand, including 2,000 more nurses.

What about this year in its totality? Listening to some of the commentary, and I do not mean from colleagues opposite, the people would be forgiven for thinking the HSE workforce is contracting this year. People have talked about cuts, they have talked about embargoes and hiring freezes, and the public would be forgiven for thinking there are fewer people working in the service now than there were at the start of the year and there will be fewer people working in the HSE this year than last year. Nothing could be further from the truth. It might surprise colleagues to hear that, this year, the HSE is increasing its workforce by 5,000 staff, nearly double what would have been hired in an average year from 2015 to 2019. That is this year; what about next year? Next year, the HSE is funded to increase its staff again by an additional 4,000 people. Where have we got to so far? There are 28,000 more people working in the HSE today than there were when this Government came into office, a 23% increase. There are 9,000 more nurses and midwives, 4,000 more health and social care professionals, 6,000 more managers and administrators, and approximately 3,300 more doctors and dentists.

In July of this year, the Minister, Deputy Donohoe, and I reached agreement on an additional €1.5 billion for base funding. It was important for many reasons, but from a workforce perspective, it was important for two reasons. First, there were 2,000 staff hired during Covid on temporary money. There was no long-term wage provided for those staff. They have all now been regularised into permanent staff. Second, the 2,000 extra staff the HSE hired in 2023 that it had no sanction or money to hire have all been secured on a permanent basis as well.

I am keenly aware that in spite of these unprecedented increases in staff, there are individual teams in community settings and in hospitals who are down a therapist, a nurse, a doctor, an administrator or whatever it may be and this puts them under a lot of pressure. I fully accept that and it is putting their service under a lot of pressure. The regional executive officers in their regions now have the authority and the ability to prioritise and to recruit and replace staff within their agreed level of staffing. The approach is exactly what was seen in Sláintecare, which recommended more local autonomy, and it means having to prioritise within regions and hospitals. We are not just leaving them to it, however, and saying they need to figure out where to redeploy their staff. In addition to having local autonomy to prioritise and redeploy posts, there are also a very large number of vacant, fully funded posts across the country. In fact, between the posts still to be hired this year and the posts that have now been funded in the budget for next year, the HSE can expand its workforce between now and the end of next year by an additional 7,500 healthcare workers.

When it comes to the enhanced nurse staffing framework, the position is as follows. It was estimated that rolling this out required an additional 2,000 nurses. There are 1,500 of those in place in the wards and emergency departments, and the remaining 500 are fully funded and are being hired at the moment. In terms of nursing per population, Ireland now has the second highest level of nursing anywhere in Europe and second only to Finland. If we compare ourselves with the UK, per head of population for every two nurses working in the UK, Ireland has three nurses working. We have far in excess.

The huge increase in our nursing workforce in recent years has given what the HSE needs for a radical reduction in agency fees and overtime. I fully agree with the Deputy's points on agency usage. The rate is far too high and way beyond the funded level. The chief executive has now set a target of a reduction in agency fees of two thirds. It is much required. However, we are doing a lot more than leading the way in terms of numbers in nursing; we are also becoming a world leader in advanced practice. I am delighted to say that next year we will be widening advanced practice opportunities to include health social care professionals.

A particular area of focus of the budget is radiation therapy. I salute the Deputies opposite for referring to it in their motion. Colleagues will be aware that I have allocated very significant funding for cancer care for 2025. It includes funding for the national cancer strategy, community cancer support groups and new medicines. Critically, it includes nearly €3 million for radiation oncology. That includes oncologists, therapists, nurses and specialists. We have also allocated funding for new advanced practice posts.

I thank the Deputies again for the opportunity to discuss this matter.

Alan Kelly (Tipperary, Labour)
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I had to grin earlier because, whenever the Minister is in the Chamber, I seem to have to go out to take a phone call about my father's healthcare. The work of the staff in both Limerick and Nenagh, whom I have been dealing with in the past few months again, has been exceptional. I acknowledge Dr. Scott, Dr. Sohail, Dr. Vijay, healthcare assistant Ray, nurse manager Louise, healthcare attendants Patrick and Tom, nurse Ionela, nurse Ji Ji and nurse Johncy. It is important to acknowledge that, despite all the issues we have in our health system and that we debate here, there are real people looking after very sick people in our care. They deserve to be acknowledged.

As the Minister knows, I am exceptionally familiar with the mid-west. I do not think I have spoken more about anything than issues in the mid-west in my political career. I preface all my comments based on my knowledge of it. In my office, there is a corriboard poster from 2005 or 2004. It was left there by a previous Labour Party representative, Kathleen O'Meara, who worked very hard on fighting the Hanly report. In fairness to the Minister, I acknowledge he has always said the reconfiguration in the mid-west did not work. It should never have happened. The clinicians who actually advised that it be done have never answered questions about it but politicians have had to face it. The Minister has had to, and so indeed did I when I sat where he is now sitting. Clinicians have never had to face it. It is very difficult for politicians to go against clinical advice. In this scenario, the resources were not available and politicians should have gone against clinical advice because what was to be put in place was never going to work at the scale required. We are now trying to backfill at a rate. I acknowledge there is work going on.

There are issues concerning staffing. I acknowledge everything the Minister has said in this regard but there are issues and processes in place that mean the bureaucracy around filling certain posts is ridiculous. Some posts are left open. In this regard, I refer to my colleague Louise Morgan Walsh, who works in Nenagh hospital, and other staff in a range of other settings. Positions have been left vacant for over a year. I know of someone who was considering applying for a position but who went to Australia. That individual came back for a family event the following year and the position was still not filled. That is just ridiculous.

The Minister referred to the pay and numbers strategy. I have spoken to representatives of the unions and will be supporting them in their campaign, but I have also spoken to people across the HSE who talk to us because they believe the relevant information needs to be in circulation. There are qualified people on panels that have been in place for months or years but the related positions are never filled. The Minister states there is prioritisation in each region. I support that but the gaps that exist are simply not acceptable in some scenarios. I will give a classic and very important example. Cancer care in UHL is the best in Ireland, and the KPIs show that. In the past five years, particularly during the Covid pandemic, so many people have told me how brilliant it is. I know about it personally – trust me – but the fact is that the posts involved, such as in nursing, are very specialised. The numbers are down and, for the first time ever, people are saying to me that they do not have enough nurses and that hospital KPIs are slipping. I have raised this with the Minister before, including a month ago, but the position is still the same. Scalp treatment is not happening.

There is a discrepancy between what the Minister states about funding and what happens on the ground. What is required is happening in some cases but not in others. The reason has nothing to do with funding; it is that there is nobody to do the work. The staff are not in place. There is an effort to prioritise the treatment of cancer patients based on need. Unfortunately, some have to wait a little longer because they are not as great a priority. That is a clinical decision, which is fair enough, but the KPIs are dropping. That is just one example. It should not arise. I actually believe the Minister believes it should not arise and in that regard I am not making a political point, but the bureaucracy and what is left in place regarding the prioritisation of the filling of posts within each regional division – some of the regions are not even set up fully – means what is required is not happening at the level it should.

I want to make several more points. The privatisation of much of the healthcare system is happening. I am aware that the Minister has referred to the comments of the chief executive in this regard. I accept Mr. Gloster's belief; I actually believe him when he states he wants to cut the amount by two thirds, but sometimes, because of the bureaucracy I have spoken about, the easy choice is to get agency staff. Advertisements that I could print off and show the Minister offer an incentive of €4,710 to come to Ireland to work. We need every one of the staff but also the people on panels.

I have sung so many times in here about the community nursing home in Nenagh being given over to a private company to run it. There are 15 or 16 people being held in a specially built 50-bed unit. It is the most modern nursing home in Ireland, yet it is left with 15 or 16 people. It is not making a huge difference to trolley figures because the issues in UHL are so much bigger.

I want to focus on a couple of specific points. The backfilling of positions that arise from retirements and maternity leave is simply not happening. Given the layers of bureaucracy, it takes so long to replace staff. I know of nurses in multiple settings in the mid-west who, although their shifts will be over at 5 o'clock this week, will be staying on till 9 o'clock. They are absolutely exhausted. I know them; they are my friends and neighbours.

When it comes to community care in the mid-west, many of the issues affecting UHL arise because too many people end up there who should not end up there in the first place. This is because the resources in the community are not up to the level required. I am going to beg the Minister for something I have spoken about so many times. I know all about home care packages and home help, given my domestic situation with my parents, both of whom are in their mid-80s. The Minister can announce a zillion home care packages and a zillion additional home help hours but these will not matter if we do not have the bloody people. The reason we will not have the people is that they are not getting paid enough and there is competition to do other work. I know people who were doing home care but who went off to work in other settings because they were just better. We need a registered employment agreement that sets the basic hours, pay, travel expenses and all the extras associated with the work. This would save the State money because it would help people to stay in their homes rather than end up in big, freezing nursing homes or in acute care costing €1,600 per night. I beg of the Minister to push this.

In my remaining time, I want to put something on the record that I asked the Taoiseach about yesterday.

I have four questions. We need dates before the election. A commitment was given that the new 96-bed block in University Hospital Limerick, which I look at multiple times a week, staring out the window, would be opened in the first quarter, to be fair to the Minister-----

Stephen Donnelly (Wicklow, Fianna Fail)
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I misspoke. It is in quarter two.

Alan Kelly (Tipperary, Labour)
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The Minister has misspoken a couple of times because he referenced it a couple of times. I have researched it. What date will it open? The second thing is that the community nursing home in Nenagh will be handed back to what it should be used for on the same day. The second thing is that medical assessment units, MAUs, are committed to going to 24 hours. When will that happen? The MAU in Nenagh is going up to midnight. There are very few referrals after 6 o'clock and at weekends. It is sitting there. Whatever process is in place is not working. I believe it should be 24-hour. I would love it but I do not think the resources are in place to do that.

When will we get a decision about a model 3 hospital in the mid-west? It is a no-brainer. I know a report is being done on it. It is as sure as the nose on my face that we need a model 3 hospital in the mid-west to deal with the demographics, the pathways management and so on. When will there be a decision on that? Will the Minister please answer those four questions in his response?

David Cullinane (Waterford, Sinn Fein)
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I thank the Labour Party for tabling this motion and giving us an opportunity to discuss this important issue. In all the discussions on budget 2023 and budget 2024, as the Minister knows, I pointed out robustly that the health service was not getting the funding it needed to stand still, that we were running significant deficits, and that at some point, a cheque would have to be written to cover that deficit. There was serious pushback, not necessarily from the Minister, Deputy Donnelly, but from the Government, from the Ministers for Public Expenditure, National Development Plan Delivery and Reform and Finance, and indeed the Taoiseach, when these issues were raised with them. In the summer of this year, €1.5 billion had to be made available to fill that big hole that was in the HSE's finances because of reckless funding of the health service for two years, but that was not without its consequences. That resulted in a recruitment embargo that was put in place in 2023.

Stephen Donnelly (Wicklow, Fianna Fail)
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There is no link between those two things.

David Cullinane (Waterford, Sinn Fein)
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That recruitment embargo was put in place by the head of the HSE. I did not interrupt the Minister. I have my time. The Minister can dispute what I am saying but it is indisputable. The HSE said there was a need to contain costs. He sent communications to the health service that he was putting in place a recruitment embargo with very limited exceptions relating to final-year nurses and hospital consultants, but across a whole range of other grades, we had a recruitment embargo. The Minister will also know that the Irish Nurses and Midwives Organisation has said that because 2,000 nursing posts were vacant at the end of 2023, on 31 December, those posts are now vanished and gone. We are hearing the same across a range of other grades too. The Minister talked about radiation therapists. SIPTU told us last week that there is a 30% shortage in these grades. That has been the case for some time. There is equipment in cardiac services that is not being properly utilised because they do not have the staff.

This is an example of the inefficiencies in healthcare that we talk about. We cannot and are not recruiting the staff needed to make the best use of expensive equipment that exists in the healthcare system because of either an embargo on the one hand, or limited and curtailed recruitment on the other. I will get to what the Minister said about additional staff who have come into the health service in a moment. The Irish Cardiac Society was before the health committee today. It referred to significant workforce issues, including an embargo on filling vacant positions since October 2023. It gave one recent example where novel services to manage patients in the community were partially suspended because of the embargo. It also gave examples of where cardiac physiologist posts are only at two thirds of where they were four years ago. There are vacancies in these posts in hospitals up and down the State. The Irish Cardiac Society made the point that we have cardiac equipment that is not being properly utilised because we do not have the staff. It specifically mentioned the recruitment embargo but also a suppression of posts.

It strikes me that we have the Irish Cardiac Society, the Irish Nurses and Midwives Organisation, SIPTU, Fórsa, which will be before the Oireachtas committee today, and front-line healthcare staff who want to come and work in the public system all telling us that there is a problem with recruitment, that the embargo is wrong, and about the consequences of this, including in community services, where it is important that we have the staff. The only person who does not accept any of that is the Minister for Health, who keeps talking about all the additional staff who have been recruited. Additional staff have been recruited. I recognise that. Nobody is disputing the fact that the health service has grown but one cannot dispute that an embargo was put in place which caused reputational damage to the HSE, and that thousands of needed posts were suppressed. Funding for those posts is needed to equip the healthcare system for the increased demand.

Today, I got a reply to a parliamentary question to the Minister on agency spending. There was €650 million in agency spending in 2023, up from €300 million in 2019. The figure so far this year, up to the end of August, is €470 million, despite all the Minister's talk about productivity, savings, task forces, and how we would save money and clamp down on waste. Last year, €650 million was spent on agencies and over €150 million of that was on nursing. People look at that and say we are spending hundreds of millions on agency spending which is going up and up every year, yet we have nursing posts that were scrapped, vanished and gone. That is inefficient. It is the Minister's responsibility, which he has to accept. I accept all of the recommendations and proposals in this Private Members' motion from the Labour Party.

Mark Ward (Dublin Mid West, Sinn Fein)
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Concerns have been raised with me that vital developmental checks are not being carried out on newborn babies due to a lack of public health nurses. Parents from Clondalkin, Lucan, Newcastle, Rathcoole and Palmerstown have contacted me with these concerns. When a baby is born, developmental checks are carried out at regular intervals from birth and throughout their infancy. A public health nurse visits and typically checks the baby's weight and overall health. The public health nurse is expected to carry out a developmental assessment when the baby is three months old. However, people from my area have been telling me that some babies are not getting this assessment due to a lack of public health nurses in their area. We all know that early intervention and diagnosis is key for children. These children and parents are being failed from birth.

One of the hardest things that I have to do as a public representative is to send on a response from the HSE to say that a child could be waiting for anywhere from four to six years for an assessment of needs. It is difficult for me as a public representative. I can only imagine what it is like for a parent who has to receive that letter. There is a postcode lottery for care for children, depending on where they live. In my area, the average waiting time in Clondalkin for an appointment with a community disability network team is two years. It is four years in Lucan and four and a half years in Palmerstown. Imagine how much a child can regress in four years. That waiting period is just to get assessed, not to get the other therapies that may be needed, such as speech and language and occupational therapy. I have responses from the HSE to state that parents are still waiting on an initial stage one phone call from a community disability network team after two years. What system is in place such that it takes two years to make a phone call? This is another example of how the Government has failed children.

We all know about the low staffing levels in CAMHS. It will be no surprise that I will finish on this. One of my biggest concerns with CAMHS is that it remains unregulated under this Government. I had legislation passed in February to regulate CAMHS but the Government decided to kick it down the road for nine months. Nine months is up on 28 November, the day before the much-speculated about date for the election. Children, parents and the staff working in CAMHS simply cannot wait for CAMHS to be regulated. I am calling for immediate action today to regulate CAMHS as the failure to do so leaves children at continuing risk.

Pauline Tully (Cavan-Monaghan, Sinn Fein)
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This day last week, I attended a protest at Cavan General Hospital. That protest was held by workers from across the hospital, including nurses, clerical workers, porters and healthcare assistants. They were represented by three unions, which were Fórsa, SIPTU and the INMO. The demonstration was held as the first step in opposition to the pay and numbers strategy introduced by the HSE in the summer and the fact that all positions which were unfilled as of 31 December 2023 are now declared obsolete or, in the words of the HSE, decommissioned. I spoke at length with different individuals there. One clerical worker told me that she frequently works up to three hours in addition to her nine-hour shift to ensure that patient files are properly updated.

Nurses tell me that even on their days off, they get text messages asking them to come in to provide cover because the service is chronically understaffed. They know what it feels like to be in that position and they do not want to jeopardise the safety of the patients. However, they are jeopardising their own health and well-being because they are losing their days off and they are also losing out on time with their families. Most of this additional work is not paid as overtime but it is done as time in lieu, but the difficulty is taking that time off subsequently when there is such chronic understaffing. This is having an impact on patient care and the healthcare workers themselves. Many are considering going abroad where they can do their jobs without having to worry about coming in on their days off or doing additional hours.

It is evident that the HSE and the Department of Health are trying to ignore the unions, which are there to represent the healthcare workers. We saw what happened with the CDNTs. There was no engagement with staff in CDNTs prior to the Progressing Disability Services programme being set up, and it has been a disaster. If something is not done, we are heading down the same route here. We need realistic workforce planning. The HSE must directly employ staff and stop engaging agency staff, which is far more expensive. There is a clear road to privatisation and that must stop.

Martin Browne (Tipperary, Sinn Fein)
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I also thank the Labour Party for bringing the motion to the House today.

Members of the Fórsa trade union are due to join their colleagues in SIPTU and the INMO to protest on the Western Road in Clonmel on Thursday. I call on anyone who can attend to do so, and to show their support and solidarity between 12.30 p.m. and 1.30 p.m. While I suggest that Government representatives should attend, I assume they will not, as they are fully briefed on the damage that has been inflicted on the health service as a result of the decision to cut roles that were funded up to now.

I heard the Taoiseach cite facts and figures to beat the band the other day, but what he did not do was list the experiences of workers or service users and their families who experience ongoing difficulties and delays in getting the services they need. Again, we appear to be at a stage where that is taken for granted by this Government, despite what it claims in public. We do not hear Government representatives speak for the children whose physiotherapy needs are relegated to once a fortnight or the fact that the CDNT teams in Tipperary have gone from a vacancy rate of approximately 30% to more than 50%. The Government is not exactly shouting from the rooftops the fact that posts that were vacant at the end of December are no longer funded. They include, for example, the post of clinical psychologist in both CAMHS teams in Tipperary or the occupational therapist in team 2.

The Government apparently prides itself on the work done but, in my opinion, the job has not been done. Behind each vacancy figure is an individual - a family that has been left without. If the Minister speaks to the unions I have mentioned, he will see that behind each of these figures are staff members who in their own words are running themselves ragged in the process and really not achieving what they set out to achieve, which is quality patient care.

This is the Minister's record. What we need and what Sinn Féin would do is roll out a workforce plan where training and recruitment are in sync with each other; where training targets and need are related; and where every graduate would be offered a job in the public system, not the race to the bottom the Government appears to pursue.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I thank the Labour Party for bringing this important motion forward this morning. The motion is timely, particularly in a Mayo context, as I attended a protest on this very issue outside Mayo University Hospital, MUH, just last Thursday. I know the Acting Chair is very familiar with it. More than 100 protesters - members of trade unions like Fórsa, SIPTU and the INMO - were there on the day. I commend them on giving up their time to highlight the precarious position this Government has left them in regarding the delivery of healthcare in Mayo.

I want to know how the Minister and the Government expect MUH to deliver safe and appropriate healthcare when 82 positions are vacant, if safer staffing levels are adhered to. The INMO representative spoke about vanishing vacant staff positions that were not filled by the end of 2023. Some 2,000 hospital positions across the State disappeared. In MUH, a total of 82 staff positions evaporated as a result of the New Year's Eve cull. How is that possible? What is certain is that the level of need has not reduced; in fact, it is the opposite. The missing staff in Mayo include two advanced nurse practitioners, 47 staff nurses, 17 midwives and a range of nursing specialists and management positions. Currently, there is no spend on agency healthcare attendance or nursing staff. While I do not believe in spending on agency staff, when we are in an absolutely dire situation, as MUH is, it is needed in the interim.

Those are just the vacancies in hospitals. Across the healthcare sector in Mayo, there are huge shortages of staff, including in mental health services and services for older people. Everyone in Mayo knows the outworking of these missing staff, which is cancelled appointments, ambulances queued outside emergency departments, no hope of getting a child seen by CAMHS in a timely manner and no physiotherapy or occupational therapy for older people. Once again, the Government turns its face away from the most vulnerable.

The bad news for patients and staff is that it will get worse as winter deepens and additional demand is placed on them. I feel very sorry for staff who are forced to work in these conditions. The stress they are under must be unbearable. If the safe staffing levels are to be introduced, they are short 25 additional nurses.

Michael Ring (Mayo, Fine Gael)
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I thank the Deputy.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I have five minutes.

Michael Ring (Mayo, Fine Gael)
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The Deputy's time is up.

Rose Conway-Walsh (Mayo, Sinn Fein)
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When the Minister goes to hospitals, everything is cleared.

Michael Ring (Mayo, Fine Gael)
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The Deputy is taking other people's time.

Rose Conway-Walsh (Mayo, Sinn Fein)
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Yes, but I have five minutes. I am sorry, Acting Chair. I will stop after five minutes. You know how important-----

Michael Ring (Mayo, Fine Gael)
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There are two more speakers.

Rose Conway-Walsh (Mayo, Sinn Fein)
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Yes, they have two and a half minutes each. When the Minister goes to hospitals, everything is clear and pristine. He is given PowerPoint presentations. He needs to speak to the nurses, staff and healthcare assistants on the front line. He needs to call when the hospitals are not expecting him to call to see exactly what is going on in these situations. It is not fair on staff or the people in Mayo that they have to tolerate situations like this. Is it any wonder that people who need to be in hospital are afraid to go there because of the current situation?

Michael Ring (Mayo, Fine Gael)
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I call Deputy Ó Murchú. Sorry, Deputy Munster is next on the list.

Imelda Munster (Louth, Sinn Fein)
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The Minister, who has just left the building, is aware-----

Michael Ring (Mayo, Fine Gael)
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The Deputy does this every week but he will not do it with me.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I had five minutes.

Michael Ring (Mayo, Fine Gael)
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I am not talking about Deputy Conway-Walsh; I am talking about the Deputy behind her whose name is down here. He jumps the list every week and he then goes on too long. I call Deputy Munster. He will not do it today.

Imelda Munster (Louth, Sinn Fein)
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You are fairly ratty this morning, Acting Chair.

Ruairi Ó Murchú (Louth, Sinn Fein)
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The Acting Chair did not let me go over time the last time.

Michael Ring (Mayo, Fine Gael)
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He will not do it today. I can tell the House that.

Imelda Munster (Louth, Sinn Fein)
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Will the Acting Chair stop the clock? I was about to address the Minister but he has left the building. Perhaps he has gone for coffee or something. He cannot be too concerned about the pre-winter crisis in hospitals across the State. I was going to say to him that we are already seeing worrying cutbacks in patient services, even ahead of the winter surge, and Our Lady of Lourdes Hospital in Drogheda is certainly no exception to that. In recent weeks the emergency department there has experienced delays and overcrowding and on three occasions it has had to issue public notices for people to attend only in emergency cases. Along with that, some outpatient clinics have been reduced and cancelled and elective surgeries are now being examined or reviewed on a daily basis. All of that is ahead of the winter surge. This happens every single year.

At some stage we must say to ourselves that whatever about the higher echelons of HSE management - or mismanagement for the want of a better word - the buck actually stops with the Minister. We could set our clock for this time every year where we stand up here and flag the fact that appointments are being cancelled, patients do not have access to public health services, people are sitting on chairs and waiting for 24 hours in overcrowded emergency departments, yet the Minister just sits there. He has not even bothered to stay this time. He is away. At some stage the Minister must accept responsibility. The buck stops with him, and with the Government.

Ruairi Ó Murchú (Louth, Sinn Fein)
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My intention was to go last so as not to take time from anybody. In fairness, Deputy Munster has dealt with a considerable amount of information on Our Lady of Lourdes Hospital, including the warnings relating to the emergency department. On Thursday, 10 October, Fórsa, the INMO and SIPTU organised a large demonstration and protest outside the hospital, but that is not what we want to see. We want to see what the nurses and medical staff are asking for, which is safe staffing. They talked about the absolute disaster that was the moratorium and the suppression of posts.

I will deal with one section of the health service. I was at a meeting last night in the Clan na Gael Hall in Dundalk on Maxi's law. Unfortunately, we had the tragic loss of Mark Maxi Kavanagh recently, which brought to light the issue of mental health services.

This request will be put to all politicians. It relates to equality of access. It is the difference between someone who has VHI or other private health insurance and someone who does not. We do not have enough beds in Crosslanes. The bed provision in Louth-Meath is below the State average, although the State average is nowhere near where it needs to be. Even the answers to parliamentary questions at this time state that 55 positions are vacant in Louth-Meath mental health services and that is before we get into the idea of suppression of posts.

I will bring up a specific issue about CAMHS. Anyone who has phoned CAMHS in Dundalk in the past two weeks will get a warning stating that CAMHS north Louth is experiencing a crisis in administration, the number of administration staff has been cut, there is only one person working three days per week and calls will only be answered between 10 a.m. and 12 noon on Mondays and Fridays. It goes on to state the clinician will try to continue with appointments and will answer the door for appointments, but that is all. While the service is trying to do that, CAMHS north Louth believes certain functions will be compromised. Then it asks for feedback. I can imagine the feedback. I and other elected representatives are getting it. None of this is good enough in any way, shape or form. We need to get serious across the board. If we are talking about-----

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

Ruairi Ó Murchú (Louth, Sinn Fein)
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-----entrance into mental health services-----

Michael Ring (Mayo, Fine Gael)
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We move to the Social Democrats.

Ruairi Ó Murchú (Louth, Sinn Fein)
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-----we must talk about the fact that we do not have the assessment procedures in Our Lady of Lourdes Hospital or Crosslanes.

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

Róisín Shortall (Dublin North West, Social Democrats)
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I thank the Labour Party for tabling this motion on staffing levels in the HSE. The Social Democrats are happy to support it.

There is no doubt that in recent weeks there have been several claims and counterclaims. This has made it difficult to get to the truth of the matter and the facts. The Minister's plan seems to be to muddy the waters instead of engaging in any kind of meaningful way with the unions. We have been repeatedly told that an additional 28,000 healthcare professionals have been employed since the Government came into office. That figure is a welcome one. However, the Minister repeatedly fails to say the base figure. It is all very well to say that a large number of additional staff have been hired, but the key thing is the starting point. I can tell the Minister and the House that there were approximately 120,000 healthcare staff in 2020. For context, it is important to point out that this figure was barely 4% higher than the level in 2008. Of that 2020 figure, the number of doctors was just 3.3 per 1,000 head of population, which is the sixth lowest rate in the EU. The number of nurses was 12.9 per 1,000 people, which is admittedly above the EU average of 8.4 and the OECD average of 8.8, so the Minister often uses those figures. However, the OECD has repeatedly said that the figures for Ireland are overestimated because we are not comparing like with like. Ireland includes midwives, unlike most countries, and has traditionally counted nurses who work in management, education and research, while the majority of other countries only include practising nurses who provide direct patient care. I understand this will change, which is welcome, but until the distinction is made between front-line work and other work, we must acknowledge that our figures are inflated. When the Minister spins the line that Ireland now has the second highest level of nurses in Europe, I will be forgiven for taking it with a pinch of salt.

The substantial loss of institutional knowledge during the austerity period must also be acknowledged. Approximately 10% of staff nurses left during this period and this loss of skills has compounded the current problem. After all, it is not just a question of numbers; it is also a question of experience and institutional knowledge. Another good indicator is the level of staff turnover, which is too often ignored. The staff turnover rate for nursing and midwifery was 6.4% in 2020. By the end of last year, it had jumped to 8.7%. I appreciate that there are several variables to consider with turnover, not least of which is the housing crisis, but job dissatisfaction is clearly a driver. A recent INMO survey found that a whopping 63% of respondents had considered leaving in the previous month.

It is also important to consider the environment in which our healthcare staff are working. Among the 38 OECD member states, Ireland has the highest bed occupancy rate at 90% and, as we know, it is over 100% in many of our hospitals at times. This is well above the recommended maximum occupancy rate of 80% to 85%. While the number of hospital beds has increased, this year the European Commission found that Ireland still had the fifth lowest number of beds in the 27 EU member states. This means our healthcare staff are working in environments that are chronically overcrowded, leading to much higher workloads and considerable pressure. This is unsustainable. We have heard this from the INMO and SIPTU as regards nurses and from other representative bodies, Fórsa in particular, as regards other healthcare professionals.

I accept that a safe staffing framework is now in place for nursing, but it needs to be fully implemented. Furthermore, we must ensure it reflects the reduced working week, which was reduced from 39 hours to 37.5 hours per week. The INMO has said that no provision was made for this loss of nursing hours. That must be addressed, because it was a pertinent issue that arose in the Workplace Relations Commission, WRC, hearing. There was a request that those figures be recalibrated. That must be done urgently. Last week, I asked the Minister to ensure the numbers are recalibrated so the facts can be put on the table. This back and forth dispute of figures should not continue. We need to have the facts of the matter, put them on the table and ensure the commitment to safe staffing levels is adhered to.

In other areas of the health service, staffing numbers are going in the wrong direction, despite the Government's talk about record numbers. At a recent health committee meeting, SIPTU said the number of healthcare assistants in the HSE decreased between January 2023 and July 2024. It has fewer healthcare assistants now than it had at the beginning of last year, at a time when the demand for homecare is growing rapidly. Is it any wonder the State is becoming more and more reliant on private providers? It is beginning to seem as though this is a deliberate policy and that a policy of outsourcing and privatisation is at play. At the same meeting, SIPTU told committee members that we have a 30% shortage of radiation therapists. This crisis is reflected in the level of outsourcing which has cost approximately €10 million in the current year.

Representatives of SIPTU and the Irish Cancer Society will be in the coffee dock this afternoon to speak to Members about these issues. I ask Members to try to make time during the day to drop along to hear about the illogic of what is happening. We could be treating far more people with vital life-saving cancer treatments, but we simply do not have the staff. Clear steps can be taken to address that, but the Government is not listening. Regrettably, many other areas of the health services are chronically understaffed, from the National Ambulance Service to CAMHS, which many people have mentioned. We need to move to a situation where we have safe staffing levels, not only in nursing as previously committed to, but right across the health service.

We need to start regarding that as investment rather than a cost because, ultimately, the savings will be made if people have access to early intervention and are able to recover from their conditions.

Michael Ring (Mayo, Fine Gael)
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I call People Before Profit-Solidarity Deputies Boyd Barrett, Murphy and Barry.

Paul Murphy (Dublin South West, RISE)
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It is me and Deputy Boyd Barrett.

Michael Ring (Mayo, Fine Gael)
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That is grand.

Paul Murphy (Dublin South West, RISE)
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The Minister for Health has the neck to come in here and claim that the pay and numbers strategy is not a recruitment moratorium when the health unions are telling us that is precisely what it is. To be clear, it does not matter to health workers or to patient safety whether or not it is officially called a recruitment moratorium. If it looks like a duck, walks like a duck and quacks like a duck, it is a duck. The unions would not be protesting or balloting for strike action if this were not a serious issue for workers and for patient safety. The Government's countermotion shows that, as usual, it is speaking out of both sides of its mouth. On one hand, it claims that the previous HSE official recruitment moratorium was necessary. On the other hand, it admits that more recruitment is necessary. On one hand it claims that the HSE has recruited too many staff, but on the other hand it says it is funding the HSE to recruit thousands more staff. Which one is it? Either the Minister for Health and the Government are confused and do not know, or they are deliberately misleading the Dáil. Either way, it is time they stopped gaslighting health workers and the public.

The Government amendment boasts about the number of extra nurses recruited in a range of different hospitals. I was particularly interested to see reference to the increase at Tallaght hospital, suggesting that this has somehow fixed the problem. I can tell him from first-hand experience that it has not. I brought my wife to the emergency department on Thursday night. We got there at approximately 7.30 p.m. and she was seen the next morning at 10 a.m. - 14 and a half hours. She was not the worst. There were people there who had to wait for 17 hours to be seen. When we arrived, there were 152 people waiting. Sick people and older people were sitting on hard chairs overnight because they had emergencies and needed to be seen. This is so normalised that there are announcements on a half-hourly basis saying how many people are waiting and what the average waiting time is. We have normalised the idea that hundreds of people have to wait overnight on a Thursday to get seen in a hospital. Of course, once you get admitted the care you get from the nurses and all of the health staff is excellent. In a rich country, however, this should not be normal and should not be accepted. Patients should not be forced to put up with this and staff should not be forced to work in these conditions. The truth is not that we have too many health staff in our health service; we have nowhere near enough staff. Anyone can see the huge pressure they are under. We should get a commitment to lifting the de facto recruitment moratorium. The Government should listen to front-line health workers, who are the real experts here, and it should invest in recruiting all the necessary staff to provide a first-class single-tier universal health service.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I thank Deputy Duncan Smith and his colleagues for this important motion. This debate is about whether we have safe and adequate staffing levels in our hospitals and health services, and whether the pay and numbers strategy is an embargo by another name to prevent the recruitment necessary to reach the safe and adequate staffing levels required to ensure patient safety and provide treatment for the patients who require it.

We have a sort of mystery here. Fórsa referred to the mystery of the disappearing jobs in the health service. We also have the mystery of how the Government tells us we have record levels of recruitment and apparently some of the best staffing levels in nursing anywhere in Europe. Then we have what the health workers say, which is exactly the opposite. They say they are chronically understaffed in every single area of the health service, they are completely demoralised and patient safety is being seriously jeopardised across the health service. I can tell the Minister from the off that I believe the health workers and not the Minister. There is a reason the INMO and Fórsa are balloting for industrial action. These are conscientious people. They do not want to strike or like going out on strike. They are balloting because they are demoralised, stressed, overworked and worried about the safety of their patients.

The hospital consultants tell us a different story. Waiting lists will increase by 74,700 by the end of 2024 if current trends continue, an increase of 11% compared with the start of the year. They say that 746,000 people are waiting for outpatient appointments and there are now a record 913,000 people on some form of public hospital or health waiting list.

Representatives of a cancer care group are coming in here today, but I have been talking to them over the past few weeks because we have raised this repeatedly. I talked to the radiation therapists again this morning, before this debate, just to confirm what is going on in cancer care. There has been significant capital investment in machinery in Galway and Cork hospitals and St. Luke's Hospital, among other places, but there are no staff to run many of the machines. They are sitting idle. The Government is having to pay €7 million to outsource cancer treatment to the private sector but, due to the pay and numbers strategy, it will not recruit the necessary staff. If you are diagnosed with cancer, you are supposed to get treatment within three weeks. There is a target that 90% of cases should meet that timescale. Pre Covid, we were at 80% of that target, but it is now down to 60%. Four out of ten people are not getting the timely treatment they need for conditions that are a threat to their life. Radiotherapists are working 12-hour days and are overworked and overstretched. The Government says it is trying to recruit. Health workers and even the advertisements in the hospitals themselves tell us a different story, however.

Hospital workers from St. Michael's Hospital and Loughlinstown hospital, both of which are in my area, came to me and said they are chronically understaffed, patient levels are not safe and so on. We had a meeting, we protested and asked questions. We then got a letter saying that 21 posts would be authorised because there were 21 less in the hospital than were needed. How many of them are being advertised? This is a month after they told us they are trying to recruit these 21 posts. There were two nursing jobs advertised. There are five health and social care professional jobs vacant, acknowledged by the HSE. How many jobs are being advertised on the website? None. Somebody is playing games here. The Government says it is trying to recruit people but in actuality is not advertising the jobs. It is not trying to recruit people because of the pay and numbers strategy. It is not backfilling posts if people leave, which is leaving places chronically understaffed and patient safety jeopardised. The Government is deceiving the public.

Mattie McGrath (Tipperary, Independent)
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More than 1 million people are now on waiting lists for various medical treatments and consultations, a stark increase from the situation when the current Government took office. The public health service is grappling with a severe shortage of staff, which is directly affecting the ability of healthcare professionals to provide safe and effective care. The understaffing issue is not just a matter of numbers. It has profound implications for patient safety and the well-being of existing staff. That is a fact. At the end of this, the Minister will refer, as the Taoiseach and Tánaiste do every day, to 25,000 extra staff having been recruited. How many of these people are front-line staff? This is the problem. How many of them are pen-pushers and managers? We have managers and more managers. It is an intolerable situation. There is a recruitment moratorium and vacant positions. The growing waiting lists are an impact of staff shortages. The shortage of staff has several detrimental effects on the healthcare system, such as an increased workload for existing staff. There are also longer waiting times and reduced quality of care. Those are three simple and basic facts. It is just not acceptable that this carries on under Government after Government.

When I first came in here, the budget for the HSE and the Department of Health was €5 billion. It is now €25 billion or €26 billion, and growing. A Supplementary Estimate was passed last week. Where is the accountability? Is anybody holding these people to account? So much good work is going on. The good front-line staff and nurses give their lives and work so hard. They are dedicated, only to be tricked around like this. The Government says there is no moratorium on recruitment, yet there is one. The people doing this work are sick and tired of it. They are doing their best but many of them are getting injured and the fatigue and stress levels and everything else make it impossible for them to continue. The situation is going backwards rather than forwards.

Danny Healy-Rae (Kerry, Independent)
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I thank the nurses, doctors and carers. Their performance in County Kerry has been outstanding and is outstanding. I sympathise with all the members of the INMO who are protesting today outside Tralee University Hospital. They should not have to be there. I say to the Minister, Deputy Donnelly, that his operation as Minister is the worst part of the Government. He is the worst cog in the Government's wheel. What he has allowed to happen is shameful. There has been a recruitment embargo since this time last year, such that we were not taking on any nurses despite the fact that many nurses retire, get sick or take leave. One girl I know about - it is happening more broadly - who went on a career break for three years is home since last March but cannot get her job back. That is the carry-on that is happening.

I am completely disappointed and disillusioned by the Minister, Deputy Donnelly. I see that Micheál Martin is backing him to the hilt. He is ensuring him free passage into the next Dáil by giving him a sole nomination in Wicklow. That is what Micheál Martin thinks of him, but we do not think that of him. He allowed the reimbursement for taking people who were in danger of going blind up to the North to be reduced. Shame on him. An eye unit in University Hospital Kerry in Tralee was closed down many months ago. The eyes of people in County Kerry are as important as those in any other part of Ireland. It is a disgrace and a shame.

Michael Healy-Rae (Kerry, Independent)
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I thank the Labour Party for bringing forward this very important motion.

If you can get a vet into your yard within an hour or an hour and a half, but if your grandmother goes to an emergency department she might have to wait for 24 hours to see a doctor, that is a bad sign for the health service. We are spending billions of euro on that service, but you can get a vet quicker than you can get a doctor. The money is being spent but it is not hitting the right place. Our lovely young girls and boys who are educated and want to be involved in the healthcare profession are leaving. Every day, I meet mums, dads and grandparents who say their young daughters and sons who wanted to be involved in health care here are in Australia, America or England. They are all around Europe but they are not at home. What is being done to attract them? Nothing. If they came home, they would not get planning permission for nor afford to buy a house. The standards and reimbursement they would get here are far less than those they can get abroad. That is wrong. We should be keeping those people at home.

Early this morning, I wanted to travel to Tralee in Kerry to stand in solidarity with the hard-working and dedicated people from the INMO and other groups who are protesting in Ratass, outside University Hospital Kerry. I decided that it was more important to be here to make my points on their behalf. I say clearly to the people protesting in Tralee today that we are here to stand up for them and speak for them but, unfortunately, the people in government - the Minister and everybody else - are not listening. I say to the people working today in Kenmare Community Hospital, in Listowel, Killarney or Cahirsiveen hospitals or in any of our other local hospitals in Kerry, that I know they are overworked and underpaid but we will continue to fight for them and be their voice.

Michael Collins (Cork South West, Independent)
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We find ourselves in an unbelievable situation. Four or five years ago there was a vote of no confidence in the then Minister for Health, Deputy Harris, and it led to a general election. That vote was called on the basis of the health service and health scandals. Nothing has got any better since then. People are waiting three to five years for cataract treatment, while others are waiting three or four years, in desperate pain, for hip or knee surgery. They are waiting for ordinary operations and procedures. We are lucky to have the cross-border treatment scheme but, just in case people would get some comfort from that, the Fine Gael-Fianna Fáil Government robbed the people trying to go abroad to get cataract treatment by cutting the money almost by half. Good God almighty, have those in government any heart at all? They have no heart. They think they can get away with anything. They do not think people will realise that. When they go knocking on doors, they will look inside the doorway and see that the mother or father of the household cannot see properly and is in danger of falling down steps or whatever and that is because the Government is not dealing with the issue. The Government has been praising itself this week for opening an eye surgery clinic in Cork but at the same time they closed one in Kerry, as Deputy Danny Healy-Rae said. There are many situations throughout the country where people are suffering.

One of the good aspects of the health system is cancer care. Many people get access to it and have to be worked on immediately. I praise Cancer Connect, which is celebrating this weekend, for delivering a great service to and from Cork.

Another issue I need to bring up is a relief nurse for Bere Island and another for Cape Clear. I have been to the two islands in the past week. The number one thing they need is a relief nurse. They have a full-time nurse but if that nurse gets sick or wants to go on holidays, there is no healthcare on Cape Clear or Bere Island.

Michael Ring (Mayo, Fine Gael)
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I call Deputy Pringle of the Independent Group.

Danny Healy-Rae (Kerry, Independent)
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A Chathaoirligh Gníomhach, on a point of order, where has the Minister gone? What is more important than being here-----

Michael Ring (Mayo, Fine Gael)
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Deputy, you have had your time.

Danny Healy-Rae (Kerry, Independent)
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Where has the Minister gone?

Michael Ring (Mayo, Fine Gael)
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He is over there.

Danny Healy-Rae (Kerry, Independent)
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He is not the Minister.

Michael Ring (Mayo, Fine Gael)
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He is a Minister. Do not be so disrespectful. Deputy Healy-Rae should sit down now. I call Deputy Pringle.

Danny Healy-Rae (Kerry, Independent)
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The Minister is not here.

Michael Collins (Cork South West, Independent)
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What about Bere Island and Cape Clear?

Danny Healy-Rae (Kerry, Independent)
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I am never disrespectful to anyone.

Michael Ring (Mayo, Fine Gael)
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He is a Minister.

Danny Healy-Rae (Kerry, Independent)
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I have no respect for the man who is not here.

Michael Ring (Mayo, Fine Gael)
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You had your time, Deputy.

Thomas Pringle (Donegal, Independent)
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I welcome the opportunity to speak on this motion regarding public health service staffing. I fully support this motion, particularly its call on the Government to lift the recruitment moratorium, commit to restoring staff positions abolished in 2023 and 2024 and fund the additional recruitment needed for appropriate staffing and the expansion of services. I thank the Labour Party for putting forward the motion.

Our public health service is at breaking point. Hospitals are experiencing record-breaking overcrowding. Understaffing in the health service is severely impacting the ability of staff to provide safe care and is putting both patients and staff at risk. Staff are expected to constantly work under severe pressure. It is not sustainable or acceptable. Something has to give and unfortunately it is the public who are left to suffer this Government's inaction.

For many years, I have been raising the fact that Letterkenny University Hospital needs urgent reform and far greater focus on recruitment. Two months ago, Letterkenny University Hospital was forced to cancel patients' surgeries due to overcrowding as more than 1,000 patients attended the emergency department in one week. Overcrowding adds significant pressure to the already extremely stressful environment that workers in Letterkenny hospital have to endure. It adds to the distress of the patients in Donegal who are forced to wait even longer to access necessary treatment. Last year saw more than 4,000 hospital cancellations at Letterkenny University Hospital. It is clear that understaffing is a significant issue at Letterkenny hospital and that staffing levels across the public health service need to be addressed immediately.

As I often say, however, recruitment is only part of the solution. We need to focus on retention as well. I have seen so many young medical professionals from Donegal leave in search of a better life and a much better health system to work in. That is to be expected, given the immense stress and pressure they are forced to work under within the HSE. It is vitally important to do everything we can to retain all health workers, including migrant doctors, nurses and consultants, who play a vital role in our hospitals and keep our healthcare system from collapsing.

In June I raised with the Minister the fact that several doctors and consultants have been unsuccessful in securing visas for their partners or children. Many of these doctors and consultants have been forced to take the decision to leave Ireland. I am sure the Minister is aware of this already, yet he refuses to do anything about it. These healthcare workers make an immense contribution to our society. They are keeping our health service from the brink, yet the Minister continues to treat them unreasonably.

Severe staff deficits also exist in the National Ambulance Service. This needs to be addressed urgently.

As Letterkenny hospital is unable to take patients quickly enough, ambulances are forced to queue outside and wait for their patients, rather than dropping them off. This is causing severe delays for the ambulance service and putting people suffering an emergency in County Donegal in a very dangerous position. For years, I have been calling for at least three additional ambulances and crews in County Donegal to meet the demand we have. We need one in Letterkenny, another in Inishowen and one in Killybegs. As it stands, a call out to Glencolumbkille can barely meet the call-out requirements when the crew is based in Killybegs. Additionally, though, the crew from Killybegs is often expected to cover Donegal town as well. It a dangerous and unsustainable situation.

We need to be investing in adequately staffing our ambulance service, our public health service and our community hospitals. I strongly believe we should be investing in better community healthcare because it is often underfunded, understaffed and underutilised. Not only would this significantly benefit the community, it would also take the pressure off our regional and national hospitals. This is something the Government needs to consider going forward and needs to fund. During the general election, we may actually see some changes happening. Whoever is in the new Government, perhaps they will actually deal with the situation once and for all rather than letting it continue on from crisis to crisis and lurching from disaster to disaster as we have.

Marian Harkin (Sligo-Leitrim, Independent)
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I thank the Labour Party for tabling this motion because it allows us to discuss this important issue. I will spend my time focusing on the more local impacts of Government healthcare policy. I will concentrate on the impacts on Sligo University Hospital, SUH. This is what matters to the people living there because it is their local hospital. What are we talking about? Last week, healthcare workers took time out to make the case for patients at SUH. Staff are carrying a major workload and this is partly due to the HSE's moratorium on employing staff. It is having an extremely serious impact on the experience of patients and on the staff delivering the service, who are burnt out at this stage.

It is not just now, though. Last December, workers left their posts at SUH to highlight the same concerns. If we do not listen to the healthcare workers in our hospitals, then we are not facing up to the reality of what is happening. They are telling us that the HSE's pay and numbers strategy will have a detrimental impact on services. SIPTU is also telling us that certain areas are being left behind in terms of adequate staffing. This is my main concern. We must have a safe staffing framework for all grades and areas in the health service. Just two years ago, 50 consultants from SUH wrote to the Taoiseach concerning conditions for staff and patients at SUH. They said the working conditions were unacceptable and unsafe and it was unsafe for patients too. One consultant said, "I have worked as a consultant for over 17 years and I have never seen the demand on our services so high nor the morale of our staff so low." One of the reasons for this is that in the wake of the 2008 economic crash, SUH lost 60 beds, which, proportionally, was far more than any other hospital in the country. A 40-bed unit is due to start construction soon, I hope, and that is great, but this will not even bring us back to the 2008 numbers.

It is not just the local consultants and staff saying this. What is the Irish Hospital Consultants Association, the national body, saying? Three years ago, the organisation said that meeting the healthcare needs of the 152,000 people in the west and north-west regions currently waiting to be assessed or treated by a consultant would only be possible by urgently filling vacant permanent hospital consultant posts. One year later, in 2022, the same organisation, a national organisation, said that failing to recruit consultant medical and surgical specialists in the north west would inevitably lead to patient harm and poor clinical outcomes. The truth of the matter is that because there is no model 4 hospital north of a line from Dublin to Galway there are great difficulties in recruiting consultants, no matter how much money is poured into it. This is the reality of the situation. The other parts of the country have their model 4 hospitals and their specialties, but there is nothing north of this line from Dublin to Galway in respect of model 4 hospitals. This is contributing to the problem.

I have discussed this matter with the Minister, Deputy Stephen Donnelly. He said that he sometimes disagrees with my figures on patients in hospitals waiting for beds from Trolley Watch. I will just use two figures. In 2014, ten years ago, 2,017 people were waiting on beds in the hospital in Sligo. Last year, 8,193 people were waiting. The numbers have almost quadrupled. If this fact does not tell us that there is a severe emergency where SUH is concerned and if the Government does not listen to the national body representing consultants, then I do not know what is going to happen. The Government must listen because the people in the north west matter as much as the people represented by the Minister of State and every other Deputy in this House.

Violet-Anne Wynne (Clare, Independent)
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I sincerely thank the Labour Party for bringing forward this important motion. Starting with vacancy numbers, a response to a parliamentary question stated there were 240.42 whole-time equivalent nursing vacancies in UHL. As we heard at a recent meeting of the health committee, SIPTU was able to provide information to me that indicated there were more than 70 healthcare assistant vacancies and approximately 70 support staff vacancies. This has led to a significant number of vacancies across all grades. In fact, it was said it is not safe. I acknowledge that the Minister, Deputy Donnelly, has disputed the former figure, which I did find strange since it originated from his Department. I am also submitting a request for clarification. If I can be so bold, I would like to go back to the Minister's suggestion, made at that recent meeting of the committee, of having a private meeting with me regarding questions I put forward at the end of my speaking time.

The pay and numbers strategy decommissions critical posts as it uses December 2023 as a starting point, when there were already significant gaps. The embargo has become a ceiling and recruitment restrictions remain. It has explained to me that hands are tied. Positions known to be becoming vacant cannot be advertised until they are vacant, and this is causing significant delays of up to six months. We experienced this in the Ennis urology service during the summer. The stress and strain being put on patients is completely unnecessary.

On 10 October, the health committee heard that there are enough nursing hours for safe staffing, but staff had to be redeployed and surge areas were not staffed with permanent staff. I must mention that surge areas are required due to the lack of other hospitals for patients to present at. At least this is the case in UHL. The hospital serves 430,000 people, which is more than double the average and points to the desperate need for another emergency department in the mid-west. We need to reopen Ennis hospital. Critically, management of surge areas was pointed to as a significant contributing factor to the death of Aoife Johnson. It is deeply distressing that years later we are still having issues managing surge capacity. Without permanent staff, we cannot guarantee that a tragedy of this type will not be repeated.

Colm Burke (Cork North Central, Fine Gael)
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I thank all the speakers today for contributing their views on this matter. I reiterate what the Minister, Deputy Donnelly, said in respect of the value we place on all the staff working in our health service. These are the people working tirelessly daily to provide care to those most in need right across the country. The Members here went through each of the hospitals in their own local areas. I am very much familiar with the hospitals around the country and the challenges they face.

As highlighted by the Minister, recruitment across the HSE has been incredibly strong over the lifetime of this Government. To suggest otherwise ignores the unprecedented level of investment in recruitment in the health service, which the Minister has set out. In fact, since 2020, we have seen the biggest staff increases since the HSE was established, with 23% growth. Each additional staff member hired has had an impact and contributed to an improvement in the services across the country. The expansion of our workforce in recent years has led to a reduction in waiting lists and in overcrowding in our health service.

While the increase in our workforce has brought benefits for staff and patients, it is important the HSE operates within its budget. The pay and numbers strategy ensures workforce growth is managed in an affordable and sustainable manner, with prudent controls in place to meet our fiscal responsibilities.

Under the new regional structures, the health regions and national services have been provided with their own staffing allocations in which to operate. Each regional executive officer can prioritise recruitment and replacements within their approved numbers, as appropriate. This ensures autonomy is devolved, thus removing any obstacle to normal recruitment and replacement in the workforce. This new operational model enables service areas to prioritise service provision and maintain financial controls within each region. Service areas can also reprioritise, should they wish, and remain adaptive within overall national policy and guidance.

Regarding our cancer services, I acknowledge the incredibly important role radiation therapists play in the provision of cancer services. I am pleased to say that an independent review of radiation therapist profession has recently been finalised. I accept there are radiation therapist vacancies across all radiation and oncology centres. The radiation therapist review was established to help address issues of recruitment and retention. These vacant posts are still available to be recruited for and posts are being advertised. In addition to recruitment and retention, this strategic review considered important issues such as career development and strategic workforce planning for radiation therapists. This important review has published 16 recommendations which aim to help and support radiation therapy provision into the future and overcome the current challenges faced by the service. An oversight group has been established to oversee the progression of these recommendations, driving long-term improvements for the radiation therapist profession and thus enhancing cancer care outcomes.

Another crucial area of growth has been in our National Ambulance Service. Since 2019, investment in National Ambulance Service, NAS, has increased by 37%, or €63 million, with a HSE national service plan, NSP, allocation in 2024 of €231 million. This growth in funding has seen total staff numbers rise to 2,363 as of the end of August 2024. This represents a staff growth of 430 or 22% since the end of 2019. In line with the constant developing healthcare needs of its patients, the National Ambulance Service is in a process of strategic reform to position itself as a dynamic and agile mobile urgent and emergency care service. This process of reform has been supported by a substantial increase in investment in recent years to provide for additional front-line staff and modernised fleet and equipment. In the recent budget announcement, the Government committed to increasing capacity in the NAS with an overall allocation of €280 million for the service in 2025. This includes €8 million for new service development posts, which will further increase the number of staff in the National Ambulance Service.

In budget 2025, funding of €2.841 million was secured for the new development measures for new posts for the children's disability network teams to cover 20 senior grade and 20 staff grade therapists, 20 therapy assistants and 15 psychologist training placements. The funding will also facilitate the continuation of the assessment of need waiting list initiative to enable the procurement of private assessments for long-waiting families. While recruitment and retention of staff is a challenge across the sector overall, a significant priority for the Government is filling vacancies within the 93 CDNTs. The HSE national recruitment service continues to explore a range of options to enhance the recruitment and retention of staff in CDNTs, including sponsoring student training in return for a commitment to work in the HSE; developing an apprenticeship programme for social workers in conjunction with Tusla and UCC, with 12 apprentices commencing in the 2024 academic year and a further 12 in 2025; supporting the grow our own bursary programmes for graduates in health services in the health sciences to train in the UK as health and social care professionals and return to work in the HSE; and launching an international recruitment campaign for health and social care professionals to supplement the national pool.

With regard to recruitment going forward, the Minister, Deputy Donnelly, has set a target of doubling the number of student places across health-related professions to increase the supply of staff needed to meet the demand for health services. There has already been a significant increase in the number of student places in recent years. Last year alone, more than 660 additional student places were provided in the higher education sector on health-related courses. This includes more than 200 student places across nursing, midwifery and allied health professions in Northern Ireland. The Government has also allocated funding in 2024 and 2025 to support the infrastructure for increased availability of clinical placements to match additional student training. That is extremely important with regard to the placements.

Overall, it should be noted that the Government has put significant funding into the health sector, with a budget of €25.8 billion allocated for 2025. The Department of Health's additional allocation in budget 2025 is almost an extra €3 billion. This includes €5.5 million for the roll-out of advanced practitioner nurses in healthcare and social care services, and €2.1 million for additional training places and 209 internship training places for student nurses.

The Government's job is to ensure the significant investment in the health services is responsibly managed and leads to better results for patients through the appropriate recruitment and employment of staff. The new regional structure delegates authority to REOs, allowing them to assess the needs in their respective areas and recruit as required within their budgets. The Government believes that this is the most efficient means of maintaining an adaptable and responsive health service in line with the vision of Sláintecare, a vision that has cross-party support. In summary, I reiterate the pay and numbers strategy is not a recruitment moratorium. In fact, it is an expansionary document and includes 4,210 additional posts for new developments and initiatives in 2024. The Government has provided extensive funding for recruitment, both in this year and next, our healthcare workforce will continue to grow and provide safe staffing and the delivery of quality healthcare.

Going back to the radiation therapists, I was involved in that over the past 18 months as regards increasing their numbers. It is not only about increasing the number of places that are in the hospitals but also increasing the number of places in our universities. Trinity College Dublin, which has a four-year course, has proposed to increase the student intake numbers from 30 to 50. UCC which has a two-year masters course, has proposed to increase the student intake numbers from 12 to 24. I am glad to report that will now progress in 2025. I would like to have got it through in time for the academic year starting in September 2024. It was not possible but that has now been resolved and I hope we will have more people in training. Efforts will be made to make sure all of the posts that are currently vacant are filled within a very short timeframe. That is the target at present.

Brendan Howlin (Wexford, Labour)
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I thank all Deputies for participating for what will be the Labour Party's last Private Members' business of this Dáil. It is important, therefore, we selected the issue of health. It is one of the two overarching social and economic priorities for this country, the other being housing. Health is a critical issue and we sought to be constructive in the motion we tabled to allow the Government the opportunity to embrace ideas coming from this side of the House to improve our health services, which is critical for every part of this country and for every Member of this House.

In that context, quite frankly it was disappointing to see the four-page amendment that was submitted by the Minister for Health. It is an amendment like none I have ever seen, more of a self-congratulatory speech than an amendment to a serious motion tabled.

If we are going to be serious about tackling real issues that everybody in this House is familiar with, the first step is recognising that. I would have thought that on the eve of contested ideas in a general election, we might have at least acknowledged from a collective point of view what the problems are. Instead of that, all we got from the Government side is a head-in-the-sand view. Never mind the issues that every Member of this House has brought before the House, look at quality and volume of money we are spending. If it is not having the impact, however, it is no good.

I want to deal with a number of specifics, one of which is hospital overcrowding. It used to be a winter phenomenon. We used to dread going into the winter months, and we had winter plans to deal with it. Now, it is a permanent feature of our acute hospital system. My colleagues have dealt extensively with the staffing crisis in our hospitals, and it is a staffing crisis. It has been met by the HSE with a range of ad hoc measures, including spending 3% of the health budget, an enormous sum of money - €650 million last year - on agency staff recruited from the private sector to plug the gaps that are so obvious in our acute health system. All this puts more pressure on existing staff, leading to burnout and disillusionment. It is a vicious circle, making it even more difficult to recruit and retain staff, worsening our health services even more. We are a wealthy nation now. We should not only aspire to having one of the best health systems in the world; we are in a position to build it. We have the resources, a population that has provided healthcare professionals to countries across the globe, and a highly skilled and committed cohort of health workers. In that context, it is unacceptable that we not only expect but take as normal overcrowding and long waiting lists for treatment in our acute hospital system.

I raise one issue in particular that can be resolved immediately and have a hugely beneficial impact on both patient care and staff morale in my own local hospital, Wexford General Hospital. Last May, the Minister, Deputy Donnelly, confirmed on South East Radio that Wexford General Hospital would get its long-promised 97 additional acute bed extension. This was to be part of 706 acute hospital inpatient beds announced for the HSE Dublin and south-east region. Currently, the number of acute beds in the region is 2.2 per 100,000, a number which is, of course, exaggerated by the concentration of acute beds serving the nation in Dublin. The problem is that although full planning was achieved for this extension in Wexford in 2023, we are still waiting for the commencement of work. This six-storey extension will provide single-occupancy rooms, private en suites, a staff base, staff changing facilities and occupational therapy and physiotherapy rooms to immeasurably improve facilities on site in Wexford. This development was originally promised at the same time as a similar extension was announced for St. Luke's General Hospital in Kilkenny. That extension is built and in operation and is called the Ormond wing. More power to them and good luck to them; it is needed, but we are still waiting in Wexford. Why? The built environment has a huge impact on the well-being of patients and staff. Having space, hygienic surroundings, proper capacity for infection control and basic facilities for staff to rest, change and eat are essential to facilitate and hold on to staff in any health facility. When the coffers of the State are overflowing, there is simply no excuse for delaying this urgent build at Wexford General Hospital and the many other urgent builds across the country. It seems to me that the Department of Health is traumatised now by the overruns at the national children's hospital and will not plough on with the urgent works needed at hospitals elsewhere.

This is likely my last opportunity to make a direct plea to Government on this issue. Build Wexford hospital's extension and provide the 97 beds to a hospital that has proven itself in the midst of the most stressful of times, coping in an exemplary fashion with a major fire on 1 March 2023. At that time, 200 patients were evacuated safely with no injuries reported to either patients or staff.

Our ambulance service, too, needs resourcing, as our motion underscores. We hear of cases where people in urgent need of hospitalisation are waiting unacceptably long times for an ambulance to arrive. I cite one very recent case in Wexford, where a man attending an opera festival event took ill. Remember, thousands of visitors are in Wexford right now, greatly expanding the 25,000-plus local population there. Luckily, a local pharmacist was in the premises in Wexford town centre and immediately recognised that the man was having a stroke. She called an ambulance at once. Wexford General Hospital is only a short distance away from this facility. The caller was told that the closest available ambulance - this happened this week in Wexford - was in Waterford. The closest available ambulance to the major population centre of Wexford at a time of burgeoning population was in Waterford. The man had to be carted onto a private car and brought to hospital. It is entirely unacceptable that a town the size of Wexford, with an expanded population at this time, was dependant on an ambulance from Waterford in a medical emergency.

Recently published figures show that, on 41 separate occasions in Wexford during the first six months of this year, an ambulance failed to arrive within an hour of a high-priority call. This is not acceptable. I should say that the figures for my Cork colleagues are worse. There were 77 instances there. In Tipperary, there were 35 instances in the first six months of this year where people were waiting more than an hour in an emergency case. There were 34 instances in Kilkenny. Our problem seems to be that ambulances are caught up at accident and emergency departments, trying to discharge patients into overcrowded accident and emergency facilities. It comes back to the lack of beds. We must stop this deadly cycle of thousands of hospital beds promised again and again with no delivery. I should tell the House that the man I referred to is making a good recovery despite his ordeal.

I thank all contributors to this important motion. Everybody in this House wants to provide the best possible health service. We in the Labour Party are proposing today specific and immediate steps to bring about improvements now. I hope the Minister and Government will accept and act on them. By tabling this self-congratulatory amendment, however, I am afraid that does not look likely.

David Cullinane (Waterford, Sinn Fein)
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Hear, hear.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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In accordance with Standing Order 80(2), the division is postponed until the weekly division time this evening.