The first question today comes from the acting leader of Sinn Féin, Deputy Cullinane.

That is quite an elevation. Hospitals are at breaking point. Several have already begun cancelling scheduled care to cope with overflows from record emergency department admissions. Yesterday morning, more than 515 patients were admitted to hospital without a bed. They were left on trolleys or chairs in ward corners, corridors and waiting rooms. Last week, more than 1,800 patients were languishing on hospital trolleys. The Saolta University Health Care Group, which serves the north-west and west regions, is worst affected, along with Limerick, Cork and Waterford university hospitals.

The cancellation of elective and often time-sensitive care is unsustainable. It will lead to the worsening of conditions, physical health and mental well-being. Last month, the chief executive officer of the University Limerick Hospitals Group stated that the Irish Patients Association is quite right to point out that significant reductions in scheduled care are not sustainable in the long term.

The truth is that we need more staff and capacity in public hospitals but this Government and the previous Government have failed to deliver.

Consequently, many healthcare staff are considering leaving the service. They tell me that all the time. It does not give them any pleasure to do so, but they say it is because they do not feel valued or respected and they are burnt out. Day in, day out, healthcare workers are dealing with crisis after crisis on the front line. They forgo lunch and annual leave because they know that if they take such breaks, they will heap more pressure on their colleagues and cause patients to suffer. This level of moral injury is unsustainable and unacceptable. The Tánaiste will have seen recently front-line nurses have been protesting outside some hospitals because of unsafe staffing levels. What is the Government's plan to address the appalling working conditions to help retain our highly skilled healthcare workers?

I am also hoping the Tánaiste can confirm the Government's intention to address the issues raised by student nurses and midwives, who are again protesting outside the Dáil today. They should not have to protest. It is disgraceful that people who are trying to do their best in our health services have to come to the Dáil to protest to get the Minister for Health to act on what has been a running sore and a long-running issue, namely, fair pay and allowances for student nurses and midwives. A temporary pandemic payment was put in place at the end of this academic year, but we need a permanent solution. That means a permanent solution for fourth years and for first, second and third years.

I am shocked, but not surprised, that the Irish Nurses and Midwives Organisation, INMO, and, indeed, other healthcare trade unions learned of the changes to the intern pay rates in The Irish Times this morning, like everyone else. This is an industrial relations issue; they should not have to wait to read it in the newspapers. There should have been discussions with the public health trade unions, and yet that is not what happened.

What is happening is unacceptable. Student nurses are telling me in their droves, and I have met many student nurses and midwives over the course of the past year, that they want to work in our public health services and be part of ensuring we deliver the best, world-class healthcare services we all want. However, if they do not feel valued and respected, they are going to leave. We need to recruit and retain more nurses.

When will the McHugh review be published to give clarity on its recommendations? Will there be discussions and negotiations with the Irish Nurses and Midwives Organisation and other healthcare trade unions so that fair pay and allowances can be put in place for student nurses and midwives?

I thank the Deputy. For many in society, when it comes to the pandemic, things are largely back to normal. Many people are able to go back to their workplaces and schools, colleges, shops and businesses are open. For our hospitals, however, the pandemic is as bad as it ever was. There are 500 people in hospital with Covid today and almost 100 people in ICU. Hospitals are trying to manage Covid care as well as regular healthcare, and there is a big backlog of unmet need, given that non-Covid care was reduced so much during the initial phase of the pandemic. Therefore, hospitals are very busy at the moment. People in our hospitals and across our health service are working extremely hard. We are facing into a very busy winter as we try to manage the pandemic, provide regular care and address the unmet needs of those whose healthcare needs were not met during the pandemic. We acknowledge the extraordinary work of all our health service workers in that regard.

On the issue of student nurses, which I am aware the Deputy has raised and has a real interest in, it is the Government's policy to protect and support the continued education of all students, including student nurses and midwives. A longer term review of matters related to student nurse and midwife allowances and internship pay has been conducted by Mr. Sean McHugh. I am advised the Minister for Health, Deputy Donnelly, will outline his plans regarding the report shortly, and these plans include a 12.5% increase in payments to student nurses and midwives in their internship year and a continuation of the pandemic placement grant. Payments may be required to be backdated to October.

While they are on their clinical placements, student nurses and midwives in years 1, 2 and 3 and in the first semester of year 4 continue to receive a weekly accommodation allowance of €50.79 as well as reimbursement of their travel costs.

Supernumerary student nurses and midwives also received an additional and exceptional pandemic placement grant during the academic year of 2020 to 2021. This was designed to support them with undertaking clinical placements during the pandemic. As the pandemic is still continuing and staff in hospitals face particular challenges, the pandemic placement grant will continue to be paid. The Minister for Health will announce details of this shortly. The pandemic placement grant was introduced by the Minister as an exceptional payment to support students attending clinical placements during the last academic year. As the pandemic is still ongoing and staff in hospitals continue to face particular challenges, this grant will continue to be paid. The Minister, Deputy Donnelly, will announce further details as soon as possible.

We will have to wait and see exactly what is in the memo the Minister brings to Cabinet. The reality is there have been three meetings between the Irish Nurses and Midwives Organisation and the HSE. This is an industrial relations issue, and yet that healthcare trade union and those student nurses and midwives outside the Dáil had to read in a newspaper what may or may not be in the memo. I ask the Tánaiste directly whether there will be engagement with the Irish Nurses and Midwives Organisation on precisely what is in the memo.

The Tánaiste has outlined what might be in place for first, second and third years. It is unacceptable. This is an emergency pandemic payment of €100 which many of them said fell far short. There is no sense this will be permanent. There is no sense any permanent solution is being put in place for first, second and third years.

I do not believe the Tánaiste gets it. If he were outside today, like many of us were, speaking to those student nurses and midwives they are telling us directly, and it does not give me any pleasure to say this, that they do not feel valued and that the first chance they get they will be gone. Let us avoid them going. Let us treat them fairly and with respect.

Will the Tánaiste also explain when the recognition payment that was promised for those on the front line and in healthcare will be paid? We heard about it before the budget and during the budget. There was a lot of talk about this exceptional payment for those on the front line in healthcare. We have heard nothing since.

I thank the Deputy. There will, of course, be engagement between the Minister and the HSE on one hand and the Irish Nurses and Midwives Organisation and SIPTU health on the other on this issue of student nurses and student midwives which, as the Deputy said, is an industrial relations issue. It is appropriate there should be further engagement. I do not know when the Minister, Deputy Donnelly, will formally bring a proposal to Cabinet, but there is Cabinet meeting on Thursday and one again next Tuesday, so I imagine it will be quite soon.

The proposals being made in the report provide for a 12.5% increase in the payment to student nurses and student midwives in their internship year and the continuation of the pandemic placement grant, recognising that the pandemic is ongoing. This may need to involve some back payments also.

It is worth pointing out the only healthcare students paid salaries are student nurses and midwives in their fourth year. They are paid between €21,000 and €22,000 on an annualised basis. During the 36-week internship in fourth year they are counted as point 5 full-time equivalent staff as they have not yet qualified.

In terms of recruitment in the round, it is worth acknowledging we have a budget of €22 billion. This is 50% higher than it was only six or seven years ago. On a per capita basis it is probably one of the highest in the world. The HSE has recruited 7,000 or 8,000 additional staff since the pandemic. It has authorisation to recruit a similar number again on top of this. It is doing a good job in recruiting as many staff as possible, notwithstanding the fact we face recruitment and retention challenges that are a feature of all health services.

I have been studying health for many years. It is the reason I got into politics. I do not think we realise what we are facing into over the coming months. I am not saying this in any political way but genuinely. I have never seen so many people, and I have family members who work in the healthcare area, who are so exhausted. They are facing into a perfect storm because of where we are with Covid. We do not fully know where we are going. This winter will not be like last winter because we will have other issues such as the flu. It is a perfect storm. This year they are absolutely, completely exhausted. Last year we rallied but this year I am not sure whether rallying will be enough.

The trolley watch figures given out by the INMO are so disturbing. University Hospital Limerick, UHL, is my nearest category 1 hospital and I have never seen the figures like these, with 75 people on trolleys. I have never heard the kind of stories I am hearing from University Hospital Kerry, and I know many people working in both hospitals.

Where is the winter plan? It was released last year in September; it is now November. The Tánaiste will obviously have a date for it in return to my question. We also know that the efficacy of the of Covid-19 vaccines is dropping and all international studies are showing that.

What are we doing on clean air quality? Ventilation is probably the issue that has been most underassessed and utilised as regards combating Covid-19 because it is an airborne disease. Do we have a regulatory proposal for the winter months regarding ventilation and clean air across all workplaces as people come back to work?

I welcome that the National Immunisation Advisory Council, NIAC, which did not meet for more than two weeks, incredibly, is finally allowing for booster shots for the 340,000 healthcare workers. I presume it will be for all healthcare workers. It will be done in about three weeks because we have the infrastructure in place. That was good planning.

There are, however, a number of other issues we need to deal with on top of that. I have said for a month now we need serial testing in nursing homes. There have been 12 outbreaks in the last week. We need to just learn from the past and not blame anyone. For a period over the winter months we need serial testing in nursing homes to protect our most vulnerable there.

I agree with the previous speaker on student nurses. This report should be with the student nursing unions before it is leaked to the media once again. It is scandalous that happened. There should be proper interaction so what is being proposed can be negotiated with them and can be told to their faces.

I thank the Deputy for his questions. Nobody knows for sure what we are going to face into this winter with the health service. Much of that will depend on the pandemic and on whether cases peak and fall, continue to rise, or level off at a certain point. Looking around Europe and at other parts of the world, it is hard to know for sure what trajectory we are going to follow. We will respond to it in a strategic and nimble way.

What is clear is that our health service, our hospitals and our primary care are going to be very busy this winter. They are busy every winter but this winter is going to be as busy as any we have seen in the past and perhaps more so and the system will be under pressure. That is because of three things: the impact of the pandemic, which is ongoing; regular healthcare needs which have not stopped; and a significant backlog of unmet healthcare need because certain services were curtailed or shut altogether in the early stages of the pandemic.

We are doing a number of things. Phenomenal additional resources - €22 billion - are being spent this year in the health service. That extra €4 billion that the health service had in a previous year is being retained. The health service is receiving more funding in 2022 than many Opposition parties even called for. There are an extra 850 beds in the system, above where we were when the pandemic began, and more can be added. There is additional intensive care unit, ICU capacity and more funding for community care, home care, general practice and for the use of private hospitals, as appropriate and as needed, under the existing agreement. These are all the tools we can use at the moment to manage the situation.

The second aspect is the vaccine booster programme, beginning this week for all of those between 60 and 80 and is already under way for people under 60 who are immunocompromised. The next group that has been approved is healthcare workers, and I believe this can be done very swiftly. I welcome NIAC's decision in that regard. NIAC will next consider people under 60 who have chronic conditions and who may well also need the booster shot. There is very good evidence from other jurisdictions, including Israel, the country first vaccinated and first boosted, that the booster shots are very effective. We are going to see an extensive booster programme and all of us in this House have called for that.

On ventilation, there is advice in the Work Safely Protocol which is agreed between Government, unions and employers, and that is updated regularly. Serial testing in nursing homes and the extension of antigen testing to schools are under review by NPHET.

The 60- to 69-year-olds are a group I have raised many times in the House in regard to the length of time they had to wait for their second vaccine. They now have to wait another five to six months to get their boosters because they were in the category that received AstraZeneca. What comfort can the Tánaiste give people in that category, as everyone else gets boosters over the next three weeks, regarding the efficacy of their vaccines and how the boosters that are given to them will not discriminate because of their being in that category?

Second, I am all for COVAX and distributing some of our vaccines to poorer nations across the world, particularly the vector vaccines. However, the mRNA vaccines are not really distributable to poorer nations because they do not have the infrastructure. Will consideration be given by early next year, after we have dealt with those aged under 60 who have underlying conditions, to putting in place a booster vaccine programme for the whole population? We have the infrastructure to do it and we have 90 million vaccines, some of which we will not be distributing under COVAX. We will have more than ample vaccines to do so.

At the outset, it is really important to say that all four of the vaccines that have been used in Ireland are very effective, perhaps not as effective against transmission as we hoped but extremely effective in reducing hospitalisation and the need for ICU care and against death. What is remarkable is that, in the past two weeks or so, we have had as many cases of Covid detected as we did in the first six months of the pandemic, yet we have not seen comparable numbers, thankfully, in our hospitals and ICUs, let alone deaths. It is because of the strength and efficacy of those vaccines that we are in a much better position relatively than we would be had we not had those vaccines, and a much better position than we were in last winter or last year.

The advice and decision from NIAC, as adopted by the Government, is that anybody receiving a booster shot will receive an mRNA vaccine, that is Pfizer, Moderna or the new one that will be approved quite soon. However, my understanding is that people cannot receive a booster shot until five to six months after their previous shot. I will double-check that for the Deputy. I believe we are going to need an extensive vaccination programme. We have now got approval for the over-60s, healthcare workers and people under 60 who are immunocompromised. I think we will need approval, and we will be seeking advice and approval from NIAC, on extending the vaccine booster programme more widely, particularly to those under 60 with chronic conditions. I know NIAC and NPHET are examining the evidence on that all the time.