The situation in our health service continues to disimprove with up to one million people on outpatient and inpatient waiting lists and severe overcrowding in our accident and emergency departments on a consistent basis. We learned today that more than 6,000 people who are waiting for elderly care services could be waiting for up to two years. These are just a number of the issues, all of which have been impacted by the chronic crisis in recruiting and retaining qualified consultants. There are 3,176 approved consultant posts in our health service but as only 2,713 have been filled, there are about 463 unfilled qualified consultant posts. Our accident and emergency departments are left without specialist qualified consultants on too regular a basis and there is a chronic shortage across the board in psychiatry across the country. There are other examples. In effect, the shortage of qualified consultants is impacting on the quality and timeliness of care for many patients throughout the country.

There is general agreement that the cuts to new entrant consultant salaries, particularly those introduced in October 2012, constitute the key factor in this chronic inability to attract and recruit consultants to the Irish health service. A cut of up to 30% was introduced in October 2012. This pay differential is a major inhibitor in terms of recruiting qualified consultants. We have an unprecedented number of unfilled permanent posts as a result of that, which is clearly undermining the quality and provision of essential care to patients across the acute hospital service.

The Public Service Pay Commission has confirmed the difficulty in recruiting consultants.

Everybody seems to have identified the pay differential between consultants recruited post 2012 and their colleagues recruited before that. The differential which can be up to 57% is the major factor. When we add the fact that we have 40% fewer consultants than the Organisation for Economic Co-operation and Development, OECD, average we see the impact on the hospital services. For example, in the Dublin Midlands Hospital Group, there are 6,500 new patients waiting to see a consultant urologist. St. James's Hospital has advertised twice and has failed to recruit a consultant. In Cork, approximately 6,000 patients are awaiting outpatient reviews for eye surgery. In a recent survey by the Irish Hospital Consultants Association, IHCA, of 300 recently appointed consultants, post-2012, 70% are seriously considering resigning from their public hospital posts unless the discrimination against them ends. Does the Taoiseach accept that we have a very serious issue in recruiting qualified consultants to the health service? Does he accept that the post-2012 pay differential is a key factor and does he accept this is having an impact on patient care, adding to waiting lists and undermining overall quality and what does he propose to do about it?

The Government appreciates and understands that we have enormous challenges in our health service particularly when it comes to access, overcrowding in our emergency departments, the fact that many patients have to wait far too long to see a specialist or far too long for the operation or procedure they need.

There are other truths as well. When we ask 14,000 of our patients, as we do every year, how they rate their experience of our health service, 85% of public patients say they rate our public health service highly, that their experience is good or very good or even excellent. When it comes to patient outcomes, for example, we see big improvements in survival rates for cancer, heart attack and stroke over the past five to ten years. This is happening because of new technology and the hard work of our front-line staff and Government investment and policies behind them. For example, on the issue of overcrowding, today 297 patients await a hospital bed. That is down 24% on this day last year and down 20% on the same day two years ago. If one looks at the HSE special delivery unit, SDU, official numbers, month on month, there has been a decrease in the number of people waiting on trolleys every month since May.

Not in Tipperary.

That of course is of no comfort to anyone who is waiting but it does mean that over the summer approximately 1,000 fewer people were waiting on trolleys than was the case for the summer of last year. If we consider waiting times, yes, there are far too many people on waiting lists but the most important point is how long they wait. People now wait on average fewer than six months for an operation or procedure that they need. There are 50,000 waiting more than three months and most people wait fewer than six months for an operation or procedure. For example, at the end of July 2017, there were almost 8,000 patients waiting more than three months for cataract procedures. That number is down to 4,000. We all get lots of queries about hips and knees. The number waiting more than three months in July 2017 was 2,400. That is down to 1,717. Similarly, there were 2,600 people waiting for tonsil procedures during the summer of 2017. That is down to 1,150. We can see that the investment in the National Treatment Purchase Fund, NTPF, in particular, is reducing waiting times considerably for patients waiting for an operation or procedure. We now plan to bring that approach to outpatients as well, making sure that money actually follows the patient.

The Taoiseach should take a walk out to some of the hospitals.

The budget provides for a record level of investment in our health service, more than €17 billion next year, which is more than an extra €1 billion than was provided for health last year. There was a protest some weeks ago demanding an extra €1 billion for health. We have provided more than that for next year. We need more and more to make sure that money gets to the patient. That has not always been happening.

The Taoiseach might explain why he did not answer the question. I very specifically focused on the issue of recruitment and retention of qualified consultants. I pointed out that there is a crisis in recruiting consultants because of a pay differential - the discriminatory pay difference between those recruited after 2012 and those before 2012 - and the Taoiseach chose not to answer the question at all.

He did refer to improvements in cancer and heart disease. The cardiovascular strategy of the late 1990s and the cancer strategies and the centres of excellence are the bedrock or foundation stone for the different quality of care in those two sectors.

It was long before the Taoiseach arrived on the scene.

I am glad the Taoiseach outlined the impact of the National Treatment Purchase Fund. He opposed its inclusion in the confidence and supply agreement three years ago. It took us a long time to convince him and his colleagues about the merits of the National Treatment Purchase Fund and I am glad that in some areas, the numbers are reducing. Hopefully over the next year with the budget allocation that will also happen.

The Public Service Pay Commission has acknowledged the difficulty. Does the Taoiseach acknowledge the issue?

The Taoiseach to respond.

In 2005, more than half the posts advertised received between zero and two applications. That increased to 60% in 2016. In Waterford, of 40 approved-----

Go raibh maith agat.

-----consultant posts, 36 are in place, but 20 of these are filled on a non-permanent basis. In Letterkenny 12 out of 18 are non-permanent.

The Taoiseach to respond.

The Taoiseach must accept and acknowledge there is a real problem in recruiting and retaining staff-----

The Taoiseach to respond.

-----in our acute hospitals.

The Taoiseach to respond.

What does the Government intend to do about that specific and very important issue that affects the quality of care of patients?

Deputies, please. Time is a factor.

I will answer the Deputy's question with a straight answer. The Government accepts we have a problem in recruiting and retaining consultants in our public hospital system. What is being done about it? We have a three-year pay agreement, which involves pay increases and pay restoration for consultants, including two pay increases next year and an increment. We have negotiated with ICTU an arrangement for new entrants recruited after 2011-12 to equalise the pay scales. It does not do that fully for consultants, but it goes a considerable way towards that. There will be two pay increases, pay restoration, an increment, as well as special measures for new entrants, all happening next year. Those pay increases take a big chunk out of that extra €1 billion for healthcare next year. We need to ensure we do not allow all the money go into extra pay and pay rises. We also need to ensure there is money for new services, new drugs, new equipment and new buildings.

We accept the Public Service Pay Commission report, which I have read as have the Ministers for Health and Public Expenditure and Reform. The best thing we can do now is to engage with the IMO and the IHCA on what can be done to improve the situation. We also need to bear in mind some realities. We probably need a new approach. We have more doctors working in our health service than ever before, but we are not seeing that matched in an increase in activity in-----

We have too many non-permanent people.

Go raibh maith agat.

-----the number of outpatient appointments-----

We have too many specialists.

Go raibh maith agat.

-----happening and the number of procedures being done.

Go raibh maith agat.

They could be unqualified doctors.

Unfortunately there is no direct link between spending-----

I call Deputy McDonald, who has three minutes

-----and staffing on the one hand, and outcome and activity on the other.

That is because we have too many who are unqualified.

We must observe the clock.

We potentially need a new approach that links pay to outcomes, as is the case, for example, in the NHS and other systems.

If we want four minutes for questions, let them change the Standing Orders. Taoiseach-----

We also need to be realistic that there are hospitals that get applications and those that do not.

There must be some respect for the Chair.