I want to revert to an issue I have raised with the Tánaiste on a number of occasions, namely overcrowding in the accident and emergency department of University Hospital Limerick, UHL.

This morning, there are 90 people on trolleys in UHL. That is a good day now. It would have been unthinkable a number of years ago but there are 90 people on trolleys this morning. Almost one quarter of all those on trolleys in the country are in UHL. The Tánaiste is or claims to be a republican. Almost everybody in this House claims to be a republican. One of the key aspects of republicanism is equality. There is a disparity in healthcare across this country. People's experience of UHL is generally quite good other than the accident and emergency department, where the experience is almost universally negative. That is unfortunate because it the only encounter many people have with the hospital.

Why does that disparity continue to exist? I see the Minister, Deputy Donnelly, in the Chamber. When I raised the matter with him he told me there had been 2,000 new posts since this Government came into office. When I asked UHL for a breakdown of those posts, I found out the actual figure is only two thirds of that figure. I welcome the fact that there are over 1,300 new posts. It is not quite as good as what the Minister is claiming but it is a big improvement. Nevertheless, the disparity continues. UHL management indicated it has 13% fewer staff than other comparable model 4 hospitals and the population it has to deal with is 13% higher and it has fewer staff. It also pointed out that the number of people over the age of 70 in its catchment area is 20% higher, which places additional requirements on the hospital. What will be done in this Republic under this republican Government to bring about an equality of healthcare across this State?

The people I represent are not second-class citizens. They are not first-class citizens either. There are no first and second classes in this State. There is a disparity, however. I have been to accident and emergency departments with family members in Dublin and also in Limerick. There is a massive disparity in treatment. It is huge. I do not think some members of my family are first-class citizens and some are second-class citizens. This is unacceptable and it is very much concentrated in the mid-west. I want to know what the Government and the Minister of Health, who the Tánaiste appointed when he was Taoiseach, and who is still the Minister for Health, will do. I argued at the time that the Minister of Health should bring this matter to the Taoiseach's office to have it sorted out but he did not do so. It may be beyond any Minister for Health to sort it out but it needs to be sorted out because the accident and emergency department in Limerick is unfit for purpose.

It is my understanding that University Hospital Limerick has the largest capital investment programme at the moment in terms of new projects that are in the pipeline. The Minister has indicated that to me. Much of that has to happen. As the Deputy knows, work on the new €90 million project, consisting of a 96-bed inpatient block and renal dialysis unit, commenced in October 2022. The Government also committed to the delivery of a second 96-bed inpatient block at University Hospital Limerick. That will make a difference. An additional 150 beds have been opened in the UL Hospitals Group since 1 January 2020, 98 of which are in UHL itself. The €2 million purpose-built injury unit at Ennis hospital opened in April 2022. The number of whole-time equivalent staff has gone up to well over 1,000. The budget in 2022 was 19% higher than in 2019. A new geriatric emergency medicine unit was opened, with a focus on preventing emergency department attendance and admissions for those aged over 75. New plans were announced to make UHL one of the five regional scheduled care hubs. There has also been work in Croom orthopaedic hospital to take pressure off theatres, wards and clinical areas.

In respect of accident and emergency departments generally, it is my view that there needs to be a focus not just on resource allocation but also on the organisation of emergency medicine in the country. That has to happen at hospital level and there has to be whole-of-hospital involvement in emergency medicine, with all the departments and disciplines, if you like, working to take over cases within emergency departments and, likewise, within the HSE itself. Very often, the emergency department becomes the focal point of public outcry and anger because, as the Deputy said, for many people, it is the first port of call in respect of their experience of hospitals. We have developed many alternative care pathways, from first responders through to primary care, enhanced community care and medical assessment units. Ultimately, in all care, the sooner we get the patient to the person who can meaningfully treat that patient with the requisite qualifications, the better. It is my view that, to a certain extent, and this has been going on for a number of years, the unrelenting focus on accident and emergency departments sometimes misses the point of the broader hospital environment and the broader reform agenda that is required.

I thank the Tánaiste for his engagement, which is greatly appreciated. He is right that there are many projects under way in Limerick. There are also other projects under way across the State. In St. Vincent's University Hospital, for example, instead of having elderly people coming into the hospital, the hospital is sending out teams. I wonder whether something like that could be considered for UHL given the age cohort of the population of the mid-west. It certainly seems to be a success in St. Vincent's University Hospital and it could well help many people in the mid-west.

The Tánaiste spoke about a whole-of-hospital response, and I agree with him, but beyond that, there has to be a whole-of-hospital-group response. Since I came into this Dáil in 2020, I have called for a greater utilisation of Ennis, Nenagh and St. John's hospitals. The reality is that if a young man or woman, and it is mainly young men and women who play sport, has an injury while training at nighttime, he or she will end up in UHL because the local injuries unit stops operating at 8 p.m. I proposed in a motion in this Dáil that these units open 24-7. Moving towards that, even if they were open until 10 o'clock at night, it would bring many benefits and alleviate a lot of pressure on the emergency department in UHL.

I do not disagree with the Deputy in terms of alternatives. Sporting injuries, unless they are very serious, should not automatically end up in the emergency department of UHL.

It does not work.

in County Cork, the Gurranabraher centre injury unit has become a phenomenal service.

It is a long way from Kilmeedy to Gurranabraher.

I know, but there are injury units in the mid-west and they are going to be expanded. The Deputy is right. To me, that is elementary and should be pursued. There is also the alternative pre-hospital pathway that has been developed since September of this year between the UL Hospitals Group and the National Ambulance Service, which will see definitive care provided in the community to patients who call 999 or 112 and reduce the numbers of ambulances bringing patients directly to the emergency department. That involves specialist emergency medicine doctors and National Ambulance Service personnel responding to low acuity ambulance calls. Again, that is from 10 a.m. to 6 p.m. We have to work to extend the time. It is, however, a very good service and idea. The medical assessment unity pathway is for 112 and 999 patients in Ennis and Nenagh hospitals. That has now been extended to St. John's Hospital. Generally speaking, I agree with the thrust of the Deputy's argument. Much of that work is under way.