The Minister for Health, Deputy Stephen Donnelly, received a letter two weeks ago from almost 80 GPs in County Donegal and a letter last week from consultants in Letterkenny University Hospital in Donegal calling for urgent action in the emergency department at Letterkenny University Hospital. In the letters, GPs and consultants warn of a service collapse and call on the Minister and senior officials to step in and carry out an external review of the emergency department, with an action plan put in place regarding access to the emergency department and acute services.

Letterkenny University Hospital is in crisis. Over the past few weeks, patients have been forced to wait for more than 24 hours and, in many cases, 36 to 48 hours to be seen. There are no seats available for those waiting in the emergency department it is so crowded. There is a serious risk to patients in Donegal arising from deteriorating conditions in the emergency department and a lack of hospital resources. Letterkenny University Hospital is one of the busiest hospitals in the State, yet it gets far less funding per patient than most other hospitals. This is yet another sign of Donegal being ignored and under-resourced. It cannot be ignored and it requires urgent action from the Government.

The Minister has said there is a recruitment issue in Letterkenny. I once again take this opportunity to urge the Government and the HSE to collaborate with Cuba in sending doctors to Ireland to relieve pressure on Ireland's health service. Cuba has in the past provided medical services in 165 countries, with more than 605,698 employees. Cuba currently serves 59 nations, including Portugal, Italy and Sweden within the EU. The services are there and Cuba is willing to do it. All it needs is for the Government to ask. I do not believe that is too much to ask. If there are issues with recruitment, I am not sure why this solution has not been sought. Collaboration with Cuba would significantly improve conditions in Letterkenny University Hospital and the State of the healthcare system in this country overall. I have been raising this issue since June of last year but the Minister has failed to engage with me or with the Cuban ambassador on this issue, despite numerous attempts. The recruitment issue will not rectify itself. It requires thinking outside the box. If he was serious about addressing the situation in Donegal, he needs to consider this as an alternative as well.

Recruitment is only part of the solution. We also need to focus on retention. At least 88 overseas nurses and midwives have taken up roles in Letterkenny University Hospital since the beginning of last year. I will take this opportunity to express my solidarity to the migrant nurses who were outside Leinster House on Tuesday calling for family reunification as many are separated from their spouses and children due to their low pay not meeting visa conditions. They provide a service to the country and they should not be punished for it. They deserve pay parity with HSE workers to bring them above the visa threshold.

What will the Tánaiste do to address recruitment and retention issues in Letterkenny University Hospital to allow the fourth busiest accident and emergency department in the State to respond to the needs of the community once and for all?

I thank the Deputy for the question and I thank all of the staff who help to keep our health services working on a 24-7 basis. They deliver a public service under very challenging circumstances.

The Minister for Health received a letter and I have read the letter. He is very concerned with the issues raised in the correspondence and will meet with representatives of the GPs next week and will discuss the issues they have raised in their letter.

The budget for the hospital has increased from €142 million in 2019 to €177 million, which is a 24.5% increase. This is significant in itself. There are 2,144 whole-time equivalents employed by Letterkenny University Hospital, which is more than a 20% increase since 2020. There has been a lot of capital investment in the hospital. Capital projects completed in past two years include the expansion of gynaecology services, the opening of the acute stroke unit, the provision of an additional endoscopy theatre and a new maternity theatre. An additional 49 acute beds have been delivered since 2019 to the hospital and further capital projects are under way that will add capacity and services for patients. These include expansion of the renal department, expansion of the oncology day unit and the electrical infrastructure upgrade.

There is a lot of pressure on the emergency department. I believe there were 43,000 attendances in 2022, which is a 13% increase on 2019. In 2023, there were 40,000 attendances between January and September, which is a 25% increase in overall numbers over 2019. Most importantly, the attendance figures for patients aged 75 or older is more than 6,200, which is a 1,100% increase compared to 2019. We are witnessing a post-Covid increase in attendance across the health system. It is evident in Letterkenny and it is evident across most European healthcare systems. It also reflects the growing and ageing population.

We have expanded community care and other measures with a view to providing people the care they need outside of the emergency department and improving patient flow and discharge from the hospital with more home support packages and nursing home supports. Increased funding has been provided for additional GP access to diagnostics and primary care allowing for patients to be referred directly for X-rays and scans. In community healthcare organisation, CHO 1, which includes Letterkenny University Hospital, 14,500 of these scans had been completed by early October this year.

The Minister will meet with the staff. I note that the letter relates to access to the emergency department but we need to look not just specifically at the emergency department but the entire continuum from primary care to community care to diagnostics and the wider hospital group. That is a management issue locally and regionally under the Saolta University Health Care Group in how hospitals are organised, how patients are triaged and how patients are referred to various services.

The Tánaiste has outlined some of the positive stuff that happened in Letterkenny over the past couple of years and that is true but in reality all of that happened because the hospital flooded. That is why it happened and that is why this work was carried out. The hospital is greatly increasing the numbers at all times and even with all the work that has been done, we are in this crisis situation.

The letter from GPs states : "We have patients who are refusing to attend the emergency department because they would rather ‘take their chances’ and stay at home." From first-hand experience I know this is actually happening, whereby patients are deciding to stay at home rather than going to get the treatment they need. This is because of the delays and so on. The emergency department is being used as a gatekeeper for the rest of the hospital. This is part of the problem in what has happened.

Letterkenny University Hospital is consistently the fourth or fifth busiest hospital in the State with more than 23,000 patients a year being discharged from the hospital. Since 2020, the number of patients being seen in under six hours by the emergency department has declined from 80% to 52%. While the standard is 80%, only 52% are seen within the time. Patient numbers waiting for more than nine hours have increased from 6% to 27% in the same period. There is a problem. I am glad the Minister is meeting with the GPs. I hope an action plan will come out of that and we will actually see the problem being resolved.

The Minister will meet with the doctors. I take the Deputy's point that emergency departments can become the gatekeepers for the rest of a hospital. That was the point I was making in that it does need a more whole-of-hospital approach. Where that happens, there are very good outcomes in hospitals across the State.

The Deputy referred to Cuban GPs.

Cuban doctors.

They are exported by their government.

Yes.

I am not sure that is a system that I would like to be co-operating with.

It is all right for Portugal.

They have exported their doctors for oil to Venezuela. They do so in some areas in Africa for humanitarian benefits. However, it is a very repressive regime in terms of the suppression of civil society.

Sweden takes them.

These are issues the Deputy would raise with me if it applied to a different jurisdiction. We need a more open and honest debate about these things. There seem to be certain countries we cannot talk about at all. It is dressed up in idyllic terms. I have been to Cuba and they have a strong primary care system. However, the level of State control over individuals and over people is not something we in this democracy cherish or would endorse. The day that governments get to export their GPs - try that with the Irish Medical Organisation, IMO, someday here, say "lads, actually we are going to export you now." That is what has happened in Cuba for 50 years. When the Soviet Union collapsed, there was an increase in export of GPs from Cuba to get oil back in.

What is happening in Ukraine?

Oh no, please. We are way over time. That concludes Leaders' Questions.

I do not understand.

Nor does he.

We are not going to get into it. We are going on to Questions on Policy or Legislation. Can Deputies, please, stick to the allocated time for the questions and the answers?